CBT without medications for adult ADHD: An open pilot study of five patients.

Medications are considered the primary treatment for symptoms of adult attention-deficit/ hyperactivity disorder (ADHD), although medications alone may not produce sufficient functional improvements for many patients. Moreover, some adults with ADHD decline pharmacotherapy due to lack of response, side effects, medical contraindication, or personal choice. This article reports on the clinical outcomes of five adults with ADHD who completed cognitive behavioral therapy (CBT) without concurrent medication treatment. Nonparametric analysis of pretreatment and posttreatment clinical data indicated significant improvements on various measures of ADHD symptoms, overall functioning, depression, and anxiety. Although limited by the small sample size, the current pilot study provides preliminary evidence that CBT may be helpful for adults with ADHD who decline or are unable to take medications in cases in which their symptoms and impairments are relatively mild and uncomplicated. The limitations of this open pilot study and directions for future research also are discussed. Keywords: attention-deficit/hyperactivity disorder (ADHD); adult ADHD; cognitive behavioral therapy; nonmedication treatment; psychosocial treatment Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental syndrome that is categorized as a disorder usually first diagnosed in infancy, childhood, or adolescence (American Psychiatric Association [APA], 1994). The worldwide prevalence of ADHD in children is estimated to be at 6.5% (Polanczyk, de Lima, Horta, Biederman, & Rohde, 2007). Most children diagnosed with ADHD will continue to struggle into adolescence and adulthood with ongoing symptoms, if not the full syndrome (Barkley, Murphy, & Fischer, 2008; Faraone, Biederman, & Mick, 2006). Many adults experience significant impairments in various life roles that result from long-standing features of ADHD that were not identified or diagnosed in childhood (Barkley et al., 2008). Consequently, increased numbers of adult patients are seeking assessment and treatment for ADHD. ADHD is currently understood as a disorder of impaired executive functions that result in downstream self-regulation problems. Executive functions can be defined as "those self-directed actions of the individual that are being used to self-regulate" (Barkley, 1997, p. 56). That is, higher order cognitive processes allow individuals to interrupt responses to the immediate environment in order to organize and execute goal-directed actions across time that will improve future outcomes. Using this model helps to make sense of the symptoms and impairments associated with ADHD as being more than the result of difficulties with mere inattention or impulsivity. The short-term effectiveness of pharmacotherapy in the treatment of adult ADHD has been well documented, and it is currently considered the first line of intervention (Dodson, 2005; Prince, Wilens, Spencer, & Biederman, 2006). However, medications alone may represent insufficient treatment for many individuals with ADHD (Gualtieri & Johnson, 2008). At least one study has documented ongoing organizational and time management skill deficits in over half of a sample of children with ADHD despite effective medication management (Abikoff et al., 2009). Similarly, symptom improvements in adults with ADHD treated with medication may not necessarily translate to improved executive functioning skills (e.g., planning, organization, time management, task follow through) and desired improvements in adult role functioning. It is estimated that relying on pharmacotherapy alone will be insufficient treatment in half of clinicreferred cases of adult ADHD (Wilens, Spencer, & Biederman, 2000). Thus, many adult patients with ADHD may seek out adjunctive treatment. There has been increased research into the development of various nonmedication treatments for adult ADHD (see Ramsay, 2010b, for a review). …