Efficacy of Cognitive-Behavioral Therapy for Adults with ADHD: A Systematic Review Abstract:
Attention-deficit/hyperactivity disorder (ADHD) impacts individuals’ adaptive functioning from childhood through adulthood. The first-line treatment for adults with ADHD is pharmacological intervention, with cognitive-behavioral therapy (CBT) also being recommended. However, CBT efficacy remains under-researched in this population. We conducted a systematic review of randomized clinical trials to investigate the effectiveness of CBT in improving the core ADHD symptoms in adults. Data were extracted following PRISMA guidelines, including studies published from January 2012 to August 2022. We performed scientometric and descriptive analyses, finding that CBT improved aspects related to the disorder’s core symptoms and individuals’ daily functioning. Future research is recommended to delve deeper into the efficacy of CBT, aiding in understanding the cognitive and behavioral processes influencing the expression of core symptoms of the disorder.
Keywords:
ADHD; adults; cognitive-behavioral therapy; systematic review
Resumo:
O TDAH impacta no funcionamento adaptativo dos indivíduos desde a infância até a vida adulta. O tratamento de primeira linha para adultos com TDAH é a intervenção farmacológica, sendo também recomendada a TCC. No entanto, a eficácia da TCC ainda é pouco pesquisada nesta população. Realizamos uma revisão sistemática de estudos clínicos randomizados para investigar a eficácia da TCC na melhoria dos sintomas centrais do TDAH em adultos. Extraímos dados dos artigos seguindo as diretrizes PRISMA, incluindo na análise estudos publicados de janeiro de 2012 e agosto de 2022. Realizamos análises cienciométricas e descritivas, e verificamos que a TCC melhorou aspectos relacionados aos sintomas centrais do transtorno, bem como o funcionamento diário dos indivíduos. É recomendado que pesquisas futuras sejam mais detalhadas sobre a eficácia da TCC, a fim de auxiliar no entendimento dos processos cognitivos e comportamentais que influenciam na expressão dos sintomas centrais do transtorno.
Palavras-chave:
TDAH; adultos; terapia cognitivo-comportamental; revisão sistemática
Resumen:
El trastorno por déficit de atención e hiperactividad (TDAH) afecta el funcionamiento adaptativo de las personas desde la infancia hasta la edad adulta. El tratamiento de primera línea para adultos con TDAH es la intervención farmacológica, además de la terapia cognitivo-conductual (TCC). Sin embargo, la eficacia de la TCC sigue siendo poco investigada en esta población. Este estudio trata de una revisión sistemática de ensayos clínicos aleatorizados para investigar la eficacia de la TCC en la mejora de los principales síntomas del TDAH en adultos. Se extrajeron datos de los artículos publicados desde enero de 2012 hasta agosto de 2022 siguiendo las pautas PRISMA. Se realizó un análisis cienciométrico y descriptivo, el cual encontró que la TCC mejoró aspectos relacionados con los principales síntomas del trastorno, así como el desempeño diario de las personas. Se recomienda que futuras investigaciones aporten más detalles sobre la eficacia de la TCC para ayudar a comprender los procesos cognitivos y conductuales que influyen en los principales síntomas del trastorno.
Palabras clave:
TDAH; adultos; terapia cognitivo-conductual; revisión sistemática
Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by a high frequency and intensity of inattention, and/or hyperactivity-impulsivity, which can interfere with both adaptive and developmental functioning (American Psychiatric Association, 2022 ). Although traditionally associated with childhood and often seen as resolving naturally in adolescence and early adulthood, the identification and prevalence of ADHD diagnosis in adults has grown in recent years (Zalsman & Shilton, 2016 ).
Estimates are that at least 5% to 7.2% of children (Posner et al., 2020 ) and 2.5% to 4.4% of adults present the diagnostic criteria for the disorder worldwide (American Psychiatric Association, 2022 ; Rivas-Vazquez et al., 2023 ). However, this number may be underestimated due to underdiagnosis and misidentification, since many adults with ADHD may choose not to seek assistance or attribute their symptoms to other reasons (Waltereit, Ehrlich, & Roessner, 2023 ).
