Cognitive-behavioral therapy for ADHD in medication-treated adults with continued symptoms

https://doi.org/10.1016/j.brat.2004.07.001Get rights and content

Abstract

The purpose of the present study was to examine the potential efficacy, patient acceptability, and feasibility of a novel, cognitive-behavioral therapy (CBT) for adults with attention-deficit hyperactivity disorder (ADHD) who have been stabilized on medications but still show clinically significant symptoms. Thirty-one adults with ADHD and stable psychopharmacology for ADHD were randomized to CBT plus continued psychopharmacology or continued psychopharmacology alone. Assessments included ADHD severity and associated anxiety and depression rated by an independent evaluator (IE) and by self-report. At the outcome assessment, those who were randomized to CBT had lower IE-rated ADHD symptoms (p<.01) and global severity (p<.002), as well as self-reported ADHD symptoms (p<.0001) than those randomized to continued psychopharmacology alone. Those in the CBT group also had lower IE-rated and self-report anxiety (p's<.04), lower IE-rated depression (p<.01), and a trend to have lower self-reported depression (p=.06). CBT continued to show superiority over continued psychopharmacology alone when statistically controlling levels of depression in analyses of core ADHD symptoms. There were significantly more treatment responders among patients who received CBT (56%) compared to those who did not (13%) (p<.02). These data support the hypothesis that CBT for adults with ADHD with residual symptoms is a feasible, acceptable, and potentially efficacious next-step treatment approach, worthy of further testing.

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)

  • S. Sprich et al.

    Adoptive and biological families of children and adolescents with ADHD

    Journal of the American Academy of Child & Adolescent Psychiatry

    (2000)
  • H. Abikoff et al.

    Hyperactive children treated with stimulants

    Is cognitive training a useful adjunct. Archives of General Psychiatry

    (1985)
  • L. Adler et al.

    Management of ADHD in adults

    Journal of Clinical Psychiatry

    (2002)
  • R. Barkley

    ADHD and the nature of self-control

    (1997)
  • R. Barkley et al.

    Attention-deficit hyperactivity disordera clinical workbook

    (1998)
  • A. Beck et al.

    An inventory for measuring clinical anxietypsychometric properties

    Journal of Consulting and Clinical Psychology

    (1988)
  • A. Beck et al.

    An inventory for measuring depression

    Archives of General Psychiatry

    (1961)
  • J. Beck

    Cognitive therapybasics and beyond

    (1995)
  • L. Bellak et al.

    Attention-deficit hyperactivity disorder in adults

    Clinical Therapeutics

    (1992)
  • J. Biederman et al.

    Patterns of psychiatric comorbidity, cognition, and psychosocial functioning in adults with attention deficit hyperactivity disorder

    American Journal of Psychiatry

    (1993)
  • J. Biederman et al.

    Adults with attention-deficit/hyperactivity disordera controversial diagnosis

    Pediatrics

    (1998)
  • J. Biederman et al.

    Diagnosis and treatment of adult attention-deficit/hyperactivity disorder

  • R.T. Brown et al.

    Methylphenidate and cognitive therapyA comparison of treatment approaches with hyperactive boys

    Journal of Abnormal Child Psychology

    (1985)
  • J. Cohen

    A power primer

    Psychological Bulletin

    (1992)
  • M. Craske et al.

    Mastery of your anxiety and panic (MAP-3)

    (2000)
  • K.S. Dobson

    A meta-analysis of the efficacy of cognitive therapy for depression

    Journal of Consulting and Clinical Psychology

    (1989)
  • M.K. Dulcan et al.

    AACAP Official Action. Summary of the practice parameters for the assessment and treatment of children, adolescents, and adults with ADHD

    Journal of the American Academy of Child and Adolescent Psychiatry

    (1997)
  • DuPaul, G. (1990). The ADHD rating scale: normative data, reliability, and validity. Unpublished manuscript of the...
  • D.E. Faries et al.

    Validation of the ADHD Rating Scale as a clinician administered and scored instrument

    Journal of Attention Disorders

    (2001)
  • D.L. Fehlings et al.

    Attention deficit hyperactivity disorderdoes cognitive behavioral therapy improve home behavior?

    Journal of Developmental Behavioral Pediatrics

    (1991)
  • First, M., Spitzer, R., Gibbon, M., & Williams, J. (1996). Structured clinical interview for DSM-IV Axis I...
  • Cited by (0)

    View full text