New Study shows Teens with ADHD helped by Cognitive Behavioral
In a recent issue of Attention Research Update - http://www.helpforadd.com/2011/december.htm
- I reviewed a study of cognitive behavioral therapy (CBT) for adults with
ADHD that yielded encouraging findings. Promising findings of this
approach for adults raises the question of whether CBT could also be helpful
for teens with ADHD.
Developing effective nonmedical interventions for teens with ADHD is important
for several reasons. First, as many as 20-30 percent of adolescents
with ADHD may not benefit significantly from medication and/or continue to
struggle despite the help that medication provides. Others experience
adverse side effects that preclude them from staying on medication.
In addition to these limitations of medication treatment, many teens refuse
to stay on ADHD medication and adherence to medication treatment typically
declines with age. And, diversion of medication has become a real problem
as it is not uncommon for teens taking ADHD meds to be approached by peers
looking to use their medication.
Despite the need for research-based alternatives to medication treatment
for teens, work on this issue is limited. Thus, while there is an extensive
research base on psychosocial interventions for children with ADHD, much
less work has been conducted with adolescents. And, prior to the study
reviewed below, there had not been a single published report on the use of
CBT in adolescents with ADHD.
Participants in this study [Cognitive behavioral treatment outcomes in adolescent
ADHD. Antshel, Farone, & Gordon (2012). Journal of Attention Disorders.
] were 68 teens ages 14-18 diagnosed with
ADHD at the Adult ADHD Treatment and Research Progrm at SUNY Upstate Medical
University. Approximately 60 percent were male. These teens were
selected from consecutive referrals to the program over a 4-year period (other
referred teens were excluded because they did not meet diagnostic criteria
for ADHD.) Many had additional disorders and only 20% were diagnosed
with ADHD alone. All were receiving concurrent medication treatment.
Cognitive Behavioral Treatment
All teens received a CBT program consisting of 6 different modules.
Module 1: Organization and Planning
- The four sessions in this module
helped teens learn to use and maintain a notebook with a task list and a
calendar system to improve their organization for school assignments.
There was also a focus on problem-solving skills such as breaking large tasks
into smaller and more manageable steps. Teens also learned to develop
an action plan for overwhelming tasks.
Module 2: Reducing Distractibility
- Three sessions focused on helping
teens reduce their tendency to become distracted. Teens were taught
to recognize the length of time they could hold their attention to tasks
and to divide tasks into chunks that did not exceed this time. Teens
also learned to tools such as alarms and timers to help stay on task, and
a procedure called 'distractibility delay' that involves writing down distractions
when they emerge as opposed to acting on them.
Module 3: Cognitive Restructuring
- In this module, which varied from
two to five session based on individual needs, teens were taught skills to
maximize adaptive thinking during times of stress, and to apply adaptive
thinking skills to difficulties associated with ADHD.
As an example, consider a teen who becomes highly self-critical when she
forgets to turn in an assignment and who thinks that the organization problems
associated with ADHD will prevent her from ever being successful. One
can imagine how such thinking could contribute to 'giving up', low self-esteem,
and even to the emergence of depressive symptoms.
In cognitive restructuring, the teen would be taught to challenge these self-critical
thoughts and to consider alternatives. For example, the clinician would
point out that this was just one assignment she forgot to hand in and that
she had been turning in most of her work. And, that she was working
hard to develop strategies for addressing this problem that were showing
early signs of success.
As evident in this example, the goal is to help teens develop the skills
to recognize when their thinking is overly negative and to challenge that
thinking with more adaptive alternatives.
Module 4: Reducing Procrastination
- This module focused on applying
previously learned skills to addressing problems with procrastination.
Module 5: Improving Communication Skills
- Teens received training
in "...active listening, learning to wait for others to finish speaking before
adding to the conversation, maintaining appropriate eye contact, and learning
to stay on topic."
Module 6: Anger and Frustration Management
- This module emphasized
cognitive restructuring skills to help teens deal more appropriately with
anger and frustration. Teens were also provided with stress reduction
techniques and with instruction on how to act assertively but not aggressively.
Modules 4-6 were covered across four sessions making the total program 13
to 16 sessions. The CBT program was delivered individually in 50-minute
with parents attending all sessions for core modules 1 and 2 as well as the
session on procrastination.
Ratings of ADHD symptoms, emotional and behavioral functioning were obtained
from parents, teens and teachers before and after treatment. Teens'
grades and school attendance were also obtained and parents rated teens'
adherence to medication treatment. Although parents and teens were
obviously aware that the teen received CBT, teachers were blind to the child's
participation. In theory, therefore, teachers' ratings were not biased
by this knowledge.
- Comparing parents' ratings before and after treatment
indicated a number of positive changes. Parents reported significant
reductions in teens' inattentive symptoms and oppositional behavior.
Parents also reported that their teen was getting along better with peers
and making better academic progress. Also noteworthy is that teens
were being more cooperative with medication treatment and required lower
doses of medication.
- Teachers also reported significant reductions in
adolescents' inattentive behavior. This is an especially important
finding because teachers were presumably not aware that the teen had received
CBT. Teachers also reported significant gains in the adolescents' academic
progress, a reduction in learning problems, and increases in self-esteem.
- Reports obtained from adolescents themselves indicated
less positive change than that reported by parents and teachers. Changes
in core ADHD symptoms were quite modest. However, adolescents' reports
did indicate a reduction in overall school problems and increases in their
overall feelings of personal adjustment.
School record data
- Examination of school records data revealed a
substantial reduction in the number of classes that teens were missing each
week along with a reduction in tardiness.
The results summarized above applied equally to males and females as well
as to teens with the inattentive type vs. combined type of ADHD. However,
teens with comorbid Oppositional Defiant Disorder or Conduct Disorder were
found to benefit less.
Summary and Implications
Results from this study highlight the potential of well-designed CBT as a
treatment for adolescents with ADHD. As has been found in several studies
of CBT for adults with ADHD, this approach promoted better adjustment among
adolescents in multiple domains as reported by parents, teachers, and adolescents
themselves; school record data also indicated better class attendance and
fewer late arrivals to school. Also noteworthy was that over the course
of treatment, teens showed better compliance with medication treatment and
required lower doses of medication.
While these are encouraging findings, the authors stress the need to consider
this work preliminary - essentially, a 'proof of concept' study that justifies
further research on CBT for adolescents with ADHD. The main limitation
of the study is the absence of a control group. Thus, one can't say
for sure that the gains which occurred resulted from the CBT program as opposed
simply to the passage of time. The duration of any treatment benefits that
accrued is also unknown and would require additional work in which the teens
were followed over time.
Another important caveat is that all teens who participated in this study
were receiving medication. Whether CBT would be effective as a stand
alone treatment is thus unknown.
These limitations not withstanding, results from this study highlight the
potential benefits of CBT for adolescents with ADHD and indicate that large
well-controlled trials are warranted. Hopefully, such work will become
available in the near future.