Understanding Avoidance/Procrastination in AD/HD via Cognitive Behavioral Therapy

One of the oldest principles in modern psychology is the concept of operant conditioning. In simplest terms, behaviors are more likely to be repeated if they are followed by positive outcomes, and they are more likely to be avoided when they’re followed by negative outcomes. The effort put into a sale becomes more likely when one is awarded with a commission. Going over the speed limit becomes less likely after receiving a traffic ticket. Many aspects of our day-to-day life can be understood by this principle.

The concept of avoidance is one of those aspects that we can understand through the lens of behavior theory. For instance, take a child who has math homework to complete. It is true that not doing the math homework could very well lead to poor grades and further consequences from school or their parents. On the surface, avoiding the homework would seem like it isn’t in the child’s best interest. There is a long-term incentive to completing the homework, however the short-term incentives may be mediated by the child’s perceptions of the work itself.

Take for example a child who is confident in their math abilities. They’ve previously scored well on math quizzes, been complimented for their performance on math problems, and generally find math homework occasionally challenging but not overwhelmingly difficult. The prospect of avoiding their math homework may not be that appealing, since they may not see the work as that burdensome, they’re have a degree of self-confidence in their ability to complete it in short order, and they may even draw a sense of satisfaction out of completing it correctly.

Now consider a child who struggles not necessarily with math, but with focusing on challenging tasks. This might be a child whose underlying math skills are average or good, but they find focusing on challenging tasks difficult. Attending to a task requiring sustained effort, such as math homework, requires a much greater degree of self-control compared to others. Because this task requires more effort, that child may find it more frustrating, time-consuming, and generally more aversive. In this situation, the value of avoiding the task outright is greater for this child, even if the long-term consequences from doing so remain negative.

In the second scenario, the behavior of avoidance is followed by an immediate positive outcome, specifically reduced emotional distress. This is referred to as negative reinforcement, because the behavior of avoidance removes the unpleasant experience of distress when doing math homework. In turn, the fact that avoidance behavior was reinforced makes future avoidance in other frustrating situations more likely.

This process delineates one of the main targets of Cognitive Behavioral Therapy for AD/HD. Most individuals who enter talk therapy for AD/HD describe procrastination or avoidance as one of their main and most frustrating problems. For many, their ability to do the tasks on their agenda isn’t the issue. They are very capable of responding to e-mails or completing home projects or completing the core features of their professions. What many find so aversive is the “ugh” feeling when confronted with a difficult task. This is often an overlearned reaction to difficult tasks, specifically that the benefit of immediate disengagement is highly rewarding, even if intellectually it’s understood that procrastination is a self-defeating strategy.

In this way, talk therapy treatment for AD/HD has similarities to exposure treatment for anxiety disorders. Helping a person overcome their fear of panic attacks often involves encouraging people to “face their fears” of physical sensations they attribute to panic or helping a person overcome the trauma of a car accident often requires gradually returning to riding or driving in vehicles again.

For those with AD/HD, learning how to cope with the sometimes-reflexive urge to disengage from hard or boring tasks is one of the core aspects of treatment, but also the thing many find most difficult. To help achieve this there are a few interventions that can help get over the hump of initiating tasks and sustain effort in seeing them to their completion.

One of these interventions is responding more adaptively to the thoughts, conclusions and assumptions one makes when confronted with procrastination through cognitive restructuring. It can be common for those with AD/HD to have initial reactions to difficult or boring tasks emphasizing the length of time those tasks will take (e.g. “this is going to take forever, I’m never going to get this done”), their perception of how poorly they’ve done similar tasks in the past (e.g. “I always do poorly on this stuff, it’s not going to be good enough anyway”), how previous attempts at coping strategies haven’t panned out (e.g. “nothing works so what makes this any different?”) or any range of other overly negative predictions and assumptions.

Cognitive Behavioral Therapy attempts to identify these thoughts and evaluate them for their accuracy and their usefulness. A skilled therapist can help you determine whether these thoughts or assumptions you have about tasks are completely true or whether there is a more accurate way to look at your problems. If there is some measure of overgeneralization, black and white thinking, or selective reasoning being applied to your work, being able to identify and correct this thinking can go a long way to help initiate and sustain effort on difficult tasks.

Take a person who is tasked with a work project, but thinks to themselves that “this task is going to take forever,” and “other people don’t have to work as hard as I do to get things like this done.” Pausing to evaluate the evidence for these beliefs could result in the person recognizing that while the project will require effort it won’t take “forever,” and there are ways to break down the task into more achievable parts that will help contribute to the sense that they are making progress. And while it may be true that some others might find tasks like this easier to complete, many people struggle with task initiation, and there are certain techniques to make problems like this easier to manage. These subsequent thoughts are a) more accurate, b) less likely to result in hopelessness/despair, and c) more likely to promote initiation on the task at hand.

Persisting in difficult tasks is one of the main points of emphasis in the behavioral treatment of AD/HD. Understanding the influence of the strong incentives for avoidance and how to counter it is how those with AD/HD can overcome those initial feelings of dread, inadequacy and hopelessness and spur themselves to action. CBT for AD/HD can help with this process and complement the medical treatment of the condition.