The disorder plays a significant role on the adaptive functioning of individuals, resulting in impairments in several domains (Thomas et al., 2015 ). These people may experience significant deficits in social and interpersonal issues (Sodano et al., 2019 ), resulting in lower-quality relationships, fewer close friendships, lower marital satisfaction, and a higher likelihood of divorce compared to typical individuals (Wymbs et al., 2021 ), especially when diagnosed in adulthood (Z. Young et al., 2016 ).
These individuals often face limitations in employment opportunities, susceptibility to addiction, vulnerability to depressive and anxiety disorders, reckless behavior in traffic, and the risk of premature death from accidents and suicide (Geffen & Forster, 2017 ). It is also common for them to face more difficulties in their daily lives, especially in terms of time management, execution of daily tasks, and financial management (Holst & Thorell, 2020 ; Zalsman & Shilton, 2016 ).
According to health guidelines, the first-line treatment for adults with ADHD is pharmacological intervention (Bolea-Alamañac et al., 2014 ; National Institute For Health and Care Excellence [NICE], 2018 ), by virtue of its effects on the main symptoms of the disorder and on symptoms related to anxiety, depression, social skills, and executive functions (Pan et al., 2019 ; Parkin, Nicholas, & Hayden, 2022 ).
Although the pharmacological treatment is effective and safe for dealing with ADHD symptoms, it often presents significant limitations, such as individual concerns about its need for symptom improvement and possible side effects (Khan & Aslani, 2021 ), which can result in high rates of non-adherence and/or treatment discontinuation (Pan et al., 2019 ). Decision to discontinue treatment may depend on several factors, such as the patient’s individual characteristics, properties of the medication (duration of effect and risk-benefit assessment), and aspects related to the health system (Gajria et al., 2014 ).
Several treatment approaches were developed and refined through experimentation and generation of clinical hypotheses, thus being the scientific part of clinical practice (APA, 2006 ). The use of these strategies is called Evidence-Based Practice (EBP) and consists of integrating scientific research for greater effectiveness in implementation (Blease, Lilienfeld, & Kelley, 2016 ). EBP aims to improve psychological practice and public health by applying empirically supported principles in psychological assessment, case formulation, therapeutic relationship, and intervention (APA, 2006 ).
Among the evidence on psychotherapeutic approaches, third-wave therapies such as Cognitive Behavioral Therapy (CBT) significantly outperform other methods (David, Cristea, & Hofmann, 2018 ). CBT refers to a set of psychotherapeutic interventions that explore the relationship between emotions, cognitions, and behavior (Stallard, 2022 ). Along with other third-generation therapies, it seeks to understand and question distorted cognitions, improve emotional management and daily functionality, and promote quality of life (Leichsenring & Seinert, 2017 ).
Although there is research emerging to document the benefits of third-wave interventions in adults, this is still a recent approach and with little data to prove its superiority over conventional therapies (Marini & Della Barba, 2021 ). Similarly, guidelines produced by the National Institute for Health and Care Excellence (NICE) in the United Kingdom also recommend behavioral interventions for ADHD, alone or in combination with pharmacological treatment (NICE, 2018 ).
CBT impacts the disorder by restructuring negative cognitions, increasing awareness of maladaptive patterns, developing strategies for dealing with stress, frustration, and regulating emotions (Pan et al., 2019 ). In addition, it can help in the creation of organizational strategies, problem solving, planning, impulse control, and time management, which are deficient in people with ADHD (Cherkasova et al., 2016 ). Thus, CBT can play a crucial role in reducing functional impairment, promoting positive effects on the emotional aspects of ADHD (Z. Young et al., 2016 ).
This approach is also recommended for individuals who would benefit from medication, but who still present deficits in social skills, problem-solving, self-control, or emotional management and expression (NICE, 2018 ). In addition, CBT is an effective alternative for those who do not wish to take medication or who face problems with pharmacological treatment. It is also an option for those who consider medication ineffective (Caye et al., 2019 ).
