Psychotherapy in Adult Attention Deficit Hyperactivity Disorder

Implications for Treatment and Research

Alexandra Philipsen

Expert Rev Neurother. 2012;12(10):1217-1225.

Abstract and Introduction

Abstract

Attention deficit hyperactivity disorder (ADHD) is a risk factor for co-occurring psychiatric disorders and negative psychosocial consequences in adulthood. Previous trials of psychotherapeutic programs for adult ADHD were based on cognitive behavioral psychotherapeutic approaches and showed significant effects. Targets of psychotherapeutic interventions include not only coping with the core symptoms and associated problems such as depression and anxiety, but also probable consequences such as low self-esteem. Improvements in ADHD symptomatology and associated symptoms have been reported after psychotherapeutic treatment. The support of other participants is strongly regarded as helpful by patients in group therapy. This manuscript provides an overview of psychotherapy approaches and results of studies evaluating programs developed to treat adults with ADHD. Finally, the specific requirements of psychotherapy for adult ADHD as well as further research questions will be discussed.

Introduction

Adult attention deficit hyperactivity disorder (ADHD) is a serious mental disorder with high comorbidity rates for affective disorders, substance abuse, anxiety and personality disorders, lower educational status and higher risks for unemployment, divorce or imprisonment compared with the general population.^[1] ADHD has an enormous impact on the lives of affected individuals and their families. The current treatment guidelines recommend multimodal therapy composed of stimulants as first-choice medication and disorder-specific psychotherapy.^[2] Accordingly, the guidelines of the National Institute for Health and Clinical Excellence recommend drug treatment only as part of a comprehensive program including psychological and behavioral needs.^[101]

If comorbid disorders such as severe depression and addiction are a primary concern, guidelines specify that these should be treated first, for example, with antidepressants and detoxification. Subsequent to the treatment of comorbidities, the extent of impairment through ADHD should be reassessed.^[1,3,101]

In childhood ADHD, psychotherapeutic interventions with or without medication constitute an integral part of guideline-based treatment and can be adjusted to patients' individual requirements.^[101] However, in contrast to psychopharmacological trials, few studies have addressed the effects of nonmedical treatment in adult ADHD.^[4,5]

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Table 1. Structure and topics of group programs in adult attention deficit hyperactivity disorder as described in the studies.
	Psychoeducation	Remediation program	DBT	CBT	Cognitive behaviorally oriented group rehabilitation	Mindfulness training	Metacognitive training	R&R2
	Wiggins et al. (1999)¹⁰	Stevenson et al. (2002)¹⁹	Hesslinger et al. (2002),¹³ Philipsen et al. (2007),¹⁴ Hirvikoski et al. (2011)²⁶	Bramham et al. (2008)¹²	Virta et al. (2008)²⁰	Zylowska et al. (2008)²⁴	Solanto et al. (2008, 2010)^18,25	Emilsson et al. (2011)³⁸; Young et al. (2012)³⁹
Format	4 weekly sessions	8 weekly sessions; 2-h sessions	13–14 weekly sessions; 2 × 50 min each	3-times daily workshops; 1 day per month, 6 sessions	10–11 weekly sessions; 1.5–2 h each, short break	8 weekly sessions; 2.5 h each	12 weekly sessions; 2 h each with break	15 twice=weekly sessions; 2 × 50 min each (2011); 90 min with break (2012)
Additional Support	−	Support people (SO or students), at least one weekly phone contact	Individual sessions and phone calls if required	−	2 psychoeducational lectures, 1 lecture for patients, and SO	CD with guided meditation	−	Weekly 30-min meetings with coaches (psychology undergraduates)
Group size	9	?	4–9	8–15	6–8	?	5–8 (2008);? (2010)	10^†
Therapists per group (n)	?	1	2	2^†	1	1	2 (2008);1 (2010)	2^†
Homework; exercises	+	+	+	+	+	+ daily mindfulness practice	+	+
Manual for therapists	−	+	+	+	+	+	+	+
Workbook or written materials for participants	+	+	+	+	+	?	+	+
Session topics	1. Introduction and basic characteristics of ADHD; 2. Goal setting and time management; 3. Task completion; 4. Structuring the physical environment and prioritization	Motivation, concentration, listening, impulsivity, organization, anger management, self-esteem (session number not specified)	1. Introduction, agreements; 2 + 3. Neurobiology/mindfulness; 4. Chaos and control; 5 + 6. Dysfunctional behavior/behavior analyses; 7. Emotion regulation; 8. Depression/medication; 9. Impulse control; 10. Stress management; 11. Dependency/abuse; 12. ADHD in relationships/self-respect; 13. Retrospect/outlook	1. Psychoeducation; 2. Anger and frustration; 3. Emotions and ADHD; 4. Relationship skills; 5. Time management and problem solving; 6. Future with ADHD	1. Introduction; 2. Neurobiology, medication and motivation; 3. Motivation and initiation of activities; 4. Organization; 5. Attention; 6. Emotion regulation; 7. Memory; 8. Information for SO and communication; 9. Impulsvity and comorbities; 10. Self-esteem; 11. Conclusion	1–8. Psychoeducation on ADHD, mindfulness meditation	1. Information and psychoeducation; 2–6. Time and task management; 7–9. Implementation and maintenance of organizational systems; 10–11. Planning; 12. Summarize and progress reinforcement	1. Neurocognitve; 2. Problem solving; 3. Emotional control; 4. Pro-social skills; 5. Critical reasoning

^†Personal communication.
?: Not given in the manuscript; CBT: Cognitive behavioral therapy; CD: Compact disc; DBT: Dialectical behavioral therapy; SO: Significant others.

Table 2. Structure and topics of individual programs in adult attention deficit hyperactivity disorder as described in the studies.
	CBT following McDermott's adaptation of CT for ADHD	CBT			Problem-focused therapy
	Wilens et al>. (1999)²⁹	Rostain and Ramsay (2006)¹⁵	Safren et al. (2005, 2010)^16,17	Virta et al. (2010)²¹	Weiss et al. (2010)
Format	In the study at least 1 month	16 sessions over 6 months, 50 min each, initially weekly sessions	12 weekly sessions, 50 min each, 15 weeks maximum	10 weekly sessions, 60 min each	9 sessions
Homework, exercises	?	?	+	+	?
Manual for therapists	−	Case conceptualization (published 2008)	+	+	+
Workbook or written materials for participants	?	?	+	+	?
Session topics	Following McDermott's adaptation of CT: strong emphasis on changing beliefs, but also on developing new coping strategies	Psychoeducation, patient-centered conceptualization of associated difficulties, review of coping strategies, cognitive and behavioral modification of dysfunctional patterns, identification/using personal strengths and supportive resources	1–4. psychoeducation and organization and planning; 5–7. coping with distractibility, thereafter: cognitive restructuring, optional: procrastination, anger management, communication skills	1. Goals and symptoms; 2. Attention; 3. Motivation and initiation of activities; 4. Organization and planning; 5. Stress management and relaxation; 6. Self-esteem; 7–9.Individually chosen topics; 10. Continuation, ending	Modules to address common problems in adult ADHD; e.g., finance, relationships, work problems, parenting