Managing ADHD: What is Your Implementation Plan?

Published on September 11, 2018
Medscape Features APSARD in the first US Adult ADHD Guidelines

As part of the mission of the APSARD Psychosocial Treatment Committee, the committee members will share blogs related to issues relevant to non-medical treatments for ADHD.

J. Russell Ramsay, Ph.D.
Associate Professor of Clinical Psychology
University of Pennsylvania, Perelman School of Medicine

Implementation intentions stem from a line of self-regulation research focused on the observation that a purely goal-focused approach to behavior change does not inexorably produce actions necessary to achieve that goal (Gollwitzer, 1999). Consequently, more specific, action-oriented plans designed for specific contexts (and tied to an overarching goal) have been found to improve follow through. These plans are framed in “If X, then Y” conditional statements in which a specific action or obstacle is tied with a specific setting, such that the setting itself then provides a cue for the desired action: “If situation X is encountered, then I will perform the goal-directed response Y!” (Gollwitzer & Oettingen, 2016, p. 223). Thus, someone with the goal of losing weight might identify that he is prone to snacking after seeing someone at work eating candy from the vending machine. His implementation intention might be “If I have the urge to go to the vending machine, then I will go get water or coffee instead.” The theory is that the vending machine becomes a cue for the coping response.

Although not yet studied in adults with ADHD, non-clinical studies of implementation intentions with children with ADHD indicate that they promote better task follow through (Gawrilow, Gollwitzer, & Oettingen, 2011a, 2011b; Gawrilow et al., 2013). The “If X, Then Y” (or “When X, Then Y,” if using “possibility language”) strategy has been a facet of our CBT approach for adult ADHD and it has been a valuable intervention domain (Ramsay & Rostain, 2015). In a small open study of adults with ADHD who completed CBT without medication, significant improvements on an activation measure were achieved, consistent with this and other implementation tenets (Ramsay & Rostain, 2011).

Procrastination is arguably the most common problem faced by adults with ADHD. Specific implementation plans can be designed for the initial behavioral step of task engagement, such as for a college student: “If I can get to the library, then I can open my economics assignment.” These statements are particularly useful for managing the pivot points within a task plan, such as defining the step for returning to the task after a brief break (“When I finish my coffee, then I can re-read the last few sentences I wrote to get re-engaged.”). Implementation plans can also be designed for re-engaging in tasks after being distracted, dealing with rationalizations for escaping a task, managing obstacles (“If the main section of the library is crowded, then I will take the elevator to the 5th floor stacks.”), or navigating other “tipping points” that represent risks for somehow getting distracted from one’s objectives.

The implementation plan or the “If/When X-Then Y plan,” is a useful, “sticky” take-away skill. These reminders can be externalized if the form of coping cards or other means to increase the likelihood of engagement in and follow through on tasks and endeavors.

Gawrilow, C., Gollwitzer, P. M., & Oettingen, G. (2011a). If-then plan benefit delay of gratification performance in children with and without ADHD. Cognitive Therapy and Research, 35, 442-455. doi: 10.1007/s10608-010-9309-z
Gawrilow, C., Gollwitzer, P. M., & Oettingen, G. (2011b). If-then plans benefit executive functions in children with ADHD. Journal of Social and Clinical Psychology, 30, 616-646.
Gawrilow, C., Morgenroth, K., Schultz, R., Oettingen, G., & Gollwitzer, P. M. (2013). Mental contrasting with implementation intentions enhances self-regulation of goal pursuit in schoolchildren at risk for ADHD. Motivation and Emotion, 37, 134-145. doi: 10.1007/s11031-012-9288-3
Gollwitzer, P. M. (1999). Implementation intentions: Strong effects of simple plans. American Psychologist, 54, 493-503.
Gollwitzer, P. M., & Oettingen, G. (2016). Planning promotes goal striving. In K. D. Vohs, & R. F. Baumeister (Eds.), Handbook of self-regulation: Research, theory, and applications (3rd ed.) (pp. 223-244). New York: Guilford.
Ramsay, J. R., & Rostain, A. L. (2011). CBT without medications for adult ADHD: An open pilot study of five patients. Journal of Cognitive Psychotherapy: An International Quarterly, 25, 277-286. doi: 10.1891/0889-8391.25.4.277
Ramsay, J. R., & Rostain, A. L. (2015). Cognitive behavioral therapy for adult ADHD: An integrative psychosocial and medical approach (2nd ed.). New York: Routledge.