Dec 15, 2011
Many adults with ADHD do not obtain their diagnosis until adulthood and have struggled with difficulties related to undiagnosed ADHD for their entire lives. As documented in recent studies, this includes elevated rates of depression, anxiety disorders, substance use, work difficulties and interpersonal problems.
As with children and adolescents, medication treatment for adults with ADHD can be quite helpful, especially for reducing core ADHD symptoms of inattention and hyperactivity/impulsivity. However, as is true for children and adolescents, many adults with ADHD continue to struggle despite benefits provided by medication. In addition, some derive little if any benefit and even when core ADHD symptoms diminish, difficulties in other important areas often remain. Thus, medication alone is frequently an insufficient treatment treatment guidelines developed in the US and overseas recommend multimodal treatment for ADHD in adults. This would include psychoeducation, pharmacotherapy, and cognitive behavior therapy (CBT).
Cognitive behavior therapy was originally developed for the treatment of depression and anxiety disorders and is focused on identifying problematic ways of thinking, i.e., cognitions, that contribute to problematic behaviors. Once problematic ways of thinking are identified, the client is encouraged to evaluate whether their cognitions are accurate and to consider alternative ways for thinking about their situation. As faulty thinking patterns are altered, more adaptive ways of behaving can begin to take shape.
For example, an adult who struggled throughout their schooling because of undiagnosed ADHD might think of themselves as stupid and unable to learn. One can imagine how these thoughts could lead to poor self-esteem, depressive symptoms, and avoidance of situations that are linked to schooling and education. In CBT, the clinician would work with the client to develop a more realistic explanation for their academic struggles, e.g., you are actually quite capable intellectually but performed poorly because your ADHD was never diagnosed and treated. In conjunction with helping the client embrace this more reasonable way to think about their academic history, the clinician would help the client develop new and more adaptive behavior patterns. For a very nice discussion of CBT for adult ADHD see http://add.about.com/od/treatmentoptions/a/Cognitive-Behavioral-Therapy-And-The-Treatment-Of-Adult-Adhd.htm
There have been a handful of CBT trials for adults with ADHD. In general, these studies indicate that CBT can help with core ADHD symptoms in addition to benefits provided by medication. However, the benefits of CBT on co-occurring difficulties that adults with ADHD often have, e.g., depression, anxiety, relationship problems, etc., have not been clearly demonstrated. This is discouraging and somewhat surprising given that CBT is an effective treatment for depression and anxiety in adults who do not have ADHD.
A study published recently in BioMed Central Psychiatry [Cognitive behaviour therapy in medication-treated adults with ADHD and persistent symptoms: A randomized controlled trial. Emillson et al., (2011). BioMed Central Psychiatry, 11:116] presents new findings on CBT delivered in a group format to adults with ADHD. (Note – This is a peer reviewed open access journal and you can review the entire study online at http://www.biomedcentral.com/content/pdf/1471-244X-11-116.pdf). The goal of this study was to test whether a cognitive behavioural group treatment program called Reasoning and Rehabilitation for ADHD Youths and Adults, i.e., R&R2, alleviated core ADHD symptoms and comorbid problems in adults with ADHD who were receiving medication.
The study was conducted in Iceland and involved 54 adults with ADHD (34 women, mean age 34.1), all of whom were receiving ADHD medication. In addition to their ADHD diagnosis, 35 reported depression, 20 reported some form of anxiety disorder, 12 reported a history of drug/alcohol abuse, and 9 reported some other psychiatric problem; only 8 reported no comorbid difficulties.
Participants were randomly assigned to cognitive therapy or to the treatment as usual condition; the latter involved medication only, although participants were free to pursue whatever additional treatments they wished. Adults assigned to CBT remained on medication. Thus, the researchers could learn whether CBT added to any benefits already being provided by medication treatment.
R&R2 ADHD Group Cognitive Behavioural Therapy
The treatment is a 15 session structured CBT intervention that aims to decrease core ADHD symptoms and improve social functioning, problem solving, and organizational skills. It targets the following 5 areas:
- Neurocognitive functioning – Learning strategies to improve attentional control, memory, impulse control and planning.
- Problem solving – Developing adaptive problem solving strategies, anticipating consequences, and managing conflict.
- Emotional Control – Learning to manage feelings of anger and anxiety.
- Pro-social skills – Learning to recognize the thoughts and feelings of others, negotiation skills, and conflict resolutions skills.
- Critical reasoning – Learning to evaluate options and develop behavioral skills to pursue goals appropriately.
These areas were covered in twice weekly small group sessions that lasted for 90 minutes. In addition to the group meetings, coaches met individually with participants each week for 30 minutes to review session material and assist with assigned homework. Thus, during the 15-week treatment, participants devoted 3.5 hours weekly to the program, not counting travel time; it was thus a fairly time-intensive treatment.
The researchers employed a wide range of measures to evaluate core ADHD symptoms and comorbid difficulties. Adults reported on their ADHD symptoms using the Barkley ADHD Current Symptoms Scale. They also reported on depressive and anxiety symptoms using the Beck Depression Inventory and the Beck Anxiety Inventory; both are widely used measures that have been shown to provide reliable and valid information. Finally, participants completed a measure developed specifically for the study that assessed emotional control, antisocial behavior, and social functioning.
