Cognitive-behavioral therapy for ADHD in medication-treated adults with continued symptoms

Psychosocial therapy in the treatment of adults with attention-deficit/hyperactivity disorder

Optimal management of attention-deficit/hyperactivity disorder (ADHD) requires a comprehensive treatment approach that reduces symptoms and improves quality of life. Psychosocial therapy, an important adjunct to pharmacotherapy for patients with ADHD, enables patients to improve functional performance across domains of life and maximizes the benefits of symptom reduction achieved via medication. This article evaluates the main types of psychosocial therapies used in the treatment of adult ADHD and discusses treatment goals within the context of skill acquisition and strength optimization. Factors influencing the success of psychosocial therapy and the role of a comprehensive treatment approach are also examined. The sequenced presentation of symptom reduction and skill acquisition plays a key role in coordinating psychosocial therapy and pharmacotherapy in a multimodal strategy for the effective treatment of adult ADHD.

Attention deficit hyperactivity disorder symptoms in adults with autism spectrum disorders

Features of attention deficit hyperactivity disorder (ADHD) and impairments on neuropsychological, tests of attention have been documented in children with autism spectrum disorders (ASDs). To date, there has been a lack of research comparing attention in adults with ASD and adults with ADHD. In study 1, 31 adults with ASD and average intellectual function completed self-report measures of ADHD symptoms. These were compared with self-report measures of ADHD symptoms in 38 adults with ADHD and 29 general population controls. In study 2, 28 adults with a diagnosis of ASD were compared with an age- and intelligence quotient-matched sample of 28 adults with ADHD across a range of measures of attention. Study 1 showed that 36.7% of adults with ASD met Diagnostic and Statistical Manual-IV criteria for current ADHD "caseness" (Barkley Current self-report scores questionnaire). Those with a diagnosis of pervasive developmental disorder-not otherwise specified were most likely to describe ADHD symptoms. The ASD group differed significantly from both the ADHD and control groups on total and individual symptom self-report scores. On neuropsychological testing, adults with ASD and ADHD showed comparable performance on tests of selective attention. Significant group differences were seen on measures of attentional switching; adults with ADHD were significantly faster and more inaccurate, and individuals with Asperger's syndrome showed a significantly slower and more accurate response style. Self-reported rates of ADHD among adults with ASD are significantly higher than in the general adult population and may be underdiagnosed. Adults with ASD have attentional difficulties on some neuropsychological measures.

Do stimulants improve functioning in adults with ADHD? A review of the literature

ADHD is prevalent in adulthood and stimulant pharmacotherapy is the primary treatment for uncomplicated presentations. ADHD is associated with significant functional impairment in major life roles. Measurement of the efficacy of stimulant treatment for adult ADHD therefore should include assessment of improvement in role function. A literature search was conducted to identify studies that measured change in function with stimulant treatment in adult ADHD using measures other than global clinical impression or global assessment of function ratings. Five studies were identified that met our search criteria. Evidence of functional improvement with stimulant treatment was found with the following validated self-report measures of functional wellbeing employed across these studies: the Medical Outcome Study 36-item Short Form Health Survey; ADHD Impact Module for Adults; Quality of Life Enjoyment and Satisfaction scale-Short Form; Sheehan Disability Scale, and Social Adjustment Scale-Self-Report. We conclude that investigations using self-report scales provide evidence that stimulant treatment translates into measurable improvement in daily function for adults with ADHD. Further investigation could better characterize the mediators and moderators of individual improvement, an important step towards the personalization of treatment for ADHD in adulthood.

Adult ADHD patient experiences of impairment, service provision and clinical management in England: a qualitative study

BACKGROUND

There is limited evidence of the unmet needs and experiences of adults with Attention Deficit Hyperactivity Disorder (ADHD) in the published scientific literature. This study aimed to explore the experiences of adults in England with ADHD regarding access to diagnostic and treatment services, ADHD-related impairment and to compare experiences between patients diagnosed during adulthood and childhood.

METHODS

In this qualitative study, 30 adults with ADHD were recruited through an ADHD charity (n = 17) and two hospital outpatient clinics for adults with ADHD in England (n = 13). Half of the participants were diagnosed with ADHD during childhood or adolescence and the remainder during adulthood. Semi-structured interviews were conducted and data was analysed using a thematic approach based on Grounded Theory principles.

RESULTS

Analysis revealed five core themes: 'An uphill struggle': the challenge of accessing services, 'Accumulated Psychosocial Burden and the Impact of ADHD', 'Weighing up Costs vs. Benefits of ADHD Pharmacological Treatment', 'Value of Non-pharmacological Treatment' and 'Barriers to Treatment Adherence'. Accessing services and the challenges associated with securing a definitive diagnosis of ADHD in adulthood was an 'uphill struggle', often due to sceptical and negative attitudes towards ADHD by healthcare professionals. ADHD-related impairment had an overwhelmingly chaotic impact on every aspect of patients' lives and many felt ill equipped to cope. A persistent sense of failure and missed potential from living with the impact of ADHD impairment had led to an accumulated psychosocial burden, especially among those diagnosed from late adolescence onwards. In contrast, positive adjustment was facilitated by a younger age at diagnosis. Although medication was perceived as necessary in alleviating impairment, many felt strongly that by itself, it was inadequate. Additional support in the form of psychological therapies or psycho-education was strongly desired. However, few patients had access to non-pharmacological treatment. In some, medication use was often inadequately monitored with little or no follow-up by healthcare professionals, leading to poor adherence and a sense of abandonment from the healthcare system.

