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.
– 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.