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Rucklidge, J. (2010). Adapting CBT for ADHD.
Journal of the New Zealand College of Clinical Psychologists, 20(3), 21-24.
Adapting CBT for ADHD
Julia J Rucklidge
This article is adapted from: Rucklidge, J. J. (2008). Gender differences in ADHD: implications for psychosocial treatments.
Expert Review of Neurotherapeutics, 8, 643-655.
ADHD is a complex neurodevelopmental nonpharmaceutical treatments have evolved
syndrome of impaired executive functioning over the years for the treatment of ADHD
that significantly affects, particularly over with varying degrees of effectiveness and
time, an individual’s ability to successfully varying degrees of empirically-based
negotiate the world. As such, treatments research supporting their effectiveness.
need to be integrative and multimodal, and Treatments also vary depending on the age
the case conceptualized with consideration of the individual affected by ADHD.
of all the individual variables present.
Although not all cases of ADHD need Over 100 studies have found that parent
treatment beyond medication, many do and and teacher programs improve child
it is up to us to identify the more complex compliance, reduce disruptive behaviours
presentations and offer these clients a and improve interactions. The programs
combination of treatments with a good that specifically offer good outcomes
empirical base such that they can make an involve operant conditioning, whereas those
informed decision on treatment choices. using a more cognitive-behavioural
approach have fared less well, at least in the
With queries related to the long-term child literature. The rationale for using
effectiveness of front-line medications for behavioural approaches lies in both the
the treatment of ADHD (Jensen et al., neurological research suggesting that
2007), we are challenged to investigate neurotransmitter pathways can be modified
alternative treatment options. Psychosocial by behavioural management (e.g. Sagvolden,
treatments have a solid grounding in Aase, Johansen & Russell, 2005) and the
empirically based research. Part of a evidence that social factors can contribute to
clinician’s role is to assist individuals with the severity and comorbid profiles
ADHD to find a “good fit” between their associated with the disorder. Although the
symptoms and their environment. Adults initial results emerging from the MTA study
with ADHD are particularly likely to hold indicated that behaviour management added
core beliefs of inadequacy and display nothing to the effect of medications,
concomitant behaviours, such as avoidance, subsequent publications have shown that
that exacerbate the core symptoms of this was only true for those with
inattention, hyperactivity and impulsivity uncomplicated ADHD but for those with
(Ramsay & Rostain, 2005b). Psychosocial additional comorbidities (e.g., anxiety and
treatments, target these secondary problems. disruptive behavioural disorders), the
Particularly for those identified in adulthood psychosocial component statistically
with ADHD, instilling hope and reframing improved outcomes (Conners et al., 2001).
the past may be some of the more important Moreover, data collected 2 years post MTA
foci of the early stages of therapy. further diminished the superiority of the
medicated groups (Group, 2004).
It is clear that individuals with ADHD, Behavioural treatments are also known to
regardless of gender, struggle far beyond the allow for a decrease in the dose of
symptoms of ADHD and that these other medications used and parents of children
problems need due consideration when receiving both medication and behavioural
developing treatment plans. As such, many treatments report more “normalized”
Julia Rucklidge, a Clinical Psychologist, is an Associate Professor at the University of Canterbury, Department of Psychology, and
Director of the ADHD Diagnostic Assessment and Research Unit.
Rucklidge, J. (2010). Adapting CBT for ADHD.
Journal of the New Zealand College of Clinical Psychologists, 20(3), 21-24.
children compared with parents of children sense the treatment effects would largely
who only received medications (Greene & disappear. This externalising of rewards and
Ablon, 2001). punishers is also consistent with behavioural
management practices, like token systems.
