ramsay-russell Russell Ramsay, PhD
University of Pennsylvannia

Cognitive-behavioral therapy (CBT) is considered an evidence-supported, psychosocial treatment that has been found to be effective through several outcome studies, including randomized trials comparing CBT with active control treatments. Two recent outcome studies have extended research on CBT for adult ADHD in terms of the benefits of this treatment approach.

In the first study (Wang et al., 2016), 10 adults with ADHD participated in a 12-session course of a published, manualized CBT designed for adult ADHD.  In addition to completing pre- and post-rating scales for ADHD (symptoms and executive functioning), subjects also received resting-state functional magnetic resonance imaging scans before and after treatment. Twelve healthy control participants were matched by age and gender and also completed the clinical scales and received a single r-fMRI. The scans for the CBT group were used to compute changes in regional functional connectivity strength from treatment. Within the adult ADHD group, all participants were either medication naïve or had been off of prescribed medications at least 6 months prior to the study, thus none were medicated during CBT. The results indicated that, in addition to post-treatment improvement on self-ratings of ADHD symptoms and executive functioning (organization and self-monitoring), completion of individual CBT was associated with increased functional connectivity in the frontal-parietal network and cerebellum. Treatment was also linked to the lessening of pre-CBT deficits in right superior frontal gyrus when compared with healthy controls, with these improvements resulting from increased connectivity in the dorsal attention network. These particular changes had also been obtained in previous studies examining the effects of stimulant medications on the ADHD brain. The study is limited by the small sample size, that participants were not randomly assigned, and, although diagnosis included a structured diagnostic interview, outcome measures were based on self-report. Nevertheless, examining the effects of psychosocial treatment on brain functioning is an important level of evidence. Moreover, it should not be overlooked that positive clinical results were obtained in a sample of unmedicated adults with ADHD completing a course of CBT.

Whereas medication status in the Wang et al. (2016) was used to control for the effects of medication on r-fMRI scans, Cherkasova et al. (2016) directly examined the comparison of group CBT delivered to ADHD adults either with or without medications in a randomized clinical trial. Eighty-eight adults were randomized to a 12-session, manualized (unpublished) group CBT augmented with individual coaching check-ins either with or without medication.  Treatment effects were obtained at the end of treatment and at 3- and 6-month follow-up, using unblended ratings and observer ratings. The results indicated that both groups attained significant improvements in symptoms and functional outcomes when compared with baseline. When comparing groups, CBT with medications outperformed CBT alone for both self- and observer-ratings but these differences in improvements diminished over time, with there being no significant differences between groups in observer ratings of functioning at 6-month follow-up, and the CBT without medication group improved more gradually throughout the follow-up measurements with initial differences diminishing to the point that they were no longer significant. Both groups continued to receive booster coaching sessions after the completion of the CBT group. The authors suggested that the CBT with medication group may have reached a peak of effectiveness quicker, with the nonmedication group needing more time to achieve similar improvements. The limitations of the study were that it was unblended insofar as there was not a placebo control for the nonmedication group, there was no control or “sham” treatment comparison group, and the sample was comprised of generally high-functioning individuals.

Nonetheless, the bar has been set higher for outcome research on CBT for adult ADHD. While none of these findings should be used to diminish the importance of medications in treatment options considered for adults with ADHD, individuals who refuse medications, cannot tolerate side effects, or for whom they are ineffective may still benefit from psychosocial treatment.

Wang, X., Cao, Q., Wang, J. Wu, Z., Wang, P., Sun, L., et al. (2016). The effects of cognitive-behavioral therapy on intrinsic functional brain networks in adults with attention-deficit/hyperactivity disorder. Behaviour Research and Therapy, 76, 32-39. doi: 10.1016/j.brat.2015.11.0030005-7967/

Cherkasova, M.V., French, L.R., Syer, C.A., Cousins, L., Galina, H., Ahmadi-Kashani, Y., & Hechtman, L. (2016). Efficacy of cognitive behavioral therapy with and without medication for adults with ADHD: A randomized clinical trial. Journal of Attention Disorders. Epub ahead of print. doi: 10.1177/1087054716671197