Cognitive Behavioral Therapy (CBT) is a one to one therapy, for adolescents or adults, where a therapist teaches an ADHD patient how thoughts, feelings, and behaviors are all interrelated and how each of these elements affects the others. CBT emphasizes cognition, or thinking, because a major goal of this therapy is to help patients identifying thinking patterns that lead to problem behaviors. For example, the therapist might discover that the patient frequently has negative automatic thoughts such as “I’m stupid” in challenging situations. We call the though ‘automatic’ because it invades the patients consciousness without any effort. Thinking “I’m stupid” can cause anxiety and depression which leads to failure. Thus, stopping the automatic thought will modify this chain of events and, hopefully, improve the outcome from failure to success.
CBT also educates patients about their ADHD and how it affects them in important daily activities. For example, most ADHD patients need help with activity scheduling, socializing, organizing their workspace and controlling their distractibility. By teaching specific cognitive and behavioral skills, the therapist helps the patient deal with their ADHD symptoms in a productive manner. For example, some ADHD patients are very impulsive when conversing with others. They don’t wait their turn during conversations and may blurt out irrelevant idea. This can be annoying to others, especially in the context of school or business relationships. The CBT therapist helps the patient identify these behaviors and creates strategies for avoiding them.
So, does CBT work for ADHD? The evidence base is small, but when CBT has been used for adult ADHD, it has produced positive results in well-designed studies. These studies typically compare patients taking ADHD medications with those taking ADHD medications and receiving CBT. So for now, it is best to consider CBT as an adjunct to rather than a replacement for medication. There are even fewer studies of CBT for adolescents for ADHD. These initial studies also suggest that CBT will be useful for adolescents with ADHD who are also taking ADHD medications. Some data suggest that CBT can be successfully applied in the classroom environment but, again, the evidence base is very small.
How can this information be used by doctors and patients for treatment planning? Current treatment guidelines suggest starting with an ADHD medication. After a suitable medication and dose is found, the patient and doctor should determine if any problems remain. If so, than CBT should be considered as an adjunct to ADHD medications.
Antshel, K. M. & Olszewski, A. K. (2014). Cognitive Behavioral Therapy for Adolescents with ADHD. Child Adolesc Psychiatr Clin N Am 23, 825-842.
Safren, S. A., Sprich, S., Mimiaga, M. J., Surman, C., Knouse, L., Groves, M. & Otto, M. W. (2010). Cognitive behavioral therapy vs relaxation with educational support for medication-treated adults with ADHD and persistent symptoms: a randomized controlled trial. JAMA 304, 875-80.
Solanto, M. V., Marks, D. J., Wasserstein, J., Mitchell, K., Abikoff, H., Alvir, J. M. & Kofman, M. D. (2010). Efficacy of meta-cognitive therapy for adult ADHD. Am J Psychiatry 167, 958-68.
Hello APSARD Members,
The APSARD Social Media and Website committee is trying out a new blog feature. We will be showcasing various clinical/clinical-research programs specializing in various aspects of the assessment and treatment of ADHD. The purpose is to highlight some of the professional activities of APSARD members and the availability of these programs as helpful resources for people with ADHD at all stages of life.
If there is such a program/clinic that you think should be featured, please send your suggestion to info@APSARD.org. Of course, it will be up to a representative of the particular clinic/program to provide the blog-overview.
University of Pennsylvania Adult ADHD Treatment and Research Program
J. Russell Ramsay, Ph.D.
The University of Pennsylvania Adult ADHD Treatment and Research Program was originally established during a meeting on March 8, 1999. Psychiatrist Dr. Anthony Rostain, who had previously launched the Children’s Hospital of Philadelphia’s ADHD program, which remains a leader in the field of childhood and adolescent ADHD, approached psychologist, Dr. J. Russell Ramsay about the prospect of starting an adult ADHD specialty clinic in their department. Rostain envisioned a program offering a two-pronged intervention approach of pharmacotherapy and psychosocial treatment, namely cognitive-behavioral therapy adapted to adult ADHD. Seeing as Ramsay was (and continues to be) on the clinical staff at the Center for Cognitive Therapy at PENN, Rostain reached out to him for a potential collaboration (most likely because none of the other clinical staff had any interest in ADHD).
The initial task before accepting any referrals was to hammer out the components of a comprehensive diagnostic evaluation. After discussions and consultations with colleagues from within and outside of PENN who had some experience with ADHD, an evaluation framework was set. In the ensuing years, the evaluation has undergone various additions, deletions, and other revisions but is still consistent with its initial framework and function.
The team has grown over the years from a two -person operation to include an intake coordinator; a medication consultation and treatment arm that is staffed by advanced psychiatry residents who receive year-long supervised training with Dr. Rostain; and a psychosocial treatment arm staffed by advanced pre-doctoral clinicians in clinical psychology, who also handle the comprehensive diagnostic evaluation arm of the program as part of a year-long practicum experience, supervised by Dr. Ramsay. In fact, many of these trainees have gone onto use archival and other clinical data gathered through the program for their doctoral dissertation projects. More recently, in what has become the third intervention arm, Lisa Tuttle, an Adult ADHD Coach, has established a mindful self-management course, a 12-week psychoeducational skills class based that is composed of a hybrid of executive function and cognitive-behavioral coping skills.
