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Adult receiving cognitive behavioural therapy

NIHR Signal Cognitive behavioural therapy could benefit adults with attention deficit hyperactivity disorder (ADHD)

Published on 21 August 2018

doi: 10.3310/signal-000636

Cognitive behavioural therapy improves the core symptoms of attention deficit hyperactivity disorder (ADHD) in adults, compared with a range of other treatments. This Cochrane review found a general trend for improvements in inattention, hyperactivity and impulsiveness, especially when therapy was combined with medication.

The review included trials that compared cognitive behavioural therapy to other specific interventions or to a range of control conditions, including waiting list and no treatment. It also looked at cognitive behavioural therapy plus drug treatment, versus drug treatment alone.

The included trials were rated very low to moderate quality. They also used a variety of outcome measures, which made it difficult to compare the interventions.

Despite these limitations, the review provides evidence that reinforces current guidance and practice.

Share your views on the research.

Why was this study needed?

Attention deficit hyperactivity disorder (ADHD) is a group of behavioural symptoms which usually begin in childhood. While the symptoms of inattentiveness, hyperactivity and impulsiveness usually improve with age, they can continue into adulthood. In the UK, 3 to 4% of adults are thought to have the condition. In adults, it can affect social interactions, study and work performance. Drug treatments are often used to manage the symptoms.

Previous studies suggest that cognitive behavioural therapy (CBT) could be effective for treating adults. CBT aims to change a person’s thoughts and behaviours by teaching techniques to control the core attention and executive deficits of ADHD and to modify the distorted negative beliefs and self-esteem as these can lead to emotional maladjustments such as anxiety and depression.  

This Cochrane review aimed to assess the effectiveness of CBT for adults with ADHD.

What did this study do?

This systematic review found 14 randomised controlled trials that included 700 adults with ADHD. All the trials looked at the effects of talking therapies, including mindfulness-based interventions, Internet-based CBT, metacognitive therapy and dialectical behaviour therapy. Most CBT programmes were of 8 to 12 sessions and were delivered on an individual or group basis. The trials lasted between 8 and 15 weeks.

None of the trials took place in the UK. Four took place in the USA, eight in Europe and one each in Australia and China. 

Outcomes were measured by clinicians or the patients themselves, using validated clinical-symptom-specific scales and scores. The quality of the evidence ranged from very low to moderate which reduces confidence in the results.

What did it find?

  • Compared with being on a waiting list, CBT led to a large improvement in self-reported ADHD symptoms (standardised mean difference [SMD] -0.84, 95% confidence interval [CI] -1.18 to -0.50; 5 studies, 251 participants; moderate-quality evidence). It showed a greater improvement in clinician-reported symptoms, but the quality of the evidence was very low (SMD -1.22, 95% CI -2.03 to -0.41; 2 studies, 126 participants).
  • Cognitive behavioural therapy was more effective than supportive therapy for improving clinician-reported ADHD symptoms (SMD -0.56, 95% CI -1.01 to -0.12; 1 study, 81 participants; low-quality evidence). However, it didn't show a benefit over supportive therapy for self-reported symptoms (SMD -0.16, 95% CI -0.52 to 0.19; 2 studies, 122 participants; low-quality evidence).
  • Drug treatment plus CBT was more effective than drug treatment alone for both clinician-reported and self-reported core symptoms. For clinician-reported symptoms, the SMD was -0.80 (95% CI -1.31 to -0.30; 2 studies, 65 participants; very low-quality evidence). For self-reported symptoms, the mean difference was -7.42 points on the 0 to 54 point Current Symptoms Scale (95% CI -11.63 to -3.22; 2 studies, 66 participants; low-quality evidence).
  • Cognitive behavioural therapy showed a benefit over other specific interventions for clinician-reported ADHD symptoms (SMD -0.58, 95% CI -0.98 to -0.17; 2 studies, 97 participants; low-quality evidence), and for self-reported symptom severity (SMD -0.44, 95% CI -0.88 to -0.01; 4 studies, 156 participants; low quality evidence).
  • None of the studies reported severe adverse events, but five people reported some type of adverse event such as distress and anxiety.

What does current guidance say on this issue?

The 2018 NICE guideline on the diagnosis and management of ADHD recommends drug treatment for adults whose ADHD symptoms cause them significant problems and suggests that non-pharmacological treatment should be considered for adults who choose not to have drugs, have difficulty adhering to medication or who have found it ineffective.

A combination of medication and non-pharmacological treatment is recommended if the person is still experiencing symptoms. The guideline suggests that non-pharmacological treatment may involve elements of or a full course of CBT.

