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:

1. Neu­rocog­ni­tive func­tion­ing — Learn­ing strate­gies to improve atten­tional con­trol, mem­ory, impulse con­trol and planning.
2. Prob­lem solv­ing — Devel­op­ing adap­tive prob­lem solv­ing strate­gies, antic­i­pat­ing con­se­quences, and man­ag­ing conflict.
3. Emo­tional Con­trol — Learn­ing to man­age feel­ings of anger and anxiety.
4. Pro-social skills — Learn­ing to rec­og­nize the thoughts and feel­ings of oth­ers, nego­ti­a­tion skills, and con­flict res­o­lu­tions skills.
5. 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.

Mea­sures

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.)

Results

Twenty of 27 par­tic­i­pants (74%) who began CBT treat­ment com­pleted it. This was com­pa­ra­ble to the treat­ment as usual condition.

Post-treatment find­ings

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.

Three-month follow-up

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.  His research focuses on var­i­ous issues related to ADHD, the impact of atten­tion prob­lems on aca­d­e­mic achieve­ment, and atten­tion train­ing.  He also pub­lishes Atten­tion Research Update, a com­pli­men­tary online newslet­ter that helps par­ents, pro­fes­sion­als, and edu­ca­tors keep up with the lat­est research on ADHD.

–> For related arti­cles by Dr. David Rabiner on atten­tion deficits, click Here.

(Pic source: Big­Stock­Photo)

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