Individuals seeking assessment and clinical services through the program undergo a comprehensive evaluation that involves a host of ADHD symptom and comoribidity inventories (including both self- and other-reports), structured clinical interviews (including SCID-5), and a brief testing battery. Results and recommendations are reviewed during a feedback session (including recommendations for individuals whose presentation does not support an ADHD diagnosis) and are summarized in a written report. Treatment options provided by the program as well as referral options to colleagues in the Greater Philadelphia region are provided. Dr. Rostain is also a certified evaluator with both Major League Baseball and the National Football League for their therapeutic use exemption programs.
The upcoming special issue of the Journal of Attention Disorders highlights research on the prevalence of ADHD around the world as well as throughout the lifespan. These articles are important, not only further documenting the global reach of ADHD, but also shedding light on heretofore under recognized populations of children, adolescents, and adults who may benefit from various supports and treatments — many of which will be reviewed at the APSARD conference next week in Washington, D.C. A benefit of an APSARD membership is access to this important and informative journal.
By Roberta Waite and Meghan S. Leahy
In the 1970’s, Kabat-Zinn popularized mindfulness meditation (MM) as many people sought non-medication interventions for a variety of conditions. Consequently, mindfulness interventions are increasingly used to address many health-related concerns. Today, MM is seen as a practical skill to use that benefits well-being, including being viewed as an option for individuals affected by ADHD.
Mindfulness focuses attention on the person’s current experience, preparing them to be receptive to experiences instead of avoiding them via repression. This allows the person to adopt a fresh perspective or apply a
“beginner’s mind” to ways of receiving life experiences (Greenberg et al., 2012). MM suggests an open and purposefully attentive state of mind (Thomas & Atkinson, 2016). The individual’s attention remains in the here-and-now, and thoughts and emotions that surface are observed non-judgmentally (Bachmann et al., 2016). Because ADHD is characterized by a persistent pattern of age inappropriate displays of attention and/or hyperactive-impulsive behaviors that create functional impairments across multiple settings, consistent practice of MM may help to improve one’s attentional control, thereby decreasing their inattention and impulsivity. Specifically, mindfulness can facilitate improvement of ADHD on three fundamental levels – neuropsychological, structural/functional, and behavioral.
Neuropsychological and Structural/Functional Level
On a neuropsychological level, MM can improve functioning on tasks measuring executive functioning including attention, cognitive control, as well as working memory. Since we also know that neuronal plasticity can be improved by intense, persistent, and habitual restorative interventions, MM may improve psychological performance. This is of interest since ADHD is recognized to be linked to structural, functional, and neurochemical brain abnormalities. MM which is characterized as a form of mental training, may moderate neuropsychological deficits in ADHD. Specifically, areas of attention control and emotion regulation can be positively affected by strengthening areas of brain thought to bring about these deficits.
Through use of MM, individuals affected by ADHD can foster behavioral inhibition skills by learning to observe emotional states as transient events, thus promoting emotional regulation. While emotion regulation does not serve as a primary diagnostic trait of ADHD, it is a factor in many areas of functioning, particularly in interpersonal relationships. By enhancing emotional regulation through MM the person develops strategies that aid in affecting the occurrence, experience, and expression of emotions (Bachmann et al., 2016).
Although the full mechanism of mindfulness mediation remains elusive as it relates to changes within the neurobiological process, it can be postulated that MM alters “brain structure and function by myelinogenesis, synaptogenesis, dendritic branching, or adult neurogenesis” (Bachmann et al., 2016, p. 117). Even more, it seems that MM may have favorable effects on neuronal protection, renewal, and/or preventing cell death as well as improving cognitive control to create a steady pattern of deactivation in brain regions related to a mindfulness state (Bueno et al., 2015). Taken together, it is evident that “habits of mind” such as practicing MM modifies both the structure and the functioning of the brain. By stimulating both neuroplasticity and mental self-discipline, MM also aids in stress reduction which is quite relevant for persons affected by ADHD, as stress magnifies restlessness and concentration difficulties, as well as frustration and irritability. Cultivating ways of managing stress via MM (e.g., focusing on the present and increasing self-awareness) ultimately promotes the overall well-being of individuals who practice it. Healthy psychological functioning among persons affected by ADHD appears to depend on the well-coordinated operation of neuronal networks. To that end, great promise exists with MM since it provides a tool with which persons with ADHD can better promote self-regulation (Bachmann et al. 2016).
