INTRODUCTION — Once thought to be exclusively a disorder of childhood, longitudinal follow-up studies have shown that attention deficit hyperactivity disorder (ADHD) persists into adulthood in approximately 50 percent of cases [1-6], ADHD is associated with significant impairment in adult functioning in occupational, academic, and social spheres.
While stimulant medication (methylphenidate and amphetamine) and nonstimulant medication (atomoxetine) can reduce the core symptoms of ADHD, they often insufficiently address difficulties in executive self-management with respect to time and organization [7], as well as problems in social and emotional self-regulation, leading to continued distress and impairment for adults with ADHD [8,9]. Cognitively based psychotherapies therapies have been developed to address these problems.
This topic reviews psychotherapy for ADHD in adults. The epidemiology, pathogenesis, clinical manifestations, assessment, diagnosis, and pharmacotherapy of adult ADHD are reviewed separately. ADHD in children and adolescents is reviewed separately.
●(See "Management of attention deficit hyperactivity disorder in adults".)
●(See "Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications".)
APPROACH TO TREATMENT — Our approach to selecting treatment for ADHD in adults is reviewed separately. (See "Management of attention deficit hyperactivity disorder in adults".)
OVERVIEW — We typically use medication as the first-line treatment for adult attention deficit hyperactivity disorder (ADHD). Specific, structured psychotherapies as adjunctive treatment can provide benefit. In individuals who do not want to take medications we provide psychotherapy only. The prominence of different clusters of symptoms and/or deficit areas inform the selection among psychotherapies (see "Attention deficit hyperactivity disorder in adults: Epidemiology, pathogenesis, clinical features, course, assessment, and diagnosis", section on 'Comorbidity' and "Management of attention deficit hyperactivity disorder in adults"):
●Inattention
●Hyperactivity
●Impulsivity
●Executive dysfunction
●Emotional dysregulation
Psychotherapies have been developed to address specific symptomatic or deficit foci:
●Cognitive-behavioral therapy targeting executive dysfunction in adults with ADHD as well as co-occurring depression or anxiety disorders. (See 'CBT targeting executive function' below.)
●Dialectical behavioral therapy addresses difficulties in emotional dysregulation, impulsivity, and interpersonal functioning in adults with ADHD. (See 'Adapted dialectical behavior therapy' below.)
●Mindfulness meditation is used to treat adults with ADHD who are easily stressed, have difficulties in self-calming and maintaining attentional focus, and report racing thoughts. (See 'Mindfulness/mindfulness-based CBT' below.)
These psychotherapies vary in the extent to which they have been found to be efficacious in adults with ADHD.
PSYCHOTHERAPIES — Psychotherapies with evidence of effectiveness in adult ADHD are targeted forms of cognitive-behavioral therapy (CBT), an umbrella term that encompasses therapies that identify and target specific maladaptive cognitions and/or behaviors that create psychological distress and dysfunction. Some of the psychotherapies in this topic may not be available in some geographic areas. Earlier efforts to apply CBT to adult ADHD employed a traditional CBT approach, emphasizing distorted cognitions commonly seen in the disorder [10], such as overgeneralization, all-or-none-thinking, and disqualifying the positive.
In our clinical experience, psychotherapies that focus intensively on one area of dysfunction (eg, executive dysfunction, emotional dysregulation, or attentional focus) are more likely to bring about meaningful and lasting changes in functioning than psychotherapies that attempt to address a broad array of dysfunctions. We have found intensive targeting generally to be needed to overcome the difficulties inherent in changing longstanding habits of cognition and behavior.
CBT targeting executive function — The great majority of adults with ADHD have difficulty in some aspect of everyday executive function, particularly with respect to time management and efficiency. Research has shown that executive dysfunction is highly correlated with overall functional impairment in adults [8]. (See "Attention deficit hyperactivity disorder in adults: Epidemiology, pathogenesis, clinical features, course, assessment, and diagnosis", section on 'Executive dysfunction'.)
Two structured manualized CBT programs have been developed and tested separately and found to improve executive function in adults with ADHD [11-13]. Both employ cognitive-behavioral principles and practices to impart skills and strategies to compensate for deficits in executive self-management. Deficit areas addressed include [12,13]:
●Difficulty keeping track of tasks and activities
●Procrastination
●Difficulty prioritizing
●Disorganization
●Poor short and long-term planning
Therapeutic strategies used in these CBT programs to address these deficits include [12,13]:
●Training in specific skills:
•Systematic use of tools such as a planner, timer, and task list [12,13].
•Breaking down difficult tasks into manageable parts.
•Prioritizing tasks.
•Developing an enhanced awareness of time (eg, how long things take; how much time remains before a deadline) can be facilitated through activities such as self-timing exercises and daily time-logging.
