Clinical News You Can Use

Adult ADHD: Medication Plus Cognitive Behavioral Therapy, Latest Research

An article by Sanjay Gupta*, “Talk Therapy Alone for ADHD Doesn’t Cut It,” reviews a recent multi-site study of treatment for Adult Attention Deficit Hyperactivity Disorder [ADHD]. In sum, “talk” therapy does have a significant benefit, but it doesn’t benefit ADHD symptoms quite as much as medication or the combination of medication plus therapy.

Treating ADHD means BOTH

1) improving symptoms of concentration, focus, and memory with medications AND

2) developing skills for organization, social behavior, following-through, remembering responsibilities, and anticipating consequences.

The research addressed mainly the symptom domain.

We have known since the 1980s that “psychosocial” therapy, such as individual psychotherapy, group therapy, or social skills training, does not significantly reduce the symptoms of most children with ADHD unless medication is also used. The most common medications for children with ADHD are formulations of one of four drugs,

1) methylphenidate (e.g., Concerta, Daytrona, Focalin, Metadate, Methylin, Ritalin),

2) dextroamphetamine (Adderall, Desoxyn, Vyvanse),

3) atomoxetine (Strattera), or

4) guanfacine (Intuniv, Tenex).

A child may do well on the first drug chosen. But often, one drug may have unwanted side-effects or weak benefits for that child. So then a different one of these drugs needs to be selected. Sometimes, the child benefits more from taking the drug twice per day. Depending upon other behavioral symptoms besides those of ADHD, some children receive a second medication, such as Clonidine (catapres), riperidone, or an anti-depressant.

Adult ADHD Outcomes

The recent German study published by Alexandra Philipsen, et al, in JAMA Psychiatry shows the same is true for adults with ADHD, adding medication produces more benefit than therapy alone. The researchers analyzed data from 419 patients who had been randomly assigned to one of these four conditions: methylphenidate, individual therapy, structured cognitive behavioral group therapy, or placebo. Simply stated, the methylphenidate group experienced larger reductions in symptoms than patients in the two therapy conditions. The main measure was the ADHD Index of the Conners Adult ADHD Rating Scale.

The implications of these findings are of special importance for mental health professionals and ADHD patients.

1. A reduction of 20-25% in symptoms can be achieved by a combination of therapy and medication.
2. Medication should be added to the treatment regime in order to boost the improvement.
3. Realistic expectations are important. The state-of-the-art approaches lead only to modest gains in ADHD symptoms.

The study only measured the overall ADHD Index on the Conners. (CAARS) Note that in addition to measuring how closely the patient’s symptoms match DSM-IV symptoms for ADHD, the Conners also measures various other symptom domains as well.   We present these in order to clarify that a person with ADHD has both SYMPTOMS, as measured in the study, and IMPAIRMENTS, that is, areas of functioning which are limited by ADHD symptoms.

1) Inattention-Memory Problems – Since Working Memory deficits are thought to be central to ADHD, many patients have problems with concentration, short-term memory, forgetfulness, absent-mindedness, disorganization, and planning.

2) Hyperactivity/Restlessness – Many, but by no means all, patients feel or appear restless and have trouble sitting still.

3) Impulsivity/Emotional Lability – Many experience rapid shifts in mood (not to be confused with Bipolar Disorder), irritability, making snap choices without stopping to think about consequences.

4) Problems with Self-Concept – Lifelong difficulties with relationships, academic performance, and choices lead to a loss of self-esteem, a poor sense of competence.

The study did not determine if the treatments led to improvements in the range of domains and impairments. Nor did the study look at long-term skill improvements specifically. However, since Conners scores did not go down much in the study overall, we see that, without medication, patients lagged in the acquisition of new skills.

 

In recent years, an industry has arisen using coaching as an intervention with adults with ADHD. Motivated individuals can benefit from coaching or working with a psychotherapist to improve follow-through, completing important tasks, social interaction and relationships, and self-concept. The Philipsen study suggests that medication may enhance the ability to learn these crucial skills.

Lastly, ADHD is a lifelong condition. A person with ADHD learns

*to manage the symptoms

*to overcome the impairments,

*to acquire skills for effective performance in school, work, partnering, family life, and in the community

The study should not be read to mean that medication alone if the answer. Therapy or coaching is essential to helping many ADHD patients to manage the social, occupational, and educational effects of their primary ADHD symptoms.

*Click here to read the Sanja Gupta article.

Click here to read the abstract of the Philipsen article. 

The entire article reference is:

Philipsen A, et al (2015). “Effects of group psychotherapy, individual counseling, methylphenidate, and placebo in the treatment of adult ADHD. JAMA Psychiatry, 2146.