Although CBT has been shown to be effective in addition to or as an alternative to pharmacological treatment in several mental health conditions, including ADHD (NICE, 2018 ), there is a lack of research on its effectiveness in adults. Most of these studies have small samples and lack control groups (Fullen et al., 2020 ). The purpose of this systematic review is to investigate the effectiveness of CBT in improving the main symptoms of ADHD in adults.
Method
Data collection. Data were extracted from articles according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) model (Moher, Liberati et al., 2009 ; Moher, Shamseer et al., 2015 ), which establishes systematic methods for identifying, selecting, and evaluating properties of relevant studies. PubMed, Embase, and Scopus electronic databases were selected due to their relevance in the indexing of scientific journals in the areas of health and psychology.
The search strategy was based on a preliminary pursuit of keywords frequently used in relevant studies. The descriptors were combined using the Boolean operator AND. The Boolean OR operator was used to combine defined terms. The research strategy was: (Use of Cognitive Behavioral Therapy OR Efficacy of Cognitive Behavioral Therapy OR efficiency of Cognitive Behavioral Therapy OR effectiveness of Cognitive Behavioral Therapy OR cbt [Title/Abstract]) AND (adult*[Title/Abstract]) AND (ADHD OR Attention Deficit Disorder with Hyperactivity OR attention-deficit/hyperactivity disorder [Title/Abstract]). The asterisk after a term means that all terms beginning with that prefix were included in the search. All descriptors were obtained through the Medical Subject Heading Terms (MeSH terms) vocabulary control method, developed by the U.S. National Library of Medicine ( https://www.ncbi.nlm.nih.gov/mesh ).
Data analysis. Articles were selected in two steps: title and abstract screening, followed by full-text screening. In each of them, the authors reviewed the studies independently and the articles were selected based on consensus, according to the inclusion and exclusion criteria.
Only studies published in peer-reviewed scientific journals from January 2012 to August 2022 were selected, to cover more recent publications. These studies evaluated the effectiveness of CBT protocols in adults with ADHD and included the relevant descriptors in the title, abstract, and/or keywords. In short, articles should be randomized, written in English, and include adult participants (>18 years) diagnosed with ADHD (ICD-10 or DSM-V), medicated or not. Furthermore, a control group had to be present, so to allow comparisons.
The selected control group should undergo Treatment As Usual (TAU) - periodic visits to health professionals for medication management, without receiving additional information about the disorder or other interventions. As ADHD is associated with a high prevalence of comorbidities, studies that also address other psychiatric disorders were selected (Anker et al., 2018 ; Tsai et al., 2019 ). The interventions should be performed by a CBT therapist.
As for exclusion criteria, were disregard review articles, studies with incomplete or secondary text (i.e., literature reviews, editorials, comments, letters to the editor, books, and other studies whose full texts are not available). The review excluded studies that did not involve the use of CBT or therapies under the CBT umbrella, and written in languages other than English or Portuguese.
For the scientometric analysis, were extracted from each article: authors; year of publication; country where the study was carried out and journal of publication. For descriptive analysis: participants’ demographics (number of participants, gender and age), study design, interventions, and main results.
Results
This systematic review resulted in 521 scientific articles. After removing duplicates ( n = 420 ), we examined the remaining 101 studies by title and abstract, excluding 60 articles that did not meet the inclusion criteria. In total, 41 articles had their full text evaluated by the authors. Of the 41 publications, 19 were excluded using the exclusion criteria, and 22 studies were read in full text ( Figure 1 ).
Considering the research period, 2017 stood out with the highest number of publications (22.7%), followed by 2018 (18.1%), 2015 and 2021 (13.6% each), 2014 and 2016 (9% each) and, finally, 2012, 2013 and 2019, with 1 study each (4.54%). No publications on the topic were recorded in 2020 and 2022.
The 22 studies were carried out in 10 countries, and approximately 50% were published on the European continent, in countries such as: Germany (13.6%), Spain (4.5%), Iceland (9%), the Netherlands (13.6%), Sweden (4.5%) and Switzerland (4.5%); North American countries were represented by Canada (4.5%) and the United States (13.6%); and Asian countries, represented by China (18.1%) and Japan (4.5%). In addition, were recorded studies in which the authors did not specify the country where they were carried out (9%). No studies have been conducted in South America, Oceania, or Africa.
