Cognitive-behavioral therapy for ADHD in medication-treated adults with continued symptoms
Introduction
Although previously controversial, ADHD in adulthood is a valid, reliably diagnosed disorder which causes significant functional impairment including problems with employment, education, economic and social functioning (Adler & Chua, 2002; Biederman et al., 1993; Biederman, Wilens, & Spencer, 1998; Biederman et al., 1996; Klein & Manuzza, 1991; Lahey, Piacentini, McBurnett, Stone, Hartdagen, & Hynd, 1988; Morrison, 1980; Murphy, & Barkley, 1996a, Murphy, & Barkley, 1996b; Ratey, Greenberg, Bemporad, & Lindem, 1992; Shekim, Asarnow, Hess, Zaucha, & Wheeler, 1990; Spencer, Biederman, Wilens, & Faraone, 1994; Spencer, Biederman, Wilens, & Faraone, 1998; Sprich, Biederman, Crawford, Mundy, Faraone, & Stevenson, 2000; Wilens et al., 2002, Wilens et al., 2002; Wilens, Biederman, & Mick, 1998). Estimates of the prevalence of ADHD in adulthood range from 1% to 5% (Bellak & Black, 1992; Biederman et al., 1996; Murphy, & Barkley, 1996a, Murphy, & Barkley, 1996b; Shekim et al., 1990), a finding supported by follow-up studies of children diagnosed with ADHD indicating that impairing ADHD symptoms persist into adulthood (beyond adolescence) in 30–80% of diagnosed children (Barkley, Fischer, Edelbrock, & Smallish, 1990; Gittelman, Mannuzza, Shenker, & Bonagura, 1985; Mannuzza, Klein, Bessler, Malloy, & LaPadula, 1993; Mannuzza, Klein, Bonagura, Malloy, Giampino, & Addalli, 1991; Mendelson, Johnson, & Stewart, 1971; Weiss & Hechtman, 1993).
Psychopharmacology has been the only rigorously studied treatment option for adults with ADHD. However, in controlled studies of stimulant medications, and open studies of tricyclic, monoamine oxidase inhibitor, and atypical antidepressants, 20–50% of adults are considered nonresponders due to insufficient symptom reduction or inability to tolerate these medications (Wender, 1998; Wilens et al., 2002, Wilens et al., 2002). Moreover, adults who are considered responders typically show a reduction in only 50% or less of the core symptoms of ADHD (Wilens, Biederman, & Spencer, 1998; Wilens et al., 2002, Wilens et al., 2002). Given these data, guidelines for pharmacological interventions call for adjunctive behavioral treatments (Dulcan & Benson, 1997), and clinical recommendations and guidelines exist for providing psychotherapy for adults with ADHD (Hallowell, 1995; McDermott, 2000; Nadeau, 1995). However, prior to the present study, virtually no studies have investigated the potential efficacy of such psychosocial interventions (Safren, Sprich, Chulvick, & Otto, 2004) either in general, or as a next step approach to treating those who have been stabilized on medications but still show residual symptoms.
To improve upon therapeutic outcomes among adults with ADHD, we developed and tested a novel cognitive-behavioral treatment for adults with ADHD who were stabilized on psychopharmacology. We reasoned that psychopharmacology may ameliorate many of the core symptoms of ADHD (attentional problems, high activity, impulsivity), but believe that it does not provide a patient with concrete strategies and skills for coping with associated functional impairment (Safren et al., 2004). Quality of life impairments such as underachievement, daily organizational and administrative goals (i.e. bills, mail, hassles), weekly work or school related tasks, and relationship difficulties associated with ADHD in adulthood (Biederman et al., 1993; Murphy, & Barkley, 1996a, Murphy, & Barkley, 1996b; Ratey et al., 1992) require active problem-solving, which can be achieved with skills training over and above medication management.
With attention to problems involved in extending efficacious interventions to clinical practice, we employed a modular approach to the intervention, formulating specific components to match specific problem areas (Eifert, Schulte, Zvolensky, Lejuez, & Lau, 1997; Henin, Otto, & Reilly Harrington, 2001). The intervention approach was also based on pilot work in our laboratory on a cognitive-therapy based treatment of medicated adults with ADHD (McDermott, 2000; Wilens et al., 2002, Wilens et al., 2002). Core modules that all patients received were (1) organization and planning, (2) coping with distractibility, and (3) cognitive restructuring. Optional modules included (1) procrastination, (2) anger management, and (3) communication skills (Safren et al., 2004).
Section snippets
Study design
Thirty-one men and women who met DSM-IV criteria for ADHD in adulthood were randomly assigned to one of two conditions. The first condition was cognitive-behavioral therapy, as developed by the research team for the present study, plus continued psychopharmacology as already prescribed by their physician. The second condition was continued psychopharmacology alone. As this study represents the first step in developing and testing this intervention, the control group was a treatment as usual
Participant characteristics
Forty individuals screened for the study, undergoing the baseline evaluation. Nine of these individuals did not enroll because one did not meet criteria for primary ADHD, four had not stabilized their medications or were not on medications, one had active cannabis use that may have been the cause of ADHD symptoms, one had a severe learning disability and probably IQ less than 90, one moved after the evaluation, and one did not complete the evaluation. Thirty-one adults (14 men, 17 women) who
Discussion
The present study was designed to evaluate the potential efficacy, patient acceptability, and feasibility of a novel cognitive-behavioral therapy for adults with ADHD who have not fully responded to medications alone. The treatment was shown to be acceptable and tolerable to patients: none who were randomized dropped out. Across all of the primary outcome measures, those who were randomized to CBT showed significantly better ratings than those randomized to psychopharmacology alone. This
Acknowledgments
This study was supported by grant NIMH 60940 (Steven A. Safren, Ph.D.). The authors would like to thank Ms. Sophie Chulvick, Dr. Russel Barkley and Dr. Stephen McDermott for their critical assistance in carrying out this project.
References (63)
- et al.
The adolescent outcome of hyperactive children diagnosed by research criteriaI. An 8-year prospective follow-up study
Journal of the American Academy of Child and Adolescent Psychiatry
(1990) - et al.
Manualized beahvior therapymerits and challenges
Behavior Therapy
(1997) - et al.
Introducing flexibility in manualized treatmentapplication of recommended strategies to the cognitive-behavioral treatment of bipolar disorder
Cognitive and Behavioral Practice
(2001) - et al.
Additive effects of psychostimulants, parent training, and self-control therapy with ADHD children
Journal of the American Academy of Child and Adolescent Psychiatry
(1991) - et al.
Long term outcome of hyperactive childrena review
Journal of the American Academy of Child and Adolescent Psychiatry
(1991) - et al.
Psychopathology in the parents of children with conduct disorder and hyperactivity [erratum appears in Journal of the American Academy of Child and Adolescent Psychiatry 1988 July 27, 516]
Journal of the American Academy of Child & Adolescent Psychiatry
(1988) - et al.
Attention deficit hyperactivity disorder adultscomorbidities and adaptive impairments
Comprehensive Psychiatry
(1996) - et al.
Psychosocial treatments for adults with attention-deficit/hyperactivity disorder
Psychiatric Clinics of North America
(2004) - et al.
A clinical and demographic profile of a sample of adults with attention deficit hyperactivity disorder, residual state
Comprehensive Psychiatry
(1990) - et al.
Cognitive behavioral therapy with children and adolescents
Child & Adolescent Psychiatric Clinics of North America
(1997)