Cognitive Behaviour Therapy in Medication-treated Adults With ADHD and Persistent Symptoms

A Randomized Controlled Trial

Brynjar Emilsson; Gisli Gudjonsson; Jon F Sigurdsson; Gisli Baldursson; Emil Einarsson; Halldora Olafsdottir; Susan Young


BMC Psychiatry. 2011;11(116) 

In This Article



Participants had been referred to an outpatient rehabilitation clinic within the Mental Health Services at the Landspitali - The National University Hospital of Iceland or self-referred from an advertisement to members of the Icelandic ADHD association, a national support organization. All participants were required to have a clinical diagnosis of ADHD and to be stable on prescribed ADHD medication for at least a month, i.e. stimulants (immediate- or extended-release methylphenidate and amphetamine sulphate), atomoxetine or bupropion. The participants were told to try and keep dosages unchanged during the whole study. Exclusion criteria included patients with severe mental illness, active drug abuse, verbal IQ estimated from clinical records to be below 85, no valid ADHD diagnosis or not prescribed/taking ADHD medication.

Out of the 92 referrals initially received, 38 were excluded on the following grounds: 13 were off-medication, nine with a questionable diagnosis and four misusing drugs/alcohol. A further seven declined to participate and five either did not show up for the intake interview or they could not be reached by phone or e-mail.

The remaining 54 participants were 34 women (mean age 34.1, SD = 10.9) and 20 men (mean age 33.5, SD = 12.4). Of the 54 participants 33 were self-referrals and 21 were referred by psychiatrists. All participants had been assessed and diagnosed with ADHD by mental health professionals with expertise in diagnosing ADHD using DSM-IV criteria. All medication was prescribed by psychiatrists. At baseline, 42 (77.8%) participants were receiving methyphenidate, 11 (20.4%) were receiving atomoxetine, 5 (9.3%) were receiving bupropion, and 1 (1.9%) was receiving amphetamine sulphate. Thirteen (24.1%) participants were receiving only one medication, 16 (29.6%) were receiving two medications and the remaining 25 (46.3%) were receiving three or more drugs. Participants were asked if they had some other mental/emotional problem and 35 (64.8%) reported depression, 20 (37%) reported some anxiety disorder, 12 (22.2%) reported a history of drug/alcohol abuse and nine (16.7%) reported some other psychiatric problem. Only eight (14.8%) did not report comorbid problems.


Independent Evaluation (IE) The Kiddie-Schedule for Affective Disorders and Schizophrenia (K-SADS-PL) ADHD section, present and lifetime version[25] interview measures both ADHD symptoms and impairment on functioning (home, work and relationships) and has been modified for adults and translated into Icelandic. Magnusson et al.[26] found that the K-SADS was reliable and valid and had strong correlation with self-reported and informant rated ADHD symptoms. In the present study current symptoms were rated to measure symptom change. A total of 18 questions are rated on a 1–3 point scale from 1 = no symptoms or impairment, 2 = symptoms with moderate impairment, and 3 = symptoms indicating severe impairment in functioning. The minimum score on the K-SADS is 18 and 54 is the maximum score

The Clinical Global Impression (CGI; 27) is a single question where the clinician is asked to rate severity of illness on a 7 point scale (i.e., a score of 1 indicates not being ill and a score of 7 indicates being extremely ill) by comparing the patient to other patients with ADHD. The clinician's severity score is based on judgment regarding impairment in functioning, symptom severity and distress or coping and is supported by examples of these factors.[27] The CGI has shown to correlate well with other ADHD measures.[28,29]

Self-report Measures The Barkley ADHD Current Symptoms Scale (BCS;[30]) corresponds to the DSM-IV diagnostic criteria of ADHD. Each item was scored on a 4-point Likert scale for frequency of symptoms experienced during the previous six months. Scores range between 0 and 27 for each of the two subscales (Inattention and Hyperactivity/Impulsivity) and 0 to 54 for the Total scale. The scale is reported to have good psychometric properties and correlates well with informants' ratings of symptoms and interview-based diagnoses in childhood and adulthood in an Icelandic sample.[26]

The Beck Anxiety Inventory (BAI;[31]) is a 21-item scale designed to assess severity of anxiety symptoms. Items are scored on a 4 point Likert scale (0–3) where the respondent rates how much he or she has been bothered by various symptoms during the past week from not at all to severely.

The Beck Depression Inventory (BDI;[32]) is a 21-item scale where responders rate how they have been feeling during the past week on a 4 point Likert scale (0–3).

The R&R2 ADHD Training Evaluation Self-report Scale (RATE-S;[33]) provides four subscales: (1) ADHD symptoms; (2) Emotional Control; (3) Antisocial Behaviour; and (4) Social Functioning. The RATE-S scale has been shown to have good reliability and validity,[11,34] Gudjonsson, Sigurdsson, Adalsteinsson & Young: The relationship between attention deficit hyperactivity disorder (ADHD) symptoms, mood instability, and self-reported offending, submitted).

