Cognitive Behavioral Therapy and Adult ADHD

Cognitive Behavioral Therapy and ADHD
I have written before about the benefits of Cognitive Behavioral Therapy (CBT) for ADHD but a new study (the abstract is below) looking at the effects of CBT in adults with ADHD has just been published that shows that CBT helped adults with ADHD regardless of whether they were on stimulant therapy or not.

Two things are interesting about this study. The first is that it was performed by a pharmaceutical company and reported no improvement in symptoms from taking stimulant medication and the second is the finding that you can have a robust response to CBT even if you are not medicated for ADHD.

The use of stimulants for ADHD symptoms in the long term and in adults is only now being studied. Many people in the ADHD community insist that stimulant therapy is required for most patients with ADHD because non-Drug ADHD Treatments simply do not work. When a study is published indicating a positive effect from something like CBT, many ADHD authorities discount the findings by saying that the study was small, or poorly done, or that it did not have a good control group. These concerns are all valid but they apply to the research performed on drug treatment as well.

The U.S. Department for Health and Human Services Agency for Healthcare Research and Quality (AHRQ) has critically reviewed all the studies that had been performed, from 1980 to 2010, on the benefits of behavioral therapy and stimulant ADHD treatment.

AHRQ is this country's healthcare watch dog agency and they have been asked to look at diseases and their treatments to determine what interventions really work. According to the AHRQ webpage, their mission is to improve the quality, safety, efficiency, and effectiveness of health care for all American by generating the knowledge and tools required to improve the quality of life, save lives, and gain value for the health care dollars that we spend. As the amount of money spent on health care increases, questions such as, “What ADHD treatment really works?” becomes critically important.

When the AHRQ looked at 30 years worth of ADHD research, what they found was pretty amazing. The agency published their findings in an October 2011 report. Their report states that many of the studies performed over the last 30 years did not meet the criteria necessary to deem them 'good' studies, (for all the same reasons that I mention above regarding the non-drug treatment studies), but from the few good studies that were performed, there were only able to conclude that, in terms of long term benefits for ADHD symptoms:

1. Parent training worked well for diminishing the ADHD behaviors of preschoolers
2. Primary school age boys with ADHD combined type, showed improvements in behavior when they were treated with methylphenidate (Ritalin) or Atomoxetine (Strattera).

That’s it! Those were the only two conclusions that the AHRQ was able to make. The standards used by AHRQ were very stringent and most health care providers will disagree with the agency findings as they have seen great improvements in many ADHD patients treated with stimulant therapy.

There is no doubt that certain symptoms of ADHD, Impulsive behavior and hyperactivity for instance, are greatly improved with medications such as stimulants but symptoms of Inattentive ADHD, symptoms of disorganization, symptoms of skewed time management, symptoms of mood problems and other symptoms of ADHD likely respond better to other interventions.

The Cognitive Behavioral Program provided by MoodGym is free and has been found in studies to be as effective as Psychologist office based CBT. If you are an adult with ADHD, it cannot hurt to give MoodGym a try.

I have just returned from hiking in the Grand Canyon. We hiked down to the bottom and camped. The kids did phenomenally well and the adult's joints managed to hold up as well. The picture is from there.

BMC Psychiatry. 2012 Apr 5;12(1):30. [Epub ahead of print]
A Randomized Controlled Trial of CBT Therapy for Adults with ADHD with and without Medication.
Weiss M, Murray C, Wasdell M, Greenfield B, Giles L, Hechtman L.



Previous studies of psychological treatment in adults with ADHD have not controlled for medication status and include either medicated participants or mixed samples of medicated and unmedicated participants. The objective of this study is to examine whether use of medication improves outcome of therapy.

This was a secondary analysis comparing 23 participants randomized to CBT and Dectroamphetamine vs. 25 participants randomized to CBT and placebo. Both patients and investigators were blind to treatment assignment. Two co-primary outcomes were used: ADHD symptoms on the ADHD-RS-Inv completed by the investigator and improvement in functioning as reported by the patient on the Sheehan Disability Scale.

Both groups showed robust improvement in both symptoms and functioning, but the use of medication did not significantly improve outcome over and above use of CBT and placebo.

This study replicates previous work demonstrating that CBT is an effective treatment for ADHD in adults. Within the limits of this pilot, secondary analysis we were not able to demonstrate that medication significantly augments the outcome of CBT therapy for adults with ADHD. The study was funded by GlaxoSmithKline, Clinical Trials Registry #GSK707.

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