CBT for adult ADHD

1. Introduction

Version followed: Safren, Sprich, Perlman & Otto, Mastering Your Adult ADHD: A Cognitive-Behavioral Treatment Program, Therapist Guide and Client Workbook, 2nd edition (Oxford University Press, Treatments That Work, 2017), the session structure of the MGH programme. The 1st edition (2005) was the version used in the 2010 JAMA trial; its session order differs in places [uncertain].

CBT for adult ADHD (MGH/Safren model) is a manualised, individual, skills-based programme for adults whose ADHD persists despite medication. It was developed in the Cognitive Behavioral Therapy Program at Massachusetts General Hospital / Harvard Medical School and is meant to start once medication is stabilised [source: CHADD article; psychiatrist.com abstract]. It does not try to cure the core neurobiological deficits. Instead it teaches compensatory skills: a single calendar and task list, prioritising, problem solving, organising systems, ways to manage distractibility, and adaptive thinking. These are practised until they become habits [source: CHADD; Henin MGH slides].

How change happens: the developers' cognitive-behavioural model holds that the core symptoms (inattention, disorganisation, impulsivity) lead over a lifetime to repeated underachievement and failure. That history produces negative thoughts and beliefs and low mood, which drive avoidance (procrastination, escape into more rewarding tasks), and the avoidance worsens functioning. Change comes from building compensatory behavioural skills into routines and from restructuring the thoughts that maintain avoidance [uncertain: model as described in Safren et al., 2004 and the manual's introductory chapter, neither drawn on; consistent with the Henin slides' description of avoidance maintained by short-term relief].

2. Framework

Format. Individual outpatient sessions, normally weekly, with each session run like a class lesson. The 2nd-edition manual has 12 sessions. The JAMA trial delivered 12 individual sessions [source: Kinokuniya TOC; Medical News Today; Henin slides]. The manual does not fix a session length; around 50 minutes is the usual CBT hour [uncertain]. The programme is designed for adults already on ADHD medication, and medication management continues alongside it [source: CHADD; psychiatrist.com abstract].

Standard session structure (every session) [source: CHADD; Henin slides]:

Set the agenda, with the session's purpose and goals stated.
Rate symptoms with the Adult ADHD Self-Report Scale (ASRS; WHO licensed screener, items not reproduced) and review the trend.
Review home practice from the past week, and review skills from earlier modules.
Introduce one new skill (almost every session).
Assign practice for the coming week, writing it into the client's calendar or task list.

Phases (2nd-edition session map) [source: Kinokuniya TOC; Henin slides; OUP chapter page]:

Module	Session(s)	Content	Goal
1. Psychoeducation, organizing and planning	1	Psychoeducation; start calendar and task list	Shared model; one consolidated system in daily use
	2	Informational session with spouse, partner or family member (optional)	Supporter understands programme; coaching not nagging
	3	Organization of multiple tasks	A/B/C prioritising of the task list
	4	Problem-solving and managing overwhelming tasks	Break tasks into steps; five-step problem solving
	5	Organizational systems	Systems for papers, mail, important objects (phone/tech optional)
2. Reducing distractibility	6	Gauge attention span; distractibility delay	Work in timed chunks; park distractions
	7	Modifying the environment	Remove distractions; reminder alarms
3. Adaptive thinking	8	Cognitive model of ADHD	Notice automatic thoughts in ADHD-linked situations
	9	Adaptive thinking	Thought record, thinking errors, rational responses
	10	Rehearsal and review	Fluency with adaptive thinking
4. Additional skills	11	Procrastination (optional)	Apply all prior skills to procrastination
	12	Handling slips	Maintenance plan

The Henin slides call the cognitive module optional and also list involvement of a significant other as an optional module [source: Henin slides]. The CHADD article presents three core modules plus single-session optional modules for procrastination and for the partner [source: CHADD].