•Setting up and maintaining organizational systems [13] (eg, for filing papers).
•Maintaining effort toward long-term goals by increasing salience of long-term rewards [13].
●Self-monitoring can be a useful basis for self-reinforcement when gradual improvements are made in applying skills and modifying behavior. Monitoring may draw on checklists or logging of application of new skills.
●Self-instruction – The internalization of new mental and behavioral habits is encouraged by the use of adaptive internal speech that cues desired behavior [13].
●Cognitive reframing to address cognitive distortions that generate anxiety, perfectionism, demoralization, and depression [12,13].
Efficacy — CBT targeting executive functioning has been found to be efficacious for adult ADHD in two randomized trials [14,15]. In each, the active treatment was compared to a supportive alternative intended to control for the nonspecific effects of treatment:
●Eighty-six adults with ADHD who remained symptomatic despite medication treatment were randomly assigned to receive individual CBT or relaxation training with psychoeducation [14]. Participants who received the CBT intervention experienced a greater reduction in ADHD symptoms on both clinician-administered and patient self-administered scales compared with the control group. A greater proportion of patients receiving CBT met criteria for treatment response on the ADHD Rating Scale compared with controls (67 versus 33 percent).
●Eighty-eight adults with ADHD, some treated with medication, were randomly assigned to group CBT or to a support group [15]. Approximately half of the patients in each group were concurrently receiving medication for ADHD at the time of assignment. Participants in the CBT group experienced greater reductions in ADHD symptoms on both clinician-administered and patient self-administered measures compared with participants in the support group. A greater proportion of patients in the CBT group experienced ADHD symptom reduction compared with patients in the support group on the patient self-report rating scale (53 versus 27 percent) on the clinician-administered structured interview of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) inattentive symptoms (42 versus 12 percent).
Co-occurring conditions (eg, mild to moderate symptoms of anxiety or depression) may appear closely related to dysfunction resulting from ADHD. In such cases, psychotherapy for ADHD symptoms may serve to reduce the comorbid symptoms as well. Although this effect has been observed clinically and in studies without an active control group [12,16-18], fully controlled studies have failed to find a reduction in comorbid anxiety or depression [14,15].
With the exception of baseline severity, which was associated with a better response to treatment, in ADHD symptoms, sociodemographic and clinical characteristics of the patients receiving CBT were not associated with patients’ clinical response. The number of home exercises completed by patients was a significant predictor of the benefit that patients received from the program [15].
Administration — CBT targeting executive functioning is generally provided over 12 to 15 sessions. Participants complete assignments at home between sessions to foster generalization of new adaptive behaviors and cognitions to activities of daily life.
Our clinical experience suggests that behavioral changes resulting from the intervention may diminish in some patients over time. “Booster” sessions, for example, a six-session course of treatment at intervals of 6 to 12 months (or more) following the initial course of therapy, may be helpful to maintain treatment benefits.
Manuals guiding clinicians in the delivery of these therapies are available [10-13].
Two CBT programs targeting executive function were initially developed for individual [12] and group [13] formats, respectively, though group can be adapted to the individual format. There have been no head-to-head trials comparing the efficacy of individual versus group delivery.
Potential advantages of a group format include:
●Mutual support and encouragement
●Reducing of the stigma of an ADHD diagnosis
●Positive modeling
●Vicarious reinforcement of successful strategies
●Cost-effectiveness
The principal advantage of individual therapy is the opportunity to tailor treatment to the individual, for example, by:
●Selecting certain modules for emphasis and omitting others
●Proceeding at a faster or slower pace
Monitoring — The Barkley Deficits in Executive Function Scale (table 1) can be helpful in identifying symptomatic targets for CBT and monitoring their change over time [19]; subscales include:
●Self-management to time
●Self-organization/problem-solving
●Self-motivation
●Self-restraint
●Self-regulation of emotions
Other ADHD rating scales, used to assess and monitor the severity of adult ADHD and co-occurring disorders, are reviewed separately. (See "Attention deficit hyperactivity disorder in adults: Epidemiology, pathogenesis, clinical features, course, assessment, and diagnosis", section on 'Rating scales' and "Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis", section on 'Assessment and Diagnosis'.)
Referral and access to care — Adults with prominent deficits in executive functioning, and thus candidates for referral to a therapist with training in CBT addressing these deficits, can be identified among adults with ADHD through a clinical interview or by using an instrument such as the Barkley Deficits in Executive Function Scale (table 1) [19]. (See "Attention deficit hyperactivity disorder in adults: Epidemiology, pathogenesis, clinical features, course, assessment, and diagnosis", section on 'Executive dysfunction'.)
