Cognitive behavioural therapy (CBT) involves self-instructional training administered in a group or individual basis, to help the individual with ADHD to develop a more planned and reflective approach to thinking and behaving, including social interactions.1 It can also help individuals adopt a more reflective, systematic and goal-oriented approach to everyday tasks, activities and problem solving, including academic functioning.2
Results from a randomised controlled trial of a CBT group in adolescents with ADHD (n=119; aged 15–21 years) receiving pharmacological therapy with methylphenidate or atomoxetine showed that:3
- Patients who received CBT showed significantly reduced symptoms of ADHD compared with the control group on the Clinical Global Impression Self-Report Scale (p<0.001) and the Clinical Global Impression Clinician-Report Scale (p<0.001).3
- Patients who received CBT showed a significant reduction in functional impairment compared with the control group on the Global Assessment of Functioning (p<0.001) and the Weiss Functional Impairment Rating Scale Parent Version (p<0.05).3
CBT in combination with pharmacological treatment may reduce the symptoms of ADHD in adolescents.3
In a 6-month study of two internet-based CBT modular programmes in adults with ADHD (n=45), 48% of whom were receiving pharmacological therapy, participants were assigned to one of the following:4
- Self-help internet-based CBT
- Self-help internet-based CBT plus weekly group therapy sessions
- Wait list (control group).
Modules covered topics including behaviour analysis, mindfulness and acceptance, time management, gauging attention span, reducing distractors, organisation and planning, problem solving, behaviour activation, cognitive restructuring and anger control training.4
Patients who received internet-based CBT had a significant reduction in ADHD symptoms compared with the wait-list control patients at post-treatment (Figure).4
Figure: Results from a 6-month study of two internet-based CBT modular programmes in adults with ADHD (n=45). Figure developed using information from Pettersson R et al. J Atten Disord 2017; 21: 508-521.4
A randomised, controlled trial has explored the effectiveness of group-based CBT in adults who were already receiving medication for ADHD (n=86).5 Therapy included three core modules, focusing on:5
- Psychoeducation about ADHD, and training on organisation and planning, including problem-solving.
- Skills to reduce distractibility, such as techniques to time the length of one’s attention span.
- Cognitive restructuring, involving learning to think more adaptively in situations that cause distress.
Twelve 50-minute sessions of CBT significantly reduced ADHD symptom scores compared with relaxation and educational support, with responders continuing to maintain benefit over a 12-month follow-up period.5
Other group-based approaches to CBT have also been associated with symptomatic improvements in adults with ADHD.
- In a study of 29 adults with ADHD, 10–11 weekly sessions of cognitive–behaviourally oriented psychological group rehabilitation reduced self-reported ADHD symptoms.6
- Two studies assessing an 8- or 12-week programme of meta-cognitive therapy to target executive self-management skills in 30 and 88 adults with ADHD, respectively, reported reduced symptoms of inattention and improved executive functioning.7,8
In a meta-analysis including 18 controlled studies investigating CBT in adults aged ≥18 years with ADHD (n=255), CBT had small to medium effects versus controls (n=255) on self-reported symptoms (g = 0.65; 95% confidence interval [CI] 0.44–0.86) and functioning (g = 0.51; 95% CI 0.23–0.79; Figure).
The authors concluded that CBT for the treatment of adult ADHD showed comparable effect sizes with behavioural treatments in children with ADHD. The authors recommended that further research should be conducted to identify empirically supported principles of treatment-related change for adults with ADHD.9
Figure: Self-reported symptoms of ADHD for treatment versus control. Reproduced with kind permission from Knouse LE et al. J Consult Clin Psychol 2017; 85: 737-750.9
There is also some evidence to support the use of CBT approaches in children with ADHD. In a randomised study of boys aged 7–13 years with ADHD (n=25), CBT improved parent perception of hyperactivity in the home and child-rated self-esteem, compared with a supportive therapy control group.10
Some evidence suggests that CBT may enhance activity in neural structures typically affected by ADHD, in a similar manner to treatment with methylphenidate.11 Similarly, data from another small imaging study suggested that CBT may increase grey matter volume in structures typically characterised by volume reduction in ADHD patients, versus an ADHD control group, and that these increases may be associated with attentional performance.12 However, this research is in its infancy and further investigation is warranted.
- Taylor E, Döpfner M, Sergeant J, et al. European clinical guidelines for hyperkinetic disorder — first upgrade. Eur Child Adolesc Psychiatry 2004; 13(Suppl 1): I/7-I/30.
- Prevatt F, Yelland S. An empirical evaluation of ADHD coaching in college students. J Atten Disord 2015; 19: 666-677.
- Vidal R, Castells J, Richarte V, et al. Group therapy for adolescents with attention-deficit/hyperactivity disorder: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry 2015; 54: 275-282.
- Pettersson R, Söderström S, Edlund-Söderström K, et al. Internet-based cognitive behavioral therapy for adults with ADHD in outpatient psychiatric care: a randomized trial. J Atten Disord 2017; 21: 508-521.
- Safren SA, Sprich S, Mimiaga MJ, et al. Cognitive behavioral therapy vs relaxation with educational support for medication-treated adults with ADHD and persistent symptoms: a randomized controlled trial. JAMA 2010; 304: 875-880.
- Virta M, Vedenpaa A, Gronroos N, et al. Adults with ADHD benefit from cognitive-behaviorally oriented group rehabilitation: a study of 29 participants. J Atten Disord 2008; 12: 218-226.
- Solanto MV, Marks DJ, Mitchell KJ, et al. Development of a new psychosocial treatment for adult ADHD. J Atten Disord 2008; 11: 728-736.
- Solanto MV, Marks DJ, Wasserstein J, et al. Efficacy of meta-cognitive therapy for adult ADHD. Am J Psychiatry 2010; 167: 958-968.
- Knouse LE, et al. Meta-analysis of cognitive-behavioural treatments for adult ADHD. J Consult Clin Psychol 2017; 85: 737-750.
- Fehlings DL. Attention deficit hyperactivity disorder: does cognitive behavioral therapy improve home behavior? J Dev Behav Pediatr 1991; 12: 223-228.
- Hoekzema E, Carmona S, Tremols V, et al. Enhanced neural activity in frontal and cerebellar circuits after cognitive training in children with attention-deficit/hyperactivity disorder. Hum Brain Mapp 2010; 31: 1942-1950.
- Hoekzema E, Carmona S, Ramos-Quiroga JA, et al. Training-induced neuroanatomical plasticity in ADHD: a tensor-based morphometric study. Hum Brain Mapp 2011; 32: 1741-1749.