CBT is effective in reducing symptoms in adults with ADHD whose symptoms persist following pharmacotherapy
Is cognitive–behavioural therapy (CBT) effective at symptom reduction in adults with attention-deficit/hyperactivity disorder (ADHD) who are already using medication?
86 adults with ADHD diagnosed according to DSM-IV criteria. All participants were taking psychiatrist-prescribed medications and were still reporting clinically significant symptoms.
A US hospital, November 2004 to June 2008 (follow-up to July 2009).
CBT versus time- and attention-matched relaxation with educational support. Both treatments were delivered via 12 individual 50-min sessions.
The CBT programme was delivered consistently with manuals and comprised a combination of core and optional modules. The relaxation therapy involved training in relaxation techniques appropriate to ADHD management, combined with education and psychotherapy. Therapists saw patients in both treatment groups; 14% of sessions were externally assessed to monitor for adherence and contamination.
Primary outcome: assessor-rated ADHD symptoms. Secondary outcome: self-reported ADHD symptoms. Symptom severity was measured at baseline, post-treatment and at 6- and 12-month follow-up. Baseline assessment of symptom severity was conducted with a four-point severity grid which had been validated as sensitive to medication treatment effects. The Clinical Global Impression Scale was also used. Participants' self-reported symptoms were measured at each assessment using the Current Symptoms Scale.
91.9% of participants completed treatment and 81.4% completed follow-up.
Randomised controlled trial.
Single blinded (outcome assessors were blinded; patients and therapists were not).
43 participants were randomised to each treatment group. Following treatment, those who had received CBT had better ADHD rating scale scores than those in the relaxation therapy group (between group difference: −4.63, 95% CI −8.30 to −0.96, p=0.02, d=0.60). Clinical Global Impression Scale scores were also better in the CBT group (between group difference: −0.53, 95% CI −1.01 to −0.05, p=0.03, d=0.53). ADHD current symptom scores were collected weekly; the rate of improvement was greater in the CBT group than in the relaxation therapy group (β = −0.41, 95% CI −0.64 to −0.17, p<0.001). There was some evidence of a time and treatment method interaction in the self-report Current Symptoms Scale (β=0.08, 95% CI 0.0 to 0.15, p=0.04) although the limited clinical significance of this is noted. Both the blinded and assessor-rated scales indicated evidence that post-treatment scores were stable over the post-treatment assessment period, with no statistically significant change over the follow-up (ADHD rating scale: β=−0.17, 95% CI −0.47 to +0.13, p=0.27; Clinical Global Impression Scale: β=0 95% CI −0.05 to +0.06, p=0.97)
Greater reductions of symptom severity were detected in the CBT group compared to the relaxation therapy group. This suggests that CBT is effective at symptom reduction in these patients in addition to any benefits gained from contact time and attention from a therapist.
It used to be thought that children diagnosed with attention-deficit/hyperactivity disorder (ADHD) invariably “grew out of it”. However, it is now recognised that more than half of children with ADHD continue to exhibit the full syndrome as adults.
Adults with ADHD are more likely than unaffected individuals to experience wide ranging problems in adult role functioning, have increased risk for psychiatric comorbidities and face assorted difficulties managing the affairs of daily life.
Medications are considered a first-line of treatment for the symptoms of ADHD, though they may not produce adequate improvements in functioning. Hence, there has been growing interest in adjunctive non-medication treatments for adult ADHD.
Safren and colleagues published the first randomised controlled trial of cognitive–behavioural therapy (CBT) adapted to treat adult ADHD in which it was compared to an active control treatment (eg, relaxation and educational support) in a sample of 86 medication-treated adults. Results indicated that CBT outperformed the active treatment control on ADHD symptom ratings obtained at the end of treatment and repeated at 12-month follow-up. It is heartening that the control group also improved, although much less so than the CBT group. This study replicates the authors' previous randomised controlled trial in which CBT outperformed ongoing medication treatment in a sample of adults with residual ADHD symptoms.1
The current study has implications for clinical practice insofar as it indicates that medications, although providing necessary symptom improvement, may not be sufficient in producing coping skill improvement (and thereby functional improvement) without effective psychosocial treatment. Consequently, the take away message from Safren and colleagues' study is that CBT specifically targeting the difficulties associated with adult ADHD has clearly emerged as an evidence-based adjunct to pharmacotherapy that provides coping strategies that help members of this clinical population to achieve and sustain improvements in their daily lives.