A critical evaluation of Cognitive Behaviour Therapy (CBT) in the treatment of Adult Attention Deficit Hyperactivity Disorder (ADHD)

Attention Deficit Hyperactivity Disorder (ADHD) is considered a developmental neuropsychological condition with onset frequently occurring in early childhood (McGrath & Peterson, 2009; Voeller, 2004). The most commonly used diagnostic criteria defines maladaptive levels of hyperactivity, inattention and impulsivity as key features characteristic of the diagnosis (American Psychiatric Association, 2000, 2013). While incidence and prevalence rates have varied considerably over time, ADHD is currently believed to affect between 4% and 8% of individuals in the community with incidence rates almost doubling in the past decade (Goldstein & DeVries, 2011). This significant increase is believed to be related to greater recognition of the disorder and improved diagnostic procedures in recent times (National Collaborating Centre for Mental Health, 2009, p. 26). Regardless of the variability of incidence over time it is widely recognised that ADHD is a valid and pervasive condition which has attracted considerable research attention (Biederman, 2011).

            A substantial gender bias exists in ADHD, as evident in the fact that triple the amount of males are diagnosed with the syndrome compared to females (Goldstein & DeVries, 2011). However less is known about ADHD presentation in females (McGrath & Peterson, 2009, p. 154). Additionally, while in some Australian communities ADHD prevalence rates have been noted to be significantly lower in Indigenous samples, it has been argued that these may not be actual differences but rather cultural artefacts (The Royal Australasian College of Physicians, 2009, p. 64). Variability likely exists in definitions of normality of symptoms across cultures and this may also account for some differences observed across countries (McGrath & Peterson, 2009, p. 154). While ADHD is more common in lower socioeconomic communities, these differences are largely accounted for through co-morbidity of conditions (McGrath & Peterson, 2009, p. 154).

            Due to high rates of co-morbidity and confounding reasons which could account for elevated levels of inattention and restlessness in individuals (e.g. interpersonal dysfunction, other neuropsychiatric conditions or trauma) a thorough clinical assessment is required (Hinshaw, 2005). While the diagnostic criteria for ADHD are based primarily on behavioural features occurring in the context of an individual's developmental history, many advocate for the use of neuropsychological tests to support the assessment process (McGrath & Peterson, 2009). Best practice in the assessment of ADHD encourages a multi-modal, multi-informant and interdisciplinary assessment to investigate key factors such as the intensity of symptoms, developmental course, duration, pervasiveness, impact on functioning, cognitive/learning profiles, mental health history and neuropsychological abilities (Hinshaw, 2005; National Collaborating Centre for Mental Health, 2009, p. 24). A comprehensive assessment also informs treatment goals and methodology for intervention and commonly includes a clinical interview, broad and narrow band standardised questionnaires, observations, medical examination and neuropsychological/academic testing (National Collaborating Centre for Mental Health, 2009, p. 125). This process is similar in both adults and children however Adler and Shaw (2011) elaborate on specific consideration which must be taken into account when assessing adult ADHD. These include population specific assessment tools, variability in symptoms, adult focussed co-morbidity and personality disorders.

            The course of ADHD throughout adolescents and into adulthood follows a similar developmental trajectory to that of the general population, with regards to progressive improvement in hyperactivity, impulsivity and inattention (National Collaborating Centre for Mental Health, 2009, p. 27). In fact, meta-analyses indicate that by 25 years old a significant decline in prevalence rates is observed with only 15 percent of those diagnosed in childhood still meeting the full diagnostic criteria as adults (Faraone, Biederman, & Mick, 2006 ). However for the majority of those with ADHD in childhood, significant impairments in functioning and subclinical symptom presentation persist into adulthood resulting in up to 65%  maintaining partial remission status (Biederman, Petty, Evans, Small, & Faraone, 2010; Faraone, et al., 2006 ). This has lead to criticisms of the developmental sensitivity of assessment procedures, where clinical levels of symptomatic related dysfunction continue to exist in large proportions of adult ADHD presentations yet diagnostic thresholds are not met according to childhood definitions (Faraone, et al., 2006 ; Kessler et al., 2011). When this is coupled with the knowledge that individuals with ADHD struggle with increased co-morbidity rates for mood disorders, substance abuse, learning difficulties and other psychiatric conditions, it is clear why efficacious treatment options are needed across the lifespan (Buitelaar, Kan, & Asherson, 2011).