What are the implications?

The evidence in this review was only of very low to moderate quality. However, it supports the use of CBT to help adults manage their ADHD symptoms. This is helpful in the context of concerns from clinicians about prescribing medication for ADHD.

The 2018 NICE guideline committee acknowledged that there is uncertainty about the long-term benefits and the adverse effects of medication. They felt that their recommendation to offer non-pharmacological treatment in certain circumstances reflects good current practice.

This review strengthens the evidence-base for non-pharmacological treatments.

Citation and Funding

Lopez PL, Torrente FM, Ciapponi A, et al. Cognitive-behavioural interventions for attention deficit hyperactivity disorder (ADHD) in adults. Cochrane Database Syst Rev. 2018;3:CD010840.

No funding information was provided for this study.

Bibliography

CKS. Attention deficit hyperactivity disorder. London: National Institute for Health and Care Excellence; 2015.

NHS website. Attention deficit hyperactivity disorder (ADHD). London: Department of Health; 2016.

NICE. Attention deficit hyperactivity disorder: diagnosis and management. NG87. London: National Institute for Health and Care Excellence; 2018.

Why was this study needed?

Attention deficit hyperactivity disorder (ADHD) is a group of behavioural symptoms which usually begin in childhood. While the symptoms of inattentiveness, hyperactivity and impulsiveness usually improve with age, they can continue into adulthood. In the UK, 3 to 4% of adults are thought to have the condition. In adults, it can affect social interactions, study and work performance. Drug treatments are often used to manage the symptoms.

Previous studies suggest that cognitive behavioural therapy (CBT) could be effective for treating adults. CBT aims to change a person’s thoughts and behaviours by teaching techniques to control the core attention and executive deficits of ADHD and to modify the distorted negative beliefs and self-esteem as these can lead to emotional maladjustments such as anxiety and depression.  

This Cochrane review aimed to assess the effectiveness of CBT for adults with ADHD.

What did this study do?

This systematic review found 14 randomised controlled trials that included 700 adults with ADHD. All the trials looked at the effects of talking therapies, including mindfulness-based interventions, Internet-based CBT, metacognitive therapy and dialectical behaviour therapy. Most CBT programmes were of 8 to 12 sessions and were delivered on an individual or group basis. The trials lasted between 8 and 15 weeks.

None of the trials took place in the UK. Four took place in the USA, eight in Europe and one each in Australia and China. 

Outcomes were measured by clinicians or the patients themselves, using validated clinical-symptom-specific scales and scores. The quality of the evidence ranged from very low to moderate which reduces confidence in the results.

What did it find?

  • Compared with being on a waiting list, CBT led to a large improvement in self-reported ADHD symptoms (standardised mean difference [SMD] -0.84, 95% confidence interval [CI] -1.18 to -0.50; 5 studies, 251 participants; moderate-quality evidence). It showed a greater improvement in clinician-reported symptoms, but the quality of the evidence was very low (SMD -1.22, 95% CI -2.03 to -0.41; 2 studies, 126 participants).
  • Cognitive behavioural therapy was more effective than supportive therapy for improving clinician-reported ADHD symptoms (SMD -0.56, 95% CI -1.01 to -0.12; 1 study, 81 participants; low-quality evidence). However, it didn't show a benefit over supportive therapy for self-reported symptoms (SMD -0.16, 95% CI -0.52 to 0.19; 2 studies, 122 participants; low-quality evidence).
  • Drug treatment plus CBT was more effective than drug treatment alone for both clinician-reported and self-reported core symptoms. For clinician-reported symptoms, the SMD was -0.80 (95% CI -1.31 to -0.30; 2 studies, 65 participants; very low-quality evidence). For self-reported symptoms, the mean difference was -7.42 points on the 0 to 54 point Current Symptoms Scale (95% CI -11.63 to -3.22; 2 studies, 66 participants; low-quality evidence).
  • Cognitive behavioural therapy showed a benefit over other specific interventions for clinician-reported ADHD symptoms (SMD -0.58, 95% CI -0.98 to -0.17; 2 studies, 97 participants; low-quality evidence), and for self-reported symptom severity (SMD -0.44, 95% CI -0.88 to -0.01; 4 studies, 156 participants; low quality evidence).
  • None of the studies reported severe adverse events, but five people reported some type of adverse event such as distress and anxiety.

What does current guidance say on this issue?