According to the journals, all publications were related to psychology. The Journal of Attention Disorders represented the majority of publications included in this review (22.7%). The impact factors of the analyzed journals ranged from 1.73 to 10.10. Journals with the highest impact factor had relatively few publications, such as the Archives of General Psychiatry, with only one publication (4.5%) (impact factor = 10.10) and Psychological Medicine, with 2 publications (9%) (impact factor = 7.2).
Descriptive analysis
Regarding sociodemographic characteristics, 14 publications had a higher participation of women (63.4%). The mean age ranged from 20 to 40 years for both groups. In addition, most studies (68.1%) considered individuals both with or without comorbidity(ies), as long as their comorbid disorder(s) were stable. One study (4.5%) included comorbidities common in adults with ADHD, such as learning disabilities, oppositional defiant disorder (ODD), depression, or anxiety, while 18.1% of the studies excluded individuals who had aspects related to learning disabilities. Some studies (40.9%) also disregard individuals with IQs between 70 and 90.
Regarding the methodology of the studies, all 22 presented the complete description of their execution, to guarantee the quality of data, and the procedures necessary for randomized clinical trials. Appropriate designs were chosen for the study and randomization was adequate. Regarding the design, all studies had an evaluation at baseline and at the end of the intervention. Sixteen of them (72.7%) also had subsequent evaluations, which ranged between 2 and 12 months. All articles had at least one control group (CG) and one intervention group (IG), which allowed for comparison. The experimental groups were exposed to CBT-based interventions at some point in the study. For the control group (CG), individuals could later choose to participate or not in the intervention.
The most common interventions in the experimental group were isolated CBT, Mindfulness (22.7% each), CBT combined with medication (18.1%), followed by the ACCESS and PEGASUS protocols, CBT and usual care, in addition to Mindfulness combined with usual care (4.5% each). A study also used Hypnotherapy in the control group (4.5%). For the control group, the most used interventions were the usual treatment (27.2%), waiting list (22.7%), and psychoeducation about the disorder (13.6%). Some studies used only medication (13.6%) or placebo (8.7%), and one study used CBT combined with medication (4.5%). A complete description of the interventions performed in each study can also be found in Table 1 .
About 9% of the studies compared the effects of CBT alone and associated with medication. Another 22.7% compared the use of medication alone with the CBT associated with the medication. All groups, regardless of medication use, experienced significant improvements in major symptoms of the disorder. The intervention also resulted in improvements in daily functioning, although CBT combined with pharmacotherapy played a significant role in reducing perceived symptoms (57%). One study found no difference between groups (14%). Aspects related to anxiety, depression, quality of life, stress, motivation and time organization were also affected by the intervention in 3 of the 7 studies (42%).
Mindfulness-based interventions improved aspects related to executive functions (33%) and attention control (50%), as well as reduced central symptoms of the disorder (50%). One study (16%) showed improvement in symptoms of anxiety, depression, and stress, suggesting a significant impact on individuals’ quality of life, motivation, and time organization. However, some studies did not have as main objective to investigate the changes in these post-intervention aspects (50%). Two studies used the ACCESS and PEGASUS protocols (4.3% each). However, these instruments have few studies on their effectiveness (8.7%) ( Table 1 ).
All studies used standardized scales as a method for assessing ADHD symptoms. These were Likert-type scales with questions directed to the core symptoms of ADHD (inattention, hyperactivity-impulsivity) or secondary complaints of the disorder (e.g., functionality and quality of life). This type of measure allows to assign numerical values to the participants’ responses, facilitating their visualization and analysis, in addition to allowing psychometric procedures that help assess their validity and accuracy (South et al., 2022 ; Nemoto & Beglar, 2014 ; Norman, 2010 ).
Instruments used pre- and post-test are reliable and their psychometric properties were adapted to the population context evaluated. Most studies used the Conners Adult ADHD Rating Scale (CAARS) to assess the symptoms of the disorder (68.1%), either the self-report or observer version (Walls et al., 2017 ). Other scales used evaluated secondary aspects of the disorder.
