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New Study shows Teens with ADHD helped by Cognitive Behavioral Therapy

In a recent issue of Atten­tion Research Update I reviewed a study of cog­ni­tive behav­ioral ther­apy (CBT) for adults with ADHD that yielded encour­ag­ing find­ings. Promis­ing find­ings of this approach for adults raises the ques­tion of whether CBT could also be help­ful for teens with ADHD.

Devel­op­ing effec­tive non­med­ical inter­ven­tions for teens with ADHD is impor­tant for sev­eral rea­sons. First, as many as 20–30 per­cent of ado­les­cents with ADHD may not ben­e­fit sig­nif­i­cantly from med­ica­tion and/or con­tinue to strug­gle despite the help that med­ica­tion pro­vides. Oth­ers expe­ri­ence adverse side effects that pre­clude them from stay­ing on medication.

In addi­tion to these lim­i­ta­tions of med­ica­tion treat­ment, many teens refuse to stay on ADHD med­ica­tion and adher­ence to med­ica­tion treat­ment typ­i­cally declines with age. And, diver­sion of med­ica­tion has become a real prob­lem as it is not uncom­mon for teens tak­ing ADHD meds to be approached by peers look­ing to use their medication.

Despite the need for research-based alter­na­tives to med­ica­tion treat­ment for teens, work on this issue is lim­ited. Thus, while there is an exten­sive research base on psy­choso­cial inter­ven­tions for chil­dren with ADHD, much less work has been con­ducted with ado­les­cents. And, prior to the study reviewed below, there had not been a sin­gle pub­lished report on the use of CBT in ado­les­cents with ADHD.

Par­tic­i­pants in this study [Cog­ni­tive behav­ioral treat­ment out­comes in ado­les­cent ADHD. Antshel, Farone, & Gor­don (2012). Jour­nal of Atten­tion Dis­or­ders. DOI: 10.1177/1087054712443155] were 68 teens ages 14–18 diag­nosed with ADHD at the Adult ADHD Treat­ment and Research Pro­grm at SUNY Upstate Med­ical Uni­ver­sity. Approx­i­mately 60 per­cent were male. These teens were selected from con­sec­u­tive refer­rals to the pro­gram over a 4-year period (other referred teens were excluded because they did not meet diag­nos­tic cri­te­ria for ADHD.) Many had addi­tional dis­or­ders and only 20% were diag­nosed with ADHD alone. All were receiv­ing con­cur­rent med­ica­tion treatment.

Cog­ni­tive Behav­ioral Treatment

All teens received a CBT pro­gram con­sist­ing of 6 dif­fer­ent modules.

Mod­ule 1: Orga­ni­za­tion and Plan­ning — The four ses­sions in this mod­ule helped teens learn to use and main­tain a note­book with a task list and a cal­en­dar sys­tem to improve their orga­ni­za­tion for school assign­ments. There was also a focus on problem-solving skills such as break­ing large tasks into smaller and more man­age­able steps. Teens also learned to develop an action plan for over­whelm­ing tasks.

Mod­ule 2: Reduc­ing Dis­tractibil­ity — Three ses­sions focused on help­ing teens reduce their ten­dency to become dis­tracted. Teens were taught to rec­og­nize the length of time they could hold their atten­tion to tasks and to divide tasks into chunks that did not exceed this time. Teens also learned to tools such as alarms and timers to help stay on task, and a pro­ce­dure called ‘dis­tractibil­ity delay’ that involves writ­ing down dis­trac­tions when they emerge as opposed to act­ing on them.

Mod­ule 3: Cog­ni­tive Restruc­tur­ing — In this mod­ule, which var­ied from two to five ses­sion based on indi­vid­ual needs, teens were taught skills to max­i­mize adap­tive think­ing dur­ing times of stress, and to apply adap­tive think­ing skills to dif­fi­cul­ties asso­ci­ated with ADHD.

As an exam­ple, con­sider a teen who becomes highly self-critical when she for­gets to turn in an assign­ment and who thinks that the orga­ni­za­tion prob­lems asso­ci­ated with ADHD will pre­vent her from ever being suc­cess­ful. One can imag­ine how such think­ing could con­tribute to ‘giv­ing up’, low self-esteem, and even to the emer­gence of depres­sive symptoms.

In cog­ni­tive restruc­tur­ing, the teen would be taught to chal­lenge these self-critical thoughts and to con­sider alter­na­tives. For exam­ple, the clin­i­cian would point out that this was just one assign­ment she for­got to hand in and that she had been turn­ing in most of her work. And, that she was work­ing hard to develop strate­gies for address­ing this prob­lem that were show­ing early signs of success.

As evi­dent in this exam­ple, the goal is to help teens develop the skills to rec­og­nize when their think­ing is overly neg­a­tive and to chal­lenge that think­ing with more adap­tive alternatives.

Mod­ule 4: Reduc­ing Pro­cras­ti­na­tion — This mod­ule focused on apply­ing pre­vi­ously learned skills to address­ing prob­lems with procrastination.

