Cognitive-Behavioral Therapy for Adults with ADHD (WWK 21)
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WWK refers to the What We Know series of information sheets on ADHD. See the complete list. See the PDF version of this sheet.
There is much interest in - but also apparently much confusion about - the nature of cognitive-behavioral therapy (CBT) and the way it can be used to help adults with ADHD. Cognitive-behavioral therapy refers to a type of mental health treatment in which the focus is on the thoughts and behaviors that occur "in the here and now." This approach is quite different from traditional forms of psychoanalytic or psychodynamic therapy which involve recapturing and reprocessing the childhood experiences that are understood to have given rise to current emotional problems. A difference of CBT over these earlier therapies is that its goals and methods are quite explicit. As such, it lends itself more readily to measuring whether or not desired goals have been achieved.
Origins and Early Uses of CBT
CBT originated in a melding of "cognitive therapy," developed in the 1960's by Aaron Beck and popularized by Albert Ellis, and "behavior therapy," developed by B.F. Skinner, Joseph Volpe and others. Beck and Ellis postulated that we all have "automatic thoughts" that occur immediately in response to an event, situation, or other stimulus. These thoughts (or "cognitions") may be helpful - that is, they lead to positive feelings and effective coping - or they may be negative, in that they lead to feelings of depression or anxiety and maladaptive behavior. These negative thoughts are typically based on "irrational beliefs" or "cognitive distortions." Examples include:
- "all-or-none thinking" (which gives rise to perfectionism);
- selective attention to negative events or outcomes (and overlooking positive outcomes);
- "catastrophizing"(believing that it would be a catastrophe if something does or does not occur); and
- personalization (seeing oneself as the cause of some negative external event for which one is not, in fact, primarily responsible).
Therapy helps to identify these irrational beliefs. Then, treatment moves forward by challenging and ultimately negating these beliefs through discussion and home exercises, which typically include keeping "thought logs."
Over the years cognitive therapy has been expanded and tailored for the treatment of depression, and many specific types of anxiety, including generalized anxiety disorder, social anxiety, post-traumatic stress disorder and obsessive-compulsive disorder. The negative behaviors, as well as the negative thoughts, are addressed in treatment (hence the term cognitive-behavioral therapy). Exercises within the session and at home typically involve gradual, systematic exposure to the anxiety-arousing situations and the development and rehearsal of skills to better manage those situations, as well as challenging the irrational automatic thoughts that may occur.
How is CBT relevant for adults with ADHD?
CBT is relevant for adults with ADHD in two ways:
First, in recent years, CBT programs have been developed specifically for adults with ADHD. Some of these programs aim to help adults overcome their difficulties in everyday "executive" functions that are needed to effectively manage time, organize, and plan in the short term and the long term. Other programs focus on emotional self-regulation, impulse control, and stress management.
Additionally, it has been well established that adults with ADHD are more likely than adults in the general population to suffer from co-existing anxiety and depressive disorders. A large nationally representative study pegged these rates as 51% suffering from co-morbid anxiety and 32% suffering from co-morbid depression.1 Thus, treatments that incorporate CBT for these disorders may be quite helpful to many adults with ADHD, even though they are not designed specifically to address the symptoms and impairment associated with ADHD.
Programs that address executive dysfunction fall into the category of "cognitive-behavioral" therapy because they both: 1) impart more adaptive cognitions about how to go about planning, organizing etc. and also 2) impart more effective behavioral skills. An example of an adaptive cognition is the self-instruction to "break down complex or unpleasant tasks into manageable parts." Examples of behavioral skills are using a planner regularly, and implementing a filing system. Positive thoughts and positive behaviors reinforce each other - as the person becomes more effective in managing time, s/he comes to have more positive beliefs and cognitions about the self, and these in turn help to generate and maintain more adaptive behaviors.
Evidence-based CBT programs for adults with ADHD
Two programs developed to address executive skills in adults with ADHD have manuals that have been published and have been shown to be effective in rigorous scientific studies. These are the programs developed at the Massachusetts General Hospital in Boston5, 6 and at Mount Sinai Medical Center in New York City.7 The studies of these programs each enrolled two groups of adults with ADHD - those who were treated with the specific CBT program, and a "control" or comparison group who received a form of supportive therapy. The results of the studies demonstrated that CBT was significantly more effective than the non-specific support and attention of the therapist.4, 8
A third program, developed at the University of Pennsylvania in Philadelphia3 incorporates CBT strategies to target irrational beliefs, as well as executive skill-building. Also, currently undergoing testing for effectiveness in Germany, is a form of cognitive-behavioral treatment derived from dialectical behavior therapy (DBT).2 This approach is primarily aimed at helping adults with ADHD develop better regulation of their emotions, interpersonal behavior, and impulsivity. If found to be effective, similar programs may be developed in the US.