If you have more interest in the Conners Adult ADHD Rating Scale (CAARS), here are two sites which give examples of scoring for the CAARS and a breakdown of the symptom domains measured by the Scale, which include the major areas of difficulty in adult ADHD. The scale itself is only available to trained mental health professionals.

CAARS: Long Version (CAARS-S:L)

CAARS: Short Version (CAARS-S:S)

If you want to dig deeper into the professional literature on Cognitive Behavioral Therapy for ADHD, a good place to start is this review:

Knouse, L.A., & Safren, S. (2010). Current Status of Cognitive Behavioral Therapy for Adult Attention-Deficit Hyperactivity Disorder. Psychiatric Clinics of North America, 33 #3, 497-50

This link to the Knouse and Safren article on PubMed brings the reader to a number of other articles on this subject:

Current Status of Cognitive Behavioral Therapy for Adult Attention-Deficit Hyperactivity Disorder

 

ADHD Zone: Introducing a New Series on Attention Deficit Hyperactivity Disorder

Many families come to us for help with ADHD and related behavioral problems.  Some children (and adults) have previously received that diagnosis; then we examine the evidence and determine if the assessment seems to be correct and proceed with treatment. 

For other children, parents describe a variety of behaviors which, coupled with observation of the child in the office, lead therapists to assess the child for ADHD.  

We have written a series of practical articles for families of children 5-12.   These articles make the principles for helping these children clear and simple.    The Behavior Management principles in these articles apply, with adaptations, to children younger or older than this range of ages.

Many families stumble by using the same methods which worked for another child who does not have ADHD; they learn those methods do not work with the child who has ADHD.  Then the family may be adrift or frustrated.  Relationships become tense or hostile.  Some parents employ the same methods their parents used to rear them.  But those methods – “Good enough for my parents, then it’s good enough for me” – are not working. 

In this series, we will lay out principles which have worked well to help families coming into our clinic with an ADHD child.  The ideas in these articles work well with our ADHD families.  We will even have an article on some of these common mistakes in managing ADHD.

Here are the topics in the series:

1. ADHD Assessment and Smart Goals

• The information which will lead to a careful, adequate evaluation of the child         
• An overview of the ways we help with ADHD behavior.    
• Best TIPS for success for your child.
• A description of SMART Goals for changing the child’s behavior. 

 2. Behavior Therapy with Your ADHD Child

• The principles of how to accomplish our first priority, helping your child to become more successful, using behavior change methods.      

3. Behavior Contracting: Let’s Do It the Right Way

• Setting up an agreement with the child to change specific behaviors and to monitor the child’s performance.  Agreements work better than lectures or demands – they make sure the child fully understands the changes we want.        

4. Choose and Use Positive Reinforcement

• Picking reinforcements which will make a difference.  Selecting “rewards” can be more challenging than most parents realize.  Making consequences work effectively can be tricky.        

5. Daily Logs for Improving Child Behavior

• Using Daily Logs as part of the behavior contract. You need feedback from school in order to know treatment is working or to know whether the child’s behavior for the day merits reward.  

6. Shorehaven’s Double Reward-Double Cost Model for Changing Behaviors

• Explaining how to use immediate and short term reinforcement in order to change behavior quickly.         

7. The Troubling Ten: Mistakes Families Commonly Make Trying to Control the ADHD Child

• Listing and explaining the most common behaviors we see from parents, the ones which can change from ineffective to effective with a little guidance.

8. Executive Functions: ADHD Is a Disorder of Self-Regulation

• Explaining how an understanding of the brain’s behavior control functions can help us determine a profile of the deficits of a child and lead to more specific strategies to help.  Current research shows that problems with frontal lobe Executive Functioning, most notably Working Memory, are the cause of ADHD.  Knowing about these functions can lead us to better strategies for compensating for those problems       

9. Tips for Teachers of ADHD Children

• Listing dozens of tips and suggestions we have made for teachers of ADHD children over the years.       

10. Understand “Impairment” and Ask for Accommodations

• Using Section 504 of the Rehabilitation Act of 1973 and the IDEA (Individuals with Disabilities Education Act) to help ADHD children receive accommodations in school, changes which will support their learning.  Here are some places to learn about these federal laws.        

            http://www2.ed.gov/about/offices/list/ocr/504faq.html

            http://www.hhs.gov/ocr/civilrights/resources/factsheets/504.pdf

            http://en.wikipedia.org/wiki/Section_504_of_the_Rehabilitation_Act

            http://en.wikipedia.org/wiki/Individuals_with_Disabilities_Education_Act

            http://idea.ed.gov/

11. Important Research Findings on ADHD

• ADHD is the subject of a large amount of research.  We will focus on a few findings with major implications for parents.    

We hope these ideas will prove helpful to your family.  We welcome your feedback and comments.