Psychiatric Annals

CME Article 

Adult ADHD: Psychosocial Treatment Components andEfficacy Status

Richard Gallagher, PhD; Michael A. Feder, PhD

Abstract

Psychosocial treatments for attention-deficit/hyperactivity disorder (ADHD) in adults and emerging adults have developed to address core symptoms of ADHD (hyperactivity, impulsivity, and inattention) and associated functional impairments. These psychosocial treatments have been developed to enhance the effect of medication treatments. Evidence-based psychosocial treatments teach patients skills in organization, time management, and planning by using a cognitive-behavioral framework. The latest version of these programs also teaches mindfulness skills, so patients learn to think critically before acting impulsively. Cognitive components to address maladaptive thoughts found in ADHD and associated patterns found in comorbid anxiety and depression facilitate mental health. Research indicates that these skill-based programs lead to significant changes including reductions in core symptoms, improved executive functioning, and reduced functional impairments. This article reviews the findings from meta-analyses and details treatment targets and treatment components contained in efficacious interventions. [Psychiatr Ann. 2018;48(7):333–337.]

Abstract

Psychosocial treatments for attention-deficit/hyperactivity disorder (ADHD) in adults and emerging adults have developed to address core symptoms of ADHD (hyperactivity, impulsivity, and inattention) and associated functional impairments. These psychosocial treatments have been developed to enhance the effect of medication treatments. Evidence-based psychosocial treatments teach patients skills in organization, time management, and planning by using a cognitive-behavioral framework. The latest version of these programs also teaches mindfulness skills, so patients learn to think critically before acting impulsively. Cognitive components to address maladaptive thoughts found in ADHD and associated patterns found in comorbid anxiety and depression facilitate mental health. Research indicates that these skill-based programs lead to significant changes including reductions in core symptoms, improved executive functioning, and reduced functional impairments. This article reviews the findings from meta-analyses and details treatment targets and treatment components contained in efficacious interventions. [Psychiatr Ann. 2018;48(7):333–337.]

The treatment of attention-deficit/hyperactivity disorder (ADHD) in emerging adults and adults has gone through significant developments in the last two decades. After broad recognition that ADHD was a persistent condition that could last into adulthood, extensive research and clinical trials established the effectiveness of medications in reducing the effect of the core symptoms: hyperactivity, impulsivity, and inattention.1 However, even with improvements associated with medication use, it has been recognized that residual deficits can exist in adults afflicted with the disorder.2 This recognition has contributed to the development and testing of psychosocial interventions that primarily incorporate cognitive-behavior therapy (CBT) principles and methods.3 A review of the empirical status of psychosocial treatments, the nature of the varied efficacious treatments, and a comprehension of their treatment targets and components can inform client recommendations and treatment plans.

The prevalence of ADHD in the United States is 4.4% in adults.4 The distinguishing features of ADHD are developmentally deficient control of activity, impulsivity, and attention. These deficits contribute to many associated functional impairments in organization, time management, and planning in social interactions and in managing health. As a group, people with a lifetime course of ADHD demonstrate problems in many domains including academic and occupational achievement, social relationships, and basic and complicated tasks of daily living. Cognitive-behavioral interventions aim to alter the functional impairments rather than directly alter hyperactivity/impulsivity and inattention.

Medication and Psychotherapy

Medication treatment has been found to provide a significant benefit to adults with ADHD. A large-scale meta-analysis of pharmacological treatments using data on more than 9,000 patients indicated that they experienced reductions in symptoms of ADHD that were significant with effect sizes characterized as low to moderate.1 Stimulant treatments resulted in larger effect sizes, a finding that is supported in narrative reviews of pharmacological treatments.3 However, limits have been described, as patients who took medication experienced at least one adverse event or side effects that contributed to frequent discontinuation of treatment. These patterns have led to widespread conclusions that psychotherapeutic approaches are needed to create comprehensive care. Importantly, in the meta-analysis, patients were more likely to continue their use of medication when psychopharmacological treatment was combined with psychotherapy. The literature on medication has no objective reviews of the effect of medication on major negative consequences associated with adult ADHD including increased accidents (eg, motor vehicle accidents), reduced academic and occupational achievement, and increased legal problems.1