Finally, while not a cognitive-behavioral intervention, strictly speaking, mindfulness meditation9 was found to be helpful in one (uncontrolled) study10 and may have further potential in helping adults with ADHD improve control of their attention as well as some of the other symptoms of ADHD.
How does CBT compare to medication for the treatment of ADHD in adults?
Stimulant and non-stimulant medication has been shown in numerous studies to be effective for treating ADHD in adults. Research thus far shows that CBT can provide benefit whether or not the person is being treated with medication. There have not yet been any direct, "head to head" comparisons of CBT and medication, but clinical experience suggests that they have different effects: Whereas medication helps to control the core symptoms of distractibility, short attention span, and impulsivity, CBT is more effective at increasing the habits and skills needed for executive self-management, and may also serve to improve emotional and interpersonal self-regulation.
Where can I find cognitive-behavioral treatment for adult ADHD?
Development and testing of therapies for adult ADHD is a growing field. Because cognitive-behavioral treatments have only recently been shown to be effective, they are not yet widely available. Programs that have been evaluated included:
Those who live outside Boston, New York, or Philadelphia may be able to locate a cognitive-behavioral therapist or a neuropsychologist who is amenable to working with the published CBT manuals for therapists.3, 5, 6, 7 Listings of potential therapists are available through CHADD and through the professional Association for Behavioral and Cognitive Therapies (ABCT).
1. Kessler, R.C., Adler, L.A., Barkley, R.A., Biederman, J., Conners, C.K., Demler, O., et al., The prevalence and correlates of adult ADHD in the United States: Results from the national comorbidity survey replication, American Journal of Psychiatry., 163 (2006) 716-723.
2. Philipsen, A., Graf, E., Tebartz van Elst, L., Jans, T., Warnke, A., Hesslinger, B., et al., Evaluation of the efficacy and effectiveness of a structured disorder tailored psychotherapy in ADHD in adults: study protocol of a randomized controlled multicentre trial, Attention Deficit Hyperactivity Disorder., 2 (2010) 203-212.
3. Ramsay, J.R. and Rostain, A.L., Cognitive-Behavioral Therapy for Adult ADHD: An Integrative Psychosocial and Medical Approach, Routledge, New York, 2008.
4. Safren, S.A., Sprich, S., Mimiaga, M.J., Surman, C., Knouse, L., Groves, M. and Otto, M.W., Cognitive behavioral therapy vs. relaxation with educational support for medication-treated adults with ADHD and persistent symptoms: a randomized controlled trial, Journal of the American Medical Association., 304 (2010) 875-880.
5. Safren, S.A., Sprich, S., Perlman, C. and Otto, M., Mastering Your Adult ADHD: A Cognitive-Behavioral Treatment Program (Client Workbook ), Oxford University Press, New York, 2005.
6. Safren, S.A., Sprich, S., Perlman, C. and Otto, M., Mastering Your Adult ADHD: A Cognitive-Behavioral Treatment Program (TherapistWorkbook ), Oxford University Press, New York, 2005.
7. Solanto, M.V., Cognitive-Behavioral Therapy for Adult ADHD: Targeting Executive Dysfunction, Guilford Press, New York, N.Y., 2011.
8. Solanto, M.V., Marks, D.J., Wasserstein, J., Mitchell, K., Abikoff, H., Alvir, J.M. and Kofman, M.D., Efficacy of meta-cognitive therapy (MCT) for adult ADHD, American Journal of Psychiatry., 167 (2010) 958-968.
9. Zylowska, L., The Mindfulness Prescription for Adult ADHD: An 8-Step Program for Strengthening Attention, Managing Emotions, and Achieving Your Goals, Shambhala Press, 2012.
10. Zylowska, L., Ackerman, D.L., Yang, M.H., Futrell, J.L., Horton, N.L., Hale, T.S., Pataki, C. and Smalley, S.L., Mindfulness meditation training in adults and adolescents with ADHD: a feasibility study, Journal of Attention Disorders., 11 (2008) 737-746.
The information provided in this sheet is supported by Cooperative Agreement Number 5U38DD000335-05 from the Centers for Disease Control and Prevention (CDC). The contents are solely the responsibility of the authors and do not necessarily represent the official views of CDC. This fact sheet was approved by CHADD's Professional Advisory Board in 2013.
This What We Know information sheet was developed for the National Resource Center on ADHD by Mary V. Solanto, Ph.D., The Mount Sinai School of Medicine.
© 2013 Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD).
Permission is granted to photocopy and freely distribute this What We Know sheet, provided that this document is reproduced in its entirety, including the CHADD and NRC names, logos and contact information.
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