CONCLUSION

The findings suggest that the unmet needs of adults with ADHD are substantial and that there is a wide gap between policy and current practice in England.

Emotional dysregulation in adult ADHD: What is the empirical evidence?

Attention deficit/hyperactivity disorder (ADHD) is a common psychiatric disorder characterized by symptoms of inattention, hyperactivity and impulsivity. There is an ongoing discussion whether symptoms of emotional dysregulation should be added to the conceptualization of ADHD in order to describe the psychopathology of ADHD more precisely, at least in adult patients. Symptoms of emotional dysregulation are well defined and seem to be distinct factors of the psychopathology of adult ADHD. Assessment of this psychopathological dimension has shown sufficient reliability and validity. Empirical studies have confirmed a high prevalence of this psychopathological feature in adults with ADHD that compares to the frequency of the ADHD core symptoms, inattention, hyperactivity and impulsivity. Evidence is given that emotional dysregulation has an independent effect on social problems associated with ADHD in adult life. Moreover, pharmacological and psychotherapeutic interventions help to ameliorate emotional dysregulation together with symptoms of inattention and hyperactivity/impulsivity. Thus, there is growing evidence that emotional dysregulation might be recognized as a core feature of ADHD.

Psychotherapy in adult attention deficit hyperactivity disorder: implications for treatment and research

Attention deficit hyperactivity disorder (ADHD) is a risk factor for co-occurring psychiatric disorders and negative psychosocial consequences in adulthood. Previous trials of psychotherapeutic programs for adult ADHD were based on cognitive behavioral psychotherapeutic approaches and showed significant effects. Targets of psychotherapeutic interventions include not only coping with the core symptoms and associated problems such as depression and anxiety, but also probable consequences such as low self-esteem. Improvements in ADHD symptomatology and associated symptoms have been reported after psychotherapeutic treatment. The support of other participants is strongly regarded as helpful by patients in group therapy. This manuscript provides an overview of psychotherapy approaches and results of studies evaluating programs developed to treat adults with ADHD. Finally, the specific requirements of psychotherapy for adult ADHD as well as further research questions will be discussed.

Assessing treatment outcomes in attention-deficit/hyperactivity disorder: a narrative review

OBJECTIVE

To review measures used to assess treatment response in patients with attention-deficit/hyperactivity disorder (ADHD) across the life span.

DATA SOURCES

Keyword searches of English-language articles in the PubMed database up to and including the May 4, 2011, index date were performed with the search strings (1) (attention deficit disorder with hyperactivity [MeSH] OR ADHD) AND (outcome assessment [MeSH] OR adaptation of life skills OR executive function [MeSH]) and (2) (attention deficit disorder with hyperactivity [MeSH] OR ADHD) AND (function OR functioning OR quality of life [MeSH]).

STUDY SELECTION

Articles found through this search were then selected based on relevance to the topic area; no specific quality criteria were applied.

DATA EXTRACTION

Narrative review.

RESULTS

The vast majority of studies assessing ADHD treatments have measured treatment response using ADHD symptom measures. Additional domains relevant for assessing treatment response among children and adults with ADHD include functional impairment, quality of life, adaptive life skills, and executive function. Validated rating scales exist for assessing these additional domains, but there has been minimal research evaluating the sensitivity of these instruments for detecting treatment response in pediatric and adult samples.

CONCLUSIONS

Assessment of treatment outcomes in ADHD should move beyond symptom assessment to incorporate measures of functioning, quality of life, adaptive skills, and executive function, especially when assessing long-term treatment response. The authors recommend a potential battery and schedule of measures that could be used to more comprehensively assess treatment response in patients with ADHD.

Treating attention-deficit/hyperactivity disorder in adults: focus on once-daily medications

OBJECTIVE

To review the efficacy, safety, and abuse liability of approved treatments in adults with attention-deficit/hyperactivity disorder (ADHD), with a focus on once-daily medications.

DATA SOURCES

PubMed was searched for relevant studies/reviews in English from 2002 to 2011 on adult ADHD treatments.

STUDY SELECTION

Keywords used in the search were ADHD, adults, and treatment. Limits included only clinical trials, meta-analyses, randomized controlled trials, and reviews including adults (aged ≥ 19 years).

DATA EXTRACTION

Selection criteria returned 471 publications. Retrieved studies were excluded if they primarily focused on children, treatments not indicated for ADHD, or ADHD and comorbid conditions.

