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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Clinical Psychological practice is grounded in the principles of the Scientist-Practitioner model (Page & Stritzke, 2006). This paradigm provides a framework for training practitioners who create a synergy between scientific research and practice (O'Gorman, 2001). The foundations of the Scientist-Practitioner model rest of three tenets, asserting that practitioners must be "consumers... evaluators... (and) producers" of research (Page & Stritzke, 2006, p. 2). An essential element of this assertion is that Clinical Psychologists should readily access and critically evaluate research in order to select, recommend and advise their clients regarding evidence-based best practice. This is a crucial reminder that treatment options should not be taken at face value and that availability alone of an intervention should not dictate the implementation of such treatments. Instead, treatment choice should be driven by methodologically sound and rigorously validated research findings. Childhood learning disorders is one area in particular where a number of therapies, with controversial research support, are readily available (Kurtz, 2008, p. 12). These children and their families are particularly vulnerable to unfounded promises of quick fixes, emphasising the role of the Clinical Psychologist in guiding treatment selection (Silver, 1995). Irlen Lenses, Psychomotor Patterning and Sensory Integration Therapy are three such examples of controversial therapies (Pennington, 2009, p. 264). The current paper will briefly review the literature available on these three therapies and will provide a critique.
Irlen Lenses were developed by Helen Irlen as a treatment for a reading condition coined "Scotopic Sensitivity" or "Irlen Syndrome" (Irlen, 1983).While a thorough investigation of the validity of Irlen Syndrome as a diagnosis is beyond the scope of this paper it should be noted that many question the scientific rigour of the disorder itself and how it is measured (Jacobson, Foxx, & Mulick, 2005, p. 178; Pennington, 2009, p. 274). The condition is believed to be grounded in visual perception difficulties causing reading deficiencies (Kurtz, 2008, p. 58). It is hypothesised that the subgroup of children with reading difficulties affected by Irlen Syndrome can be assisted by utilising specially designed coloured lenses or overlays when reading. It is believed that the individually matched coloured lenses/overlays make reading individual words less arduous and tiresome by neutralising the perceptual difficulties associated with the condition, increasing fluency. It is then expected that an increase in fluency will come with the added benefit of improved comprehension (Kurtz, 2008, p. 58). This theoretical position is in stark contrast to the myriad of scientific knowledge available on the subject of reading disorders. The vast majority of cases place developmental dyslexia as primarily a deficit characterised by phonological weaknesses, not visual difficulties (Pennington, 2009, p. 59).
Interestingly the popularity of Irlen Lenses quickly spread, after the theory was introduced at the 91st Annual Convention of the American Psychological Association, even though independent validity for the treatment had not been established (Irlen, 1983; Pennington, 2009, p. 274). Further, Irlen's (1983) own tenet, that coloured lenses would only be effective with a subset of dyslexics, was largely ignored by the professional community and coloured lenses/overlays were promptly established as a broad-spectrum treatment for reading disorders (Irlen, 1983; Pennington, 2009, p. 274). Such conflict is also inherent in the published literature investigating the efficacy of lenses as a treatment (Jacobson, et al., 2005, p. 178).
At a glance, early research investigating the effectiveness of coloured lenses as a treatment was promising (Cardinal, Griffin, & Christenson, 1993; Robinson, 1994; Robinson & Conway, 1990, 1994; Whiting, Robinson, & Parrot, 1994). The various studies asserted findings such that participants experienced reductions in print distortion, increased reading rates and improved academic attitude/motivation. However reading accuracy was not consistently improved (Robinson & Conway, 1990, 1994). While the results appeared quite hopeful the validity of the findings have since been questioned due to several ethical and methodological flaws (Bowd & O’Sullivan, 2004). Concerns have been raised regarding the heterogeneity of the samples used, ineffective masking/blinding, researcher bias/financial interests, selection bias, lack of controls and underestimation of placebo effects (Menacker, Breton, Breton, Radcliffe, & Gole, 1993 ). Studies with increased methodological integrity have supported this contention, contradicting the positive findings and indicating no change in rate, accuracy or comprehension when using coloured lenses (Gole et al., 1989). More recent studies continue this pattern of inconsistent findings. For instance Solan, Ficarra, Brannan and Rucker (1998) found increased reading rates while using coloured overlays while others researchers found now such evidence (Christenson, Griffin, & Taylor, 2001).
