In a recent issue of Atten­tion Research Update 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. DOI: 10.1177/1087054712443155] 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 mod­ules 1 and 2 as well as the ses­sion on pro­cras­ti­na­tion.

Mea­sures

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.

Results

Par­ents’ report — 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’ report — 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.

Ado­les­cents’ report — 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.

– Dr. David Rabin­er is a child clin­i­cal psy­chol­o­gist and Direc­tor of Under­grad­u­ate Stud­ies in the Depart­ment of Psy­chol­ogy and Neu­ro­science at Duke Uni­ver­sity. He pub­lishes Atten­tion Research Update, an online newslet­ter that helps par­ents, pro­fes­sion­als, and edu­ca­tors keep up with the lat­est research on ADHD, and teach­es the online course How to Nav­i­gate Con­ven­tion­al and Com­ple­men­tary ADHD Treat­ments for Healthy Brain Devel­op­ment.

–> For relat­ed arti­cles by Dr. David Rabin­er on atten­tion deficits, click Here.