Criteria for moving on [source: CHADD; Henin slides]:

Do not start a new skill area until the previous one is mastered. Clients learn at different rates, so 12 sessions is a guide, not a rule.
Sessions can be reordered to fit the client. For example, bring procrastination forward if avoidance is the main problem.
A skill counts as "mastered" when it is used long enough to become habitual. In practice: the calendar and task list are checked daily across most days of the week, without prompting [synthesis: operational threshold is not specified in the sources].
Expect progress to go up and down, not in a straight line. A bad week is not a reason to abandon the module.

3. Guiding principles

Adjunct to medication, not a replacement. Begin once medication is stable and coordinate with the prescriber. Residual symptoms are the target [source: psychiatrist.com abstract; CHADD].
ADHD is neurobiological, not a character flaw. Psychoeducation states plainly that ADHD is "not related to laziness or a lack of intelligence" [source: CHADD]. Use this to reduce shame before skill work.
Teach skills like a course. Run sessions with an agenda, teach a skill, practise, and set homework, rather than offering open-ended talk [source: Henin slides].
One skill at a time, cumulatively. Teaching everything at once "makes it harder". Add one skill per session and keep reviewing earlier ones [source: Henin slides].
Mastery before progression; flexible order. Stay on a skill until it is used. Tailor the sequence to the client [source: CHADD].
A workable system beats an ideal one. There is "no such thing as the best system, but need a workable one". Agree a system the client will actually carry [source: Henin slides].
Consolidate everything. All appointments and tasks go into one calendar and one task list, with no loose papers or sticky notes [source: Henin slides].
Habit is the goal. Repetition over weeks is what makes a skill work, so review use every session [source: Henin slides].
Measure every session. The ASRS is rated at each session so that symptom change is visible to both of you [source: CHADD].
Motivation is worked on, not assumed. Motivational interviewing ties each skill to the client's own goals and is used for procrastination (short- and long-term pros and cons) [source: CHADD; Henin slides].
Change the environment, not just effort. Set the stage in advance by removing distractions rather than relying on willpower [source: Henin slides].
Plan for ADHD inside the session. Expect inattention and distractibility in session. Keep material brief, written down and repeated [source: Henin slides].
Thoughts can be too positive as well as too negative. Target catastrophic and perfectionistic thoughts, and also impulsive "red flag" thoughts that justify switching to something more interesting [source: Henin slides].
Supporters coach, they do not nag. Significant others prompt and encourage but do not take over [source: Henin slides].
Normalise slips. Lapses are expected. The final session plans how to get back on track [source: Kinokuniya TOC; CHADD].

4. Intervention inventory

Interventions are listed in manual order. Session titles come from the 2nd-edition table of contents [source: Kinokuniya TOC]. Skill content comes from the MGH programme slides and the CHADD summary written by the authors' group [source: Henin slides; CHADD]. Where the manual's exact step order was not visible, steps are written as practical procedure and marked [synthesis]. All example language is illustrative and not taken from the manual.

4.1 Session routine: agenda, ASRS rating, practice review (every session)

Purpose / when: Gives every session the same structure, tracks symptoms, and makes home practice accountable. Used in all sessions [source: CHADD; Henin slides].
Steps: (1) The client completes the ASRS self-report at the start. Note the score and plot it against previous weeks. (2) Write the agenda where both of you can see it: review, new skill, practice plan. (3) Review last week's practice: what was done, what got in the way, and what helped. (4) Briefly check earlier skills, such as whether the calendar is still in use. (5) Teach the new skill. (6) The client writes the practice into their own calendar or task list before leaving [steps 5–6 detail: synthesis].
Example language (illustrative): "Let's put today's plan on paper so neither of us loses track: first your ratings, then how the task list went, then one new skill."
Watch for: Long story-telling that eats the session, and homework reviews that turn into self-criticism. Signs it is working: the client arrives with the notebook or app and reports practice without being asked.