Core Symptoms and Functional Impairments

The catalog of challenges and negative occurrences that adults with ADHD may face is extensive. Although not all people experience the impairments, a substantial proportion do demonstrate at least one item from the catalog. The problems noted have been attributed to reduced self-regulation and deficits in executive functions that are connected to the underlying neurophysiological deficiencies in attention control and behavior control systems. At a basic level, the disorder interferes with a person's capacity to develop and enact plans across time to achieve goals5 or follow through on intentions.6 Poor use of executive functions and lack of follow through result in patient complaints of ineffective organization of important items (eg, car and house keys), failure to start tasks in a timely fashion (ie, procrastination), delayed completion of important tasks at home and at work (through weak time management), incomplete or impulsive planning, and emotional stress when noticing or being informed of failings. These issues cascade into limited achievement, problems in relationships, and, sometimes, more dangerous consequences including job loss, increased marital dissolution, poor management of health, and a greater number of motor vehicle accidents. Even for people who experience core symptom improvement, these functional issues are often present. It is the recognition of this fact that has led to the development of psychosocial treatments designed to build skills for improving responses to every day and critical situations. Treatment development has been maturing, allowing for a review of numerous studies with sound designs.

Current Empirical Status of Cognitive-Behavioral Therapy for ADHD

A recent meta-analysis using strict criteria for inclusion reviewed 32 studies that contained at least pre- to post-change scores.7 For those studies that did not contain a control group, effect size changes in self-reported ADHD symptoms were medium to large. When control groups were investigated, effect sizes were small to medium. If the control group was an active treatment condition and improvement was rated by blind evaluators (present in only two studies), the effect of treatment was significantly different than zero, but was in the small range. Detailed analysis revealed several important patterns. Medication status did not result in significant variations in treatment efficacy; patients who were both medicated and nonmedicated showed the same result in the compiled results. Additionally, length of treatment did not have a significant affect. Notably, all of the treatments reviewed did contain multiple sessions. Finally, the greatest improvement was noted in symptoms of inattention, with some associated improvements in executive functions when measured.7

Thus, CBT offers benefits that are greater than no treatment, and in even the strictest comparisons of a protocol that has been tested twice, participants in the CBT condition showed substantial gain over participants in an active control condition that did not teach skills.8 Gains that have been noted are in reductions of ADHD symptoms (primarily inattention) when evaluated in self ratings, ratings of a significant other, clinician ratings, and blind raters (in one study8). These interventions were designed for adults in general, whereas some other treatments have been specifically designed for emerging adults and college populations.

Treatment for Emerging Adults

Treatments for college students with ADHD are in the early stages of development. Pilot tests and open clinical trials characterize the evaluation designs of the available literature. The need to develop programs has been recognized because more people with ADHD have been registering to attend college with requests to receive accommodations and support services. Accommodations, often including test-taking changes such as extended time for examinations and taking examinations individually, have not made a substantial dent in the challenges that college presents to students with ADHD. In fact, developers of treatments for college students have been spurred on by recognizing that the rates of college graduation are almost 7 times lower for students with ADHD compared to those without ADHD (9% vs 61%).9 These treatments have been conducted with students at the schools that they attend, so generalization of outcomes are limited, but programs follow similar ideas on the skills targeted. The programs emphasize an understanding of ADHD; the effect that ADHD has upon attention in class; assuring self-care in terms of sleep, eating habits, and exercise; and most importantly, time management, scheduling, and planning. One of the most promising treatments, ACCESS (Accessing Campus Connections and Empowering Student Success), incorporates group skills instruction with individual mentoring during a full-semester of contact.10 The methodological rigor of investigations is not nearly as strong as it has been in evaluations of treatments for older adults, but reductions in inattention, but not hyperactivity, have been documented. Positive functional improvements in self-reported executive functioning have also been described. Using grade point average (GPA) as a measure of the effect of treatment on school performance has methodological limits, but when studied, changes have not been found. When significance has been reached in studies of psychosocial interventions, the effect sizes have been in the moderate range.11 Notably, changes in GPA have not been found when treatment with medication has been evaluated.

