Cognitive Behavioral Therapy (CBT) may be beneficial for some people with ADHD by helping them develop strategies to manage symptoms, improve executive functioning, and address associated emotional and behavioral challenges.
CBT aims to modify thought patterns and behaviors, potentially aiding in areas such as organization, time management, and emotional regulation.
Studying the effectiveness of CBT for ADHD is crucial because it can inform best practices in mental health care, ensure that treatments are evidence-based, and potentially improve outcomes for individuals with ADHD.
Understanding how CBT works specifically for ADHD can lead to more tailored and effective interventions, ultimately enhancing the quality of life for those with the condition.
William, S., Horrocks, M., Richmond, J., Hall, C. L., & French, B. (2024). Experience of CBT in adults with ADHD: a mixed methods study. Frontiers in Psychiatry, 15, 1341624. https://doi.org/10.3389/fpsyt.2024.1341624
Key Points
- The primary methods of studying CBT experiences in adults with ADHD include mixed-methods approaches, combining surveys and in-depth interviews.
- Factors like unadapted CBT framework, therapists’ lack of ADHD knowledge, and rigid therapy structures significantly affect the effectiveness and perceived helpfulness of CBT for adults with ADHD.
- The research, while enlightening, has certain limitations, such as a predominantly female sample and potential selection bias.
- This study highlights the universal relevance of adapting psychological treatments for specific neurodevelopmental conditions, emphasizing the importance of personalized mental health care.
Rationale
Attention-Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental condition affecting approximately 2.5% of adults (Song et al., 2021).
ADHD is characterized by impaired executive functions, creating significant impacts on various life aspects (Gjervan et al., 2012).
While pharmacological treatment is considered the first-line approach, the National Institute for Health and Care Excellence (NICE, 2018) recommends Cognitive-Behavioral Therapy (CBT) as the primary psychotherapeutic treatment for adults with ADHD in the UK.
However, the literature often refers to adapted CBT programs tailored for ADHD, providing limited insight into how adults with ADHD experience and perceive this form of treatment in routine clinical practice.
This study aims to explore ADHD individuals’ experience and perception of CBT delivered in routine clinical practice, to gain a better understanding of this treatment’s helpfulness and perceived effectiveness.
The next step in research is to investigate how CBT can be effectively adapted for adults with ADHD in routine clinical settings.
Method
The study employed an explanatory sequential mixed methods design, consisting of an online survey followed by in-depth, semi-structured interviews with a sub-sample of survey respondents.
Procedure
The study was conducted over a period of 3 months (June-August) in 2023. Participants completed an online survey, which took an average of 15 minutes and included 28 questions in various formats.
Following this, a subset of participants engaged in semi-structured interviews lasting approximately 30 minutes each, exploring their experience of CBT and its effectiveness in addressing their ADHD difficulties.
Sample
The study included 46 participants for the survey (71% female) and 10 participants for the interviews (70% female).
All participants were adults with a prior ADHD diagnosis who had received CBT within the UK.
Measures
The study used a custom-designed survey and interview protocol.
The survey included multiple-choice questions, 10-point Likert-scale questions, and free text boxes. The interview questions were developed by the authors, who include CBT practitioners and researchers.
Statistical measures
The survey data was analyzed using descriptive statistics and narratives.
The interview data was analyzed using thematic analysis, following Braun and Clarke’s (2006) six-stage process.
Results
The key themes that emerged from the thematic analysis were:
1. The complex structure of the CBT framework
The structured nature of CBT, which typically involves systematic approaches to identifying and changing thought patterns and behaviors, may not align well with the cognitive patterns and executive function difficulties experienced by individuals with ADHD.
Participants reported that the CBT framework often felt rigid, overwhelming, and incompatible with their ADHD symptoms, such as difficulties with working memory, attention, and consistency.
“I think there’s core things about CBT that are just seen on the face of it to me to be incompatible with ADHD.” (P5)
2. The intricacy of the therapist relationship and its impact on therapy
Many participants reported that their therapists lacked specific knowledge about ADHD, which led to misunderstandings and ineffective interventions.
The therapist-client relationship was often strained by the therapist’s inability to adapt their approach to accommodate ADHD-related challenges.
This lack of ADHD-specific expertise resulted in participants feeling misunderstood, dismissed, or unable to engage effectively with the therapy process.
“I couldn’t see the link with ADHD and she didn’t see it either. [ … ] She knew nothing [about ADHD], and she told me that straight away.” (P8)
3. Consequences of unadapted CBT
Rather than experiencing therapeutic benefits, many participants reported feeling worse after their CBT sessions.
They described increased feelings of failure, lowered self-esteem, heightened frustration with themselves, and a sense of hopelessness about their ability to benefit from therapy.
Some participants even reported that the unadapted CBT exacerbated their emotional dysregulation, leading to increased distress rather than relief.
