by Joye C. Anestis
At PBB, we have written quite a bit about attention-deficit/hyperactivity disorder (ADHD) in an effort to spread knowledge that it is a legitimate diagnosis (albeit one that is often inappropriately diagnosed). The clinical psychology field, in conjunction with psychiatry, is still trying to determine the best practices in treating this troublesome disorder. In children, stimulant medication, behavioral parent training, and behavioral classroom interventions are all considered ESTs for ADHD. Usually, these treatments are administered in combination to achieve the most comprehensive results. For example, MTA (1999) found equivalent ADHD symptom reduction for a group treated with medication alone and a group treated with medication combined with behavioral treatments (behavioral parent training, behavioral classroom interventions, Pelham's summer treatment program). Furthermore, children receiving the combined treatment experienced greater improvement in common non-ADHD domains, such as depression and anxiety, greater parental satisfaction with the treatment, and overall lower medication dosages.
While large amounts of research is regularly conducted about ADHD in childhood, relatively little is known about the diagnosis and treatment of ADHD in adulthood. Of the literature that does exist, most of it focuses on pharmacotherapy and little addresses the utility of psychotherapy, even though psychotherapy is known to be beneficial for children. A recent study (Bramham et al. 2009) examined whether group CBT would be beneficial for adults with ADHD. As is seen from the MTA study cited above, medication addresses the core ADHD symptoms, things like inattention, hyperactivity, and poor concentration. Individuals with ADHD, however, also suffer from a variety of additional concerns that are not addressed by stimulant medications. Adults with ADHD, for example, often suffer from comorbid depression, anxiety, and substance use; academic underachievement, problems with work, relationship difficulties, and problematic social interactions; and low self-esteem (importantly, these same problems also effect children with ADHD and might be exacerbated in adults who were not diagnosed in childhood). Bramham et al. (2009) hypothesized that a group CBT program will help alleviate these accompanying problems. Furthermore, the authors note that many adults do not fully respond to medication treatment, with 20-50% considered to be nonresponders and many only showing a 50% or less reduction in core ADHD symptoms.
The sample: 61 (40 males, 21 female; mean age = 32.95) Caucasian individuals diagnosed with ADHD in adulthood were assigned to receive group CBT + medication (although 2 of this group opted for CBT without medication). The investigators did not administer the medication as part of the study. Participants just continued the medication they were already taking. Most of the group had never received psychotherapy before. One-third (n = 20) of the participants dropped out during treatment. A second group of participants were placed on a wait-list for the treatment and so received medication only. This group consisted of 37 Caucasian clients (21 males, 16 females; mean age = 31.19). Oddly, the authors did not mention why the sample was not racially/ethnically diverse.
The treatment: The CBT group treatment attended 6 consecutive ADHD workshops. Session 1 focused on psychoeducation about "what it means to have ADHD." Session 2 focused on anger and frustration, with an overall goal of targeting the low frustration tolerance that can lead to explosive outbursts in individuals with ADHD. Session 3 centered on emotions, primarily focusing on the connections between mood, thoughts, and behaviors and teaching skills to improve mood by examining this cycle. Session 4 was concerned with social and relationship skills. As a group, the participants discussed ways in which ADHD symptoms have hampered their interpersonal performance. The group format also provided an opportunity to practice social skills in a safe environment. Session 5 centered on practical approaches to time management and problem solving. The last session again offered psychoeducation, this time addressing the future with ADHD.
The results: The group who received CBT + medication had significantly greater self-report ratings of self-efficacy and self-esteem and significant improvement in knowledge about ADHD. The individuals who received CBT also rated the workshops as beneficial, and especially noted that getting to know others with the disorder was helpful. Both groups showed improvement in anxiety and depression symptoms.
This is certainly an imperfect study, with quite a few serious methodological concerns (e.g., no random assignment, no psychotherapy control group). Still, as we have yet to determine an EST for adult ADHD, these findings mark an important step toward determining how to help. Especially in this age of managed care, identifying useful group interventions is certainly prudent. Group interventions are generally shorter and cheaper, making them attractive to managed care companies and clients, while allowing psychologists to treat a greater number of clients. For more information on treatments for ADHD, checkout our online bookstore!
Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.
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