ADHD patients with substance abuse should generally receive treatment for an active substance use disorder (SUD) before referring for psychotherapy for executive dysfunction as the SUD may limit compliance with and response to other psychotherapy. Other comorbidities (eg, an anxiety disorder or depression) may be secondary to ADHD-related impairment, and should not delay referral to CBT. CBT is also a potential treatment for those disorders.
The availability of CBT focusing on executive dysfunction secondary to ADHD varies, and is most likely to be available at large academic medical centers. Therapists specializing in CBT may be found in the database of members of the Association for Cognitive and Behavioral Therapies at their website. Individual and group psychotherapy rendered by licensed psychiatrists, psychologists, and social workers are typically covered by insurance in the United States.
Other CBT — Other CBT programs have been developed to address multiple symptomatic or deficit targets of ADHD with multimodal interventions. As an example, Reasoning and Rehabilitation 2, a CBT program sought to address multiple problem areas:
●Attentional control, memory, and planning
●Problem-solving skills
●Emotional control
●Prosocial skills
Efficacy — Ninety-five adults with ADHD treated with medication were randomly assigned to receive either the 15-session Reasoning and Rehabilitation 2 CBT intervention or to continue treatment as usual [16]. At the end of treatment, patients who received CBT experienced reduced ADHD symptoms compared with the group receiving treatment as usual; this difference was maintained at three-month follow-up. The effect size (0.55) was modest for a trial that did not control for the nonspecific effects of psychotherapy. The trial did not assess whether improvement occurred in each of the four problem areas above.
Co-occurring depression, anxiety disorders, and quality of life, which did not differ immediately after treatment, were improved at three-month follow-up. Nearly half the sample dropped out of CBT prior to completion of the trial.
Adapted dialectical behavior therapy — Dialectical behavior therapy (DBT), originally developed to treat borderline personality disorder, may be useful in adult ADHD, but randomized clinical trials to date have shown negative findings. Similarities between borderline personality disorder and adult ADHD include affective instability, impulsive behavior, relationship problems, and low self-esteem. (See "Psychotherapy for borderline personality disorder", section on 'Efficacy of psychotherapy'.)
DBT, as adapted for adult ADHD, [17,18], is administered to groups over 13 weekly sessions in modules that address:
●Emotional awareness and regulation – Exercises to decrease intensity of the emotion in the moment to facilitate long-term goals
●Mindfulness – Mindfulness is purposeful, nonjudgmental attention to the present moment, which is developed through meditation and other practices (see 'Mindfulness/mindfulness-based CBT' below)
●Organization
•Structure environment to reduce distracting elements
•Manage personal agenda
●Behavior analysis
•Identify antecedents and consequences of problematic behavior
•Identify alternate problem-solving strategies, preventive measures, and compensatory strategies
●Stress management
•Role of planning
●Interpersonal effectiveness
•Impact of ADHD on relationships
●Depression
•Increased prevalence among adults with ADHD (see "Attention deficit hyperactivity disorder in adults: Epidemiology, pathogenesis, clinical features, course, assessment, and diagnosis", section on 'Comorbidity')
•Medication treatment (see "Unipolar major depression in adults: Choosing initial treatment")
●SUDs
•Awareness of short-term consequences, including maladaptive behaviors and emotions
•Awareness of long-term consequences, such as loss of job or relationship
•Consider need for specialty treatment
(See "Risky drinking and alcohol use disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis" and "Cocaine use disorder in adults: Epidemiology, clinical features, and diagnosis" and "Opioid use disorder: Epidemiology, pharmacology, clinical manifestations, course, screening, assessment, and diagnosis" and "Attention deficit hyperactivity disorder in adults: Epidemiology, pathogenesis, clinical features, course, assessment, and diagnosis", section on 'Comorbidity'.)
Efficacy — There is little evidence from randomized trials to support the efficacy of DBT in adults with ADHD:
●A clinical trial of DBT skills training in 51 adults with ADHD found only marginal evidence of improvement in ADHD symptoms [20]. Study participants, who were either on a stable course of medication for ADHD or unmedicated, were randomly assigned to a DBT-based skills training group or a discussion group. Outcome was based on patient self-report on an ADHD symptom checklist. An intent-to-treat analysis failed to find significant differences between groups.
●A multi-site randomized trial of 419 German adults with ADHD compared group CBT (an adapted form of DBT [21]) and methylphenidate or placebo to clinical management, including supportive counseling, and methylphenidate or placebo [21]. DBT or clinical management were provided weekly for the first 12 weeks, then monthly for nine months; methylphenidate and placebo were provided for one year. No difference in ADHD symptoms were found between the DBT and clinical management groups at three-month and one-year follow-up. Patients who received methylphenidate experienced reduced ADHD symptoms compared with patients receiving placebo, regardless of whether they also received DBT or clinical management.