DATA SYNTHESIS

An epidemiologic survey revealed that 10.9% of adults identified with ADHD had received treatment during the prior 12 months. Treatments for ADHD in adults include pharmacologic and nonpharmacologic options. US Food and Drug Administration-approved long-acting stimulants and a nonstimulant with proven efficacy and safety profiles have been developed and include osmotic-release oral system methylphenidate hydrochloride (OROS-methylphenidate), extended-release dexmethylphenidate hydrochloride, mixed amphetamine salts extended release (MAS-XR), the nonstimulant atomoxetine hydrochloride, and the prodrug lisdexamfetamine dimesylate. Long-acting stimulants differ in formulation characteristics used to achieve extended release, with OROS-methylphenidate employing an osmotic-release technology, extended-release dexmethylphenidate hydrochloride and MAS-XR using pH-dependent beads, and lisdexamfetamine dimesylate using prodrug technology. These features variably affect pharmacokinetic characteristics, duration of action, and abuse liability. While all long-acting medications have varied pharmacokinetic features, mechanism of action, and duration of effect, all are generally efficacious and safety profiles are similar.

CONCLUSION

Approved long-acting treatments in adults with ADHD were effective in improving symptoms and were generally well tolerated.

Cognitive behavior therapy for adults with attention-deficit/hyperactivity disorder: a review of recent randomized controlled trials

To review the efficacy of cognitive behavioral therapy for adults with attention deficit hyperactivity disorder. Recent, controlled studies of the efficacy of Cognitive Behavior Therapy (CBT) treatment in adults with ADHD are reviewed. CBT is a feasible and acceptable treatment strategy in medicated adults with ADHD that leads to improvement in ADHD symptoms and co-morbid problems. CBT includes delivery of cognitive and/or emotional strategies to individuals or groups of 4 to 10 participants. The number of CBT sessions may vary from 6 to 14. Blinding may help reduce response bias. Coaching and homework may enhance motivation as well as help in generalizing strategies to patient's daily lives. Outcomes studied include participants' self-reports of symptoms and evaluator reports based on standardized measures of ADHD and its comorbidities. CBT is an effective treatment for adults with ADHD particularly when combined with medication.

An exploratory study of the effectiveness of group narrative therapy on the school behavior of girls with attention-deficit/hyperactivity symptoms

This study explored the effectiveness of group narrative therapy for improving the school behavior of a small sample of girls with attention-deficit/hyperactivity disorder (ADHD). Fourteen clinics referred 9- to 11-year-old girls with a clinical diagnosis of ADHD were randomly assigned to treatment and wait-list control groups. Posttreatment ratings by teachers showed that narrative therapy had a significant effect on reducing ADHD symptoms 1 week after completion of treatment and sustained after 30 days.

Pharmacotherapy for parents with attention-deficit hyperactivity disorder (ADHD): impact on maternal ADHD and parenting

Given the high heritability of the disorder, attention-deficit hyperactivity disorder (ADHD) is common among parents of children with ADHD. Parental ADHD is associated with maladaptive parenting, negative parent-child interaction patterns and a diminished response to behavioural parent training. We describe our previous research demonstrating that stimulant medications for mothers with ADHD are associated with reductions in maternal ADHD symptoms. Although limited beneficial effects on self-reported parenting were also found in our study, the impact of ADHD medications on functional outcomes related to parenting and family interactions may not be sufficient for many families. Many questions remain with regard to how best to treat multiplex ADHD families in which a parent and child have ADHD. In particular, future studies are needed: (1) to evaluate how best to sequence pharmacotherapy, psychosocial treatment for adult ADHD and behavioural parenting interventions; (2) to determine the best approach to maintaining treatment effects over the long term for both parents and children; and (3) to identify individual predictors of treatment response.

Training cognition in ADHD: current findings, borrowed concepts, and future directions

With both its high prevalence and myriad of negative outcomes, Attention-Deficit/Hyperactivity Disorder (ADHD) demands a careful consideration of the efficacy of its treatment options. Although the benefits of medication have a robust empirical background, nonpharmaceutical interventions evoke particular interest, as they are often viewed more favorably by parents. This review pays special attention to the use of working memory and recent cognitive training attempts in ADHD, describing its cognitive, behavioral, and biological effects in relation to current neurological theory of the disorder. While these treatments have demonstrated positive effects on some measures, there are limitations, as studies have failed to demonstrate generalization to critical measures, such as teacher-rated classroom behaviors, and have provided limited but growing evidence of functionally significant improvements in behavior. There is also a clear lack of research on the effects of training on reward systems and self-control. These limitations may be addressed by broadening the scope and procedures of the training and incorporating research concepts from other fields of study. First, it is important to consider the developmental trajectories of brain regions in individuals with the disorder, as they may relate to the effectiveness of cognitive training. Notions from behavioral economics, including delay discounting and framing (i.e., context) manipulations that influence present orientation, also have applications in the study of cognitive training in ADHD. In considering these other domains, we may find new ways to conceptualize and enhance cognitive training in ADHD and, in turn, address current limitations of interventions that fall in this category.

What do we really know about ADHD in college students?

