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

Materials and Methods:

46 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. 24 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).

Results:

Using all available data, mixed effects modeling, and pooling for the wait list crossover, 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-values < 0.0001). There was a greater proportion of responders after CBT by parent (50% vs 18%, p=.00) and adolescent (58% vs. 18% p=.02) report.

Conclusion:

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

The studies demonstrated significant reductions in the primary symptoms of ADHD at assessment, which led to improved behavioral and functional status with a reduced impact on family and society. Further trials are needed to understand the benefits of CBT and MPH when combined to reduce psychiatry co-morbidities and improve learning and overall quality of life in the long term.

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.

Materials and 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.

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.

Results:

We included 14 RCTs (700 participants), 13 of which were conducted in the northern hemisphere and 1 in Australia.

Primary outcomes: ADHD symptoms

CBT 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 outcomes

CBT 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.

Conclusion:

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.

Cultural/Social Context:

It is estimated that about 6% of China’s population had ADHD. About 90% of cases are estimated to still go undiagnosed. When diagnosed, only about 1/3 of the children receive some form of treatment, pharmacotherapy or behavioral therapy, compared to ¾ receiving treatment in the United States. Since ADHD is classified as a mental health disease, many Chinese families fear placing their children on treatment due to concerns of receiving labels placed on their child or having their child ostracized or viewed differently. Due to the mental health stigma in China and lack of medication use, study populations using children receiving therapy for ADHD will likely be limited.

Economic Context:

About 95% of China’s population is covered by at least basic medical insurance. There are two main forms of insurance: employee health insurance and residents insurance. The employee health insurance covers about 25% of China’s populations and is offered to urban employees and retirees of state owned enterprises and some private employees. Under the country’s social insurance plan, free public health care is offered. The country follows 2 medical systems: one includes modern “western” medicine and the other includes traditional Chinese medicine. Major cities are equipped with more modern medicine facilities. The government invests into traditional Chinese medicine, however it is less common due to too few professionals in this specialty. Mental health and psychiatric professionals in China is not as developed as other large countries. China has about 17,000 certified psychiatrists which averages to about 1 psychiatrist for every 83,000 people.

Language:

The Chinese language includes 8 main dialects and hundreds of less common ones. Chinese and English have very different grammar rules which can lead to difficulties in translation. In addition, certain Chinese characters may have several different meanings. It is recommended for these reasons that translation is completed by an individual proficient in both languages.

(# of subjects/ studies, cohort definition etc. )

-24 were randomized to receive CBT and 22 were placed on wait list

-Assessments were performed by a blind independent evaluation (IE) at baseline, 4 months (post CBT or post wait list) and 8 months to rate symptom severity according to the ADHD current symptom scale

-Participants who received CBT received a mean score of 5.24 lower on the IE-rated adolescent assessment of symptom severity

-Participants who received CBT received a mean score of 1.17 lower on the IE-rated clinical global impression severity scale

-Few minority patients were included in the study

-Majority of participants has professional parents

-Participants included only those who were on stable doses of ADHD medication, results can’t be generalized to those who are not

-Participants were from those seen at an urban teaching hospital

-Ruled out comorbid conduct disorder

-Used PICO terms: “Children and adolescents with ADHD, aged 3-18 years old,” “Cognitive behavioral therapy and methylphenidate,” “Healthy controls, placebo, and other treatment options,” “ADHD symptomatology and functional outcomes”

-Inclusion criteria: studies from 2017 until July 30, 2022, English, RCTs, Observational studies, Systematic reviews, age group preschool to adolescents

Exclusion criteria: older studies, not full free text, individuals over 18

-14 studies met criteria (11 RCT, 2 systematic review, 1 narrative review)

-8 studies reported a reduction in inattention

-7 studies reported a decrease in hyperactivity/impulsivity -2 studies showed an improvement in the symptom scores using the ADHD rating scale along with improved working memory

-Some studies lacked information on study characteristics

-Studies used different CBT sessions and varying formulations/dosages for MPH

-Search study was limited to studies from previous 5 years and full free text which potentially limited evidence

-Included RCTs evaluating any form of CBT for adults with ADHD as monotherapy or in conjunction with another treatment vs control

-Included 14 studies (700 participants)

-Evaluated CBT plus pharmacotherapy vs. pharmacotherapy alone, CBT vs. unspecific control conditions (waiting list, no treatment, supportive psychotherapies), and CBT vs. other interventions

-Secondary outcomes: self-reported or clinician reported anxiety, depression, self-esteem, anger

-CBT + pharmacotherapy had improved Clinical Global Impression score vs. pharmacotherapy alone

-Self reported anxiety, clinician reported anxiety and clinician reported depression were improved in patients who received CBT + pharmacotherapy vs. pharmacotherapy alone

-Trials included different outcome measures

-No studies at high risk of bias for random sequence generation but 6 were unclear risk because authors didn’t describe sequence generation process

-High risk of performance bias because characteristics of psychotherapy make it not possible to blind participants to this intervention

-1 study at high risk of detection bias due to lack of blinding of assessor

-2 studies had high risk of attrition bias due to drop out rate around 40%

-Requirements for entry: stable medications prescribed for ADHD for 2 months and no more than 10% change in dosage of existing meds for 1 month

-Participants must be between age 18 to 65

-2 assessments were done by a blind evaluator, baseline and outcome assessment

-Secondary outcomes: associated anxiety and depression

-CBT group had lower IE-rated and self-reported anxiety, lower IE-rated depression and a trend to have lower self-reported depression

-Pharmacotherapy was not controlled, instructions were given not to change meds, but it was discovered that 2 participants in the pharmacotherapy alone and 1 participant in the combined group changed medications during the study period

-Study only valuated post-outcome measurements and did not have a follow up period

-Studies published in English and Chinese were included

-Participants of interest were those below age 18

-5 full text articles met inclusion criteria

-Executive functioning

-Executive functioning did not have improvement with addition of CBT

-The number of studies that included combined CBT and drug therapy was limited

-Studies had small sample sizes