The Intervention

R&R2ADHD[33] is a 15 session manualised CBT intervention programme that was developed in 2007 for youths and adults with ADHD and antisocial behaviour. It is a revised edition of the 35-session Reasoning & Rehabilitation programme[35] that was originally developed as a prosocial competence training programme for use in correctional facilities and its feasibility and effectiveness are well supported in this population.[36,37] R&R2ADHD is a structured, manualised programme that aims to decrease impairment of core ADHD symptoms and improve social, problem solving, and organizational skills. It consists of five treatment modules (1) neurocognitive, e.g. learning strategies to improve attentional control, memory, impulse control and planning, (2) problem solving, e.g. developing skilled thinking, problem identification, consequential thinking, managing conflict and making choices, (3) emotional control, e.g. managing feelings of anger and anxiety, (4) pro-social skills, e.g. recognition of the thoughts and feeling of others, empathy, negotiation skills and conflict resolution, and (5) critical reasoning, e.g. evaluating options and effective behavioural skills.

The programme integrates group and individual treatment, the latter being achieved by group facilitators training 'coaches' who meet with the participant between sessions. The coaching role aims to support participants to transfer skills learned in the group into their daily lives. In the present study the coach role was fulfilled by psychology undergraduates. This programme was delivered according to a manual and the coaches also received directions through training and written guidelines. All R&R2ADHD facilitators had extensive experience in CBT and received training in delivering the programme.


The study was conducted in line with international guidelines, following ethical approval by the Icelandic Bioethics Committee on 01/09/2008, reference number 08-095-S1.

All 54 participants met with the first author for an intake interview when they gave informed consent. Of these 51 completed the self-reported baseline measures and 51 completed the baseline measures with the independent evaluator. The independent evaluators were psychiatrists who were blind to the treatment condition. They obtained demographic information and completed the K-SADS and CGI. Every attempt was made to maintain the blind evaluation as both independent evaluators and participants received repeated instructions to remind them to avoid disclosure of whether the participant was receiving R&R2ADHD group treatment or not.

An independent psychiatrist randomly allocated the participants to either the CBT/MED experimental condition (n = 27) or the TAU/MED control condition (n = 27). The CBT/MED condition received R&R2ADHD group therapy in addition to continued psychopharmacological treatment. The TAU/MED condition received psychopharmacological treatment only. At baseline no statistical difference (two-tailed) was found between the two conditions on dosage size of methylphenidate (t = 1.126, df = 40, p = .267), atomoxetine (t = .697, df = 9, p = .504), age (t = -.439, df = 52, p = .662), or sex (χ2 = (1, N = 54) = 0.318, p = .573). No statistical differences were found on any of the outcome measures at baseline between the two conditions (p < .05).

The participants in both conditions were not asked to refrain from engaging in other interventions during the study period. Information about other interventions was not collected and thus other treatments were not controlled for. Treatment integrity was ensured in two ways; first by adopting a structured manualised CBT programme and, second, via the independent observation of a sample of sessions by a practitioner who monitored adherence to the manualised treatment protocol. Participants in the CBT condition received 15 R&R2ADHD sessions twice weekly, each lasting 90 minutes. Three groups were run in total and coaches met with the participants once a week for 30 minutes to review sessions and help with homework. Participants were re-assessed using the same measures at Time 2 (end of treatment) and Time 3 (three month follow up). The timing of the evaluation assessments was the same for the CBT/MED and TAU/MED conditions. A log of group attendance, and reasons for non-attendance were recorded each session. Figure 1 presents a flowchart of patient participation.

Figure 1.

Flowchart of patient participations.

Statistical Analysis

Unadjusted mean scores and standard deviations on each of the outcome measures are provided for the CBT/MED and TAU/MED conditions for the three assessment periods - Time 1, Time 2 and Time 3 (see Table 1). Differences between the two conditions on the outcome measures were not statistically significant at baseline. Nevertheless, in order to reduce error variance an analysis of covariance (ANCOVA) was calculated for each of the dependent variables measuring differences between the conditions in time. The baseline scores therefore served as covariates and scores at Time 2 and Time 3 served as dependent variables. Thus intention to treat analysis (ITT) was conducted. Missing values were not imputed because the ANCOVA calculates outcome whilst adjusting for all baseline data. Between group effect sizes for the outcome assessments were measured using Cohen's d using unadjusted means for the dependent variables and SD pooled for unequal group sizes. Fischer's exact test was used to compare proportions of medication changes. Since this study follows an ITT protocol, statistical analysis of the outcome variables were completed for all participants regardless of medication changes.


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