Research on ADHD in college students began in the 1990s and has been steadily increasing in recent years. Because young adults with ADHD who attend college have experienced greater academic success during high school than many peers with the disorder, which is likely to be associated with better overall functioning, the degree to which they experience similar patterns of adjustment difficulties was not initially known. Accumulating research suggests that college students with ADHD experience less academic success and greater psychological and emotional difficulties than other students and use alcohol and drugs at higher rates. However, conclusions to be drawn from this research are limited by the use of small samples that may not be representative of the wider population of students with ADHD, and a lack of diagnostic rigor in identifying students with ADHD to be included in such research. Studies of the effectiveness of psychosocial treatments, medication treatment, and academic accommodations are extremely limited or nonexistent. Issues particularly germane to college students include feigning ADHD and the misuse and diversion of stimulant medication. Given that at least 25 % of college students with disabilities are diagnosed with ADHD, methodologically sound investigations are clearly needed in order to better understand the impact of ADHD on college students' adjustment and to develop and implement interventions that can enhance students' success.

Distinguishing comorbidity and successful management of adult ADHD

OBJECTIVE

Given high rates of comorbidity, lack of awareness and global acceptance, and varying guidelines for its management, adult ADHD may be an especially difficult condition to diagnose and treat. The objective of this review was to explore and characterize similarities and differences among comorbidities associated with adult ADHD.

METHOD

A review of the literature over the past 10 years was performed using Ovid.

RESULTS

A myriad of comorbid conditions such as impulse-control/personality, anxiety, mood, substance use, learning, and sleep disorders overlap with adult ADHD. Furthermore, a number of such conditions have symptoms that can mimic those of ADHD, including hyperactivity, impulsivity, inattention, and disruption of circadian rhythms, adding to the complexity of recognition and diagnosis of ADHD in adults. Extensive research shows that adults with ADHD appear to benefit from treatment with stimulant medications in similar ways as children, including significant improvements on driving performance. However, fear surrounding the abuse of stimulants is an important issue. Nevertheless, evidence suggests that children with ADHD who are treated with stimulant medication are less likely to develop a substance use disorder in adolescence and adulthood.

CONCLUSION

There are a wide range of comorbidities with adult ADHD with many having overlapping symptoms. The benefits observed with ADHD treatment, however, emphasize the importance of recognition and treatment of adult ADHD.

A randomized controlled trial of CBT therapy for adults with ADHD with and without medication

BACKGROUND

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.

METHOD

This was a secondary analysis comparing 23 participants randomized to CBT and Dextroamphetamine 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.

RESULTS

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.

CONCLUSION

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.

“Without a Net”

It is currently recognized that attention deficit/hyperactivity disorder (ADHD) persists into adulthood for more than half of affected individuals. ADHD in adulthood is associated with impairments in most adult roles. Medications are considered an effective treatment for the core symptoms of ADHD. Adjunctive psychosocial treatment, primarily cognitive-behavioral therapy (CBT), is efficacious in cases of residual symptoms and impairments. However, a minority of adults with ADHD may not be able to take medications due to medical contraindications, nonresponse, or intolerable side effects. The goal of this article is to discuss the case of an adult with ADHD who is unable to take medications for ADHD due to cardiac risk. The patient sought a course of CBT for adult ADHD to address difficulties he experienced at work and in his home life. His case illustrates the challenges of and opportunities for CBT for adult ADHD without medications.

Women with Childhood ADHD: Comparisons by Diagnostic Group and Gender

This study compared adult women with childhood ADHD to adult women without childhood ADHD and to adult men with childhood ADHD. The participants, all from a larger longitudinal study, included 30 women and 30 men (approximately age 23 to 24) with childhood ADHD, and 27 women without ADHD. Women with childhood ADHD were matched to comparison women on age, ethnicity, and parental education, and to men with childhood ADHD on age, ethnicity, and IQ. Self- and parent-reports of internalizing, interpersonal, academic, and job impairment, as well as substance use and delinquency indicated group differences on measures of self-esteem, interpersonal and vocational functioning, as well as substance use. Follow-up planned comparison tests revealed that almost all of these differences emerged by diagnostic status, and not by gender. This study adds to research on the negative adult outcomes of ADHD and demonstrates that the outcomes of men and women with childhood ADHD are relatively similar.

Attention-deficit/hyperactivity disorder subtypes in adolescents with comorbid substance-use disorder

BACKGROUND

Little is known about the relationship between attention-deficit/hyperactivity disorder (ADHD) subtypes and substance-use disorder (SUD). As there is literature suggesting different subtype phenotypes, there may be subtype differences in regard to the risk for developing SUD and substance treatment response.

OBJECTIVES

To characterize the sample in a Clinical Trials Network (CTN) study according to ADHD subtypes and baseline psychosocial and substance-use characteristics and to compare subtypes on response to treatment.

METHODS

Secondary analyses on data collected from adolescents (n = 276) diagnosed with ADHD and SUD (non-nicotine) and treated with stimulant medication or placebo and cognitive behavioral therapy (CBT) for substance use. Participants were characterized as inattentive or combined ADHD subtype and compared on baseline characteristics and treatment outcome.

