Cognitive-Behavioral Therapy for ADHD in Adolescents: Clinical Considerations and a Case Series

Addressing co-occurring conditions in behavioural therapy for tic disorders: a review and guideline

Co-occurring psychiatric conditions are very common in tic disorders and Tourette syndrome. These additional symptoms are often detrimental to quality of life and may impact upon the implementation and efficacy of evidence-based behavioural therapies (BT) for tics. Combining a review of the available literature, relevant theory, and expert clinical practice, we present a guideline for implementing behavioural and psychosocial interventions when common comorbidities are present. These include attention-deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), anxiety, disruptive behaviour, autism spectrum disorder (ASD) and depression. Practical recommendations are provided for assessment, formulation and management of specific and multiple comorbidities in BT for both children and adults. Despite comorbidities being common in tic disorders, few studies have comprehensively addressed how they may influence the efficacy or implementation of existing therapies or how such treatments may need to be modified or sequenced. We outline recommendations for future research, including randomised control trials of BT for those with specific or multiple comorbidities, as well as adequately powered sub-group analyses within larger scale trials or naturalistic study designs. Transdiagnostic models of psychiatric disorders and treatment, including modular cross-diagnostic therapies, which recognise the dimensionality of psychiatric disorders are also highlighted as an important focus in treatment development in tic disorders.

Interplay Among Self-Regulation Processes Over Time for Adolescents in the Context of Chronic Stress

Developmental changes in self-regulation are theorized to underlie adolescents' engagement in risky behaviors, physical health, mental health, and transition to adulthood. Two central processes involved in self-regulation, self-management (i.e., planning, concentration, and problem-solving) and disinhibition (e.g., distractibility and impulsivity) appear to develop asynchronously and may be differentially activated based on contextual factors. Using a sample identified based on exposure to chronic stressors, we investigated how changes in self-management and disinhibition affect each other over time and whether these changes occur differently for boys and girls. Youth aged 8-16 (N = 708) who attended a U.S. summer camp self-reported on components of disinhibition and self-management. Cross-lagged structural equation modeling revealed a reciprocal relationship between self-management and disinhibition, with anger coping and distractibility emerging as critical factors in shaping this relationship. Changes in concentration, planning, and problem-solving were components of self-management that drove subsequent changes in boys' disinhibition (for girls, however, planning did not). Autocorrelations for both broad processes remained strong from year to year, indicating a high degree of stability in rank order despite the myriad of physical, cognitive and socioemotional changes that occur during adolescence. We discuss implications of the reciprocal model with a focus on the relative pliability of components from each process and strategies for shaping them. Planning, concentration and distractibility are highlighted as potential targets for intervention.

School-Based Cognitive-Behavioral Therapy in an Inclusion Model for an Adolescent with Comorbid Major Depressive Disorder, Generalized Anxiety Disorder, and Attention Deficit Hyperactivity Disorder : A Case Study

The goal of the current case study was to illustrate evidence-based cognitive-behavioral treatment (CBT) for an adolescent female with comorbid major depressive disorder, generalized anxiety disorder, attention deficit hyperactivity disorder, suicidal ideations, and a history of multiple involuntary hospitalizations. Multimodal assessment of the child’s symptoms was conducted, including parent, teacher, and child self-report, academic data, and hospital records to inform case conceptualization. Treatment included a combination of psychoeducation, cognitive restructuring, positive self-talk, relaxation skills, and the support of a school-based personal aide. Significant improvements with inattentive, anxiety, and depressive symptoms were reported, with gains being maintained at 1 year follow-up. In addition to a reduction of reported psychosocial problems, treatment benefits also included a decrease in classroom disruptions, improvement in academic performance, and withdrawal of paraprofessional support at school. This study illustrates the use of school-based CBT strategies coupled with additional focused Tier 4 behavior supports as an efficacious treatment for youth with significant comorbidity.

Understanding ADHD: Toward an Innovative Therapeutic Intervention

Attention deficit hyperactivity disorder (ADHD) is a pervasive condition affecting persons across all age groups, although it is primarily diagnosed in children. This neurological condition affects behavior, learning, and social adjustment and requires specific symptomatic criteria to be fulfilled for diagnosis. ADHD may be treated with a combination of psychological or psychiatric therapeutic interventions, but it often goes unattended. People with ADHD face societal bias challenges that impact how they manage the disorder and how they view themselves. This paper summarizes the present state of understanding of this disorder, with particular attention to early diagnosis and innovative therapeutic intervention. Contemporary understanding of the mind-brain duality allows for innovative therapeutic interventions based on neurological stimulation. This paper introduces the concept of neurostimulation as a therapeutic intervention for ADHD and poses the question of the relationship between patient adherence to self-administered therapy and the aesthetic design features of the neurostimulation device. By fabricating devices that go beyond safety and efficacy to embrace the aesthetic preferences of the patient, it is proposed that there will be improvements in patient adherence to a device intended to address ADHD.

Equine-Assisted Services for Children with Attention-Deficit/Hyperactivity Disorder: A Systematic Review

Objective: This systematic review evaluated equine-assisted activities and therapies (EAATs), formerly referred to as equine-assisted services (EAS), in children and youth (ages 6-18 years) with attention-deficit/hyperactivity disorder (ADHD), according to the International Classification of Functioning, Disability, and Health. Methods: Electronic database searches were conducted of studies from inception through December 2020. Results: A total of 12 articles were included: 8 noncontrolled prospective studies and 4 randomized-controlled trials (RCTs). Furthermore, seven of moderate methodological quality studies and five of moderate high methodological quality studies were included. Evidence was found for the effectiveness of various forms of EAS, including equine-assisted physical therapy (EAPT) and therapeutic riding (TR). Improvements in body functions and structures (n = 10) were found in the domains of mental and neuromusculoskeletal functions, as well as functions of the cardiovascular system using EAPT (n = 6). Limited evidence was found regarding the positive effect on activity and participation (n = 4) following TR interventions. Quality of life (QoL) was improved in both TR and EAPT (n = 4). Conclusion: There seems to be preliminary evidence that EAS may be beneficial in promoting the physiological functions of body systems for children with ADHD. The influence on participation and QoL still requires further evidence. More generally, further controlled studies, including bigger sample sizes, are needed to understand the specific effects of different EAS on the core symptoms and consequence of ADHD.

Genetic and environmental aetiologies of associations between dispositional mindfulness and ADHD traits: a population-based twin study

To get additional insight into the phenotype of attentional problems, we examined to what extent genetic and environmental factors explain covariation between lack of dispositional mindfulness and attention-deficit/hyperactivity disorder (ADHD) traits in youth, and explored the incremental validity of these constructs in predicting life satisfaction. We used data from a UK population-representative sample of adolescent twins (N = 1092 pairs) on lack of dispositional mindfulness [Mindful Attention Awareness Scale (MAAS)], ADHD traits [Conners' Parent Rating Scale-Revised (CPRS-R): inattentive (INATT) and hyperactivity/impulsivity (HYP/IMP) symptom dimensions] and life satisfaction (Students' Life Satisfaction Scale). Twin model fitting analyses were conducted. Phenotypic correlations (r_p) between MAAS and CPRS-R (INATT: r_p = 0.18, HYP/IMP: r_p = 0.13) were small, but significant and largely explained by shared genes for INATT (% r_p INATT-MAAS due to genes: 93%, genetic correlation r_A = 0.37) and HYP/IMP (% r_p HYP/IMP-MAAS due to genes: 81%; genetic correlation r_A = 0.21) with no significant contribution of environmental factors. MAAS, INATT and HYP/IMP significantly and independently predicted life satisfaction. Lack of dispositional mindfulness, assessed as self-reported perceived lapses of attention (MAAS), taps into an aspect of attentional functioning that is phenotypically and genetically distinct from parent-rated ADHD traits. The clinically relevant incremental validity of both scales implicates that MAAS could be used to explore the underlying mechanisms of an aspect of attentional functioning that uniquely affects life satisfaction and is not captured by DSM-based ADHD scales. Further future research could identify if lack of dispositional mindfulness and high ADHD traits can be targeted by different therapeutic approaches resulting in different effects on life satisfaction.

A randomized controlled trial of cognitive behavioral therapy for ADHD in medication-treated adolescents

OBJECTIVE

To test cognitive behavioral therapy (CBT) for persistent attention-deficit hyperactivity disorder (ADHD) symptoms in a sample of medication-treated adolescents.

METHODS

Forty-six adolescents (ages 14-18), with clinically significant ADHD symptoms despite stable medication treatment were randomly assigned to receive CBT for ADHD or wait list control in a cross-over design. Twenty-four were randomized to CBT, 22 to wait list, and 15 crossed-over from wait list to CBT. A blind independent evaluator (IE) rated symptom severity on the ADHD Current Symptom Scale, by adolescent and parent report, and rated each subject using the Clinical Global Impression Severity Scale (CGI), a global measure of distress and impairment. These assessments were performed at baseline, 4-months (post-CBT or post wait list), and 8-months (post-treatment for those originally assigned to the wait list condition and 4-month follow-up for those originally assigned to CBT).

TRIAL REGISTRATION

http://clinicaltrials.gov/show/NCT01019252.

RESULTS

Using all available data, mixed effects modeling, and pooling for the wait list cross-over, participants who received CBT received a mean score 10.93 lower on the IE-rated parent assessment of symptom severity (95% CI: -12.93, -8.93; p < .0001), 5.24 lower on the IE-rated adolescent assessment of symptom severity (95% CI: -7.21, -3.28; p < .0001), and 1.17 lower IE-rated CGI (95% CI: -1.39, -.94; p < .0001). Results were consistent across 100 multiple imputations (all p < .0001). There was a greater proportion of responders after CBT by parent (50% vs. 18%, p = .00) and adolescent (58% vs. 18% p = .02) report.

CONCLUSIONS

This study demonstrates initial efficacy of CBT for adolescents with ADHD who continued to exhibit persistent symptoms despite medications.