Psychosocial treatment is a critical part of treatment for ADHD. The scientific literature, the National Institute of Mental Health and many professional organizations agree that behaviorally oriented psychosocial treatments—also called behavior therapy or behavior modification—and stimulant medication have a solid base of scientific evidence demonstrating their effectiveness.
Why use psychosocial treatments?
Behavioral treatment for ADHD is important for several reasons. First, children and adults with ADHD face problems in daily life that go well beyond their symptoms of inattentiveness, hyperactivity and impulsivity, including poor academic performance and behavior at school, poor relationships with peers and siblings, failure to obey adult requests and poor relationships with their parents. These problems are extremely important because they predict how children with ADHD will do in the long run.
Psychosocial treatments are effective in treating these important domains. In addition, behavioral treatments teach skills to parents and teachers that help them deal with children with ADHD. They also teach skills to children with ADHD that will help them overcome their impairments. Learning these skills is especially important because ADHD is a chronic condition and these skills will be useful throughout the children’s lives.
Behavioral treatments for ADHD should be started as soon as the child receives a diagnosis. There are behavioral interventions that work well for preschoolers, elementary-age students and teenagers with ADHD, and there is consensus that starting early is better than starting later. Parents, schools and practitioners should not put off beginning effective behavioral treatments for children with ADHD.
What is behavior modification?
With behavior modification, parents, teachers and children learn specific techniques and skills that will help improve children’s behavior. Parents and teachers then use the skills in their daily interactions with their children with ADHD, resulting in improvement in the children’s functioning in the key areas noted above. In addition, the children with ADHD use the skills they learn in their interactions with other children.
Parent, teacher and child interventions should be carried out at the same time to get the best results. The following five points should be incorporated into all three components of behavior modification:
- Start with goals that the child can achieve in small steps.
- Be consistent—across different times of the day, different settings, and different people.
- Provide consequences immediately following behavior.
- Implement behavioral interventions over the long haul—not just for a few months.
- Teaching and learning new skills take time, and children’s improvement will be gradual.
Cognitive-Behavioral Therapy (CBT)
CBT originated in a melding of cognitive therapy, developed in the 1960s by Aaron Beck and popularized by Albert Ellis, and behavior therapy, developed by B.F. Skinner, Joseph Volpe and others. Beck and Ellis believed that we all have automatic thoughts that occur immediately in response to an event, situation or other stimulus. These thoughts or cognitions may be helpful and lead to positive feelings and effective coping—or they may be negative leading to feelings of depression or anxiety and maladaptive behavior. These negative thoughts are typically based on irrational beliefs or cognitive distortions. Examples include:
- all-or-nothing thinking, which gives rise to perfectionism
- selective attention to negative events or outcomes (and overlooking positive outcomes)
- catastrophizing, believing that it would be a catastrophe if something does or does not occur
- personalization, seeing oneself as the cause of some negative external event for which one is not, in fact, primarily responsible
Therapy helps to identify these irrational beliefs by challenging and ultimately negating these beliefs through discussion and home exercises, which typically include keeping thought logs.
Over the years cognitive therapy has been expanded and tailored for the treatment of depression, and many specific types of anxiety, including generalized anxiety disorder, social anxiety, post-traumatic stress disorder and obsessive-compulsive disorder. The negative behaviors, as well as the negative thoughts, are addressed in treatment (hence the term cognitive-behavioral therapy). Exercises within the session and at home typically involve gradual, systematic exposure to the arousing situations and the development and rehearsal of skills to better manage those situations, as well as challenging the irrational automatic thoughts that may occur.
How is CBT relevant for adults with ADHD?
CBT is relevant for adults with ADHD in two ways. First, in recent years, CBT programs have been developed specifically for adults with ADHD. Some of these programs aim to help adults overcome their difficulties in everyday executive functions that are needed to effectively manage time, organize and plan in the short term and the long term. Other programs focus on emotional self-regulation, impulse control and stress management.
Additionally, it has been well established that adults with ADHD are more likely than adults in the general population to suffer from co-existing anxiety and depressive disorders. A large national study found 51% of adults with ADHD suffered from co-morbid anxiety and 32% suffered from co-morbid depression. Thus, treatments that incorporate CBT for these disorders may be quite helpful to many adults with ADHD, even though they are not designed specifically to address the symptoms and impairment associated with ADHD.
Programs that address executive dysfunction fall into the category of cognitive-behavioral therapy because they impart more adaptive cognitions about how to go about planning, organizing, etc. and also impart more effective behavioral skills. An example of an adaptive cognition is the self-instruction to “break down complex or unpleasant tasks into manageable parts.” Examples of behavioral skills are using a planner regularly and implementing a filing system. Positive thoughts and positive behaviors reinforce each other; as the person becomes more effective in managing time, s/he comes to have more positive beliefs and cognitions about the self, and these in turn help to generate and maintain more adaptive behaviors.
How does CBT compare to medication for the treatment of ADHD in adults?
Stimulant and non-stimulant medication has been shown in numerous studies to be effective for treating ADHD in adults. Research thus far shows that CBT can provide benefit whether or not the person is being treated with medication. There have not yet been any direct, head-to-head comparisons of CBT and medication, but clinical experience suggests that they have different effects: Whereas medication helps to control the core symptoms of distractibility, short attention span and impulsivity, CBT is more effective at increasing the habits and skills needed for executive self-management and may also serve to improve emotional and interpersonal self-regulation.