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Unread April 8th, 2005, 10:05 PM
James Pretzer James Pretzer is offline
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Default CT for ADHD

The following is re-posted from the Academy of Cognitive Therapy's mailinglist with the author's (Stephen P. McDermott, MD) permission:

While there has been a dearth of research on CT for ADHD, the literature on CT for ADHD has been increasing recently-particularly for adults.

I don't know a lot about the child literature. Behavioral approaches have certainly been studied more than CT approaches, but that may be to some extent because of the greater difficulty in finding well-trained child CT therapists than behavioral therapists. (Please feel free to correct me if I'm wrong.)

I suggest you take a look at some of Ross Greene's work with kids with Oppositional-Defiant Disorder. His treatment, which he calls Collaborative Problem-Solving, is primarily cognitive. While there is limited research on it (which you can find listed on his site:, it is increasingly popular. I understand it is now the preferred milieu modality on all juvenile inpatient units run by the state of Maine.

Most child behavioral programs rely on the parents providing the structure and motivation
for the treatment. Because of this, most child behavioral treatments have not translated well to adults with ADHD

In 1999, my colleagues at MGH and I published a description of my treatment using a modification of Beck's CT for 26 adults with ADHD (24 of whom were also on medications). It was generally a treatment-resistant group (which is why they were referred for CT), many of whom had been treated by psychopharmacologists who were very familiar with ADHD medications. It was primarily a retrospective chart review, but many of the measures were prospective clinical measures (e.g., Beck Depression Inventory, ADHD Symptom Checklist).

Our results showed: Medication significantly improved the patients' ADHD, depression and anxiety symptoms as well as functional impairment ratings over baseline, and CT significantly improved the patients' ADHD, depression and anxiety symptoms and functional impairment ratings over both baseline and medication stabilization (defined as the time when medications were no longer, or only minimally, adjusted). To our knowledge, it was the first report of treatment outcome for a psychotherapy specifically developed for ADHD. All but one of my co-authors were pediatric psychopharmacologists at MGH who specialized in ADHD research.

The reference is:
Wilens, T. E., McDermott, S. P., Biederman, J., Abrantes, A., Hahesy, A., & Spencer, T. J. (1999). Cognitive therapy in the treatment of adults with ADHD: A systematic chart review of 26 cases. Journal of Cognitive Psychotherapy, 13(3), 215-226.

In 2000, I published a chapter describing a cognitive conceptualization for ADHD in adults, with treatment guidelines.

The reference is:
McDermott, S. (2000). Cognitive therapy of adults with attention-deficit/hyperactivity disorder. In T. Brown (Ed.), Attention deficit disorders and comorbidities in children, adolescents, and adults (pp. 651-690). Washington, DC: American Psychiatric Press, Inc.

In 2004, Steve Safren and his colleagues at MGH presented the results of their 10 to 15 session protocol, developed, in part, from these guidelines. They designed a randomized and controlled pilot study in which participants were adults with ADHD with continued clinically significant symptoms (of at least "moderate" severity, as determined by an independent evaluator) despite stable medication treatment. Participants were asked not to change their medications (and were chosen, in part, because they had no plans to do so).

Approximately half of the 31 adults (14 men, 17 women) were randomized to the full intervention and the other half to continued medications alone. Individuals completed self-report assessments (for ADHD, depression and anxiety symptoms) and were assessed (with the ADHD Rating Scale, Hamilton Depression and Anxiety Scales, as well as a Clinical Global Impression [severity] rating of ADHD) by an independent assessor who was blind to study condition.

The results of this pilot study, which they have submitted for publication, are quite promising. The authors showed:
1. The CBT group had more treatment "responders" (defined as a two-point change in the Clinical Global Impression (CGI) severity rating ) with 9/16 responders (56%) compared with 2/15 responders (13%) in the Continued Psychopharmacology Alone Group (c2 (1) = 6.23, p < .02).

2. CBT resulted in lower independent evaluator (IE) rated ADHD Symptom Severity Scale scores (Mean scores: CBT from 29.4 to 15.2; Control from 26.0 to 20.8. p< .01) and ADHD CGI Scores (Mean scores: CBT from 5.0 to 3.3; Control from 4.7 to 4.1. p< .01).

