Cognitive-behavioural interventions for ADHD - Australian ADHD Clinical Practice Guideline

4. Non-Pharmacological interventions

4.2.2 Cognitive-behavioural interventions

Children and adolescents
Adults

This section summarises the evidence examining cognitive-behavioural interventions directly delivered to children aged 5–17 years with ADHD. The phrase cognitive-behavioural interventions is used to refer to a broad range of approaches that use cognitive and/or behavioural interventions to minimise the day-to-day impacts of ADHD symptoms. Overall, there are few studies evaluating these interventions in children and adolescents with ADHD. Cognitive-behavioural interventions also play an important role in addressing co-occurring conditions, such as anxiety or depressive disorders in children and adolescents with ADHD, refer to section 2.2.

Structured dyadic behaviour therapy versus non-specific supportive therapy
No evidence for this comparison was identified in NICE and one new RCT was identified in the updated search involving children aged 8–12 years with ADHD-Combined type (Curtis, Heath, & Hogan, 2021). This study in children with ADHD had moderate risk of bias and very low-certainty evidence, and compared structured dyadic behaviour therapy focused on improving behavioural self-regulation with child-centred dyadic therapy. There were statistically significant benefits of structured dyadic behaviour therapy, relative to child-centred dyadic therapy, for parent-reported ADHD inattention, hyperactivity and for oppositionality and externalising symptoms index, but no statistically significant differences were reported for conduct problems, attention problems and behavioural symptoms index.

CBT plus parent/family training versus non-specific supportive therapy
No new evidence was found. NICE previously identified one low- to moderate-quality RCT of CBT with a parent/family training component compared to non-specific supportive therapy (Fehlings, Roberts, Humphries, & Dawe, 1991). This was a small study including 25 boys with ADHD. There were benefits for parent- and teacher-reported ADHD inattention and hyperactivity symptoms.

CBT plus parent/family training versus waitlist/usual care in children with ADHD and anxiety
No evidence for this comparison was identified in NICE, and a single new pilot RCT (Sciberras et al., 2018) was identified in the updated review. This study conducted in children with ADHD and anxiety compared CBT (Cool Kids program) and usual care over 12 weeks with assessments taken at 5 months (approximately 6 weeks post-intervention). The intervention was delivered to child-parent dyads. There was insufficient evidence to decide the benefit of CBT in this group of children given the very small sample size included.

CBT plus parent/family training versus CBT plus parent/family training
No evidence for this comparison was identified in NICE and one new small RCT was identified (Ahmadi et al., 2020). This RCT conducted in children with ADHD and co-occurring PTSD, compared reminder-focused positive psychiatry and trauma-focused CBT, both involving components with children and parents. Given the very low certainty of the outcome data in this study with very serious risk of bias and very serious imprecision, there was insufficient evidence to support or refute the use of either intervention for any outcome.

CBT + Parent/family training + organisation/school-based intervention (High intensity program) vs CBT + parent/family training + organisation/school-based intervention (Low intensity program)
New evidence was identified for a new comparison consisting of one RCT (Sibley et al., 2018) with a high risk of bias, conducted in adolescents with ADHD, comparing high-intensity and low-intensity summer treatment programs over 12 weeks. There was insufficient post-intervention data to analyse and determine the statistical significance of the outcomes reported.

The below summarises the evidence from studies examining cognitive-behavioural interventions delivered to adults with ADHD. The below studies evaluate interventions such as mindfulness-based cognitive therapy (MBCT,4 studies), dialectical behaviour therapy (DBT, 2 studies), and broader cognitive behaviour therapy techniques (CBT, 7 studies). Two studies focused predominantly on mindfulness/meditation training were also identified and are described below.

CBT/MBCT/DBT versus waitlist/usual care
New evidence was identified in 4 RCTs (Anastopoulos, Langberg, Eddy, Silvia, & Labban, 2021; Dittner, Hodsoll, Rimes, Russell, & Chalder, 2018; Hepark et al., 2019; Janssen et al., 2019) and integrated into the NICE evidence (5 studies) resulting in 9 studies with low- to moderate-certainty evidence. These studies examined CBT (4 studies, Dittner et al., 2018; Pettersson et al., 2017; Anastopoulos et al., 2021; and Virta et al., 2010), mindfulness-based cognitive therapy (MBCT) (Gu et al., 2017; Hepark et al., 2015; Hepark et al., 2019; Janssen et al., 2019) and DBT (Fleming, McMahon, Moran, Peterson, & Dreessen, 2015).

There were statistically significant benefits of CBT/MBCT/DBT over waitlist/usual care for self-rated and investigator-rated ADHD total, inattention, hyperactivity/impulsivity symptoms, improvement in ADHD symptoms; and self-rated functioning, satisfaction, problems, wellbeing, quality of life; and informant rated ADHD hyperactivity/impulsivity symptoms. There were no significant differences in self-rated emotional dysregulation and in academic outcomes. There was insufficient evidence for functioning, behaviour regulation, and metacognition measured by BRIEF.

