Cognitive behavioral therapy (CBT) is one of the most popular modalities of therapy, and it’s often used to treat anxiety, depression and PTSD. But it can also be useful for treating adult Attention-deficit/hyperactivity disorder (ADHD). In a recent presentation, Rivia Mind’s own Duyen Nguyen, PMHNP-BC covered the benefits of CBT for adult ADHD and how it’s used.
Let’s dive into what was discussed.
What Does ADHD Look Like For Adults?
ADHD impacts 7-11% of children and 4-5% of adults.1 60% of children with ADHD continue to be symptomatic into adulthood. There is also some evidence of adult onset even when ADHD wasn’t present in childhood.
ADHD is known for its three core symptoms: inattention, hyperactivity, and impulsivity. For adults, however, these symptoms may look different than they would for adolescents.
Executive function deficits are a staple of ADHD in adults. Individuals with ADHD may struggle to get started on tasks, maintain concentration, and maintain any sense of organization. There are also behavioral and emotional dysregulation that can be tied into executive function deficits, such as:
- Mood lability
- Poor frustration tolerance
- Anger management
- Difficulty with interpersonal relationships
Consequences of Adult ADHD
ADHD can interfere in almost every aspect of adult life. For students, it could result in poor academic performance, low grades, and a reduced likelihood of graduation. In work, ADHD could impact your ability to gain or maintain employment, impact your occupational status and salaries, reduce productivity, and lead to lower employer-rated job performance, turnovers, and dismissals.
ADHD has been linked to increased risk of traffic collisions and violation of traffic roles, such as speeding or risk-taking behavior.1 Patients with ADHD also have higher divorce rates, healthcare costs, and a greater risk of contracting STIs due to impulsive behaviors.
Childhood vs. Adult ADHD
In childhood, hyperactivity may be one of the first tells for ADHD. However, in adulthood, hyperactivity tends to decrease. Studies show that 90% of adults with ADHD present primarily inattentive symptoms.1 ADHD is also most prevalent in female patients in adulthood, a contrast to the more or less equal prevalence in childhood.
Clinical presentation of ADHD in adults may include:
- Inattention: paying less attention to details, difficulty managing time, or frequent job turnover.
- Hyperactivity: difficulty sitting through meetings or frequent job changes
- Impulsiveness: overcommitting to projects, impractical promises, or readiness to anger.
Comorbidities of ADHD
ADHD also has a remarkably high comorbidity rate, up to 50-75%.2 As many as 47% of those with ADHD also have anxiety. 38% of ADHD patients also have mood disorders, and 15% of ADHD patients struggle with substance use.
ADHD and anxiety have common symptoms such as internal restlessness, difficulty concentrating, and fidgeting. Because of this, anxiety can exacerbate ADHD symptoms. Similarly, negative social feedback or reduced executive function due to ADHD can become causes of anxiety.
When ADHD and anxiety are comorbidities, it can result in higher rates of hospitalization, psychotic symptoms, and higher levels of externalizing behaviors, such as suicidal gestures or increased anger. Studies of interactions between ADHD and anxiety have found that ADHD symptoms often predated anxiety symptoms, but anxiety symptoms did not predict ADHD symptoms. This could be due to negative social responses that individuals with ADHD received as children. Another possibility is that executive dysfunction that comes with ADHD could reduce your ability to cope with stressors.3
When To Consider Therapy For Adult ADHD
Some patients with ADHD may be wary of treating their symptoms with medication. They may have had negative past experiences of medication or may not be suitable for medication. 20-50% of adults are found not suitable to medications, are non-responders, or are unable to handle side effects. And only a 30% reduction in symptoms is needed to be considered a “responder” to medication. Thus some might prefer therapy instead of or in addition to medication.
CBT For Adult ADHD
CBT has the most research in favor of treatment for adult ADHD. It can address comorbidity symptoms such as anxiety and depression, as well.
The goal of CBT is to decrease ADHD symptoms, as well as comorbidity symptoms of anxiety and depression, and to increase self-esteem. It typically lasts between 8-12 sessions, though it can last longer when needed. It can be given through individual therapy, group therapy, or even self-directed methods. It strives to treat symptoms of ADHD through:
- Cognitive modification: reframing maladaptive beliefs and changing dysfunctional behavioral patterns
- Behavioral modification: improving organization skills and time management, and building a tolerance of boredom and uncomfortable feelings
- Executive function training and habilitation: building adaptive skills to avoid avoidance, and working with patients to optimize their individual ways of functioning, as well as making a coping mechanism routine
CBT has three core modules: organizing and planning, tacking distractibility, and cognitive restructuring (otherwise known as adaptive thinking). In addition, it has three optional modules: tackling procrastination, anger and frustration management, and communication skills. It is an active therapy that utilizes homework and skills to practice in and out of sessions.