Two uncontrolled trials with a total of 79 adults with ADHD found that DBT was associated with reduction in ADHD symptoms [17,18].
Mindfulness/mindfulness-based CBT — Mindfulness and the closely related mindfulness-based cognitive therapy (MBCT), have shown mixed findings in the treatment of adult ADHD. Positive findings have been seen in comparison with treatment as usual [22], but not when compared with an active control [23].
Mindfulness, a purposeful, nonjudgmental attention to the present moment, is developed through meditation and other practices. In the teaching of mindfulness, an individual is guided to become aware of incoming thoughts, feelings, and sensations, to observe and accept them without judgment, and then to disengage from them. Originally inspired by teachings from the East, training in mindfulness has been applied to patient stress, anxiety, pain, and other problems [22]. MBCT combines the clinical application of mindfulness training with elements of cognitive training.
●A clinical trial randomly assigned 120 adults with ADHD to receive MBCT and treatment as usual or only treatment as usual for eight weeks [24]. Approximately half of each group concurrently received ADHD medication and psychoeducation, which is usual ADHD treatment in the Netherlands. MBCT was provided weekly and included meditation exercises, psychoeducation and group discussions.
After eight weeks, compared with patients assigned to treatment as usual only, patients assigned to MBCT experienced reduced core ADHD symptoms (mean score = -5.75 versus -1.11 points), an effect that was maintained at six-month follow-up. Superior outcomes at eight weeks and six months for the MBCT group also included mindfulness skills, self-compassion, and positive mental health. Executive functioning did not show improvement immediately posttreatment, but was improved at six-month follow-up in the MBCT group compared with control group at six-month follow-up.
●A 2018 clinical trial randomly assigned 81 medication-free adults with ADHD to receive either mindfulness training or structured psychoeducation for eight weeks [23]. After the completion of treatment and at eight-month follow-up, both groups showed improvement that was sustained, but no differences were seen between groups in ADHD symptom reduction.
Information about using MBCT in the treatment of depression can be found elsewhere. (See "Unipolar major depression: Treatment with mindfulness-based cognitive therapy", section on 'Theoretical foundation'.)
Neurofeedback — Neurofeedback involves training to enhance self-regulatory capacity over brain activity patterns (via electroencephalography) and, theoretically, over mental states. Randomized trials of neurofeedback in children with ADHD have had inconsistent results and multiple methodologic limitations [25]. (See "Attention deficit hyperactivity disorder in children and adolescents: Overview of treatment and prognosis", section on 'Other alternative therapies'.)
Other interventions — Other psychotherapeutic principles and techniques can be useful under specific circumstances that may be present in adults with ADHD:
●Several types of psychotherapy can be useful in treating the low self-esteem that often accompanies the disorder. (See "Overview of psychotherapies".)
●Marital therapy can be used to increase partners' skills in communication, conflict resolution, and problem solving, as well as provide education and support to the spouse of the patient with ADHD. (See "Overview of psychotherapies", section on 'Couple therapy' and "Unipolar depression in adults: Family and couples therapy".)
●Adults with ADHD should be educated about their elevated risk for an SUD, and encouraged to drink in moderation or abstain. Substance use should be monitored over the course of treatment and treated if unhealthy alcohol use or a SUD is present. (See "Screening for unhealthy use of alcohol and other drugs in primary care" and "Motivational interviewing for substance use disorders".)
SUMMARY
●Our approach to selecting treatment for attention deficit hyperactivity disorder (ADHD) in adults is reviewed separately. (See "Management of attention deficit hyperactivity disorder in adults".)
●The prominence of different clusters of symptoms and/or deficit areas, such as emotional dysregulation or executive dysfunction, can potentially inform the selection of psychotherapy to treat adult ADHD. (See 'Overview' above.)
●Cognitive-behavioral therapy (CBT) targeting executive function has shown efficacy in clinical trials in improving deficits in self-management characteristic of many adults with ADHD. (See 'CBT targeting executive function' above.)
●Dialectical behavioral therapy, adapted from an intervention developed for borderline personality disorder, addresses difficulties in emotional regulation, impulsivity, and interpersonal functioning that can be prominent in adults with ADHD. Evidence from randomized clinical trials has to date not borne out the promise shown in uncontrolled trials. (See 'Adapted dialectical behavior therapy' above.)
●Mindfulness or mindfulness-based CBT is postulated to help adults with ADHD who are easily stressed, have difficulties in self-calming and maintaining attentional focus, and report racing thoughts. Although showing evidence of efficacy compared with usual care, mindfulness training did not lead to superior outcomes in comparison with structured psychoeducation. (See 'Mindfulness/mindfulness-based CBT' above.)