Overall there has been a large amount of literature published on the subject of the effectiveness of Irlen Lenses however the majority of these studies are case study or self-report data, which are not subject to peer-reviewed rigour (Jacobson, et al., 2005, p. 178). Increasing focus has been placed on addressing the above mentioned methodological weaknesses, decreasing the subjectivity of the findings by utilising controlled studies and submitting to the peer-review process for empirical validation (Noblea, Ortonb, Irlenc, & Robinsond, 2004). While such approaches are improvements on early studies they are not without their flaws. One recent study found that immediate increases in reading abilities were gained by utilising coloured overlays however these improvements met a plateau after 3 months of use (Noblea, et al., 2004). Again at a glance these improvements appear noteworthy, as the study utilised a waitlist control for comparison, yet there are weaknesses inherent in the study's design. For instance, the waitlist was not an active control group so treatment improvements cannot be ruled out as a placebo, increasing motivation and engagement of participants using overlays due to an expectancy bias. More importantly this particular study excluded participants with weaknesses in phonological decoding skills, noting that such weaknesses need to be addressed primarily before coloured interventions can be of assistance. In essence the study removed a large proportion of children likely to have a reading disorder (i.e. those with phonological deficits) and may have merely provided a placebo to a group of weaker readers. The resulting increased engagement in reading may account for the increase in skills observed.
One major weakness of studies investigating Irlen Lenses has been pre-selection of participants who have shown a response to treatment and a lack of masking knowledge of their prescription colour (Ritchie, Sala, & McIntosh, 2011). This weaknesses was addressed in a recent investigation by utilising a blinded within and between subjects design (Ritchie, et al., 2011). Children were not informed if diagnosed or what their prescribed colour was if they had one. Each participant was administered reading tasks with various overlays and without. No differences were identified between or within subjects across the various conditions, indicating that when expectancy is controlled for, through masking, the effects of coloured therapies are negligible. This supports the notion that Irlen Lenses are a placebo and there is increasing evidence in support of this assertion (Bowd & O’Sullivan, 2004).
The "Doman-Delacato" method or "Psychomotor Patterning" is a treatment for neurological and intellectual conditions developed by Educational Psychologist Carl Delacato and Physical Therapist Glenn Doman in the 1960's (Kurtz, 2008). The theoretical underpinnings of Patterning are based on the belief that intellectual disability and learning difficulties are a result of neurological disorganisation caused by a failure to progress through the normal developmental stages of movement (Pennington, 2009, p. 276). It is asserted that revisiting earlier stages (e.g. crawling) and practicing them repeatedly over long periods assists with neurological reorganisation and the progression of developmental milestones (Jacobson, et al., 2005, p. 67). It is at the basis of these theoretical foundations that the paradigm begins to come unstuck. In essence, the treatment claims to alter the structure and functioning of the brain through repetitive body movements however these principles are noted to be unfounded and inconsistent with contemporary views of neurological development (American Academy of Pediatrics, 1999; Silver, 1995).
Further difficulties arise when the nature of the treatment program is examined. Treatment is rather time-consuming and requires repetition over long periods of time, often upward of months or even years (Novella, 2008). As a result developmental progression will continue in most intellectually disabled children during this time, albeit at a delayed rate (Novella, 2008). Proponents of Patterning use this progress as evidence of the program's success and do not acknowledge the normal nature of this progression (Novella, 2008). Also, the extended structure of the programs, combined with the pseudoscientific nature of the theorem, raises several ethical concerns surrounding the delivery of Patterning as a treatment. That is, by engaging in this therapy families are less likely to engage in evidence-based scientifically proven practices and are unlikely to come into contact with professionals who are familiar with critical literature (Jacobson, et al., 2005, p. 67).
Since its creation, and assertions of effectiveness by its developers, Patterning has been scrutinised empirically (American Academy of Pediatrics, 1999). While a small amount of studies have made claims of improvements in the areas of visual perceptual skills and mobility through Patterning, these findings are clouded with doubt due to methodological weaknesses (Neman, Roos, McCann, Menolascino, & Heal, 1975). For instance, critics of these positive findings suggest flaws in participant selection, procedural abnormalities, poor statistical analyses and inadequately interpreted results (Ziegler & Victoria, 1975). Even these studies in which visual-motor improvements are suggested, the findings do not present evidence of intellectual improvements (Neman, et al., 1975). This is in clear contrast to the treatment's theoretical claims. Other studies have noted short-term developmental improvements in children treated however researchers are quick to acknowledge that such results are linked to a relative increase in familial attention towards the child (Bridgman, Cushen, Cooper, & Williams, 1985).