The 2018 NICE guideline on the diagnosis and management of ADHD recommends drug treatment for adults whose ADHD symptoms cause them significant problems and suggests that non-pharmacological treatment should be considered for adults who choose not to have drugs, have difficulty adhering to medication or who have found it ineffective.

A combination of medication and non-pharmacological treatment is recommended if the person is still experiencing symptoms. The guideline suggests that non-pharmacological treatment may involve elements of or a full course of CBT.

What are the implications?

The evidence in this review was only of very low to moderate quality. However, it supports the use of CBT to help adults manage their ADHD symptoms. This is helpful in the context of concerns from clinicians about prescribing medication for ADHD.

The 2018 NICE guideline committee acknowledged that there is uncertainty about the long-term benefits and the adverse effects of medication. They felt that their recommendation to offer non-pharmacological treatment in certain circumstances reflects good current practice.

This review strengthens the evidence-base for non-pharmacological treatments.

Citation and Funding

Lopez PL, Torrente FM, Ciapponi A, et al. Cognitive-behavioural interventions for attention deficit hyperactivity disorder (ADHD) in adults. Cochrane Database Syst Rev. 2018;3:CD010840.

No funding information was provided for this study.

Bibliography

CKS. Attention deficit hyperactivity disorder. London: National Institute for Health and Care Excellence; 2015.

NHS website. Attention deficit hyperactivity disorder (ADHD). London: Department of Health; 2016.

NICE. Attention deficit hyperactivity disorder: diagnosis and management. NG87. London: National Institute for Health and Care Excellence; 2018.

Cognitive-behavioural interventions for attention deficit hyperactivity disorder (ADHD) in adults

Published on 23 March 2018

Lopez, P. L.,Torrente, F. M.,Ciapponi, A.,Lischinsky, A. G.,Cetkovich-Bakmas, M.,Rojas, J. I.,Romano, M.,Manes, F. F.