Mod­ule 5: Improv­ing Com­mu­ni­ca­tion Skills — Teens received train­ing in “…active lis­ten­ing, learn­ing to wait for oth­ers to fin­ish speak­ing before adding to the con­ver­sa­tion, main­tain­ing appro­pri­ate eye con­tact, and learn­ing to stay on topic.”

Mod­ule 6: Anger and Frus­tra­tion Man­age­ment — This mod­ule empha­sized cog­ni­tive restruc­tur­ing skills to help teens deal more appro­pri­ately with anger and frus­tra­tion. Teens were also pro­vided with stress reduc­tion tech­niques and with instruc­tion on how to act assertively but not aggressively.

Mod­ules 4–6 were cov­ered across four ses­sions mak­ing the total pro­gram 13 to 16 ses­sions. The CBT pro­gram was deliv­ered indi­vid­u­ally in 50-minute with par­ents attend­ing all ses­sions for mod­ules 1 and 2 as well as the ses­sion on procrastination.


Rat­ings of ADHD symp­toms, emo­tional and behav­ioral func­tion­ing were obtained from par­ents, teens and teach­ers before and after treat­ment. Teens’ grades and school atten­dance were also obtained and par­ents rated teens’ adher­ence to med­ica­tion treat­ment. Although par­ents and teens were obvi­ously aware that the teen received CBT, teach­ers were blind to the child’s par­tic­i­pa­tion. In the­ory, there­fore, teach­ers’ rat­ings were not biased by this knowledge.


Par­ents’ report — Com­par­ing par­ents’ rat­ings before and after treat­ment indi­cated a num­ber of pos­i­tive changes. Par­ents reported sig­nif­i­cant reduc­tions in teens’ inat­ten­tive symp­toms and oppo­si­tional behav­ior. Par­ents also reported that their teen was get­ting along bet­ter with peers and mak­ing bet­ter aca­d­e­mic progress. Also note­wor­thy is that teens were being more coop­er­a­tive with med­ica­tion treat­ment and required lower doses of med­ica­tion. Teach­ers’ report — Teach­ers also reported sig­nif­i­cant reduc­tions in ado­les­cents’ inat­ten­tive behav­ior. This is an espe­cially impor­tant find­ing because teach­ers were pre­sum­ably not aware that the teen had received CBT. Teach­ers also reported sig­nif­i­cant gains in the ado­les­cents’ aca­d­e­mic progress, a reduc­tion in learn­ing prob­lems, and increases in self-esteem.

Ado­les­cents’ report — Reports obtained from ado­les­cents them­selves indi­cated less pos­i­tive change than that reported by par­ents and teach­ers. Changes in core ADHD symp­toms were quite mod­est. How­ever, ado­les­cents’ reports did indi­cate a reduc­tion in over­all school prob­lems and increases in their over­all feel­ings of per­sonal adjustment.

School record data — Exam­i­na­tion of school records data revealed a sub­stan­tial reduc­tion in the num­ber of classes that teens were miss­ing each week along with a reduc­tion in tardiness.

The results sum­ma­rized above applied equally to males and females as well as to teens with the inat­ten­tive type vs. com­bined type of ADHD. How­ever, teens with comor­bid Oppo­si­tional Defi­ant Dis­or­der or Con­duct Dis­or­der were found to ben­e­fit less.

Sum­mary and Implications

Results from this study high­light the poten­tial of well-designed CBT as a treat­ment for ado­les­cents with ADHD. As has been found in sev­eral stud­ies of CBT for adults with ADHD, this approach pro­moted bet­ter adjust­ment among ado­les­cents in mul­ti­ple domains as reported by par­ents, teach­ers, and ado­les­cents them­selves; school record data also indi­cated bet­ter class atten­dance and fewer late arrivals to school. Also note­wor­thy was that over the course of treat­ment, teens showed bet­ter com­pli­ance with med­ica­tion treat­ment and required lower doses of medication.

While these are encour­ag­ing find­ings, the authors stress the need to con­sider this work pre­lim­i­nary — essen­tially, a ‘proof of con­cept’ study that jus­ti­fies fur­ther research on CBT for ado­les­cents with ADHD. The main lim­i­ta­tion of the study is the absence of a con­trol group. Thus, one can’t say for sure that the gains which occurred resulted from the CBT pro­gram as opposed sim­ply to the pas­sage of time. The dura­tion of any treat­ment ben­e­fits that accrued is also unknown and would require addi­tional work in which the teens were fol­lowed over time.

Another impor­tant caveat is that all teens who par­tic­i­pated in this study were receiv­ing med­ica­tion. Whether CBT would be effec­tive as a stand alone treat­ment is thus unknown.

These lim­i­ta­tions not with­stand­ing, results from this study high­light the poten­tial ben­e­fits of CBT for ado­les­cents with ADHD and indi­cate that large well-controlled tri­als are war­ranted. Hope­fully, such work will become avail­able in the near future.
Rabiner_David– 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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Categories: Attention and ADD/ADHD, Cognitive Neuroscience

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