4.2 Psychoeducation about adult ADHD and the treatment model (Session 1)

Purpose / when: Builds a shared non-blaming explanation and the rationale for skills plus medication. Used in Session 1 and revisited when shame surfaces [source: CHADD; Kinokuniya TOC].
Steps: (1) Ask what the client knows about ADHD and what they have been told about themselves ("lazy", "careless"). (2) Explain ADHD as a neurobiologically based disorder, not a matter of laziness or intelligence [source: CHADD]. (3) Explain why medication often leaves residual problems: it can improve attention, but it does not teach organisation or planning skills [source: psychiatrist.com abstract; wording synthesis]. (4) Draw the client's own version of the cycle: symptoms, then setbacks, then negative thoughts and mood, then avoidance, then more setbacks [uncertain: model from Safren et al. 2004]. (5) Outline the modules and the weekly routine. (6) Elicit 2–3 personal goals that the skills will serve.
Example language (illustrative): "Your brain handles attention and planning differently. That's not a character flaw, but it does mean you need external systems that other people may not."
Watch for: Relief, or grief about lost opportunities, both of which are common. Also watch for the belief that "skills won't work for me". It is working when the client starts describing problems in terms of the model rather than self-blame.

4.3 Motivational goal linkage

Purpose / when: Keeps engagement by tying each skill to the client's own reasons for change. Introduced in Session 1 and used whenever practice drops [source: CHADD, which says MI keeps participants connected to their own goals].
Steps [synthesis]: (1) Ask what would be different in work, home and relationships if ADHD interfered less. (2) Write these goals somewhere the client sees them (the front of the notebook or the app home screen). (3) When introducing a skill, ask how it could serve one of those goals. (4) When practice lapses, explore ambivalence (the costs and benefits of using the skill) rather than lecturing.
Example language (illustrative): "You said you want your manager to stop doubting you. How might a task list help with that?"
Watch for: Goals that belong to someone else, such as the partner or employer. It is working when the client names their own reasons for using the system.

4.4 Calendar system (Session 1 onward)

Purpose / when: One place for all time-bound commitments. This is the foundation skill [source: Henin slides].
Steps: (1) Inventory the current, often scattered, systems: sticky notes, several calendars, memory. (2) Agree on one calendar the client will carry: paper notebook or phone app. Technology options are added in the 2nd edition [source: Kinokuniya description]. The aim is a workable system, not the best one [source: Henin slides]. (3) Enter every appointment and deadline, including this therapy. (4) Set a fixed daily time to review the calendar (for example with morning coffee) and a weekly look-ahead [synthesis]. (5) Practise in session by entering the coming week together.
Example language (illustrative): "Which would you actually have on you at 3 p.m. on a Tuesday, a notebook or your phone? Let's go with that."
Watch for: Duplicate systems creeping back, and elaborate set-ups that are dropped within a week. It is working when appointments are kept and the client checks the calendar without prompting.

4.5 Task list (Session 1 onward)

Purpose / when: Captures everything that has to be done, so tasks are not held in memory. Paired with the calendar [source: Henin slides; CHADD].
Steps: (1) Keep a single task list in the same notebook or app as the calendar. (2) Consolidate everything into it: loose papers, notes and emails-to-self [source: Henin slides]. (3) Review it daily, cross off what is done and carry over what is not. (4) Move any task with a time or deadline into the calendar too [synthesis].
Example language (illustrative): "If it's not on the list, it doesn't exist. Let's empty your head and your pockets onto one page."
Watch for: A list that grows endlessly, which leads to Session 3 prioritising, and a list that is never looked at. It is working when the list is current and items are getting crossed off.

