Cognitive Behavioural Therapy for Attention Deficit Disorder

Regular readers will recall that almost 30% of adults with severe obesity may have signs of attention deficit hyperactivity disorder (ADHD) and, when present, this can be a major barrier to weight management.

Thus, all patient in our obesity clinic are routinely screened for ADHD and often treating this condition is the first step to successful weight management.

However, not all patients with ADHD are willing to undergo treatment, some do not tolerate the medications, and in others, medications are simply not effective enough.

Now, a study by Steven Safren and colleagues from Harvard University, Boston, MA, published in JAMA, demonstrates the effectiveness of adding cognitive behavioural therapy (CBT) to medication for better control of ADHD.

Safren and colleagues randomised 86 symptomatic adults with ADHD who were already being treated with medication to 12 individual sessions of either cognitive behavioral therapy or relaxation with educational support (controls). 79 participants completed treatment and 70 completed the 12 month follow-up assessments.

CBT was delivered according to the manual, “Mastering Your Adult ADHD” and consisted of 3 core modules and 2 optional modules. The first module (4 sessions) focused on psychoeducation about ADHD and training in organizing and planning (use of calendar and task list system), including problem-solving training (generating alternatives and picking the best solution, breaking down overwhelming tasks into steps).

The second module (2 sessions) involved learning skills to reduce distractibility, such as techniques to time the length of one’s attention span, and, when doing a task, write down distractions vs acting on them. The third module (3 sessions) was cognitive restructuring, which involved learning to think more adaptively in situations that cause distress.

Optional modules were one session of application of skills to procrastination and one session including the patient’s family member for support.

Patients for whom the optional sessions were not relevant had booster sessions on prior material.

The final session was focused on review and relapse prevention.

Patients in the relaxation condition received training in progressive muscle relaxation and other relaxation techniques as applied to ADHD symptoms, as well as education about ADHD and supportive psychotherapy.

Participants undergoing the CBT intervention achieved lower posttreatment scores and self-reported significant improvement in symptoms. Participants in the CBT arm were about four-times more likely to respond compared to the relaxation group. Most of this response was maintained over 6 and 12 months.

This study demonstrates that the use of CBT in adults with persistent ADHD symptoms despite medication can provide important clinical benefits not seen with relaxation techniques. It is likely that CBT may also be the treatment of choice for patients who refuse medical treatment or would like to reduce their dose of ADHD medications.

Edmonton, Alberta

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Safren SA, Sprich S, Mimiaga MJ, Surman C, Knouse L, Groves M, & Otto MW (2010). Cognitive behavioral therapy vs relaxation with educational support for medication-treated adults with ADHD and persistent symptoms: a randomized controlled trial. JAMA : the journal of the American Medical Association, 304 (8), 875-80 PMID: 20736471