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Research: Cognitive Behaviour Therapy Helps Adults with ADHD

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.)

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.

(Pic source: Big­Stock­Pho­to)

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6 Responses

  1. James Foley says:

    Thank you for this arti­cle. The most help­ful part the list of five areas tar­get­ed by CBT treat­ment in the study, show­ing a much broad­er view of Adult ADHD than I usu­al­ly see.
    My clients often come in not only with ADHD symp­toms, depres­sion and anx­i­ety, and wor­ries about ear­ly-onset Alzheimer’s, but also with the issues below, espe­cial­ly prob­lems man­ag­ing advo­cat­ing for them­selves care­ful­ly with­out explo­sions of anger, and prob­lems plan­ning a career.
    What­ev­er treat­ment mod­el you use, those were great goals to keep in mind.

    • Glad you enjoyed it, James, and thank you for your great com­ment. What is inter­est­ing about cog­ni­tive ther­a­py and train­ing is that it helps devel­op capac­i­ties which cross beyond tra­di­tion­al “dis­or­der” bound­aries, such as “man­ag­ing for them­selves care­fully with­out explo­sions of anger” and “plan­ning a career”.

  2. After recent­ly meet­ing Dr. Antho­ny Ros­tain in Toron­to, I am aware of how few prac­ti­tion­ers are offer­ing CBT to this adult pop­u­la­tion. More research is need­ed!

    • Hel­lo Mary Lynn, I’d say the kind of research we actu­al­ly need is on the rel­a­tive effec­tive­ness and scal­a­bil­i­ty of CBT (in-per­son and/ or com­put­er­ized options) vs. drug-based options, such as what the UK gov­ern­ment is doing to help deal with anx­i­ety and depres­sion. There’s more than enough research on CBT to be con­sid­ered a first-line inter­ven­tion in a vari­ety of areas, the chal­lenge is to trans­late that into solu­tions. Have a great 2012!

  3. James Foley says:

    Alvaro,
    It’s strik­ing to read your vision of the UK gov­ern­ment doing some­thing about anx­i­ety and depres­sion. Here in the US, where the polit­i­cal par­a­digm is to cut any gov­ern­ment fund­ing, it would not have occurred to me to think of gov­ern­ment involve­ment; in fact, when it comes to ADHD, my strug­gle is with insur­ance com­pa­nies, who see this and Autism Spec­trum Dis­or­ders as “edu­ca­tion­al” or “med­ical” con­di­tions not amenable to CBT or any form of psy­chother­a­py. Frus­trat­ing.

  4. Alvaro says:

    Dif­fer­ent coun­tries present dif­fer­ent oppor­tu­ni­ties and challenges…in the US we see much more inter­est among con­sumers them­selves, as par­ents, boomers, professionals…hopefully that will attract oth­er play­ers, we start to see signs, but insti­tu­tion­al change is slow.

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