CBT/DBT/Meta-cognitive therapy versus Non-specific supportive therapy
No new evidence was found. NICE previously identified 3 RCTs of very low to moderate quality exploring DBT skills training (Hirvikoski et al., 2011), CBT (Philipsen et al., 2015) and meta-cognitive therapy (Solanto et al., 2010). There was a clinically important benefit of self-rated Clinical Global Impression scale in one study. There was no clinically important benefit for ADHD total, inattention, hyperactivity symptoms (observer-rated/investigator rated and self-rated), self-rated functioning, emotional dysregulation and no difference in serious adverse events.

Mindfulness versus Psychoeducation
New evidence was identified for a new comparison consisting of 2 RCTs (Bachmann et al., 2018; Hoxhaj et al., 2018) with low-certainty evidence comparing mindfulness and psychoeducation. There were no statistically significant differences using the Conners’ ADHD rating scale (self-rated and observer-rated), including subscales for inattention/memory problems, hyperactivity/restlessness, impulsivity/emotional lability, problem with self-concept, ADHD symptoms – total, inattentive and hyperactive/impulsive, and ADHD index, and no statistically significant differences using the Brief Symptom Inventory Global Severity Index, Positive Symptom Distress Index, Positive symptom total, or for quality of life.

CBT versus cognitive training
No new evidence was found. NICE previously identified one very low-quality RCT (Virta et al., 2010) comparing short CBT with cognitive training. There was a clinically important benefit for Clinical Global Impression scale. There was no clinically important benefit for self-rated quality of life.

CBT versus psychoeducation
New evidence was identified for a new comparison consisting of a single pilot RCT, with moderate risk of bias and low-certainty evidence, conducted in adults with ADHD, comparing psychoeducation (n=17) and CBT (n=15) over 12 weeks (Vidal et al., 2013). There were no statistically significant differences for ADHD symptoms including the Conners’ ADHD rating scale (inattention, hyperactivity, impulsivity, self-esteem), Clinical Global Impression scale and quality of life measures.

Other interventions drawing on cognitive-behavioural approaches

Play-based executive functioning skills plus parent/family training versus waitlist/usual care

No evidence for this comparison was identified in NICE. Two new RCTs were identified in the updated search (Hahn-Markowitz, Berger, Manor, & Maeir, 2017; Qian et al., 2017). These studies had a high risk of bias and very low- to moderate-certainty evidence. Hann-Markowitz et al. 2017 tested the Cog-Fun intervention which uses a play-based approach to teach executive functioning skills and environmental modifications to parent-child dyads. Cog-Fun helps parents to put in place supports such as checklists, timers and daily planners and is ‘designed to compensate for the neurocognitive barriers to participation rather than to remediate them in a cognitive training model’ (Hann-Markowitz et al. 2017, p659). Qian et al. (2017) examined executive skills training with children with ADHD and their parents in a group setting compared to waitlist/usual care. Although these interventions both have elements that also fit within the category of ‘Cognitive’ training’ they are reported here given the elements focused on behavioural support and environmental modifications.

Across these studies, assessed outcomes varied. There were statistically significant benefits of the interventions over waitlist/usual care for parent-reported ADHD inattention, hyperactivity, total symptoms, and executive functioning assessed using the Behaviour Rating Inventory of Executive Function scale (BRIEF), and parent-rated child psychosocial quality of life. There were no statistically significant benefits for the interventions over waitlist/usual care for teacher-reported ADHD total symptoms and other symptoms using the BRIEF and parent-rated BRIEF subscales of shift, emotional control and plan/organise; and parent-rated functional impairment (only assessed in Qian et al., 2017) including family, learning and school, social activities, life skills, self-concept, and risky activities.

Play-based executive functioning skills plus parent/family training versus parent/family training plus non-specific supportive therapy

No evidence for this comparison was identified in NICE. New evidence was identified for this comparison consisting of 2 RCTs in young children (Halperin et al., 2020; Vibholm et al., 2018) with very low- to low-certainty evidence. Halperin et al. (2020) compared a multicomponent intervention including TEAMS (Training Executive, Attention and Motor Skills), and parent education and support to an active control condition of a child playgroup and parent education/support. Vibholm et al. (2018) also compared TEAMS to an active control (psychoeducation, social skills, building cooperation skills). TEAMS also includes other intervention components such as aerobic exercise and relaxation. Again, although these interventions have many elements that fit within the category of cognitive training, they are reported here because of their elements focused on behavioural support and problem-solving.

Across both studies, there was a statistically significant benefit of the multi-component TEAMS intervention compared to the active control condition for clinician-rated ADHD severity, using the Clinical Global Impression scale. There were no statistically significant differences for ADHD total symptoms (parent- and teacher-rated) and parent-rated other symptoms and function at home and teacher-rated function at school.

Evidence to Recommendation Statement

As previously noted, cognitive-behavioural interventions play an important role in addressing co-occurring conditions for people with ADHD (see section 2.2 on co-occurring conditions). The evidence to recommendation statement below focuses on the identified studies that examine cognitive-behavioural interventions for individuals with ADHD specifically.