RESULTS

The combined subtype presented with more severe SUDs and higher rates of conduct disorder. There were a greater proportion of boys with inattentive subtype. The inattentive subtype appeared less ready for treatment (greater University of Rhode Island Change Assessment precontemplation scores) with poorer coping skills (poorer problem-solving and abstinence focused coping) at baseline. However, the two subtypes responded equally to treatment even after controlling for baseline differences.

CONCLUSIONS

Findings from this large community sample indicate that there were no subtype differences in treatment response, although there were differences in terms of substance use, antisocial behavior, readiness for treatment, and gender prior to treatment.

SCIENTIFIC SIGNIFICANCE

This study is the first to report on subtype differences for treatment response for non-nicotine SUD in a comorbid ADHD-SUD population. Despite some baseline differences, both subtypes responded equally to treatment, suggesting limited relevance for subtype designation on treatment planning.

Developmental and behavioral disorders through the life span

Developmental and behavioral disorders including intellectual disability, learning disabilities, and attention-deficit/hyperactivity disorder are highly prevalent, chronic health conditions. Despite being versed in caring for children with these conditions, pediatricians might be less prepared for challenging questions from families about the long-term course of these conditions and what can be done to improve outcomes. Through this state-of-the-art review, we provide clinicians with an understanding of the course of these conditions and adult outcomes in several areas including vocational, social, and health domains. We also provide a review of the most current research examining factors that predict or mediate adult outcomes for people with intellectual disability, learning disabilities, and attention-deficit/hyperactivity disorder. On the basis of the current literature, we offer practice recommendations aimed at optimizing adult outcomes for those with these disorders.

Cognitive behaviour therapy in medication-treated adults with ADHD and persistent symptoms: a randomized controlled trial

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) in adulthood is not fully treated by psychopharmacological treatment alone. The main aim of the current study was to evaluate a newly developed cognitive behaviour therapy (CBT) based group programme, the Reasoning and Rehabilitation for ADHD Youths and Adults (R&R2ADHD), using a randomized controlled trial.

METHODS

54 adults with ADHD already receiving psychopharmacological treatment were randomly allocated to an experimental (CBT/MED) treatment condition (n = 27) and a 'treatment as usual' (TAU/MED) control condition (n = 27) that did not receive the CBT intervention. The outcome measures were obtained before treatment (baseline), after treatment and at three month follow-up and included ADHD symptoms and impairments rated by independent assessors, self-reported current ADHD symptoms, and comorbid problems.

RESULTS

The findings suggested medium to large treatment effects for ADHD symptoms, which increased further at three month follow-up. Additionally, comorbid problems also improved at follow-up with large effect sizes.

CONCLUSIONS

The findings give support for the effectiveness of R&R2ADHD in reducing ADHD symptoms and comorbid problems, an improving functions associated with impairment. The implications are that the benefits of R&R2ADHD are multifaceted and that combined psychopharmacological and CBT based treatments may add to and improve pharmacological interventions.

TRIAL REGISTRATION

ACTRN12611000533998 (http://www.ANZCTR.org.au/ACTRN12611000533998.aspx).

Distinguishing symptoms of ADHD from other psychiatric disorders in the adult primary care setting

Attention-deficit/hyperactivity disorder (ADHD) is frequently misdiagnosed or undiagnosed in adults. Owing to the relatively recent recognition of adult ADHD as a valid mental disorder and its overlapping symptomatology with other conditions, primary care physicians often fail to screen for ADHD in patients who present with inattention, impulsivity, and hyperactivity. A substantial proportion of adults with ADHD also have psychiatric comorbidities. Physicians need to recognize the ways in which ADHD symptoms are expressed in adults and distinguish them from symptoms of other disorders, including mood, anxiety, and substance abuse disorders.

The use of between session assignments in ADHD coaching with college students

OBJECTIVE

To provide an analysis of the use of between session assignments (BSA) in ADHD coaching with college students. The article provides a description of the structure and process of using BSA in an academic setting.

METHOD

A brief survey of ADHD coaches is used to evaluate 13 coaching clients engaged in an 8-week structured program. A case study illustrates the process of using BSA with college students.

RESULTS

Overall progress in the ADHD coaching sessions was significantly correlated with coach's rating of the client's quality of BSA during treatment, the client's positive attitude to BSA, and the usefulness of BSA. Treatment gain scores were significantly related to the client's being motivated by a desire to please their parents.

CONCLUSIONS

BSAs can be useful in the context of ADHD coaching with college students.

CBT Without Medications for Adult ADHD: An Open Pilot Study of Five Patients

Medications are considered the primary treatment for symptoms of adult attention-deficit/hyperactivity disorder (ADHD), although medications alone may not produce sufficient functional improvements for many patients. Moreover, some adults with ADHD decline pharmacotherapy due to lack of response, side effects, medical contraindication, or personal choice. This article reports on the clinical outcomes of five adults with ADHD who completed cognitive behavioral therapy (CBT) without concurrent medication treatment. Nonparametric analysis of pretreatment and posttreatment clinical data indicated significant improvements on various measures of ADHD symptoms, overall functioning, depression, and anxiety. Although limited by the small sample size, the current pilot study provides preliminary evidence that CBT may be helpful for adults with ADHD who decline or are unable to take medications in cases in which their symptoms and impairments are relatively mild and uncomplicated. The limitations of this open pilot study and directions for future research also are discussed.

