Abstract
In the last two decades, retrospective and prospective studies have shown that adults with Attention Deficit Hyperactivity Disorder (ADHD) experience a broad range of psychosocial problems [1, 2]. These include a high incidence of psychiatric problems [3], lower employment status [4], relationship problems [5], poor frustration tolerance and anger dysregulation [6], low self-esteem [1] and a high incidence of drug and alcohol abuse [4]. Most researchers now consider ADHD to be a developmental, neurobiological disorder [5] with a prevalence of between 2 and 6% of the adult population [2]. This paper focuses on interventions for psychosocial issues that can exacerbate the condition, for example: skill deficits, disorganized and chaotic working environments and poor stress management. In order to reduce the impact of psychosocial factors on ADHD, a specific intervention was designed. Several authors have reported single cases using a cognitive remediation intervention with good results [7, 8] and one small study has been conducted using a similar approach [9]. The present study uses a three-pronged approach to reduce the impact of cognitive impairments: (i) retraining cognitive functions; (ii) teaching internal and external compensatory strategies; and (iii) restructuring the physical environment to maximize functioning. Many experts in the field of adult ADHD use and recommend such an approach, albeit without systematic evaluation of these interventions [10–12]. The main contribution of this study is to systematically evaluate a cognitive remediation programme (CRP).
A CRP was designed for a small group format with three main components: (i) eight, weekly, therapist-led group sessions; (ii) support people who acted as coaches; and (iii) a participants’ workbook with exercises. Group sessions were designed to teach strategies to improve functioning in the following areas; motivation [13], concentration [8], listening [14], impulsivity [15, 16], organization [8], anger management [17] and self-esteem [18]. These topics were chosen to cover frequently cited difficulties experienced by adults with ADHD [2, 5]. The multicomponent format ensured the programme would be suitable for adults with ADHD who had diverse secondary symptoms. Support people were paired with each participant to act as coaches in the belief that coaches should assist participants maintain focus on their treatment programme by having a cueing or prompting role [10].
This study represents a first attempt to examine a psychosocial treatment of adult ADHD. Consequently, both medicated and non-medicated participants were included, so that the differential effect of taking medication while learning new skills could be examined. It was anticipated that the CRP would; (i) reduce ADHD symptomatology, (ii) improve organizational skills, (iii) reduce anger, and (iv) improve self-esteem.
Method
Overview
The study design was a randomized, controlled trial with two groups: treatment and control. Adults with ADHD were recruited to the study from ADHD support groups and via referral from psychiatrists who specialize in adult ADHD. Outcome measures were taken before (Time 1; T1) and after treatment (Time 2; T2) for the treatment group and at equivalent time intervals for participants in the control group. To examine whether there was maintenance of any treatment gains, the treatment group was followed up at 2 months (T3) and 1 year post-treatment (T4).
Recruitment
Admission to the programme was completed in three stages; (i) a telephone screen, (ii) a mail-out questionnaire, and (iii) a clinic assessment. Applicants were eliminated at each stage if they did not meet entry requirements.
In the telephone screening interview, demographic information (name, address, telephone number, gender, date of birth) was collected as well as more specific information (diagnosis of ADHD, diagnosis of any other mental health problem, medication prescribed, drug and alcohol problem and learning difficulties). If an exclusion criterion was endorsed, applicants were referred elsewhere. Exclusion criteria were; (i) no ADHD like symptoms, (ii) being under 21 years of age, (iii) current drug or alcohol problem, (iv) history of psychosis, (v) reported involvement in criminal activities, and (vi) mental retardation. The majority of applicants passed the initial screen and were sent an information package about the study.
The information package included two standardized questionnaires: the Wender Utah Rating Scale (WURS) [19] and the Parent Rating Scale (PRS) [19]. The WURS is a 25-item checklist of childhood behaviours associated with ADHD. A score of 36 or higher on this measure is thought to correctly identify 96% of adults with childhood ADHD and 96% of normals [19]. The WURS has been shown to have adequate psychometric properties [20, 21]. The PRS (a modified version of the Connors’ Rating Scale) is a 10-item checklist of childhood behaviours, completed by a significant other (usually a parent) who knew the participant as a child. The measure was administered in this study to allow comparison with previous research. It was not used as an entry measure so that applicants unable to have the measure completed remained eligible. Applicants who returned the WURS, with a score of 36 or greater (one person with a score of 34 was included), were invited to the clinic for further assessment.