Children and adolescents

Given the growing evidence examining cognitive-behavioural interventions in adults with ADHD, the GDG decided that cognitive-behavioural interventions ‘should’ be offered to support adolescents with ADHD. The added benefits of directly delivered cognitive-behavioural interventions for children with ADHD in addition to environmental modifications and parent/family training is unclear, as very few studies have examined directly delivered cognitive-behavioural interventions for children. Given the small number of studies examining cognitive-behavioural approaches in children with ADHD, it was recommended that these ‘could’ be offered given that the studies identified examining cognitive-behavioural interventions in this age group, were characterised by low certainty and a moderate to high bias.

The decision of ‘should’ and ‘could’ for adolescents and children, respectively, also considers that many of the parent/family training studies reviewed in section 4.2.1 included interventions directly delivered to children and adolescents with cognitive and/or behavioural intervention elements (for example, Pfiffner et al., 2014; Sibley et al., 2013; Sibley et al., 2016; Webster-Stratton et al., 2011). For children, these studies included intervention elements focused on skill development in key areas such as problem-solving, and emotional literacy (Pfiffner et al., 2014; Webster-Stratton et al., 2011). It is also noted in Chapter 8 that further research is needed to better understand the efficacy of cognitive-behavioural intervention approaches for children and adolescents.

Adults

In adults, evidence suggests benefits of CBT/MBCT/DBT over waitlist/usual care (and no harm). Self-rated benefits of CBT/MBCT/DBT over waitlist/usual care were moderate to large in multiple studies of moderate certainty. There is likely to have been a dilution of effects of cognitive-behavioural interventions in several of the included studies due to:

intervention accessed by waitlist/usual care groups
nonspecific supportive therapy comprising similar components of intervention to CBT/MCT/DBT.

All three studies contributing to the comparisons with nonspecific supportive therapy included ADHD-specific psychoeducational and counselling components (Hirvikoski et al., 2011; Philipsen et al., 2015; Solanto et al., 2010). It is important to note that the available outcomes do not capture important potential benefits, such as self-esteem, or self-empowerment, which may be greater in range and magnitude, and evident at time points beyond the follow-up points of many RCTs. Given the lack of evidence to support the superiority of one type of intervention delivery (i.e. individual or group) over another, for each recommendation, clinical practice points are provided.

NICE 2018 recommended that non-pharmacological treatment for adults with ADHD should be considered for adults with ADHD who have made an informed choice not to have medication, have difficulty adhering to medication and who have found medication to be ineffective or have tolerance issues. NICE 2018 recommended that if non-pharmacological treatment is indicated that ‘treatment may involve elements of, or a full course of, CBT’. Based on the updated review of the evidence, cognitive-behavioural interventions should be offered to adults. These should be offered by clinicians who should discuss these interventions and present the intervention as an option for people to consider, as described in Chapter 3. Any cognitive-behavioural interventions should be specific to the needs of adults with ADHD, be strengths-based, and foster hope and personal empowerment.

Recommendations

Clinical considerations for implementation of the recommendations

It is important that clinicians delivering cognitive-behavioural interventions for people with ADHD have ADHD-specific expertise, and where appropriate, seek additional training and supervision from a clinician with this expertise. Clinician expectations of engagement and efficacy with particular therapeutic techniques should be considered in light of the cognitive strengths and challenges typically associated with ADHD. Clinicians should also be aware of broader socio-political factors that may be influential for the person including stigma, the social model of disability, the human rights model of disability, and the emerging neurodiversity movement.

In general, cognitive-behavioural interventions for ADHD do not target ADHD symptomology. Rather, they target functional/behavioural change, psychological distress, and other mental health factors. Intervention may target contributing factors that are external to the person (such as the environment or the expectations and actions of others) as well as factors internal to the person (such as cognitions, coping mechanisms, and self-concept development). When providing cognitive-behavioural interventions for ADHD the impacts of symptoms in all life domains should be considered. A focus on individual strengths, values and interests should occur in balance with any focus on challenges with treatment areas noted above in the recommendation.

For children and adolescents, the selection of intervention approaches should consider the child/adolescent’s ability to understand their own thought processes (metacognitive ability). Younger children may benefit from a foundational focus on emotional literacy, self-esteem, proactive help-seeking, and problem-solving, whilst children approaching adolescence may benefit from simple meta-cognitive techniques. Through adolescence, increasingly sophisticated CBT techniques may be of benefit. If appropriate, parents/carers should be included in the approach, so that they can fulfil a support role for their child. If cognitive-behavioural interventions are accessed by children and adolescents with ADHD they should be provided alongside parent/family support/training.

These recommendations should be adjusted for application in Aboriginal and Torres Strait Islander communities. Adjustments could include, but are not limited to, funding training of Aboriginal and Torres Strait Islander allied health professionals, and the incorporation of Aboriginal and Torres Strait Islander cultural practices (see section 6.2). Additionally, the acceptability and feasibility of these recommendations needs to be investigated for culturally and linguistically diverse populations.

See Technical Report, section 5.1 for further details