            According to the literature the frontline treatment recommendation for primary ADHD symptoms is the use of psychopharmacology such as stimulant medication, of which approximately 75% of individuals gain a benefit (McGrath & Peterson, 2009; National Collaborating Centre for Mental Health, 2009, p. 231). However some caution the use of medication as the initial source of treatment in adults due to limitations in the literature (Teeter, 1998, p. 314). For instance, mental health co-morbidities are observed in up to 70% of adults with ADHD and research on the effects of stimulant treatments in these cases, and indeed for adult presentations of ADHD in general, are limited (McDermott, 2011; National Collaborating Centre for Mental Health, 2009, p. 231). Further, while the short-term benefits of psychopharmacology for ADHD are noteworthy additional research into the long-term effects and optimal duration of treatment has been called for (National Collaborating Centre for Mental Health, 2009, p. 231; Poulton, 2006 ). Additionally, some individuals may have adverse reactions to medication, decide not to engage in psychopharmacological treatment, gain no benefits from such drugs or require additional psychosocial support (McGrath & Peterson, 2009; National Collaborating Centre for Mental Health, 2009, p. 206; Teeter, 1998, p. 314). This necessitates psychological treatment pathways as alternatives. Although medication has the most prominent evidence base in terms of efficacy, many best practice guidelines recommend a multimodal and multidisciplinary approach to treatment (The Royal Australasian College of Physicians, 2009, p. 69).

            Cognitive Behaviour Therapy (CBT) is a broad term for an approach to intervention based on cognitive and behavioural principles, rather than a single unified model for treatment (Leahy, 2003). CBT programs generally encapsulate several core components in different combinations and modalities, including psycho-education, self-monitoring/rewarding, emotional recognition/regulation, behavioural activation/scheduling, social skills training, problem-solving and cognitive restructuring (Prochaska & Norcross, 2007, p. 318). CBT's basis heralds from social learning theory and classical/operant conditioning and has been successfully delivered for the treatment of various conditions in individual and group formats, generally ranging from 5-15 sessions in length (Flannery-Schroeder & Lamb, 2009, p. 56). Unfortunately there are a limited number of mental health professionals in Australia qualified and experienced specifically to treat adult ADHD using CBT interventions (The Royal Australasian College of Physicians, 2009, p. 69).

            The primary goals of CBT treatment for adult ADHD are to develop strategies for managing primary symptoms and improve the individual's ability to ameliorate the functional impact of the condition (McDermott, 2011). The rationale for using CBT is seen in models such as those described by Safren, Sprich, Chulvick, and Otto (2004). They assert that neuropsychological deficits (i.e. inhibition, executive functions, working memory, etc) lead to functional impairments in organisation, planning and engagement in day to day activities.  It is further hypothesised that such impairments lead to procrastination and reduced acquisition of compensatory strategies and organisation skills which may otherwise have been picked up by osmosis (Ramsay & . 2007). Therefore the explicit teaching of skills, strategies and problem solving through CBT acts to address such deficits. Further, many individuals with ADHD experience a continued pattern of failure and considerable negative experiences from a young age due to their condition (Knouse & Safren, 2010). From a CBT perspective these events further cement the functional impact of the disorder by hindering motivation and creating a maladaptive cycle of avoidance due to negative beliefs and self-concepts.  Thus when this model is applied to multimodal treatment the core neuropsychological deficits are addressed by medication, behavioural skills are taught to facilitate  compensatory strategies, and cognitive principles are utilised to challenge and change maintaining negative belief cycles (Knouse & Safren, 2010).