For emerging adults that are not enrolled in college, only one report has been published. Wymbs and Molina12 worked with couples in group sessions. This format was used in six group sessions that recruited the assistance of romantic partners to help the people address skill gaps of which they might not be aware. Both the young adults with ADHD and their partners reported significant changes in ADHD symptoms after participation. Effect sizes were moderate for self-report and low for partner report. Further development for noncollege adults in the transition phase of establishing themselves is likely to occur in the near future.

Treatment Targets and Components

The targets for improvement have been varied with no consistently agreed upon set of aims. However, many of the treatments share themes. The common themes involve psychoeducation, skills building for improving responses to daily demands, improving interpersonal interactions, and managing responses to emotional arousal. Most session content has focused on building skills for organization, time management, and planning with the next highest emphasis on logical problem-solving skills.

The psychoeducational effort is designed to assist patients in recognizing that aspects of ADHD are not likely to be in their conscious control. The acceptance of the biological nature of ADHD can diminish self-blame and can alter negative self-perceptions that one is flawed or irresponsible. Finally, psychoeducation is believed to motivate persistent practice to hone skills to work around built-in challenges.

Skill building has been conducted in individual and group formats, with group formats following a structured sequence in those programs with empirical support.13 Individual programs have been tested using a specific sequence, but authors have recommended flexibility so that treatment is tailored to individual needs.3,8 Patients are guided to learn practical tools associated with routines that they are recommended to follow persistently until behaviors become habitual. To place structure in their lives, patients are guided to refrain from reliance on their memories for remembering assignments, appointments, and other tasks. They are directed to use planners and calendars in conjunction with written to-do lists so that important tasks and time commitments are not lost due to inattentiveness. Patients are taught to develop plans for their days and weeks, so that they do not haphazardly use their time and get impulsively distracted to engage in interesting but unproductive activities. For managing materials and important items, they are guided to develop simple storage solutions and make certain to place critical objects in the same place every time they are set aside. In group settings, patients are encouraged to praise one another for following these seemingly mundane but critical steps. Individual treatments recommend that therapists establish a particularly positive, encouraging rapport to enhance motivation for tool and routine use. Even when target skills are assumed to naturally develop by adulthood, it is often the case that adults with ADHD never become proficient. Lack of proficiency occurs because inattentiveness and hyperactivity never afforded the person the concentration or patience needed to become facile in many simple routines.

Emotional regulation has been incorporated into treatment components that address interpersonal relationships. The proclivity for people with ADHD to respond impulsively when emotionally aroused is explored with patients to determine if they follow this pattern in their interpersonal interactions. The harm such reactions may have engendered in their lives is extracted in interviews and careful questioning. Once recognized as an issue, patients are taught to engage in methods for reducing emotional arousal and to engage in problem-solving so that they generate alternative responses, which are likely to be more effective. At times, significant others are integrated into treatment to repair the negative effect that impulsive responses may have had.

Some programs address common cognitive distortions that adults with ADHD often endorse. As noted, adults who have lived with the effects of ADHD often develop maladaptive cognitions and heavy doses of self-criticism about limited success or failures experienced. Adults with ADHD may predict failure, experience resulting anxiety, and avoid challenging tasks. They may endorse ideas that they have heard, believing that they are lazy and careless because they cannot accomplish tasks that seem simple on the surface. Tasks such as paying bills on time or getting out of the house without getting distracted present particular challenges. Sometimes patients experience an “ugh” reaction to tasks that prevents them from initiating the activity. This can result from beliefs that one cannot tolerate the tedium that is associated with routine chores or uninteresting work assignments.14 Importantly, recent analysis suggests that overly optimistic thoughts may lead to procrastination by people with ADHD as they believe that they can complete complex tasks easily and in short periods of time.15 Treatment for cognitive distortions requests that patients collect the thoughts that they have when they avoid or delay tasks, guide patients to challenge the veracity of the thoughts, and suggest that they replace those thoughts with more accurate predictions. For example, the thought “I do my best work when I start at the last minute” might be replaced with the thought “I feel really tense when I wait, and my work has suffered because of that.” Excessive self-criticism is unveiled, and patients are asked to replace that with valid reviews (eg, “I am a total failure” vs “I need to be more careful in using my coping routines”).