“It was just such a waste of time for everyone, and it’s a shame, [ … ] it made me feel worse going there, and that’s not what you hope when you do therapy, you expect to feel better afterwards.” (P8)
The survey results supported these themes, with participants reporting that non-adapted CBT was unhelpful and challenging, often depleting their self-esteem and increasing frustration.
Insight
This study reveals that adults with ADHD often experience significant difficulties with non-adapted CBT in the UK.
The generic CBT framework was frequently perceived as incompatible with ADHD-related challenges, particularly in terms of executive function deficits and emotional dysregulation.
Therapists’ lack of specialized knowledge about ADHD was a major barrier to effective treatment.
These findings extend previous research by highlighting the potential negative impacts of non-adapted CBT on adults with ADHD, including increased feelings of failure, lowered self-esteem, and heightened emotional dysregulation.
This contrasts with studies showing the efficacy of ADHD-adapted CBT programs, emphasizing the critical importance of tailoring therapeutic approaches to the specific needs of individuals with ADHD.
Further research could focus on developing and testing ADHD-specific adaptations to CBT that can be implemented in routine clinical practice.
Additionally, investigating the training needs of therapists to better equip them for working with ADHD clients could be a valuable next step.
Strengths
The study had many methodological strengths including:
- Mixed-methods approach, providing both breadth and depth of understanding
- Inclusion of participants from various regions in the UK, enhancing generalizability
- Use of both survey and in-depth interview data, allowing for triangulation of findings
- Rigorous thematic analysis process, including inter-rater reliability checks
Limitations
The study also had several limitations, including:
- The sample was predominantly female, which may not adequately represent the ADHD population, which is typically diagnosed more frequently in males.
- The use of convenience sampling may have attracted participants with particularly charged emotional experiences, potentially skewing the results.
- The impact of different ADHD presentations (inattentive, hyperactive-impulsive, and combined) on CBT experiences was not analyzed.
- The study refers to a wide range of non-adapted CBT treatments across the UK, making it difficult to generalize findings to specific CBT programs.
These limitations imply that while the study provides valuable insights, caution should be exercised in generalizing the results to all adults with ADHD or all CBT programs.
Implications
The results of this study have significant implications for clinical psychology practice and the delivery of mental health services to adults with ADHD. They suggest that:
- Standard CBT delivery in the UK may need substantial modification to effectively serve adults with ADHD.
- There is a pressing need for additional training for CBT therapists on working with ADHD clients.
- Service providers should consider offering ADHD-specific adaptations of CBT as a standard option.
- The potential for iatrogenic harm from non-adapted CBT highlights the importance of careful assessment and treatment planning for ADHD clients.
Variables that may influence these results include the specific type of CBT delivered, the level of ADHD-specific knowledge and training of the therapist, and the severity and presentation of ADHD symptoms in individual clients.
References
Primary references
William, S., Horrocks, M., Richmond, J., Hall, C. L., & French, B. (2024). Experience of CBT in adults with ADHD: a mixed methods study. Frontiers in Psychiatry, 15, 1341624. https://doi.org/10.3389/fpsyt.2024.1341624
Other references
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative research in psychology, 3(2), 77-101.
Gjervan, B., Torgersen, T., Nordahl, H. M., & Rasmussen, K. (2012). Functional impairment and occupational outcome in adults with ADHD. Journal of attention disorders, 16(7), 544-552. https://doi.org/10.1177/1087054711413074
National Institute for Health and Care Excellence (NICE). (2018). Attention deficit hyperactivity disorder: diagnosis and management. Retrieved from https://www.nice.org.uk/guidance/ng87
Song, P., Zha, M., Yang, Q., Zhang, Y., Li, X., & Rudan, I. (2021). The prevalence of adult attention-deficit hyperactivity disorder: A global systematic review and meta-analysis. Journal of global health, 11.
Keep Learning
Socratic questions for a college class to discuss this paper:
- How might the experiences of adults with ADHD in CBT differ from those without ADHD? What specific challenges might ADHD symptoms present in a therapeutic context?
- Given the findings of this study, what ethical considerations should therapists and healthcare providers keep in mind when offering CBT to adults with ADHD?
- How might the predominantly female sample in this study have influenced the results? In what ways might the experiences of men with ADHD in CBT potentially differ?
- This study focused on the UK healthcare system. How might the findings translate to other healthcare systems or cultural contexts? What factors should we consider when thinking about the global applicability of these results?
- The study highlights the potential negative impacts of non-adapted CBT. How might this inform our broader understanding of the importance of personalized mental health care? What other conditions or populations might benefit from similar investigations into treatment adaptations
- Given the limitations of this study, what would be the most crucial next steps in research to further our understanding of effective psychotherapy for adults with ADHD?
