Although medication is the primary treatment for adults with ADHD, and has good empirical support, many adults would rather not take it. For these adults with ADHD, it would be helpful to know whether medication is likely to provide significant benefits above and beyond those they would gain from well-conducted therapy, or whether they are likely to derive roughly equivalent benefits from therapy alone.
This important question was addressed in a recently published study titled ‘Efficacy of cognitive behavioral therapy with and without medication for adults with ADHD: A randomized controlled trial’. The study was published online in 2016 in the Journal of Attention Disorders. From the abstract:
- Objective: Recent trials have demonstrated efficacy of cognitive behavioral therapy (CBT) in medicated adults with ADHD. Efficacy of CBT in unmedicated versus medicated adults remains mostly unknown. We evaluated the effects of group CBT alone versus combined with medication on ADHD symptoms and functional outcomes in adult patients…Conclusion: CBT + medication outperformed CBT alone for ADHD symptoms, organizational skills, and self-esteem, although its superiority tended to decrease over follow-up.
Eighty-eight adults with carefully diagnosed ADHD were randomly assigned to receive 12 weeks of cognitive behavioral therapy (CBT) alone, or CBT plus medication. Over the 12 weeks, the following topics were addressed:
- Basic education about ADHD and how it impacts adults.
- Goal setting and strategies for attaining goals.
- Organization and time management.
- Managing stress.
- Identifying and correcting maladaptive thoughts.
- Anger management.
- Impulse control and strategies for effective self-regulation.
- Building self-esteem.
- Understanding common relationship problems in adults with ADHD and how to address them.
The program focused on the acquisition and practice of adaptive cognitive and behavioral skills to improve functioning in these areas. In addition to didactic presentations on these topics, sessions were used to practice new skills and identify ways to utilize new skills participants’daily lives. Participants received weekly homework focused on implementing the newly learned skills — this was an important part of the program.
Each participant was also assigned a coach that they worked with throughout the program. Coaches held twice weekly phone calls with participants in addition to a brief face-to-face session. During these coaching sessions, participants and their coach discussed the practice/implementation of new skills and discussed ways to address barriers to their implementation.
Following the 12th session, there were 3 monthly booster sessions dedicated to reviewing key concepts and trouble shooting. Telephone coaching continued during this time on a weekly basis.
Medication treatment — Adults assigned to the CBT + medication group began on medication prior to beginning CBT; they were started on a low dose of stimulant medication that was gradually increased based on feedback on efficacy and side effects. When further increases in dose did not enhance efficacy, or led to side effects, the prior dose was considered optimal. They were maintained on their optimal dose throughout the study and follow up period. Adults who did not respond to the initial stimulant were tried on a different stimulant.
Measures — A broad array of outcome measures were included so that treatment impact on core ADHD symptoms and functioning in important life domains could be examined. The domains assessed included organizational skills, self-esteem, symptoms of depression and anxiety, anger expression, and global functioning. These were all self-report measures that were completed by adults themselves. Core ADHD symptoms were also rated by an informant that each adult selected, e.g., a spouse, partner, close friend, co-worker, etc.
The measures summarized above were collected at multiple time points — at baseline, immediately following medication optimization and before CBT began, after 12 weeks of CBT, following the 3‑month booster period, and a final time 3 months later.
This data collection schedule enabled the researchers to compare the 2 groups (CBT and CBT + meds) at multiple time points to learn whether any initial advantages found for either treatment were maintained over time.
ADHD symptoms — Adults in the CBT + medication group reported significantly greater reduction in core ADHD symptoms than adults receiving CBT alone; this was evident after the 12-week CBT treatment, after the 3‑month booster ended, and at the final follow-up 3 months later. Those who received CBT only also reported a significant reduction in core symptoms but this was less than for those who also received medication.
When observer ratings were examined, adults receiving meds were also reported to show greater improvement in core symptoms than adults receiving CBT alone; this was evident immediately after CBT ended as well as after the 3‑month booster. At the final assessment 3 months later, however, significant differences between the groups were no longer evident.
Organizational skills and self-esteem — Those in the CBT + meds group reported greater improvement in organizational skills following the CBT sessions as well as after the 3‑month booster; at the final assessment 3 months later, however, these differences were no longer significant. A similar pattern was found for self-reported self-esteem. Thus, for these outcomes, those receiving CBT + meds improved more quickly, but by the final measurement point adults in the other groups had ‘caught up’.
Depression, anxiety, anger expression, and global functioning — For these measures, there was a trend towards improvement in both groups with no differences between them.
Summary and implications
Does medication provide significant additional benefits to adults with ADHD above those provided by a good course of CBT alone? Results from this study indicate there is not a clear answer to this question as it depends on what outcomes are being considered and the time frame in which they are being looked at.
For several outcomes measures — core ADHD symptoms, organization, and self-esteem — those receiving CBT + meds improved more quickly; that is not surprising given that the positive effects of medication are immediate while those resulting from therapy are likely to build over time. It was only for ADHD symptoms, however, that the incremental benefits of meds tended to persist and this was only when considering self-report and not observer ratings.
For the other outcomes, i.e., depression, anxiety, anger expression, and global functioning, no additional benefits from meds were evident. The authors point out that this may have been because participants were not clinically elevated on these measures to begin with, so there was less room to show improvement.
What general conclusions can be drawn from this study? For adults whose difficulties related to ADHD are acute, a trial of medication seems very important. The impact on core symptoms and on several important functional domains is likely to be much quicker; this can be especially important when someone is really struggling. Although those receiving CBT only generally caught up by the end of the study, this was more than a full year out (4 months CBT, 3 months of booster session, and final follow-up 3 months later). For those whose ADHD is significantly impairing their day-to-day life, the time required for meaningful improvements with CBT alone may be too great.
For adults whose ADHD related difficulties are less acute, and who do not wish to take meds, results indicated that well-conducted CBT plus coaching is likely to produce significant benefits in how they experience their lives; this will likely occur gradually over an extended time period. For many individuals, this more gradual reduction in symptoms and impairment may be fine.
Two important points qualify the above. First, except for observer ratings of core ADHD symptoms, all outcomes were based on self-report and some would suggest that these are not objective assessments. Thus, including more objective assessments of different outcomes when feasible would have strengthened the study.
Second, it is important to note that the CBT provided was quite an extensive treatment — weekly group sessions and multiple weekly coaching session for 4 month followed by monthly boosters over another 3 months. To be candid, it could be difficult to procure this treatment in many communities; medication, of course, is available pretty much everywhere.
Thus, challenges to obtaining good non-medical treatment for ADHD is a real issue that must be addressed for individuals to more easily realize the benefits that such treatment can provide.
– 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 the Attention Research Update, an online newsletter that helps parents, professionals, and educators keep up with the latest research on ADHD, and helped prepare the self-paced, online course How to Navigate Conventional and Complementary ADHD Treatments for Healthy Brain Development.