Problems with executive functioning that are often seen on tests including working memory, set shifting, and flexibility have not been consistently altered after treatment. In many cases, developers have decided to treat practical reflections of executive functioning problems by using calendars, developing checklists, and specifying specific locations for storing important items.

Recent Additions

A new psychosocial intervention for ADHD in adults integrates CBT with mindfulness meditation; this intervention is aptly titled Mindfulness Based Cognitive Therapy (MBCT). As noted above, during a CBT regimen, patients learn to identify their thoughts, feelings, and actions. In MBCT, patients explicitly learn to focus on their thoughts and feelings as they occur in real time.16 Specifically, patients learn to observe their thoughts and feelings without judging the thoughts or feelings, and then consciously choose their actions based on their evaluation of the situation and what course of action would be best. By improving awareness of one's own emotions and thoughts in real time, a person may be able to develop a mental filter to analyze their thoughts and feelings before acting upon them, thus diminishing the impulsivity and inattentiveness associated with ADHD.17 However, the exact mechanism of action is not yet fully understood.

Research on MBCT has revealed that patients who completed 8 weekly MBCT trainings along with 1 hour of daily mindfulness practice reported an improved ability to recognize their thoughts and feelings.18 Adults with ADHD who completed a similar 8-week regimen of mindfulness training self-reported reductions in ADHD symptoms, and also demonstrated improved performance on objective tests of attention and set-shifting.19 The brief nature of this treatment may make it especially appealing to patients. However, MBCT is rooted in Buddhist meditation practices and traditional Chinese medicine, which may not appeal to all patients. A recent review indicates that MBCT shows promising results when evaluated.20

It is estimated that 25% of adults with ADHD also meet criteria for major depressive disorder, and 47% percent meet criteria for anxiety disorders.4,21 As noted, adults with ADHD tend to experience failures in the social, occupational, and academic spheres, placing them at risk for developing maladaptive schemata (or underlying mental frameworks) about themselves and their abilities.14 In turn, these schemata can lead to the development of mood and anxiety symptoms.

For adults with comorbid ADHD and anxiety, the cognitive portion of CBT may focus on reducing the negative thoughts that lead to avoidance and procrastination, which can reduce the anxiety and mood symptoms, while the behavioral portion of CBT may focus on helping patients learn to use organizational tools, such as planners, to reduce the symptoms of ADHD. The working group of the Canadian Network for Mood and Anxiety Treatments22 recommends that patients with comorbid ADHD and depressive disorders have the mood disturbances addressed first if they are in the moderate to severe range. When mood symptoms fall in the mild range, the clinician and patient can determine together whether the ADHD or mood symptoms should be the first treatment target.

References

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Authors

Richard Gallagher, PhD, is the Director of Special Projects, Institute for Attention Deficit Hyperactivity and Behavior Disorders; the Co-Director, Selective Mutism Program; and an Associate Professor, Department of Child and Adolescent Psychiatry and Psychiatry, New York University (NYU) School of Medicine. Michael A. Feder, PhD, is a Post-Doctoral Fellow, Department of Child and Adolescent Psychiatry, NYU School of Medicine.

Address correspondence to Richard Gallagher, PhD, Department of Child and Adolescent Psychiatry, Hassenfeld Children's Hospital at NYU Langone, Child Study Center, One Park Avenue, 7th Floor, New York, NY 10016; email: richard.gallagher@nyumc.org.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00485713-20180606-02

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