Cochrane Database Syst Rev Volume 3 , 2018

BACKGROUND: Attention deficit hyperactivity disorder (ADHD) is a developmental condition characterised by symptoms of inattention, hyperactivity and impulsivity, along with deficits in executive function, emotional regulation and motivation. The persistence of ADHD in adulthood is a serious clinical problem.ADHD significantly affects social interactions, study and employment performance.Previous studies suggest that cognitive-behavioural therapy (CBT) could be effective in treating adults with ADHD, especially when combined with pharmacological treatment. CBT aims to change the thoughts and behaviours that reinforce harmful effects of the disorder by teaching people techniques to control the core symptoms. CBT also aims to help people cope with emotions, such as anxiety and depression, and to improve self-esteem. OBJECTIVES: To assess the effects of cognitive-behavioural-based therapy for ADHD in adults. SEARCH METHODS: In June 2017, we searched CENTRAL, MEDLINE, Embase, seven other databases and three trials registries. We also checked reference lists, handsearched congress abstracts, and contacted experts and researchers in the field. SELECTION CRITERIA: Randomised controlled trials (RCTs) evaluating any form of CBT for adults with ADHD, either as a monotherapy or in conjunction with another treatment, versus one of the following: unspecific control conditions (comprising supportive psychotherapies, no treatment or waiting list) or other specific interventions. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures suggested by Cochrane. MAIN RESULTS: We included 14 RCTs (700 participants), 13 of which were conducted in the northern hemisphere and 1 in Australia.Primary outcomes: ADHD symptomsCBT versus unspecific control conditions (supportive psychotherapies, waiting list or no treatment)- CBT versus supportive psychotherapies: CBT was more effective than supportive therapy for improving clinician-reported ADHD symptoms (1 study, 81 participants; low-quality evidence) but not for self-reported ADHD symptoms (SMD -0.16, 95% CI -0.52 to 0.19; 2 studies, 122 participants; low-quality evidence; small effect size).- CBT versus waiting list: CBT led to a larger benefit in clinician-reported ADHD symptoms (SMD -1.22, 95% CI -2.03 to -0.41; 2 studies, 126 participants; very low-quality evidence; large effect size). We also found significant differences in favour of CBT for self-reported ADHD symptoms (SMD -0.84, 95% CI -1.18 to -0.50; 5 studies, 251 participants; moderate-quality evidence; large effect size).CBT plus pharmacotherapy versus pharmacotherapy alone: CBT with pharmacotherapy was more effective than pharmacotherapy alone for clinician-reported core symptoms (SMD -0.80, 95% CI -1.31 to -0.30; 2 studies, 65 participants; very low-quality evidence; large effect size), self-reported core symptoms (MD -7.42 points, 95% CI -11.63 points to -3.22 points; 2 studies, 66 participants low-quality evidence) and self-reported inattention (1 study, 35 participants).CBT versus other interventions that included therapeutic ingredients specifically targeted to ADHD: we found a significant difference in favour of CBT for clinician-reported ADHD symptoms (SMD -0.58, 95% CI -0.98 to -0.17; 2 studies, 97 participants; low-quality evidence; moderate effect size) and for self-reported ADHD symptom severity (SMD -0.44, 95% CI -0.88 to -0.01; 4 studies, 156 participants; low-quality evidence; small effect size).Secondary outcomesCBT versus unspecific control conditions: we found differences in favour of CBT compared with waiting-list control for self-reported depression (SMD -0.36, 95% CI -0.60 to -0.11; 5 studies, 258 participants; small effect size) and for self-reported anxiety (SMD -0.45, 95% CI -0.71 to -0.19; 4 studies, 239 participants; small effect size). We also observed differences in favour of CBT for self-reported state anger (1 study, 43 participants) and self-reported self-esteem (1 study 43 participants) compared to waiting list. We found no differences between CBT and supportive therapy (1 study, 81 participants) for self-rated depression, clinician-rated anxiety or self-rated self-esteem. Additionally, there were no differences between CBT and the waiting list for self-reported trait anger (1 study, 43 participants) or self-reported quality of life (SMD 0.21, 95% CI -0.29 to 0.71; 2 studies, 64 participants; small effect size).CBT plus pharmacotherapy versus pharmacotherapy alone: we found differences in favour of CBT plus pharmacotherapy for the Clinical Global Impression score (MD -0.75 points, 95% CI -1.21 points to -0.30 points; 2 studies, 65 participants), self-reported depression (MD -6.09 points, 95% CI -9.55 points to -2.63 points; 2 studies, 66 participants) and self-reported anxiety (SMD -0.58, 95% CI -1.08 to -0.08; 2 studies, 66 participants; moderate effect size). We also observed differences favouring CBT plus pharmacotherapy (1 study, 31 participants) for clinician-reported depression and clinician-reported anxiety.CBT versus other specific interventions: we found no differences for any of the secondary outcomes, such as self-reported depression and anxiety, and findings on self-reported quality of life varied across different studies. AUTHORS' CONCLUSIONS: There is low-quality evidence that cognitive-behavioural-based treatments may be beneficial for treating adults with ADHD in the short term. Reductions in core symptoms of ADHD were fairly consistent across the different comparisons: in CBT plus pharmacotherapy versus pharmacotherapy alone and in CBT versus waiting list. There is low-quality evidence that CBT may also improve common secondary disturbances in adults with ADHD, such as depression and anxiety. However, the paucity of long-term follow-up data, the heterogeneous nature of the measured outcomes, and the limited geographical location (northern hemisphere and Australia) limit the generalisability of the results. None of the included studies reported severe adverse events, but five participants receiving different modalities of CBT described some type of adverse event, such as distress and anxiety.

Mindfulness is a technique to help reduce stress and cope with problems by noticing what is going on in the present moment, without judgement.

Metacognitive therapy is a treatment which involves looking at your own thoughts and how you think, identifying unhelpful patterns of thought, and finding more helpful ways to respond to those thoughts.

Cognitive behavioural therapy (CBT) is a type of talking treatment which focusses on how a person’s thoughts and beliefs affect their feelings and behaviour. CBT teaches coping skills for dealing with problems by changing how you think and behave.

Dialectical behaviour therapy is a type of talking therapy which is based on CBT. As well as encouraging a person to change unhelpful thinking and behaviour, dialectical behaviour therapy encourages them to accept themselves at the same time.

Expert commentary

Attention deficit hyperactivity disorder (ADHD) is an increasingly recognised issue for adults; indeed in the US, ADHD medication prescriptions for adults now exceed those for children. Some individuals have treatment that continues from childhood, some have a later-life diagnosis of a long-standing problem, sometimes through recognising a pattern when their own children are diagnosed, and some may have a late-onset variation. Health services are trying to ‘catch-up’ with this, and there is a great need for the best possible evidence on treatment options. In particular, medications work for some, but not others and they are not acceptable or desirable for many. Better understanding of the potential roles of talking therapies in this group is vital. This review shows that one type, cognitive behavioural therapy, may be helpful by itself, but particularly if combined with medication. It highlights the need for better quality research in this important and growing clinical area.

Dr Derek Tracy, Consultant Psychiatrist and Clinical Director, Oxleas NHS Foundation Trust, London; Senior Lecturer, King’s College and University College London