4.6 Informational session with spouse, partner or family member (Session 2, optional)

Purpose / when: Helps a significant other understand ADHD and the programme and plan supportive behaviour. Used when a supporter is available and the client agrees [source: OUP chapter page; CHADD; Henin slides].
Steps: (1) Get the client's consent and agree beforehand what will and will not be discussed [synthesis]. (2) Give a brief overview of ADHD and the treatment. (3) Clarify the supporter's role: reminders and coaching, not nagging [source: Henin slides]. (4) Build a concrete plan for how the supporter can help, for example a shared calendar, a weekly planning check-in, or praising use of the system [source: Henin slides for "plan"; examples synthesis]. (5) Agree how the client wants to be reminded.
Example language (illustrative): "What kind of reminder would feel like help to you, and what kind would feel like criticism?"
Watch for: The session turning into couple conflict, and the supporter taking over the tasks. It is working when both describe reminders as collaborative.

4.7 Prioritising the task list: A/B/C ratings (Session 3)

Purpose / when: Manages multiple tasks so that important work gets done before easy work [source: Henin slides].
Steps: (1) Rate each task: A = most important (must be done soon), B = less important or longer-term, C = lowest importance [source: Henin slides]. (2) Check the distribution: not everything can be an A [source: Henin slides]. (3) Rule: finish all A items before B, and B before C. (4) Each day, schedule A items into calendar time [synthesis]. (5) Re-rate as deadlines approach: B items become A [synthesis].
Example language (illustrative): "Notice how satisfying it is to tick off the C's? That's the trap. What's one A you could do first tomorrow?"
Watch for: Clients drifting to easy C tasks, which the slides flag explicitly, and everything being labelled A. It is working when A items get done on time.

4.8 Breaking down overwhelming tasks (Session 4)

Purpose / when: Turns large, vague tasks that the client avoids into doable steps [source: Henin slides; Kinokuniya TOC].
Steps: (1) Pick a complex task from the list. (2) List its steps. (3) Make each step small and concrete enough to be manageable. (4) Put each individual step on the daily task list [source: Henin slides]. The slides contrast an unmanageable item like "buy house" with an achievable step like looking up local realtors.
Example language (illustrative): "'Do taxes' isn't a task, it's a project. What's the very first thing you'd physically do?"
Watch for: Steps that are still too big. A useful test is whether the step can be started in under 10 minutes [synthesis]. It is working when the first steps get done and avoidance drops.

4.9 Five-step problem solving (Session 4)

Purpose / when: Used when a client is stuck on what to do, not just on doing it [source: Henin slides].
Steps: (1) State the problem specifically. (2) List all possible solutions without judging them. (3) Write the pros and cons of each. (4) Rate each solution from 1 to 10. (5) Carry out the best one: put it on the task list and break it down if needed [source: Henin slides, which mention a selection-of-action-plan worksheet; worksheet not reproduced].
Example language (illustrative): "Let's get every option on paper before we decide, even the silly ones."
Watch for: Jumping to the first solution, and perfectionism about picking the 'right' option. It is working when the client uses the steps on their own between sessions.

4.10 Organisational systems (Session 5)

Purpose / when: Builds systems for papers, mail, bills and important objects, with optional phone and computer tools [source: Kinokuniya TOC and description; Henin slides; CHADD for filing systems].
Steps: (1) Identify the biggest clutter or loss problem: mail, bills, keys or documents. (2) Mail and papers: set up a simple filing system with a few categories and a regular processing time [CHADD names filing systems; detail synthesis]. (3) Important objects: choose one specific home location for keys, wallet, notebook and phone. Return items there immediately, and involve family members [source: Henin slides]. (4) Optional technology: calendar alerts, task apps, cloud reminders [source: Kinokuniya description; specifics synthesis]. (5) Schedule a first decluttering step as homework.
Example language (illustrative): "Where would be the most natural place by the door for keys, phone and wallet to always live?"
Watch for: Over-engineered filing systems, and shame about clutter. It is working when fewer items are lost and bills are paid on time.