There has been increasing interest in the The key is to externalise what should
neural mechanisms underlying ADHD and a otherwise be internally represented
number of fascinating animal models have information, be that in the form of cues,
been proposed to assist us in understanding lists, reminders, bells, or timers.
the changes that occur at the neuronal level Maintenance of routines and schedules are
when rewards and punishment reinforcers also an integral part of behavioural
are in place (see Sagvolden et al, 2005, for a management practices. Of course other
comprehensive review of this theory). The issues are also important to manage and
implications of this model are that rewards modify such as sleep hygiene, diet and
for individuals with ADHD must be exercise (Staller & Faraone, 2006).
immediate, punishers are less likely to
influence behaviours in the long-term with Although cognitive-behavioural treatments
individuals affected by ADHD, and any have lost favour amongst those treating
behavioural programme needs to be children with ADHD, it has recently been
maintained over time in order to have any considered as a viable treatment for adults
lasting influence on behaviours. In other with ADHD. More and more adults are
words, psychosocial treatments serve to seeking psychotherapy to complement
provide ADHD individuals with an external medications, the assumption being that
scaffold that needs to be permanently targeted neuropsychological difficulties that stem
at the core ADHD symptoms to assist with from the disorder often lead to
behaviour management over time. dysfunctional patterns of thinking, feeling
and behaving. Over the last few years, a
These ideas are in line with those of Barkley number of studies have been published
(2006) who described the importance of investigating the efficacy of using traditional
targeting interventions at the point of CBT approaches with ADHD adults (e.g.,
performance, that is where the desired (Rostain & Ramsay, 2006; Safren et al.,
behaviour is to occur, rather than in the 2005). CBT focuses on challenging deeply
office where undesirable behaviours are held beliefs and developing coping strategies
unlikely to be activated. In other words, the for managing ADHD-related difficulties.
further in time a suggested intervention is
located, the less effective it is likely to be. Safren et al. (2005) found that there were
This would be true of both behavioural significantly more treatment responders
management strategies offered to children as among patients who received CBT and
well as CBT interventions distributed to medications (56%) compared to those who
adults with ADHD. Based on the received only medications (13%). Rostain
neurocognitive deficits present in individuals and Ramsay (2006) used a combined
with ADHD, it follows that therapies treatment approach for adults with ADHD
delivered in the clinic are going to be less using a 6 month course of concurrent
effective than those directed at pharmacotherapy (ADDerall) and CBT (16
environmental reconfigurations, curriculum sessions). Forty-one percent showed
adjustments, and other options that target significant improvement based on Brown
the structure of the natural setting (Barkley, ADD Scale (BADDS) scores, and there
2006). The cognitive deficits also imply that were significant changes on all self-report
treatments must be sustained over time; if scales and Clinical Global Impression (CGI)
the behavioural treatments and scores, 81% of participants reported at least
environmental structure created to sustain a mild improvement, and 70% reported
behaviour are eliminated, then it makes moderate to significant improvement (see
Rucklidge, J. (2010). Adapting CBT for ADHD.
Journal of the New Zealand College of Clinical Psychologists, 20(3), 21-24.
Ramsey & Rostain, 2005a, for details on employment difficulties (Murphy, 2005).
modules and modifications of CBT for Tardiness, disorganisation, poor time
ADHD). Further, mindfulness approaches management and missing deadlines are all
based on Marsha Linehan’s work with adults some of the things that will interfere with
with Borderline Personality Disorder, have job performance, suggesting that the job
been piloted and appear promising in the may be ill fitted to suit the strengths of the
treatment of emotional dysregulation in adult with ADHD. Therefore, part of the
adults with ADHD (Hesslinger et al., 2002; challenge of working therapeutically with
Solanto, Marks, Mitchell, Wasserstein & ADHD adults is about vocational
Kofman, 2008). counselling and matching patients to jobs.
Psychoeducation is also an important Coaching is another area that has developed
component of psychosocial interventions. It over the last decade as an adjunctive
is important to discuss ADHD as a treatment for adults with ADHD. However,
handicapping condition; one that can be there is no empirical data to support the
managed but not cured. Other areas to efficacy of coaching (Murphy, 2005).
cover include what medications can and
cannot aid, and the fact that medications can References
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