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


Two important findings arise from the results. As hypothesized there was a significant effect for improvement in core ADHD symptoms at the end of treatment. Secondly, large effects were found for treating ADHD symptoms and comorbid problems at follow up. The exception is the BCS hyperactivity/impulsivity scale where the effect sizes were small to medium. It is however evident from the present findings that in spite of receiving medication for ADHD, the participants were experiencing significant residual symptoms which were successfully and further improved by the CBT intervention. Safren and colleagues[16,17] also reported that combined treatments have better outcomes than medication alone in treating ADHD symptoms, depression and anxiety.

Antisocial behaviour also improved at the end of treatment and at follow-up with a large effect. This is noteworthy since participants' baseline scores for antisocial behaviour were relatively low for both conditions indicating the importance of the prosocial training component of R&R2ADHD. Given the reported high rates of comorbid antisocial problems in adult ADHD,[2–4] it seems important to include a prosocial competence component to CBT interventions when treating people with ADHD. The present study illustrates that even in participants who have not been referred for antisocial behaviour, a more positive prosocial outcome can be achieved. Alternatively, antisocial participants need to be screened out of CBT interventions that aim primarily to target core ADHD symptoms of attention, impulsivity, planning and organization deficits, else it is possible that improvement in functioning in these domains may be applied to improve antisocial skills.

Significant and large treatment effects were noted on all the self- reported measures when followed up three months later. This was supported by the independent evaluations of ADHD symptoms and global functioning which had large effect sizes. For the ADHD symptoms, effect sizes were even greater at follow up than at the end of treatment. Thus the R&R2ADHD programme was highly effective in treating ADHD symptoms and common comorbid problems of anxiety, depression, antisocial behaviour and social functioning. Improvements in comorbid problems were partly significant immediately following the end of treatment phase but significantly and further improved during the follow-up period. It is likely that those who completed the CBT intervention continued to use the strategies learned in sessions after they finished treatment and therefore the treatment effect persisted and became greater over time.

The present study shows that the RATE-S Scales, which are provided with the programme, are useful dynamic measures of change over time as people symptomatic for ADHD learn to cope better with the emotional instability associated with their symptoms. This is in line with other studies using the RATE-S.[11,34] It also shows that R&R2ADHD is an effective intervention for ADHD adults attending psychiatric community services and participants reported to facilitators that they enjoyed attending the programme. As a structured manualized programme, R&R2ADHD facilitates consistency in delivery across different populations and settings and maximises programme integrity. Thus the benefits of R&R2ADHD are multifaceted and the combination of psychopharmacological and CBT treatments may add to and improve pharmacological interventions. This is likely to be further enhanced by the integration of group sessions and individual coaching sessions as a model for programme delivery as this model provides a structured support for the transference of skills into daily life.

The strengths of the current study are its RCT design and the independent outcome measures used in addition to self-report measures. There was a modest drop-out rate for this kind of a study and the drop-out rate was comparable between both conditions. The main limitations of the study are the small numbers of participants and the difficulties to obtain outcome measures for all participants at the end of treatment and at follow-up. The attrition rate for outcome measures is a common problem with this kind of research.[38]

A second limitation is that we were unable to control for change in medication as study participants remained under the care of their individual treating psychiatrists. Although there were some changes in medication, these did not significantly differ between the two conditions. Furthermore, we did not control for the possibility that the TAU/MED condition were receiving some other non-pharmacological interventions.

A further limitation is that the participants in the CBT/MED condition received more attention than the TAU/MED participants during the treatment phase and therefore nonspecific placebo effects could limit the results. However, most changes occurred during the period between the end of treatment and three month follow-up and both conditions did not receive any contact during this period.


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