Cognitive behavioural therapy improves the core symptoms of attention deficit hyperactivity disorder (ADHD) in adults, compared with a range of other treatments. This Cochrane review found a general trend for improvements in inattention, hyperactivity and impulsiveness, especially when therapy was combined with medication.
The review included trials that compared cognitive behavioural therapy to other specific interventions or to a range of control conditions, including waiting list and no treatment. It also looked at cognitive behavioural therapy plus drug treatment, versus drug treatment alone.
The included trials were rated very low to moderate quality. They also used a variety of outcome measures, which made it difficult to compare the interventions.
Despite these limitations, the review provides evidence that reinforces current guidance and practice.
Why was this study needed?
Attention deficit hyperactivity disorder (ADHD) is a group of behavioural symptoms which usually begin in childhood. While the symptoms of inattentiveness, hyperactivity and impulsiveness usually improve with age, they can continue into adulthood. In the UK, 3 to 4% of adults are thought to have the condition. In adults, it can affect social interactions, study and work performance. Drug treatments are often used to manage the symptoms.
Previous studies suggest that cognitive behavioural therapy (CBT) could be effective for treating adults. CBT aims to change a person’s thoughts and behaviours by teaching techniques to control the core attention and executive deficits of ADHD and to modify the distorted negative beliefs and self-esteem as these can lead to emotional maladjustments such as anxiety and depression.
This Cochrane review aimed to assess the effectiveness of CBT for adults with ADHD.
What did this study do?
This systematic review found 14 randomised controlled trials that included 700 adults with ADHD. All the trials looked at the effects of talking therapies, including mindfulness-based interventions, Internet-based CBT, metacognitive therapy and dialectical behaviour therapy. Most CBT programmes were of 8 to 12 sessions and were delivered on an individual or group basis. The trials lasted between 8 and 15 weeks.
None of the trials took place in the UK. Four took place in the USA, eight in Europe and one each in Australia and China.
Outcomes were measured by clinicians or the patients themselves, using validated clinical-symptom-specific scales and scores. The quality of the evidence ranged from very low to moderate which reduces confidence in the results.
What did it find?
- Compared with being on a waiting list, CBT led to a large improvement in self-reported ADHD symptoms (standardised mean difference [SMD] -0.84, 95% confidence interval [CI] -1.18 to -0.50; 5 studies, 251 participants; moderate-quality evidence). It showed a greater improvement in clinician-reported symptoms, but the quality of the evidence was very low (SMD -1.22, 95% CI -2.03 to -0.41; 2 studies, 126 participants).
- Cognitive behavioural therapy was more effective than supportive therapy for improving clinician-reported ADHD symptoms (SMD -0.56, 95% CI -1.01 to -0.12; 1 study, 81 participants; low-quality evidence). However, it didn’t show a benefit over supportive therapy for self-reported symptoms (SMD -0.16, 95% CI -0.52 to 0.19; 2 studies, 122 participants; low-quality evidence).
- Drug treatment plus CBT was more effective than drug treatment alone for both clinician-reported and self-reported core symptoms. For clinician-reported symptoms, the SMD was -0.80 (95% CI -1.31 to -0.30; 2 studies, 65 participants; very low-quality evidence). For self-reported symptoms, the mean difference was -7.42 points on the 0 to 54 point Current Symptoms Scale (95% CI -11.63 to -3.22; 2 studies, 66 participants; low-quality evidence).
- Cognitive behavioural therapy showed a benefit over other specific interventions for clinician-reported ADHD symptoms (SMD -0.58, 95% CI -0.98 to -0.17; 2 studies, 97 participants; low-quality evidence), and for self-reported symptom severity (SMD -0.44, 95% CI -0.88 to -0.01; 4 studies, 156 participants; low quality evidence).
- None of the studies reported severe adverse events, but five people reported some type of adverse event such as distress and anxiety.
What does current guidance say on this issue?
The 2018 NICE guideline on the diagnosis and management of ADHD recommends drug treatment for adults whose ADHD symptoms cause them significant problems and suggests that non-pharmacological treatment should be considered for adults who choose not to have drugs, have difficulty adhering to medication or who have found it ineffective.
A combination of medication and non-pharmacological treatment is recommended if the person is still experiencing symptoms. The guideline suggests that non-pharmacological treatment may involve elements of or a full course of CBT.
What are the implications?
The evidence in this review was only of very low to moderate quality. However, it supports the use of CBT to help adults manage their ADHD symptoms. This is helpful in the context of concerns from clinicians about prescribing medication for ADHD.
The 2018 NICE guideline committee acknowledged that there is uncertainty about the long-term benefits and the adverse effects of medication. They felt that their recommendation to offer non-pharmacological treatment in certain circumstances reflects good current practice.
This review strengthens the evidence-base for non-pharmacological treatments.
Citation and Funding
Lopez PL, Torrente FM, Ciapponi A, et al. Cognitive-behavioural interventions for attention deficit hyperactivity disorder (ADHD) in adults. Cochrane Database Syst Rev. 2018;3:CD010840.
No funding information was provided for this study.
CKS. Attention deficit hyperactivity disorder. London: National Institute for Health and Care Excellence; 2015.
NHS website. Attention deficit hyperactivity disorder (ADHD). London: Department of Health and Social Care; 2016.
NICE. Attention deficit hyperactivity disorder: diagnosis and management. NG87. London: National Institute for Health and Care Excellence; 2018.
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