4.11 Gauging attention span (Session 6)

Purpose / when: Sets a realistic work interval to use in distractibility delay [source: Kinokuniya TOC].
Steps: (1) Pick a typical boring or hard task, such as paperwork or reading reports. (2) Ask the client to estimate, or to time during the week, how long they can stay on it before drifting [timing procedure: synthesis; the manual's exact method was not seen, uncertain]. (3) Set the starting interval at or slightly below that span, so the first trials succeed [synthesis; the slides say to choose "a reasonable" interval].
Example language (illustrative): "Let's find your honest number, not your ideal number. How many minutes before your mind wanders?"
Watch for: Overestimating the span, which leads to early failure. It is working when the chosen interval is completed most of the time.

4.12 Distractibility delay (Session 6)

Purpose / when: Keeps the client on a difficult or boring task by working in timed chunks and postponing distractions [source: Henin slides].
Steps: (1) Choose the task and the interval from 4.11. (2) Set a timer and work until it goes off. (3) When a distracting thought or urge comes up ("I should check email"), write it on a distraction sheet and go straight back to the task. Do not act on it [source: Henin slides]. (4) When the timer goes off, take a short break and review the written distractions: do any that are urgent, and put the rest on the task list [source: Henin slides; break detail synthesis]. (5) Start the next chunk. Lengthen intervals gradually as success builds [synthesis].
Example language (illustrative): "When the urge to check your phone hits, write 'phone' on the pad and get back to it. The pad holds it for you until the timer rings."
Watch for: Breaks that turn into the end of work. Set a timer for the break too [synthesis]. It is working when chunks are completed and fewer distractions need to be written down over time.

4.13 Reminder alarms / self-monitoring cues (Session 7)

Purpose / when: Catches drift away from the planned task during long periods of unstructured work [source: Henin slides].
Steps: (1) Set a recurring phone or computer alarm at regular intervals, for example every half hour [source: Henin slides]. (2) At each alarm, the client asks whether they are doing what they planned or have got distracted [source: Henin slides, paraphrased]. (3) If off-task, check the task list and return to the A item.
Example language (illustrative): "When it buzzes, just check: is this what I meant to be doing right now?"
Watch for: Habituation, where the client dismisses the alarm automatically. Vary the sound or interval [synthesis]. It is working when the client catches off-task drift earlier.

4.14 Modifying the environment (Session 7)

Purpose / when: Removes the triggers for distraction before work starts, to set the stage for success [source: Henin slides; Kinokuniya TOC].
Steps: (1) List the usual distractors in the work and home settings: phone, open browser tabs, TV, noise, clutter, interruptions from others. (2) For each, decide whether to remove, reduce or block it. For example: phone in another room, notifications off, door closed, desk cleared, noise-cancelling headphones [examples: synthesis]. (3) Make the changes before beginning the task. (4) Pair with distractibility delay.
Example language (illustrative): "Willpower runs out. Let's make the easy choice the right one by moving the distractions out of reach."
Watch for: Workplace limits, for example in an open-plan office. Problem-solve these with 4.9. It is working when the client starts tasks with fewer false starts.

4.15 Introducing the cognitive model of ADHD: identifying automatic thoughts (Session 8)

Purpose / when: Shows how thoughts in ADHD-related situations affect mood and avoidance [source: Kinokuniya TOC; Henin slides].
Steps: (1) Revisit the cycle from Session 1, now focusing on thoughts [uncertain: model source]. (2) Take a recent episode, such as facing a pile of paperwork. Identify the situation, the automatic thoughts, and the mood with an intensity rating from 0 to 100 [source: Henin slides]. (3) Show how the thought led to avoidance and how avoidance brought short-term relief, which reinforces it [source: Henin slides]. (4) Homework: record the first columns of a thought record (time/situation, automatic thoughts, mood and intensity) in ADHD-linked situations [source: Henin slides].
Example language (illustrative): "In that moment, staring at the forms, what went through your mind?"
Watch for: Clients who say "I don't have thoughts, I just don't do it". Use the mood shift or the urge to escape as the cue. It is working when the client brings in recorded examples.