Claims have been made by the founders of Patterning that reading improvements have been observed in children engaged in their treatment programs (Delacato, 1963, 1966). They state that improvements in reading results following treatment are support of these claims. Such claims have not been substantiated due to a lack of statistical significance in such improvements (American Academy of Pediatrics, 1999). Any improvements may also be the result of natural development over time as discussed earlier. Several studies have directly assessed the impact of Patterning on reading and improvements have been found to be negligible (American Academy of Pediatrics, 1999). All in all quite a number of well designed studies have assessed the efficacy of Patterning as a treatment, with the majority refuting its claims of success (American Academy of Pediatrics, 1999; Freeman, 1967; Jacobson, et al., 2005, p. 67; Sparrow & Zigler, 1978; Ziegler & Victoria, 1975). Within a decade of its launch Patterning was quickly established to lack its predicted effects (Jacobson, et al., 2005).
Sensory Integration Therapy
Sensory Integration Therapy (SIT) was developed by Dr Jean Ayres, Occupational Therapist and Psychologist, in the 1970's to assist individuals in organising their Central Nervous System's (CNS) response to sensory stimuli (Kurtz, 2008, p. 104). That is, some individuals with Intellectual and Developmental Disabilities are hypothesised to struggle to process sensory input resulting in hypo or hyper sensitivity (Kurtz, 2008, p. 105). While Sensory Integration Disorder (SID) cannot be validated as a recognised syndrome it is widely accepted that children with Autism Spectrum Disorders (ASD), Attention Deficit Hyperactivity Disorder (ADHD) and Anxiety Disorders regularly experience sensory sensitivity (American Academy of Pediatrics, 2012; Pennington, 2009, p. 275). However the principles of SIT are based on the theoretical underpinning of SID. This theory is noted to be erroneous and inconsistent with contemporary understandings of how the CNS operates and by extension SIT is likely to be ineffective (Pennington, 2009, p. 275). SIT utilises a number of techniques and tools such as tactile stimulation, weighted vests, brushing and purposeful movements to deliver a specifically tailored "sensory diet" (Jacobson, et al., 2005, p. 252).
SIT is an extremely popular approach utilised widely by Occupational Therapists (Kurtz, 2008). It has been extensively studied and reviewed in relation to its efficacy and effectiveness (American Academy of Pediatrics, 2012; Hoehn & Baumeister, 1994; Vargas & Camilli, 1999 ). A number of studies report positive results in relation to meeting functional goals however the ability to generalise these results is limited due to them being based on case studies or being observational in nature (American Academy of Pediatrics, 2012). Such research is often biased by subjectivity. While a small number of controlled studies have reported positive results through the use of SIT these studies are restricted by considerable methodological flaws and thus their conclusions are tenuous (Baranek, 2002). It is interesting to note that its use is widespread in spite of their being minimal evidence of its effectiveness. In fact there is evidence from one small study that SIT may actually have a negative impact on the attainment of behavioural outcomes (Devlin, Healy, Leader, & Hughes, 2011). In this study it was observed that SIT had a constricting effect on behavioural improvements brought about through behavioural intervention. That is, the results suggest that the behavioural intervention alone was most effective in reducing self-injurious and challenging behaviours and the inclusion of SIT impeded progress.
A recent meta-analysis provides a concise overview of the current state of the literature in the field of SIT (Vargas & Camilli, 1999 ). The findings of the review indicate many studies investigating the efficacy and effectiveness of SIT as a treatment display poor scientific rigor. As a result a large number of studies were excluded from the analysis. The meta-analysis concludes that the ability to detect a treatment effect for SIT is minimal, particularly in more recent studies where methodology has been enhanced. SIT appears to significantly lack the theoretical and empirical validation required of a widely employed treatment (American Academy of Pediatrics, 2012).
Overall none of the three controversial treatments discussed in this current paper have demonstrated conclusive efficacy or effectiveness in the literature. Further, government and registration bodies caution their use as treatments by professionals due to a lack of convincing evidence (American Academy of Pediatrics, 1999, 2009, 2012). Thus it is an ethical obligation of Clinical Psychologists to educate clients and other professionals regarding the current state of research for such treatments (Pennington, 2009). In the event that such questionable therapies are utilised anyway, clinicians should assist clients in monitoring the progress of such interventions. This should be done by setting specific and functional goals, assessing their level of effectiveness through simple pre and post test measures and setting time-limits on expectations for improvement (American Academy of Pediatrics, 1999, 2009, 2012; Pennington, 2009).
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