Module 1: Organizing and Planning
In the organizing and planning session, you will use a calendar and a task list system to help to prioritize tasks and build organization skills. Tasks are rated as:
- “A” tasks: tasks with high importance that must be completed in a short period of time
- “B” tasks: medium importance tasks that can be completed within a moderate time frame
- “C” tasks: tasks that are least important, but easy and appealing to do
Work with your therapist to rate your tasks, and then tackle A tasks first. Once A tasks are finished, you can move onto B, and then finally C. The task list should be reviewed every day.
This module also involves exercises in problem solving. There are 5 steps that CBT recommends for problem solving:
- Articulate the problem
- List all the possible solutions
- List the pros and cons of each solution
- Rate each solution
- Implement the best option
For example, one solution might be to break a large, daunting project into smaller tasks, which will decrease avoidance.
Module 2: Tackling Distractibility
The first step of tackling distractibility is to gauge your distractibility. Once you have a sense of the limits of your attention span, you can divide your tasks into steps that gently push at the boundaries of that attention span to expand it.
One way to reduce distractibility is by keeping a piece of paper and a timer on you. Set a timer as you set to work. When a distracting thought comes, write it down on the piece of paper and then return to work. When the timer goes off, look at your paper. Is what you wrote down still worth following up on? You can do so at that time.
During module 2, you’ll also work on controlling your environment to limit distractions, such as clearing your workspace and silencing your phone. You’ll go back to organizational skills for this by creating a designated place for each important item in your workspace. That way, you won’t be distracted by having forgotten something you need.
Module 3: Cognitive Restructuring
During cognitive restructuring, you and your therapist will identify negative automatic thoughts that could be interfering with your life. You can keep an automatic thought record to track those thoughts, the situation that causes them, and your mood when they occur. You can then identify the flaw in the thinking and write out a rational response.
Common negative thoughts include:
- Mental filter: dwelling on negative details and overlooking positives. Example: I can never do anything right.
- Emotional reasoning: I feel it so it must be true.
- Should statements: focusing on what you should have done instead of what you can do next time.
- Overly optimistic thoughts: I can do this tomorrow.
It’s important to note that patients should not overlook all negative thoughts. The goal is to achieve balance, to keep negative thoughts from taking over and interfering with your life.
How Effective Is CBT For Adult ADHD?
In 14 randomized controlled trials, CBT treatment for adult ADHD resulted in a significant reduction of symptoms.4 There was also a significant reduction in comorbid anxiety, depression, and anger.
Multiple studies have shown a 50% decrease in ADHD symptoms after CBT, and these gains were maintained after 6 and 12 month follow-ups. At the end of the day, CBT has been found more effective than supportive psychotherapies or waiting lists, and CBT with pharmacotherapy has been found more effective than pharmacotherapy alone.
At Rivia Mind, we work with skilled and compassionate clinicians who are experienced with using CBT and other effective modalities to treat ADHD. If you’re interested in treating your ADHD with therapy, visit our psychotherapy page to learn more about this treatment plan. Contact Rivia Mind today to learn more or visit our provider page to schedule an appointment.
Resources:
- Prakash, J., Chatterjee, K., Gua, S., Srivastava, K., and Chauhan, V.S. (2021), Adult Attention-Deficit Hyperactivity Disorder: From Clinical Reality Toward Conceptual Clarity. Industrial psychiatry journal, 30(1), 23-28
- Quenneville, A.F., Kalogeropoulou, E., Nicastro, R., Weibel, S., Chanut, F., and Perroud, N. (2022), Anxiety Disorders in Adult ADHD: A Frequent Comorbidity and a Risk Factor For Externalizing Problems. Psychiatry research, 310, 114423
- Gair, S.L., Brown, H.R., Kang, S., Grabell, A.S., Harvey, E.A. (2021). Early Development of Comorbidity Between Symptoms of ADHD and Anxiety.
- Lopez, P.L., Torrente, F.M., Ciapponi, A., Lischinsky, A.G., Cetkovich-Bakmas, M., Rojas, J.I., Romano, M., Manes, F.F. (2018). Cognitive-behavioural interventions for attention deficit hyperactivity disorder (ADHD) in adults. Cochrane Database of Systematic Reviews, 2018(3).