3. CBT resulted in lower self-report ADHD Current Symptom Scale scores (Mean scores: CBT from 29.7 to 14.8; Control from 26.4 to 23.9. p< .0001).

4. CBT also resulted in significantly lower IE rated Hamilton Anxiety scores (p< .04) and
self-reported Beck Anxiety Inventory scores (p< .04), as well as significantly lower IE rated Hamilton Depression scores (p< .04) with a trend for lower self-reported Beck Depression Inventory scores (p< .04).

5. Outcome analyses of ADHD and CGI ratings were robust against covarying out baseline depression and depression changes.

Steve and colleagues concluded their protocol for CBT for residual ADHD symptoms in adults was feasible to administer (the PI and three therapists learned how to deliver the
intervention) and acceptable to patients (no participant dropped out of the intervention
condition). They wrote, "It demonstrated initial evidence for efficacy, with a strong effect compared to no additional treatment (and) demonstrated effects on core ADHD symptoms over and above reductions in depression." They have begun an efficacy study comparing CBT to Relaxation with Educational Support for approximately 60 adults with residual ADHD symptoms despite stable medication treatment.

The reference is:
Safren, S. A., Otto, M. W., Wilens, T. E., Sprich, S., Biederman, J., & Winette, C. (2004,
May 6, 2004). Cognitive-Behavioral Therapy for Residual ADHD in Adults. Paper presented at the Annual Meeting of the American Psychiatric
Association, New York.

Steve's protocol is described in detail in his chapter:
Safren, S. A., Sprich, S., Chulvick, S., & Otto, M. W. (2004). Psychosocial treatments for adults with attention-deficit/hyperactivity disorder. Psychiatric Clinics of North America, 27(2), 349-360.

Caroline Stevenson and her group in Australia have published two promising studies of the
treatment of adults with ADHD with Cognitive Remediation, a therapeutic program originally developed for adults with brain injuries which they adapted. The second study used what they called, "*a self-directed psychosocial intervention with minimal therapist contact," using a treatment manual they developed for their first study, as well as the use of "*a support person whose role was to telephone and remind (patients) to complete readings and exercises on a weekly basis" (as in their first study). "Support people were recruited from senior undergraduate and postgraduate psychology students provided with training and then randomly assigned to work with a participant with ADHD."

Stevenson et al write of their first study: "The programme was successful in reducing ADHD
symptomatology (d = 1.4), improving organizational skills (d = 1.3) and reducing feelings of anger (d = 0.5), with improvements maintained up to 1 year post treatment."

In their second study, they report, "Following the treatment programme, participants reported that their ADHD symptoms were significantly reduced, that their organizational skills improved, their self-esteem increased and their anger management improved. As in our previous study, medication was not necessary to benefit from the programme. Moreover, depression, anxiety, stress, intellectual ability and learning skills did not unduly influence outcome. At the 2-month follow-up, key therapeutic gains had been maintained. Compliance with the programme was found to be necessary to obtain optimum treatment outcome."

There references are:
Stevenson, C., Whitmont, S., Bornholt, L., Livesey, D., & Stevenson, R. (2002). A cognitive
remediation programme for adults with Attention Deficit Hyperactivity Disorder. Australian and New Zealand Journal of Psychiatry, 36(5), 610-616.

Stevenson, C. S., Stevenson, R. J., & Whitmont, S. (2003). A Self-directed Psychosocial
Intervention with Minimal Therapist Contact for Adults with Attention Deficit Hyperactivity
Disorder. Clinical Psychology and Psychotherapy, 10, 93-101.

For the sake of completeness, Hesslinger and his associates in Germany reported on the use of a structured skills training program for adults with ADHD which was a modification of DBT, but it was only a small pilot study with 8 treatment patients, and a control group of 7 patients, 4 of whom dropped out after 3 months. They have an interesting protocol, though.

The reference is:
Hesslinger, B., van Elst, L., Nyberg, E., Dykierek, P., Richter, H., Berner, M., et al. (2002). Psychotherapy of attention deficit hyperactivity disorder in adults: A pilot study using a structured skills training program. European Archives in Psychiatry and Clinical Neuroscience, 252(4), 177-184.
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