An important strength of the study was that in addition to the self-report measures noted above, participants were evaluated by clinicians who did not know whether they had received CBT treatment or were in the control condition. These clinicians provided an independent assessment of adults’ ADHD symptoms and overall level of functioning.
These measures were collected on both groups of participants before treatment began, immediately following the CBT program, and again 3 months later. Although baseline assessments were obtained on nearly all participants, the post-treatment assessment was collected on only 17 adults in each group. At the 3-month follow-up, self-report measures were collected on a similar number but the independent evaluation was only conducted with 8 adults from the CBT group and 13 from the treatment as usual group. This reflected difficulty getting participants back to the study site for the interviews to be collected, a common difficulty in such studies. (Presumably, the self-report measures could be returned via mail.)
Twenty of 27 participants (74%) who began CBT treatment completed it. This was comparable to the treatment as usual condition.
Independent raters – After controlling for baseline ratings of ADHD symptoms, CBT participants received significantly lower symptom ratings from independent evaluators immediately after treatment. The magnitude of the treatment vs. control differences would be considered large. Independent clinicians raters also tended to rate CBT participants as functioning better overall.
Self-reports – Controlling for baseline ratings, CBT participants reported significantly fewer problems with attention and with hyperactivity-impulsivity. The magnitude of the differences were large for attention problems and smaller for hyperactivity-impulsivity. However, no post-treatment differences were evident in participants’ reports of anxiety or depression. There were also no differences found for emotional control or social functioning. CBT participants did report greater reductions in antisocial behavior.
Independent raters – Differences in ratings of ADHD symptoms made by independent raters remained significant and of large magnitude. In addition, ratings of overall adjustment also significantly favored CBT participants at follow-up.
Self-reports – Group differences in self-reported ADHD symptoms remained significant at follow-up. In addition, group differences were also evident in participants’ reports of depression, anxiety, emotional control, antisocial behavior, and social functioning. In all cases, the differences were of a magnitude that would be considered large.
Summary and Implications
The key findings from this study are that group CBT improved core ADHD symptoms at the end of treatment according to blind, independent observers and participants themselves. And, three months after treatment ended, evidence emerged that CBT was associated with significant reductions in a range of comorbid difficulties that many adults with ADHD struggle with. Because all participants were receiving medication, these findings suggest that the CBT program yielded benefits beyond those provided by medication.
A key strength of the study was the use of ‘blind’ clinicians to assess outcomes for core ADHD symptoms. Because these clinicians did not know the treatment of the adults they were evaluating, their ratings would not be influenced by this knowledge. A limitation, however, is that these clinicians only rated core ADHD symptoms and overall functioning, rather than each of the domains covered in participants’ self-reports. Had these clinicians evaluated participants on depression, anxiety, etc., and reached conclusion consistent with the self-report findings, the results from this study would be even stronger.
A second limitation is that fewer than half the participants were evaluated by the independent clinicians at the 3-month follow-up. The adults who completed the 3-month independent evaluation may have been a more motivated group than those who did not, perhaps because they had attained greater benefits. However, the same argument would apply to those in the control group who returned for the 3-month follow-up. It was also the case that the subset of adults who completed the follow-up evaluation did not differ from other participants at baseline on any of the study measures. These factors serve to mitigate concerns about the validity of the follow-up data. However, the fact remains that only a small number of participants fully completed the follow-up assessment which highlights the need for replicating these findings with a larger sample.
Two other caveats are worth noting. First, the study was conducted in Iceland and whether similar findings would be attained with adults from other countries is unknown. There is no reason to assume that special characteristics of Icelandic adults with ADHD would explain the findings, however. Second, those in the CBT group received substantial amounts of attention and time from clinicians relative to those in the treatment as usual group. Thus, it is possible that it was the extra attention alone and not the specific nature of the CBT program that accounts for the more positive outcomes in the CBT group. It would be difficult to conclusively rule out this possibility in future studies, however, as it would be ethically problematic to involve adults with ADHD in a time consuming intervention that was not intended to produce tangible benefits, but simply to function as a control for the amount of attention that CBT treated participants received.
In summary, results from this study highlight that although medication treatment provides important benefits to many adults with ADHD, the addition of a well-conceived and structured group CBT treatment can yield significant incremental improvements. These gains appear to extend beyond alleviating core ADHD symptoms to include many of the important comorbid problems that adults with ADHD often struggle with. Making such treatment more widely available to adults in the community, in addition to conducting additional research on treatments for adults with ADHD, should thus be an important priority.
(Note – If you are interested in learning more about cognitive behavioral treatment for adults with ADHD, an excellent book you can consult is titled “Cognitive-Behavioral Therapy for Adult ADHD: An Integrative Psychosocial and Medical Approach” by Drs. Russell Ramsay and Anthony Rostain. It is available on Amazon and elsewhere.)
– Dr. David Rabiner is a child clinical psychologist and Director of Undergraduate Studies in the Department of Psychology and Neuroscience at Duke University. He publishes Attention Research Update, an online newsletter that helps parents, professionals, and educators keep up with the latest research on ADHD, and teaches the online course How to Navigate Conventional and Complementary ADHD Treatments for Healthy Brain Development.
–> For related articles by Dr. David Rabiner on attention deficits, click Here.
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