Research indicates CBT plus stimulants to treat ADHD

Attention Deficit Hyperactivity Disorder (ADHD) is the most common neurodevelopmental disorder in the pediatric population, affecting 5-6% of children and adolescents. The core symptoms (inattention, impulsivity and hyperactivity) affect every aspect of an individual’s life including 33% more emergency room visits, 50% more bicycle accidents, a 35% school dropout rate, a three to five-fold increase in parental separation or divorce and a two-fold increase in substance abuse. Stimulant medication is effective in improving the core symptoms as well as neuro-cognitive performance, selfesteem, family functioning, academic focus and social adjustment. However, at best only about 75% of ADHD children respond to stimulant medication alone. Between 50-90% of children with ADHD also have mood disorders and about 35% are co-morbid for anxiety.

Researchers at the Centre for Cognitive Therapy in collaboration with pediatrician Dr. Judith van Stralen have recently published important research (Blouin, Maddeaux, Firestone, van Stralen, J Atten Disord, 2010, 13(4): 414-9) documenting the importance of monitoring both behavioral and neuro-cognitive responses to stimulant medication. The research also indicates the need for comprehensive assessment when prescribing stimulant medication. ADHD children with a co-morbid anxiety disorder show the same behavioral improvement when given stimulant medication as non-anxious children. However, they do not exhibit positive changes in neurocognitive functioning. It is critical to combine medication with psychotherapy among anxious ADHD children. It has been established that cognitive therapy is highly effective for childhood anxiety. Successful treatment of anxiety among these children would be expected to improve cognitive response to medication, academic performance and general psychosocial adjustment.

Although both behavioral and cognitive factors are important in assessing the development of ADHD children, self-perception seems to be a critical component of future adjustment. Many adults diagnosed with ADHD as children report that they were constantly subjected to critical commentary and told they were under-performing. It is now thought that many ADHD children compensate for this by developing positive illusions about their competence – thinking they are more competent than they actually are. This hinders developmental adjustment, because a realistic acceptance of their difficulty is a prerequisite to accepting strategies to help adapt successfully to ADHD into adulthood. More aggressive ADHD children are more at risk for developing positive illusions, while those who have depressive symptoms are less so. The positive illusion may have immediate functional benefits (feel better now), but more negative long term consequences (prone to developing other problems).

CBT is effective at helping children with self perception and anxiety frequently requiring treatment among those with ADHD. This appears important for long term academic and psychosocial outcome.

ATTENTION DEFIFICT DISORDER

To be diagnosed with ADHD a child must exhibit 6 or more symptoms of inattention or 6 or more symptoms of hyperactivity (or both) for a period of 6 months or more, beginning before age 7. Inattention symptoms include: inattention to detail, difficulty sustaining attention, doesn’t listen, doesn’t follow through on instructions, difficulty organizing, often avoids tasks like homework that requires sustained attention, loses things regularly, easily distracted, forgetful. Hyperactivity symptoms include fidgety, leaves seat in classroom, runs about or climbs incessantly when inappropriate, difficulty engaging in quiet leisure activities, always on the go, often talks excessively. The symptoms must be present in more than one setting and there must be clear impairment in social or academic functioning.

Getting the most from our research analysis

Research indicate that mood, anxiety and self perception are critical to outcome in ADHD.

Consistent negative feedback harms self perception. Positive illusions about competence develop to compensate. Both adult and childhood ADHD benefits from CBT.

SMARTER THERAPY: Treating ADHD Effectively

1. Stimulant medication is effective in 75% of ADHD children. Anxiety reduces the benefits of medication on cognitive tasks.
2. CBT is effective at improving mood, reducing anxiety and enhancing medication response.
3. Positive Illusions can impede a child’s development and can be treated with CBT in ADHD.

A Publication of the Centre for Cognitive Therapy. Written by Dr. Arthur Blouin.