On a behavioral level, MM places emphasis on improving the ability to control attention and inhibit automatic responses. Practitioners of MM have improved ability to self-reflect and consequently are better able to foster self-esteem and empathy for others. Abrams (2013) reports that MM reduces behavior problems, and increases on-task behavior and academic performance. Cassone (2015) sees MM as a useful tool for improving self-regulation, specifically, orienting, alerting, and executive attention.
By identifying and acknowledging their thoughts in the here-and-now, patients with ADHD have the opportunity to fully consider them in a non-judgmental way, which can lead to improved self-awareness and focus on managing behaviors. Research has shown that MM has reduced both the inattentive and hyperactive symptoms in children and adults (Thomas & Atkinson, 2016). These behavioral changes have been shown to have effects that last beyond end-of-treatment. The changes prompted by MM do not simply improve the daily lives of the individual patients, but can make a meaningful difference in their relationships with their family, friends, and colleagues. It reduces stress in daily interactions and as a result, improves not just mood, but quality of life.
Take Away: Benefits of Mindfulness Meditation and ADHD
• “Mindfulness” is a term that has dual meanings: it can be both a process and an outcome.
• Mindfulness techniques can be taught to children as young as 7 years-old.
• Mindfulness makes it easier to exist in the moment, experiencing and processing events as they take place rather than automatically reacting to them, which allows for behavior change.
• Mindfulness practice leads to becoming more engaged in activities, with family, friends, and colleagues, which can deepen relationships on many levels.
• With practice, mindfulness meditation improves the ability to handle challenges and adverse events.
• Mindfulness, with or without medication has shown to be a viable treatment for adults with ADHD.
• Mindfulness works especially well when used in conjunction with Cognitive Behavioral Therapy and other treatments for ADHD.
• Mindfulness can be used to address many issues that are co-morbid with ADHD, including anxiety, OCD, depression, substance misuse/abuse, and eating disorders.
• Mindfulness improves physical health by reducing stress, lowering blood pressure, and improving sleep, cardiac, and GI issues.
Abram, J. (2013). The impact of mindfulness practice on the behavior, wellbeing, and cognition of preadolescent students. Retrieved from http://archives.evergreen.edu/masterstheses/Accession89-10MIT/Abrams_MIT2013.pdf
Bachmann, K., Lam, A., & Philipsen, A. (2016). Mindfulness-based cognitive therapy and the adult ADHD Brain: A neuropsychotherapeutic perspective. Front Psychiatry, 7. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4921925/
Bueno, V., Kozasa, E., da Silva, M., Alves, T., Louza, M. & Pompeia, S. (2015). Mindfulness meditation improves mood, quality of life, and attention in adults with attention deficit hyperactivity disorder. BioMed Research International. Retrieved from https://www.hindawi.com/journals/bmri/2015/962857/
Cassone, A. R. (2015). Mindfulness training as an adjunct to evidence-based treatment for ADHD within families. Journal of Attention Disorders, 19(2),147-157.
Greenberg, J., Reiner, K., & Meiran, N. (2012). “Mind the trap”: Mindfulness practice reduces cognitive rigidity. PLoS One, 7(5) doi:http://dx.doi.org/10.1371/journal.pone.0036206
Kabat-Zinn, J. (1996). Full Catastrophe Living. Piakus Books, London.
Thomas, G. & Atkinson, C. (2016). Measuring the effectiveness of a mindfulness-based intervention for children’s attentional functioning. Educational & Child Psychology, 33(1), 51-64.
Ryan J. Kennedy, Donald M. Quinlan, and Thomas E. Brown
Comparison of Two Measures of Working Memory Impairments in 220 Adolescents and Adults with ADHD. Journal of Attention Disorders. Online First, August 1, 2016. DOI: 10.1177/1087054716661232
This study compares two normed measures used in ADHD evaluations to assess impairments in working memory. Although individuals with ADHD may have excellent recall of long-term memories, they often report having chronic difficulty with their short term working memory (WM). They often forget things in the here-and-now: what others have just said to them, where they have put something, what they were about to do, what they have just finished reading, and so on. Measures compared were:
1) A normed story recall test consisting of two brief stories from the Wechsler Memory Scale read aloud to the patient only once. Immediately after each story is read aloud by the examiner, the patient is asked to retell it to the examiner, as close to verbatim as possible. Responses are then scored relative to age norms.
2) The Working Memory Index (WMI), a combination of two subtests from the Wechsler Adult Intelligence Scale–Fourth Edition: the digit span (forward and backward) and mental arithmetic. Both are administered orally.
Results support our hypotheses that adolescents and adults with ADHD tend to score significantly lower on both of these tasks, with significantly more difficulty on story memory, than do most persons of comparable age in the general population.
We suggest that the story memory task has more ecological validity than numerically-based measures of working memory. It provides an objective measure to assess an individual’s ability to pay attention to a sizable, but manageable, chunk of verbal information and to remember what has been heard. This is not so different from many daily life situations where one needs to pay attention to what someone is saying and keep it in mind long enough to understand and recall what has been said. The story memory task can be administered in approximately 10 minutes.