Discussion
Twenty-two randomized clinical trials published on the topic in the last 10 years were included in this review. These research showed a growing interest in the subject and revealed a tendency to increase the number of publications on the subject over the years. In addition, it was found that most of the research was conducted in European and Asian countries. Literature on CBT for adults with ADHD is limited and studies from South America, Oceania, and Africa are lacking. Further research on the subject is recommended to promote global advancement.
The articles were published in 15 different journals, with varying impact factors and research scopes. Many publications had different scopes, which suggests that this topic is interdisciplinary in the field of mental health. The Archives of General Psychiatry and Psychological Medicine journals published less, despite both having a high impact factor, which suggests an influence of the rigorous acceptance criteria of articles in these journals.
All studies were based on the cognitive model and on the different types of third wave therapies, with interventions focused on the development of attention and organization skills, cognitive restructuring and change of internal and external environment. Focusing on these aspects can be a good strategy, since adults with ADHD are generally more exposed to stressful events due to academic or professional failures and/or interpersonal difficulties (Uchida et al., 2015 ; Weibel et al., 2020 ).
Even with most individuals diagnosed with ADHD having at least one other comorbid disorder (Tsai et al., 2019 ) and a decrease in quality of life (Gjervan et al., 2012 ; Uneri et al., 2015 ), none of the studies focused on comorbidities or life satisfaction. Whereas mood and anxiety disorders are commonly associated with ADHD (Ohnishi et al., 2019 ; Weibel et al., 2020 ). In summary, CBT can help not only in the treatment of the core symptoms of ADHD, but also in secondary aspects of the lives of adults with this condition.
ADHD is a disorder capable of generating significant losses in adulthood. This review reinforced evidence of CBT’s effectiveness for the treatment of affected people, as well as its contributions to the patients’ quality of life. New analyses of randomized trials, with larger samples and robust methodology, are needed to more accurately determine treatment effectiveness in a more diverse population of adults with ADHD, especially in the Brazilian context.
Despite some limited samples, the overall quality of the studies found was adequate. However, to improve the reliability and validity of future investigations, it is recommended that studies detail the randomization and blinding process more clearly, including active control groups. In addition, it is important to promote discussions about the reliability of the researcher and/or therapist.
Finally, studies looking at ADHD symptoms may use specific subscales to assess attention, hyperactivity, and impulsivity to identify possible improvements. Furthermore, including supplementary measures related to difficulties in daily living, quality of life, and comorbid mental health is essential to gain a more comprehensive understanding of the therapeutic effects of CBT. Further investigation into the effectiveness of CBT may provide insight into the cognitive and behavioral processes that impact the manifestation of the core symptoms of ADHD.
Limitations and contributions
The review was restricted to studies in English and Portuguese, and did not identify research in Latin America. Further research may focus on covering this population as well. Interpretation of pre- and post-treatment effects in the reviewed studies was challenging due to sampling, with about half of the studies having samples smaller than 100 subjects. Even with reliable randomization, limitations of small samples persist, including insufficient statistical robustness, limited generalization, and greater likelihood of non-representative population outcomes.
Despite limitations in the literature, this review adds to the evidence base on the effectiveness of CBT in reducing ADHD symptoms. Recommendations for future research include investigating the usefulness of group versus individual therapy, determining the optimal duration and number of sessions, and identifying the most effective treatment period.
This study may also provide useful data for future systematic reviews and meta-analyses. Finally, new research may enrich the analyses when considering the effects of the combination of medication and CBT, especially for individuals who choose not to use medications or for whom the medication is not effective or tolerable.
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How to cite this article:
Carvalho, N. P., da Silva, A. R., Caiafa, L., & de Paula, J. J. (2024). Efficacy of cognitive-behavioral therapy for adults with ADHD: A systematic review. Paidéia (Ribeirão Preto), 34, e3420. https://doi.org/10.1590/1982-4327e3420
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Associate editor:Luciana Carla dos Santos Elias