            A number of reviews have taken place to date regarding the effectiveness and efficacy of CBT for adult ADHD (Knouse & Safren, 2010; McDermott, 2011; Vidal-Estrada, Bosch-Munso, Nogueira-Morais, Casas-Brugue, & Ramos-Quiroga, 2012 ; Weiss et al., 2008 ). The results generally conclude that the evidence base for CBT with adult ADHD is preliminary but promising. A range of empirical evidence has begun to amount including controlled studies and randomised controlled trials (RCT's) however this research base is formative in comparison to child studies (Hinshaw, 2005; Weiss, et al., 2008 ). Some attempts have been made to extrapolate adult generalisations from the child research base however these attempts are questionable due to the considerable variance in developmental presentation between adult and childhood ADHD (Weiss, et al., 2008 ). When examining the effectiveness and efficacy of CBT treatment for adult ADHD, generally a moderate to large effect size is observed (Weiss, et al., 2008 ). However these results should not be taken at face value.

            Several authors question the methodological rigour of a number of studies purporting the success of these CBT programs (Knouse & Safren, 2010; McDermott, 2011; The Royal Australasian College of Physicians, 2009, p. 78; Vidal-Estrada, et al., 2012 ; Weiss, et al., 2008 ). While a detailed review is beyond the scope of this paper, concerns have been raised regarding variability between outcome measures/determinants of success, lack of control for the effects of medication, absence of active control groups, overreliance on self-report measures and negligible use of independent evaluators of outcomes. Further, minimal data is available on the durability of effects, as follow-up outcomes were not effectively tracked (Knouse & Safren, 2010). Instead the focus has primarily been on acute symptom presentation. It is also important to note that not all studies have indicated a positive outcome, with some studies showing no improvement in external reports of symptoms (Virta et al., 2008). These null effects may only be the tip of the iceberg, as we must always be wary of publication bias when interpreting the literature (Scargle, 2000).

            Yet not all studies have fallen victim to the above mentioned limitations. Some studies have demonstrated sound methodology and support the efficacy of CBT for adult ADHD (Vidal-Estrada, et al., 2012 ). Of these studies, CBT clearly emerges as the most beneficial psychosocial treatment for adult ADHD. These findings should always be tempered with the limitations of RCT's in mind (Grossman & Mackenzie, 2005; Kline, 2009). For instance, RCT evidence for CBT can be distorted by the level of therapeutic allegiance present in researchers (Tolin, 2010). Studies have shown that 69% of variance in treatment outcome can be accounted for by the level to which the therapist allies themself with the paradigm and should attempt to be controlled for in research (Luborsky et al., 1999). It is also yet to be determined to what extent medication and CBT have an additive effect when treating adult ADHD as this question has not yet been adequately studied (Knouse & Safren, 2010).

            An analysis of the most effective interventions, denoted by the largest effect sizes, reveals a number of common components of the most beneficial CBT programs for adult ADHD (Knouse & Safren, 2010). These commonalities include a time-limited approach (averaging approximately 10 sessions), workbook based homework to guide participants outside of the sessions, a highly structures approach, over-learned organisation and planning skill development, and promotion of adaptive thinking patterns to increase motivation/engagement (Knouse & Safren, 2010). Due to limitations in the literature and the relatively small number of well-controlled studies available, it is not completely clear whether the greatest gains are obtained from the behavioural or cognitive components of the treatment or if their effects are additive.

            While the evidence base for CBT treatment of adult ADHD is still emerging, the results to date are promising. Future research has been called for to address the above mentioned methodological limitations. Additional RCT's with active controls should be at the forefront of these research efforts (Weiss, et al., 2008 ). In summary, the literature suggests that CBT should be used as the primary psychosocial treatment for adult ADHD as part of a multimodal and multidisciplinary approach. The treatment format should be time-limited, skills based and highly structured to gain the most benefit.

  

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