4.16 Thought record with thinking errors and rational responses (Session 9)

Purpose / when: Builds adaptive thinking by labelling distortions and generating balanced responses [source: Henin slides; CHADD].
Steps: (1) Use the full thought record: time/situation, automatic thoughts, mood (0–100), thinking error, rational response [source: Henin slides]. (2) Label the thinking error. Errors named in the slides include all-or-nothing thinking, mind reading, fortune telling and catastrophising; the manual's full list was not seen [uncertain]. (3) Generate a rational response that is realistic, not just positive. For example: break the work into steps and take breaks, remember that nobody is perfect, and recall that similar past tasks turned out fine [source: Henin slides, paraphrased]. (4) Re-rate mood. (5) Link the response to an action step, such as a task-list item or a distractibility-delay chunk [synthesis].
Example language (illustrative): "Let's check the evidence. Is it really true that you'll mess it up completely, or is that fortune telling?"
Watch for: Responses that are just reassurance, and the client using the record to beat themselves up. It is working when mood ratings drop and the client acts on the task.

4.17 Positive self-coaching / addressing overly positive ("red flag") thoughts (Sessions 9–10)

Purpose / when: Targets impulsive or overly optimistic thoughts that justify avoidance, and builds encouraging self-talk [source: Henin slides; CHADD].
Steps: (1) Help the client notice red-flag thoughts, such as "I have to do this interesting thing right now" or "I'll do it later, I work better under pressure" [first example paraphrased from Henin slides; second illustrative]. (2) Treat each as a cue to check the task list. (3) Write a short coaching statement to use instead, for example: finish this chunk first, then the fun thing [synthesis]. (4) Practise self-coaching in the moment of starting tasks [CHADD names positive self-coaching].
Example language (illustrative): "When you hear 'just five minutes on this first', that's your red flag. What will you tell yourself instead?"
Watch for: Grandiose time estimates. It is working when the client catches red-flag thoughts and delays the rewarding activity.

4.18 Rehearsal and review of adaptive thinking (Session 10)

Purpose / when: Consolidates cognitive skills so they become fast and automatic [source: Kinokuniya TOC].
Steps [synthesis]: (1) Review thought records from the week. (2) Role-play or rehearse aloud high-risk situations, such as a looming deadline or criticism at work. (3) Help the client compress the full record into a quick mental routine they can use in the moment (notice, label, respond, act). (4) Integrate with the skills from Modules 1–2.
Example language (illustrative): "Let's run through Monday's meeting. What's the first thought likely to pop up, and what's your answer?"
Watch for: Rote use without belief in the response. It is working when the client generates responses quickly without the form.

4.19 Application of skills to procrastination (Session 11, optional)

Purpose / when: Brings all the skills to bear on chronic procrastination [source: Kinokuniya TOC; CHADD; Henin slides].
Steps: (1) Choose a task the client is currently putting off. (2) Identify the trigger: is the task too big (break it into chunks), is the client unsure where to start (problem-solving worksheet), or are unhelpful thoughts in the way (thought record)? [source: Henin slides]. (3) Weigh the short- and long-term pros and cons of doing versus delaying it, MI-style [source: Henin slides]. (4) Write a personal anti-procrastination plan listing the steps and skills to use [source: Henin slides]. (5) Schedule the first step in the calendar.
Example language (illustrative): "Putting it off feels better today. How does it look a week from now?"
Watch for: The plan itself being procrastinated. It is working when the target task is started and finished.

4.20 Handling slips / relapse prevention (Session 12)

Purpose / when: Prepares for lapses after treatment ends and preserves gains [source: Kinokuniya TOC; CHADD for "ups and downs"].
Steps [synthesis; session content not seen in detail, uncertain]: (1) Review the ASRS trend and the skills that helped most. (2) Name likely slip triggers: job change, stress, illness, a medication change, holidays. (3) Define early warning signs, such as the calendar unchecked for 3 or more days or loose papers piling up. (4) Write a recovery plan: restart the daily calendar review, re-read the client's notes, use problem solving. (5) Frame a slip as a cue to go back to the skills, not as failure. (6) Consider booster sessions.
Example language (illustrative): "You will have weeks when the system falls apart. What's the first sign, and what's step one to rebuild it?"
Watch for: All-or-nothing beliefs about slips. It is working when the client can describe a concrete plan for getting back on track.

