The efficacy of cognitive‐behavioral therapy for adults with ADHD

Cognitive‐behavioral therapy (CBT) for attention‐deficit/hyperactivity disorder (ADHD) (henceforth referred to as CBT‐ADHD) differs from traditional CBT, as the latter is most often practiced to treat disorders that primarily involve emotions such as anxiety and depression. Instead, the primary focus of CBT‐ADHD is to target executive dysfunction, which has been shown to be a major predictor of functional impairment in school and in the workplace for children and adults with ADHD ¹ .

CBT‐ADHD aims to improve the executive functions of time management, organization, and planning. As such, it features specific strategies – both cognitive and behavioral – to facilitate time awareness, prioritizing, scheduling, tracking, and overcoming distraction and procrastination ² , ³ . These intervention programs also typically include components of traditional CBT with respect to identifying and restructuring negative automatic thoughts that generate anxiety and depression, which are prevalent among individuals with ADHD ⁴ and contribute further to distress and impairment.

The UK and Australian ADHD guidelines recommend to utilize CBT as a first‐line intervention, in conjunction with medication, for adults with ADHD. Although Cortese et al ⁵ state that “CBT is not designed to treat the core symptoms of ADHD”, the DSM‐5 set of ADHD symptoms has been utilized as a primary outcome measure in virtually all the studies of the efficacy of CBT‐ADHD, with significant positive findings. In fact, multiple core symptoms of ADHD overlap with executive dysfunctions and are addressed in the program. These include failure to complete tasks; difficulty with organization; avoidance of tasks requiring sustained mental effort; losing things; and forgetting things.

The earliest trials of CBT‐ADHD in adults were published in 2010, and included respectively 86² and 88³ participants, who were randomly assigned to receive CBT‐ADHD in either individual ² or group ³ modality, or to receive an active control condition (“psychological placebo”) intended to control for the non‐specific effects of treatment, principally social support. The control condition was either relaxation with educational support ² or a support group ³ . Targets and strategies, as well as the number of sessions (twelve) were otherwise quite similar in the two studies. Results in both studies were based on blinded, investigator‐rated, well‐validated structured assessments of core ADHD symptoms, which, it should be noted, is the “gold standard” for outcomes of clinical trials, and has been determined to be more reliable and valid than self‐report measures for this purpose. Results revealed moderate effect sizes of 0.52 and 0.58, respectively, favoring CBT‐ADHD. The adult protocol was subsequently revised for the needs of college students with ADHD, with comparable positive results ⁶ .

A total of 17 randomized controlled trials completed by 2023, including the two studies above, were entered into a meta‐analysis ⁷ , categorized with respect to whether the control condition was waitlist, treatment as usual (TAU), or an active control intervention. TAU typically involved some combination of medication management and individual supportive follow‐up visits. The active control condition was psychoeducation, support, or relaxation (as described in one of the studies above ² ). Effect sizes for investigator‐rated core ADHD symptoms for waitlist, TAU, and active control were 1.03, 0.66 and 0.32, highlighting the importance of an active control to isolate the specific benefits of CBT over and above the generic effects of social support or psychoeducation.

Importantly, from a clinical perspective, a separate meta‐analysis found that CBT‐ADHD added significantly to the benefits of stimulant therapy, thereby providing support for combination treatment ⁸ .

In a meta‐analysis including 20 randomized controlled trials of CBT‐ADHD, of which five had active controls and 12 were uncontrolled pre‐test/post‐test comparisons, CBT significantly improved symptoms of anxiety and depression, as well as quality of life and emotion dysregulation ⁹ . These changes were predicted by the reduction in ADHD symptoms, and thus may be an indirect effect of facilitating the individual's performance and management of daily life functions.

As Cortese et al highlight, maintaining engagement is an obvious concern in treating individuals with attentional difficulties. In the CBT‐ADHD programs for adults ³ and college students ⁶ , engagement is elicited and maintained by the use of multiple strategies, including: a) initially highlighting the importance of attending all sessions, in that each participant is effectively serving as a “co‐therapist” for the others; b) highlighting that the number of home exercises has been shown to predict benefit from the program; c) conducting a round‐table review of each participant's experience with the home exercise at the start of each session; d) utilizing the Socratic method and facilitating discussion when new strategies are presented; e) reassuring participants that they should never skip a session because they have not completed the home exercise (“because any and all experience shared is helpful as ‘grist for the mill’”); f) reviewing the upcoming home exercise at the end of each session, with anticipatory trouble‐shooting.

Feasibility was monitored in these studies via the completion rates of treatment, defined as having attended at least 9 of the 12 group sessions, which were reported as 87% and 83% for the adult and college programs, respectively. Acceptability of treatment was assessed via participant‐completed ratings of the “helpfulness” of each of the eleven strategies presented in the program on a 4‐point scale: 0 (“not at all helpful”); 1 (“slightly helpful”); 2 (“moderately helpful”) and 3 (“very helpful”). Results revealed that, in the adult study, six of the eleven strategies were rated by more than half of the participants as either “moderately helpful” or “very helpful”. For college students, the corresponding figure was eight of the eleven strategies. There was notable overlap between the strategies rated most helpful by the adults and college students.

There is a clear need for a definitive large‐scale study in which CBT and medication, along with their respective placebo control conditions, are compared separately and together. Furthermore, there has been little investigation of the long‐term maintenance of gains of CBT‐ADHD, or of the potential utility of booster sessions. There would also be value in tailoring and testing CBT‐ADHD for treatment of individuals with specific co‐occurring symptoms, including anxiety, depression, and substance use, and in assessing the relative benefits of individual and group modalities for these subgroups.

In conclusion, research to date provides strong support for the efficacy of CBT‐ADHD for clinical use both as a standalone treatment for ADHD, and as a beneficial adjunct to medication.