Short cognitive behavioral therapy and cognitive training for adults with ADHD - a randomized controlled pilot study

In clinical practice, a growing need exists for effective non-pharmacological treatments of adult attention-deficit/hyperactivity disorder (ADHD). Here, we present the results of a pilot study of 10 adults with ADHD participating in short-term individual cognitive- behavioral therapy (CBT), 9 adults participating in cognitive training (CT), and 10 controls. Self-report questionnaires, independent evaluations, and computerized neurocognitive testing were collected before and after the treatments to evaluate change. There were distinctive pre-hypotheses regarding the treatments, and therefore the statistical comparisons were conducted in pairs: CBT vs control, CT vs control, and CBT vs CT. In a combined ADHD symptom score based on self-reports, 6 participants in CBT, 2 in CT and 2 controls improved. Using independent evaluations, improvement was found in 7 of the CBT participants, 2 of CT participants and 3 controls. There was no treatment-related improvement in cognitive performance. Thus, in the CBT group, some encouraging improvement was seen, although not as clearly as in previous research with longer interventions. In the CT group, there was improvement in the trained tasks but no generalization of the improvement to the tasks of the neurocognitive testing, the self- report questionnaires, or the independent evaluations. These preliminary results warrant further studies with more participants and with more elaborate cognitive testing.

European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is among the most common psychiatric disorders of childhood that persists into adulthood in the majority of cases. The evidence on persistence poses several difficulties for adult psychiatry considering the lack of expertise for diagnostic assessment, limited treatment options and patient facilities across Europe.

METHODS

The European Network Adult ADHD, founded in 2003, aims to increase awareness of this disorder and improve knowledge and patient care for adults with ADHD across Europe. This Consensus Statement is one of the actions taken by the European Network Adult ADHD in order to support the clinician with research evidence and clinical experience from 18 European countries in which ADHD in adults is recognised and treated.

RESULTS

Besides information on the genetics and neurobiology of ADHD, three major questions are addressed in this statement: (1) What is the clinical picture of ADHD in adults? (2) How can ADHD in adults be properly diagnosed? (3) How should ADHD in adults be effectively treated?

CONCLUSIONS

ADHD often presents as an impairing lifelong condition in adults, yet it is currently underdiagnosed and treated in many European countries, leading to ineffective treatment and higher costs of illness. Expertise in diagnostic assessment and treatment of ADHD in adults must increase in psychiatry. Instruments for screening and diagnosis of ADHD in adults are available and appropriate treatments exist, although more research is needed in this age group.

Current status of cognitive behavioral therapy for adult attention-deficit hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) is a valid and impairing psychological disorder that persists into adulthood in a majority of cases and is associated with chronic functional impairment and increased rates of comorbidity. Cognitive behavioral therapy (CBT) approaches for this disorder have emerged recently, and available evidence from open and randomized controlled trials suggests that these approaches are promising in producing significant symptom reduction. A conceptual model of how CBT may work for ADHD is reviewed along with existing efficacy studies. A preliminary comparison of effect sizes across intervention packages suggests that targeted learning and practice of specific behavioral compensatory strategies may be a critical active ingredient in CBT for adult ADHD. The article concludes with a discussion of future directions and critical questions that must be addressed in this area of clinical research.

Understanding attention-deficit/hyperactivity disorder from childhood to adulthood

Attention deficit/hyperactivity disorder (ADHD) is among the most common neurobehavioral disorders requiring treatment in children and adolescents. The disorder is often chronic, with prominent symptoms and impairment spanning into adulthood. It is often associated with co-occurring disorders, including disruptive, mood, anxiety, and substance abuse disorders. The diagnosis of ADHD is clinically established by review of symptoms and impairment. The biological underpinning of the disorder is supported by genetic, neuroimaging, neurochemistry, and neuropsychological data. All aspects of an individual's life need to be considered in the diagnosis and treatment of ADHD. Multimodal treatment includes educational, family, and individual support. Psychotherapy alone and in combination with medication is helpful for treating patients with ADHD and comorbid disorders. Pharmacotherapy, including stimulants, noradrenergic agents, α-agonists, and antidepressants, plays a fundamental role in the long-term management of ADHD.

Cognitive behavioral therapy vs relaxation with educational support for medication-treated adults with ADHD and persistent symptoms: a randomized controlled trial

CONTEXT

Attention-deficit/hyperactivity disorder (ADHD) in adulthood is a prevalent, distressing, and impairing condition that is not fully treated by pharmacotherapy alone and lacks evidence-based psychosocial treatments.

OBJECTIVE

To test cognitive behavioral therapy for ADHD in adults treated with medication but who still have clinically significant symptoms.

DESIGN, SETTING, AND PATIENTS

Randomized controlled trial assessing the efficacy of cognitive behavioral therapy for 86 symptomatic adults with ADHD who were already being treated with medication. The study was conducted at a US hospital between November 2004 and June 2008 (follow-up was conducted through July 2009). Of the 86 patients randomized, 79 completed treatment and 70 completed the follow-up assessments.

INTERVENTIONS

Patients were randomized to 12 individual sessions of either cognitive behavioral therapy or relaxation with educational support (which is an attention-matched comparison).

MAIN OUTCOME MEASURES

The primary measures were ADHD symptoms rated by an assessor (ADHD rating scale and Clinical Global Impression scale) at baseline, posttreatment, and at 6- and 12-month follow-up. The assessor was blinded to treatment condition assignment. The secondary outcome measure was self-report of ADHD symptoms.

RESULTS

Cognitive behavioral therapy achieved lower posttreatment scores on both the Clinical Global Impression scale (magnitude -0.0531; 95% confidence interval [CI], -1.01 to -0.05; P = .03) and the ADHD rating scale (magnitude -4.631; 95% CI, -8.30 to -0.963; P = .02) compared with relaxation with educational support. Throughout treatment, self-reported symptoms were also significantly more improved for cognitive behavioral therapy (beta = -0.41; 95% CI, -0.64 to -0.17; P <001), and there were more treatment responders in cognitive behavioral therapy for both the Clinical Global Impression scale (53% vs 23%; odds ratio [OR], 3.80; 95% CI, 1.50 to 9.59; P = .01) and the ADHD rating scale (67% vs 33%; OR, 4.29; 95% CI, 1.74 to 10.58; P = .002). Responders and partial responders in the cognitive behavioral therapy condition maintained their gains over 6 and 12 months.

CONCLUSION

Among adults with persistent ADHD symptoms treated with medication, the use of cognitive behavioral therapy compared with relaxation with educational support resulted in improved ADHD symptoms, which were maintained at 12 months.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00118911.

Efficacy of meta-cognitive therapy for adult ADHD

OBJECTIVE

The authors investigated the efficacy of a 12-week manualized meta-cognitive therapy group intervention designed to enhance time management, organization, and planning in adults with attention deficit hyperactivity disorder (ADHD).

METHOD

Eighty-eight clinically referred adults who met DSM-IV criteria for ADHD according to clinical and structured diagnostic interviews and standardized questionnaires were stratified by ADHD medication use and otherwise randomly assigned to receive meta-cognitive therapy or supportive psychotherapy in a group modality. Meta-cognitive therapy uses cognitive-behavioral principles and methods to impart skills and strategies in time management, organization, and planning and to target depressogenic and anxiogenic cognitions that undermine effective self-management. The supportive therapy condition controlled for nonspecific aspects of treatment by providing support while avoiding discussion of cognitive-behavioral strategies. Therapeutic response was assessed by an independent (blind) evaluator via structured interview before and after treatment as well as by self-report and collateral informant behavioral ratings.

RESULTS

General linear models comparing change from baseline between treatments revealed statistically significant effects for self-report, collateral report, and independent evaluator ratings of DSM-IV inattention symptoms. In dichotomous indices of therapeutic response, a significantly greater proportion of members of the meta-cognitive therapy group demonstrated improvement compared with members of the supportive therapy group. Logistic regression examining group differences in operationally defined response (controlling for baseline ADHD severity) revealed a robust effect of treatment group (odds ratio=5.41; 95% CI=1.77-16.55).

CONCLUSIONS

Meta-cognitive therapy yielded significantly greater improvements in dimensional and categorical estimates of severity of ADHD symptoms compared with supportive therapy. These findings support the efficacy of meta-cognitive therapy as a viable psychosocial intervention.

Attention deficit hyperactivity disorder in adults

OBJECTIVE

To examine available literature regarding attention deficit hyperactivity disorder (ADHD) in adults.

METHODS

An electronic literature search of peer-reviewed English language articles using MEDLINE (without time limits) was undertaken.

RESULTS

Symptoms of ADHD in adults exert a substantial negative impact on daily life, including work, social life and relationships. Co-morbidities are common, further impairing quality of life. Diagnosis of adult ADHD can be difficult, as current criteria require evidence of symptom onset before the age of 7 years and impact on activities typically undertaken by children. Drug therapy is the first-line treatment for adult ADHD, particularly stimulant medication. However, methylphenidate (MPH) immediate-release tablets require three or more times daily dosing, which can impact on compliance, while demonstrating a loss of symptomatic benefit later in the day. Extended-release preparations of MPH, mixed amphetamine salts and dexamphetamine can provide symptom control for 6-12 h and the non-stimulant atomoxetine has demonstrated benefit in reducing ADHD symptoms. These therapies are generally well tolerated, but may be associated with adverse effects on the cardiovascular system, which need to be further assessed in controlled clinical trials. Psychological therapy may be beneficial in adults who continue to experience clinically significant symptoms while receiving pharmacotherapy.

CONCLUSION

Further research in all areas of adult ADHD is urgently needed.

Women with ADHD: it is an explanation, not the excuse du jour

PURPOSE

To call attention to attention deficit hyperactivity disorder (ADHD) as a psychiatric disorder that can limit women's potential and overall well-being.

CONCLUSION

ADHD, a legitimate neurobiological disorder that is often hidden, ignored, or misdiagnosed among women, causes them to struggle in silence. Proper interventions for women with ADHD that provide significant attention to context mitigate challenges across psychological, academic, occupational, and social domains. This should amend the diagnosis du jour concept, thereby supporting mechanisms to improve early intervention and positive outcomes.

PRACTICE IMPLICATIONS

Primary care practitioners play a central role in recognition, intervention, and recovery of women with ADHD.

Adult ADHD and its comorbidities, with a focus on bipolar disorder

Attention deficit hyperactivity disorder (ADHD) is a syndrome that most often presents in childhood. However, the condition is also relatively common in adults, with prevalence rates reaching 5% in the general population, with more than half the children affected by ADHD retaining the condition during their adult years. While the disorder in children is most often described as a disorder involving hyperactivity and impulsiveness, ADHD presents with very different characteristics in adulthood, notably with less externalizing symptoms and with a higher rate of psychiatric comorbidities, including major depressive disorder, bipolar disorder (BD), anxiety disorders and substance abuse. This review will focus on the evidence relating to bipolar disorder BD and its potential link with ADHD, looking at epidemiological, familial and neuroimaging studies. The comorbid presentation of people suffering with ADHD and BD (ADHD/BD) is associated with a more severe disease course, more severe mood disorder symptoms, and lower functional scores. Importantly, the co-segregation of these two conditions makes ADHD diagnosis challenging because its symptoms are often mistakenly assumed to be part of BD. As a result, patients with comorbid ADHD/BD are under-diagnosed and under-treated. Optimal diagnosis, understanding and treatment of the comorbid condition are important, as ADHD/BD has been associated with significant functional impairment and suboptimal treatment responses when compared to ADHD or BD populations alone.

Randomized, controlled trial of atomoxetine for attention-deficit/hyperactivity disorder in adolescents with substance use disorder

OBJECTIVE

To evaluate the effect of atomoxetine hydrochloride versus placebo on attention-deficit/hyperactivity disorder (ADHD) and substance use disorder (SUD) in adolescents receiving motivational interviewing/cognitive behavioral therapy (MI/CBT) for SUD.

METHOD

This single-site, randomized, controlled trial was conducted between December 2005 and February 2008. Seventy adolescents (13 through 19 years of age) with Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) ADHD, a DSM-IV ADHD checklist score greater than or equal to 22, and at least one nontobacco SUD were recruited from the community. All subjects received 12 weeks of atomoxetine hydrochloride + MI/CBT versus placebo + MI/CBT. The main outcome measure for ADHD was self-report DSM-IV ADHD checklist score. For SUD, the main outcome was self-report number of days used nontobacco substances in the past 28 days using the Timeline Followback interview.

RESULTS

Change in ADHD scores did not differ between atomoxetine + MI/CBT and placebo + MI/CBT (F4,191 = 1.23, p = .2975). Change in days used nonnicotine substances in the last 28 days did not differ between groups (F3,100 = 2.06, p = .1103).

CONCLUSIONS

There was no significant difference between the atomoxetine + MI/CBT and placebo + MI/CBT groups in ADHD or substance use change. The MI/CBT and/or a placebo effect may have contributed to a large treatment response in the placebo group. Clinical Trials Registry Information-A Randomized, Placebo-Controlled Trial of Atomoxetine for Attention-Deficit/Hyperactivity Disorder in Adolescents with Substance Use Disorder. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00399763.

Life impairments in adults with medication-treated ADHD

OBJECTIVE

In developing psychosocial approaches to augment outcomes for medication-treated adults with ADHD, it is important to understand what types of life-impairments are most affected by continued ADHD symptoms that occur despite medication treatment. This may assist in delineating targets for interventions, as well as assessments of functional outcomes that are sensitive to change in this population.

METHOD

The sample consists of 105 adults with ADHD presenting for entry into clinical trials of CBT for residual ADHD. Life impairments are rated by a clinician using the LIFE-RIFT, which has subscales for work impairment, interpersonal impairment, life-satisfaction, and recreation, ADHD symptoms using the ADHD Rating Scale, overall ADHD severity using the clinical global impression, and associated distress using the Hamilton Depression and Anxiety Rating Scales.

RESULTS

The most problematic impairments are in the domain of work, followed by interpersonal. Generally, the subscales of the LIFE-RIFT are associated, at the bivariate level, with all 4 symptom indices. Work and interpersonal impairments are uniquely associated with overall severity of ADHD symptoms using both the CGI and the ADHD Rating Scale. However interpersonal and life-satisfaction impairments are uniquely associated with depression, and life-satisfaction is uniquely associated with anxiety.

CONCLUSION

In medication-treated adults with ADHD, work and interpersonal impairments appear to be the most problematic areas of life-impairment, which are uniquely associated with ADHD severity. Life-satisfaction appears to be uniquely associated with distress as defined by anxiety and depression symptoms, with interpersonal impairments also playing a role. Psychosocial treatments for medication treated adults should target work and interpersonal domains and should include skills for managing associated distress.