5. Handling problems

The sources give only brief guidance on difficulties: introduce skills gradually, practise until habitual, plan for distractibility in session, don't advance before mastery, expect ups and downs, and use MI for motivation [source: Henin slides; CHADD]. Everything else below is [synthesis] unless tagged.

Forgetting sessions or homework (non-adherence is a symptom, not defiance). The session time and the homework must go into the client's calendar before they leave. Send a reminder text if your service allows it. Make homework one small task, not several. Review practice first thing every session, so that not doing it is noticed without blame [synthesis; the rule of reviewing prior practice every session is from CHADD]. If practice is repeatedly missed, shrink the task rather than repeating the same assignment.
Abandoning the system after a week or two. This is expected [source: Henin slides on habit formation]. Ask what made it hard to carry or check, then simplify: fewer categories, one app, and a daily check tied to an existing habit. Do not move on to new skills until the calendar and task list are in use [source: CHADD].
Stuck or plateaued (ASRS flat for several weeks). Check medication adherence and timing with the prescriber. Check for untreated comorbidity (depression, anxiety, substance use, sleep problems). Consider whether a skill was taught but never practised; if so, go back to it. Consider reordering, for example bringing procrastination forward [source: CHADD on reordering; rest synthesis].
Overwhelm (a huge backlog, crisis in work or finances). Triage with A/B/C ratings and problem solving. Pick the one or two most consequential A items and break them down in session. Postpone new skill teaching in that session but keep the routine [synthesis].
Distractibility inside sessions. Keep the written agenda visible, chunk the session, summarise frequently, have the client write down the key points, and gently refocus tangents [source: Henin slides on planning for in-session distractibility; techniques synthesis].
Resistance: "I've tried planners before" / "This is too basic." Validate past failures as attempts made without support or habit-building. Use MI: draw out the client's own goals and their ambivalence about structure. Offer a two-week experiment instead of a commitment [synthesis; MI use from CHADD].
Shame, demoralisation or ADHD-related grief. Revisit the psychoeducation (not laziness, not lack of intelligence) [source: CHADD]. Use a thought record on self-critical thoughts about past failures [synthesis].
Comorbid depression or suicidal thinking. Low mood is common. Screen at intake and whenever mood drops, using your service's standard suicide risk-assessment and safety-planning procedures, and include lethal-means counselling about safe storage where relevant. If depression is severe enough to block skill practice, treat it first or in parallel [synthesis].
Substance use or medication misuse. Coordinate with the prescriber. Treat substance use as a priority problem when it undermines practice [synthesis].
Ruptures (feeling judged about homework, feeling lectured). Name it, invite feedback, take responsibility for the pace or tone, and re-collaborate on goals. Ask the client how they want missed practice to be handled [synthesis].
Partner conflict or nagging. Return to the coaching-not-nagging agreement [source: Henin slides]. Agree specific reminder formats. If the conflict is entrenched, refer to couples work [synthesis].
Clients not on medication. The programme was designed and tested for medication-treated adults [source: Medical News Today; CHADD]. With unmedicated clients, expect slower skill uptake and discuss a medication evaluation. Applicability is less established, and the presenter of the MGH slides notes that unmedicated samples need study [source: Henin slides; uncertain].
Over-reliance on the therapist as external structure. From the middle sessions onward, hand over agenda-setting and the week's planning to the client, so the systems belong to them before Session 12 [synthesis].
Excessive cognitive work for a client who just needs behavioural skills. The cognitive module can be treated as optional [source: Henin slides]. Use it when negative thinking or avoidance blocks skill use.

Sources

Sources: