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

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.

Early Neural Markers of Implicit Attitudes: N170 Modulated by Intergroup and Evaluative Contexts in IAT

The Implicit Association Test (IAT) is the most popular measure to evaluate implicit attitudes. Nevertheless, its neural correlates are not yet fully understood. We examined event related potentials (ERPs) in response to face- and word processing while indigenous and non-indigenous participants performed an IAT displaying faces (ingroup and outgroup members) and words (positive and negative valence) as targets of category judgments. The N170 component was modulated by valence of words and by ingroup/outgroup face categorization. Contextual effects (face–words implicitly associated in the task) had an influence on the N170 amplitude modulation. On the one hand, in face categorization, right N170 showed differences according to the association between social categories of faces and affective valence of words. On the other, in word categorization, left N170 presented a similar modulation when the task implied a negative-valence associated with ingroup faces. Only indigenous participants showed a significant IAT effect and N170 differences. Our results demonstrate an early ERP blending of stimuli processing with both intergroup and evaluative contexts, suggesting an integration of contextual information related to intergroup attitudes during the early stages of word and face processing. To our knowledge, this is the first report of early ERPs during an ethnicity IAT, opening a new branch of exchange between social neuroscience and social psychology of attitudes.

Decision-making in people who relapsed to driving under the influence of alcohol

BACKGROUND

Alcohol use has been previously associated with neurocognitive impairments, especially in decision-making cognition. However, some studies have shown little to no decision-making deficits in relation to different characteristics of people with drinking problems. Relapsing to driving under the influence (DUI) of alcohol is an important issue with legal and psychosocial aspects. We evaluated decision-making performance in second-time DUI offenders by using the Iowa Gambling Task (IGT).

METHOD

Thirty-four male second-time DUI offenders who had been selected for an official psychoeducational rehabilitation program and 31 healthy controls that were matched for age, education, and alcohol use were included. Along with psychiatric assessment, we applied conventional neuropsychological testing comprising cognitive set-shifting, response inhibition, attention, and visuospatial abilities. Also, we used the Temperament and Character Inventory (TCI) to assess personality patterns. A computerized version of IGT was used.

RESULTS

No significant differences were found between the groups in regard to sociodemographics and conventional neuropsychological testing. DUI participants had significantly higher scores only in "self-transcendence" subdomain of TCI. On the fifth block of the IGT, DUI participants had significantly lower net scores than controls (U = 380.0, p < 0.05). Also, DUI participants chose significantly more risky decks compared to controls.

CONCLUSIONS

Our results suggest that there may be subtle decision-making deficits in DUI participants, which goes undetected on conventional neuropsychological testing and which is not correlated with TCI subdomains related with impulsivity patterns.

Classical conditioning in the vegetative and minimally conscious state

Pavlovian trace conditioning depends on the temporal gap between the conditioned and unconditioned stimuli. It requires, in mammals, functional medial temporal lobe structures and, in humans, explicit knowledge of the temporal contingency. It is therefore considered to be a plausible objective test to assess awareness without relying on explicit reports. We found that individuals with disorders of consciousness (DOCs), despite being unable to report awareness explicitly, were able to learn this procedure. Learning was specific and showed an anticipatory electromyographic response to the aversive conditioning stimulus, which was substantially stronger than to the control stimulus and was augmented as the aversive stimulus approached. The amount of learning correlated with the degree of cortical atrophy and was a good indicator of recovery. None of these effects were observed in control subjects under the effect of anesthesia (propofol). Our results suggest that individuals with DOCs might have partially preserved conscious processing, which cannot be mediated by explicit reports and is not detected by behavioral assessment.

Can electromyography objectively detect voluntary movement in disorders of consciousness?

Determining conscious processing in unresponsive patients relies on subjective behavioural assessment. Using data from hand electromyography, the authors studied the occurrence of subthreshold muscle activity in response to verbal command, as an objective indicator of awareness in 10 disorders of consciousness patients. One out of eight vegetative state patients and both minimally conscious patients (n = 2) demonstrated an increased electromyography signal specifically linked to command. These findings suggest electromyography could be used to assess awareness objectively in pathologies of consciousness.

[Neurobiology of consciousness]

Disorders of consciousness have captivated neurologists, neuroscientists, and philosophers for decades, but few consistent studies have been conducted on these conditions due to their difficult experimental approach. In recent years, an increasing number of cognitive neuroscience research groups have examined the physiology of consciousness from an experimental perspective, despite the methodological and epistemological complexities of the field. While describing consciousness can be challenging, a close definition must acknowledge a combination of wakefulness and awareness. Form a neurobiological standpoint, it has been argued that the ascending reticular system and its thalamic projections are critical in modulating awareness and wakefulness sleep cycles. Awareness may be a function of the neural networks within the cortex, the thalamus, and the cortico-cortical system. Different models have been employed to tackle this difficult problem, including non-invasive in vivo studies, examination of conscious patients with brain lesions, and studies on both animals and patients with disorders of consciousness. This article reviews the scientific evidence for the neural basis of conscious and unconscious processes in different states of consciousness, focusing on patients in the vegetative and minimally conscious state.

Strategies of Buenos Aires waiters to enhance memory capacity in a real-life setting

Human learning and memory evaluation in real-life situations remains difficult due to uncontrolled variables. Buenos Aires waiters, who memorize all the orders without written support, were evaluated in situ. Waiters received either eight different orders and customers remained seated in their original locations (OL), or changed locations (CL). Match between orders, subjects and location was decreased only in CL. Waiters’ feature/location strategy links client with position at the table and beverage later. The hypothesis we raise is that memory-schemas link working memory to long-term memory networks through rapid encoding, making the information resistant to interference and enabling its fast retrieval if necessary cues are present.

Prefrontal and executive attention network lesions and the development of attention-deficit/hyperactivity symptomatology

OBJECTIVE

To investigate the association between focal stroke lesions of Posner's executive attention network and a specific region of interest in the frontal lobes (orbital frontal and mesial frontal) and either attention-deficit/hyperactivity disorder (ADHD) or traits of the disorder (ADHD symptomatology).

METHOD

Twenty-nine children with focal stroke lesions were studied with standardized psychiatric assessments and anatomical brain magnetic resonance imaging. The pattern of lesion overlap in subjects with ADHD symptomatology was determined.

RESULTS

Fifteen of 28 subjects with no prestroke ADHD were diagnosed with ADHD symptomatology at the time of assessment. The extent of lesions within the executive attention network was marginally related to ADHD symptomatology (p = .088; effect size = 0.66), whereas the extent of lesions in the specific frontal region of interest was significantly related to ADHD symptomatology (p = .040; effect size = 0.82).

CONCLUSIONS

Lesions within Posner's executive attention network and its orbital frontal connections may be linked to important mechanisms in the expression of ADHD symptomatology after childhood stroke. These findings are consistent with functional and structural imaging findings in studies of idiopathic ADHD.

Impaired set-shifting and dissociable effects on tests of spatial working memory following the dopamine D2 receptor antagonist sulpiride in human volunteers

RATIONALE

Dopamine (DA) D(2) receptor antagonists have been shown to produce similar impairments to those seen in Parkinson's disease. These include working memory and set-shifting deficits. Theories of DA function have predicted that distraction or impaired switching may be important determinants of such deficits.

OBJECTIVES

In order to test these hypotheses, we have followed up our previous findings with more refined tests (1) that allow measurement of spatial working memory (SWM) and distraction, (2) that allow separation of executive and mnemonic components of SWM and (3) that allow isolation of set-shifting from learning deficits.

METHODS

Thirty-six young healthy male volunteers were tested on two occasions after oral administration of either 400 mg sulpiride or placebo. All participants performed the delayed response task. Sixteen participants received task-irrelevant distractors during this task, and were also given a self-ordered SWM test. The remaining participants were given delayed response tasks with task-relevant distractors, and tests of attentional and task set-shifting.

RESULTS

Sulpiride impaired performance of the delayed-response task both without distraction and with task-relevant distraction. By contrast, the drug protected against deficits from task-irrelevant distraction seen in the placebo group. Task set-switching was also impaired by sulpiride, with participants being slower to respond on switch trials compared with non-switch trials. There was also a trend for attentional set-shifting to be impaired following sulpiride. In contrast, self-ordered SWM performance was enhanced by sulpiride on the second test session only.

CONCLUSIONS

These results support models of central DA function that postulate a role in switching behaviour, and in certain aspects of working memory.

Attention function after childhood stroke

We investigated attentional outcome after childhood stroke and orthopedic diagnosis in medical controls. Twenty-nine children with focal stroke lesions and individually matched children with clubfoot or scoliosis were studied with standardized attention and neuroimaging assessments. Stroke lesions were quite varied in location and commonly involved regions implicated in Posner's model of attention networks. Children with stroke lesions performed significantly more poorly regarding attention function compared with controls. Performance on the Starry Night, a test demanding alerting and sensory-orienting but not executive attention function, was significantly associated with lesion size in the alerting and sensory-orienting networks but not the executive attention network. Furthermore, earlier age at lesion acquisition was significantly associated with poorer attention function even when lesion size was controlled. These findings support the theory of dissociable networks of attention and add to evidence from studies of children with diffuse and focal brain damage that early insults are associated with worse long-term outcomes in many domains of neuropsychological function. In addition, these results may provide clues towards the understanding of mechanisms underlying attention in children.

Verbal learning and memory after childhood stroke

Verbal learning and memory (VLM) following pediatric stroke was characterized in a cross-sectional neuropsychological and neuroimaging study of 26 subjects, aged 5 to 17, with a history of pediatric stroke and 26 age, SES, and gender matched orthopedic controls. Further comparisons were made between the VLM profiles of stroke subjects with right versus left hemisphere lesions and early (> 12 months) versus late (12 months) strokes. Overall, stroke subjects scored significantly lower than control subjects on several VLM indices (California Verbal Learning Test-Children; CVLT-C), as well as on measures of intellectual functioning (IQ) and auditory attention/working memory (Digit Span). Subgroup analyses of the stroke population found no significant differences in VLM, Digit Span, Verbal IQ or Performance IQ when left-hemisphere lesion subjects were compared to right-hemisphere lesion subjects. In contrast, early strokes were associated with significantly fewer words recalled after delay, reduced discriminability (fewer correct hits relative to false positive errors on recognition testing), and relatively worse auditory attention/working memory scores (Digit Span). These findings indicate that pediatric stroke subjects demonstrated more VLM impairment than control subjects, and early strokes were associated with greater recall and recognition deficits. In stark contrast with adult-onset stroke, both left- and right-hemisphere lesions during childhood resulted in similar VLM performance.

Attention deficit hyperactivity disorder and neurocognitive correlates after childhood stroke

We investigated the frequency and neurocognitive correlates of attention deficit hyperactivity disorder and traits of this disorder (ADHD/Traits) after childhood stroke and orthopedic diagnosis in medical controls. Twenty-nine children with focal stroke lesions and individually matched children with clubfoot or scoliosis were studied with standardized psychiatric, intellectual, academic, adaptive, executive, and motivation function assessments. Lifetime ADHD/Traits were significantly more common in stroke participants with no prestroke ADHD than in orthopedic controls (16/28 vs. 7/29; Fisher's Exact p < .02). Lifetime ADHD/Traits in the orthopedic controls occurred exclusively in males with clubfoot (7/13; 54%). Participants with current ADHD/Traits functioned significantly worse (p < .005) than participants without current ADHD/Traits on all outcome measures. Within the stroke group, current ADHD/Traits was associated with significantly lower verbal IQ and arithmetic achievement (p < .04), more nonperseverative errors (p < .005), and lower motivation (p < .004). A principal components analysis of selected outcome variables significantly associated with current ADHD/Traits revealed "impaired neurocognition" and "inattention-apathy" factors. The latter factor was a more consistent predictor of current ADHD/Traits in regression analyses. These findings suggest that inattention and apathy are core features of ADHD/Traits after childhood stroke. This association may provide clues towards the understanding of mechanisms underlying the syndrome.

Putamen lesions and the development of attention-deficit/hyperactivity symptomatology

OBJECTIVE

To investigate the association between focal stroke lesions of the putamen and either attention-deficit/hyperactivity disorder or traits of the disorder (ADHD/Traits).

METHOD

Twenty-five children with focal stroke lesions were studied with standardized psychiatric assessments and anatomic brain magnetic resonance imaging. The pattern of lesion overlap in subjects with ADHD/Traits was determined.

RESULTS

Fifteen of 25 subjects had ADHD/Traits. The densest area of overlapping lesions (n = 7) in subjects with ADHD/Traits included the posterior ventral putamen. The median lesion volume was 9.7 cm3, and the distribution was highly skewed. Lesion volume was not associated with ADHD/Traits. Therefore the following analyses focused on the 13 subjects with lesions < 10 cm3: ADHD/Traits were exhibited in 6/7 subjects with putamen lesionsversus 2/6 with no putamen lesions (Fisherexacttestp= .1). Half (4/8) of the subjects with ADHD/Traits had overlapping lesions encompassing the posterior ventral putamen. None of the 5 subjects without ADHD/Traits had lesions in this empirically derived region of interest (Fisher exact test p = .1).

CONCLUSIONS

Lesions within the dopamine-rich ventral putamen, which is part of the ventral or limbic striatum, tended to increase the risk of ADHD/Traits. ADHD/Traits may therefore be a disinhibition syndrome associated with dysfunction in this cortical-striato-thalamocortical loop.

Psychiatric disorders after childhood stroke

OBJECTIVES

To determine the rate, types, and correlates of psychiatric disorder (PD) following stroke and orthopedic disorders in children and adolescents.

METHOD

Children aged 5 to 19 were assessed. The study used a cross-sectional design that compared 29 stroke subjects with 29 congenital clubfoot or scoliosis subjects. Assessments of psychiatric status; cognitive, adaptive, academic, and family functioning; family psychiatric history; neuroimaging; and neurological status were conducted. The main outcome measure was a current PD not present before the stroke or orthopedic disorder.

RESULTS

Poststroke PD occurred significantly more often than postorthopedic diagnosis PD (17/29 [59%] versus 4/29 [14%], p < or =.001). Subjects with ongoing poststroke PD had significantly more impaired intellectual and adaptive functioning, higher intensity family psychiatric history scores, and tended toward higher neurological severity index scores, but they were not different regarding lesion volume or family functioning compared with stroke subjects without PD. Regression analyses showed that neurological severity and family psychiatric history independently contributed significantly to predicting PD.

CONCLUSIONS

The data suggest that there are significant biopsychosocial correlates of PD in children with focal neurological lesions. These include a relatively abnormal neurological exam, lower IQ, and increased family psychopathology.