Cognitive-Behavioral Therapy for Adult ADHD by Mary F. Solanto
Mary V. Solanto, PhD, is Associate Professor of Psychiatry and Director of the ADHD Center in the Division of Child and Adolescent Psychiatry at Mount Sinai School of Medicine in New York City. Dr. Solanto has worked extensively with adults and children with ADHD. Her research and publications address the cognitive and behavioral functioning of individuals with ADHD, the effects of psychostimulants, and the characteristics of the predominantly inattentive subtype of ADHD. Dr. Solanto is active in the training of psychiatrists and psychologists to diagnose and treat ADHD and related disorders. She serves on the editorial board of the Journal of Attention Disorders and the advisory board of the Journal of Child Psychology and Psychiatry. Dr. Solanto is the author of Cognitive-Behavioral Therapy for Adult ADHD: Targeting Executive Dysfunction (2011).
In your book Cognitive-Behavioral Therapy for Adult ADHD: Targeting Executive Dysfunction, you describe a 12-session treatment program for adult ADHD. What aspects of cognitive behavioral therapy are the most helpful to adults with ADHD?
The most helpful aspects of the treatment include, first, the mutual support of the group members, and learning they are not alone in confronting these problems. Secondly, participants benefit by learning specific skills and strategies - ways to manage time, organize, and solve problems. These components together help the participants to develop new hope and confidence in managing their lives and achieving their goals.
How much does the structured nature of the 12-session cognitive-behavioral treatment model help adults with ADHD?
We conducted a rigorous scientific study to quantify the benefit that adults derive from the treatment. In this study, sponsored by the National Institute of Mental Health, adults with ADHD were randomly assigned to receive either the CBT program or a support group. A support group was included in order to be able to see how much benefit the active treatment provided over and above the attention and support of the therapist and group members. The results revealed clinically meaningful improvement in the treated group that was statistically superior to that in the support group. (Reference: Solanto et al. American Journal of Psychiatry., 167 (2010) 958-968.)
In your book, you state that these 12 steps can be adapted for individual therapy. Is there a difference in the efficacy of group cognitive-behavioral therapy versus individual cognitive-behavioral therapy for adult ADHD?
There has not yet been a head-to-head study comparing group and individual therapy, so there is no definitive answer to this question. However, our clinical experience indicates that for many people the group treatment offers benefits that individual treatment does not - in particular, as described, with respect to the support of, and interaction with, other group members. The groups develop a positive esprit de corps that helps to motivate and carry the participants along.
Are there any adults with ADHD for whom cognitive-behavioral therapy is contraindicated?
There are some co-existing disorders that should take precedence with respect to treatment before the adult with ADHD would be ready to optimally benefit from CBT for ADHD. These conditions include severe depression, severe anxiety, active substance or alcohol abuse, and borderline personality disorder. People with significant problems of anger management would also likely do better in individual rather than group treatment. It should be noted that specific forms of CBT are available to treat these conditions as well.
Please explain the importance of ADHD adults creating a structured schedule for themselves.
Everyone needs to have some structure or plan for the day in order to be optimally effective in achieving goals. Adults with ADHD have difficulty in setting up and maintaining this structure because they are easily distracted by many outer and inner stimuli and impulses, and are unaccustomed to planning. That is why we devote considerable effort in the program to the regular use of a planner for scheduling activities and tasks, as well as prioritizing and planning activities for the day, week, month, or longer, and remaining focused on long-term goals.
Where can adults with ADHD locate a cognitive-behavioral therapist or treatment program?
Because this treatment was only recently developed, there are few practitioners available outside the established programs in New York (Mount Sinai), Boston (Mass General) and Philadelphia (U Penn). Adults with ADHD may be able to locate a cognitive-behavioral therapist or a neuropsychologist who is amenable to working with the published CBT-ADHD manuals for therapists. Listings of potential therapists are available through CHADD (CHADD.org) and through the professional Association for Behavioral and Cognitive Therapies (ABCT.org).
One of the symptoms of ADHD is lack of follow-through. What is the retention rate of a cognitive-behavioral treatment program for adult ADHD?
We tracked and reported the attrition rate in our 2010 treatment study: In the course of the 3-month program, 12 of the 43 adults (28 percent) assigned to the support group missed more than 3 sessions, compared to only 6 of 45 adults (13 percent) assigned to the CBT group. This rate (0-1 person per 8-member group) is consistent with our clinical experience since then as well. Continued engagement and effort in the program is fostered by the participant's own increasing awareness that s/he is making positive changes as s/he applies the new strategies. The participants in the support group, on the other hand, although benefiting from the encouragement of the group, did not see the same measure of positive change, and thus were more likely to drop out.
What post-treatment follow-up is recommended for participants after an adult ADHD cognitive-behavioral treatment program?
That varies greatly with the individual and we have no general recommendations. Some may need periodic refreshers to maintain and strengthen their use of the strategies. For example, we offer a 6-session "booster" program that focuses on the "Three P's" of procrastination, prioritization, and perfectionism that addresses "sticky" problems in those areas.
What is your response to critics that state because ADHD is solely a neurobiological disorder, medication treatment, not therapy, improves overall functioning?
Just because a person has ADHD - or any other brain-based condition for that matter - does not mean s/he can't learn new, more adaptive behaviors and cognitions. Learning itself changes the brain. It has been shown, for example, that cognitive-behavioral treatment for depression produces normalizing brain changes that are visible on fMRI, a type of neuroimaging. I think that ultimately we may find the same sort of thing for psychological treatments of ADHD as well.
What are three main points you would like readers to know about cognitive-behavioral therapy for the treatment of adult ADHD?
First, the greater the effort invested in the treatment program, the greater the pay-off. Our efficacy study clearly showed, for example, that the greater the number of weekly home exercises completed by the participant, the greater the overall benefit he or she derived from the program. Just like learning to play an instrument, or learning a new language, or developing a muscle, learning new habits of the mind requires continued practice.
Secondly, it's never too late! Most of the adults we treat were never before identified as having ADHD. We have seen people in their 60's and over come into the program and make gains.
Thirdly, it's important to have the right kind of CBT - focused specifically on ADHD. Because many adults with ADHD also have anxiety and/or depression, CBT for those conditions may also be helpful, but that treatment won't address the core problems of time-management, organization etc that are specifically due to ADHD.
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