The clinic assessment included the Semi-Structured Interview for Adult ADHD [5] and a DSM-IIIR symptom checklist [22]. The Semi-Structured Interview for Adult ADHD [5] provides a thorough evaluation of both medical and psychological factors that can produce ADHD symptoms and was selected to assist in making differential diagnoses. This measure was selected because a diagnostic semistructured interview for adults that includes ADHD is not currently available. Two alternative interview schedules have been devised [23, 24], however, the Barkley measure was selected for this study. The DSM-IIIR checklist was used to establish that participants met criteria for ADHD and that the symptoms were impairing functioning. Inclusion criteria were; (i) evidence of ADHD symptoms from childhood (i.e. a score of 36 or over on the Wender Utah Rating Scale), (ii) current endorsement of the DSM-IIIR criteria for ADHD by the applicant, (iii) a lifelong history consistent with ADHD, (iv) evidence that the symptoms were causing impairment in day-to-day functioning, and (v) willingness to participate in a study and sign a consent form.
In total, 69 applicants completed all three phases of the assessment; of these, 57 met entry criteria for the study. It is noteworthy that over 75% of participants had been diagnosed with ADHD prior to entry into the study. After subsequent dropouts for other reasons (i.e. lack of baby sitter n = 1, work/college on night of the programme n = 5, moving overseas/interstate before programme commenced n = 3, other n = 4), 44 applicants participated.
Participants
Participants were admitted to the study either on prescribed medication for ADHD stabilized at their optimum dose or non-medicated. Participants were asked to maintain their medication status throughout the treatment and up until the two-month follow up. Beyond this, it did not seem reasonable to request that participants refrain from making treatment changes (i.e. either starting medication, changing dose or coming off their medication). It is important to note that no differences were found between medicated and non-medicated participants on any assessment measure.
Participants’ WURS scores were not significantly different from the American adult ADHD standardized sample [19] suggesting the sample was representative (Z = 0.7; see Howell [25], p.162] for method). Furthermore, there was a moderate positive correlation between PRS and WURS (r = 0.39, n = 38, p < 0.025) indicating some consistency between self-report and a significant others’ recollection of childhood behaviours.
Participants receiving medication were randomly assigned to either control (n = 11) or CRP groups (n = 13). One medicated participant withdrew from the CRP, leaving n = 12. Most medicated participants were taking only stimulants (n = 19), two were taking only antidepressants and two were taking both medications. Non-medicated participants were also randomly assigned to control (n = 10) or CRP (n = 11). Group characteristics related to age, gender, WURS and PRS are illustrated in Table 1. There were no significant differences between groups (Treatment vs Control). Age and gender distributions were similar. On the WURS, the treatment (CRP) group had significantly worse scores than the control (t = 2.60, df = 41, p < 0.05). However, PRS scores were not different. Moreover, there were no significant differences between the groups on pretreatment measures (i.e. ADHD symptomatology, organizational skills, self-esteem, state or trait anger).
Participants pretreatment (T1) mean age, mean Wender Utah Rating Scale and mean Parent Rating Scale scores and gender distributions by group (treatment/control)
Cognitive remediation programme
The CRP was described to participants as a programme that would teach strategies to manage ADHD. A clinical psychologist facilitated all sessions. Group sessions followed the same format each week; reviewing previous sessions and homework, introduction of new skills and suggesting a homework exercise. The therapist followed a manual (available on request) to ensure treatment consistency.
Support people
Support people were recruited for the CRP to aid participants with the acquisition of skills by having a cueing or prompting role. Undergraduate students were recruited for those participants who were unable to bring their own support person. (Note that there was no significant difference in treatment outcome between participants who had their own compared with a student as support person). Support people were trained and asked to: (i) remind their partner to attend sessions, (ii) attend sessions and take notes as required, and (iii) to discuss problems with homework exercises. Support people were asked to make at least one telephone contact to their partner between sessions.
Outcome
Outcome measures were administered to the CRP groups at pretreatment, eight weeks later at post-treatment and at the follow-ups two months and one year later. The control group completed the measures on two occasions at an interval of eight weeks to equate with the preand post-treatment measurements. After eight weeks, people in the waiting list group were offered treatment, consistent with best ethical practice. For ease of explanation in the following text, T1 will refer to the first administration of the measures (pretreatment and first control measure); T2 to the second administration (post-treatment and second control measure) and T3 to the 2 month follow-up in the treatment group only. An additional follow-up was undertaken 1 year posttreatment to ascertain whether improvements had been maintained (long-term) in the treatment groups, hereafter T4.
Analysis
Two types of analysis were undertaken; both used parametric statistics as the data met the necessary assumptions. The first set of analyses used two-way ANOVA, with one between factor, group (Treatment vs Control), and one within factor, time (T1 vs T2). This was employed on all the dependent variables. The second sets of analyses were conducted solely on the Treatment group, to ascertain if treatment gains were maintained at 2 months (T3) and 12 months post-treatment (T4). These used paired t-tests on all the dependent variables and compared T1 scores with T3 and T1 with T4 scores, respectively. Finally, all reported results are significant at the 5% level.
Results
Effect of treatment
Table 2 illustrates mean scores, by group, for each dependent variable prior to treatment, immediately after treatment and at two and 12 months post-treatment for the treatment group (CRP) only. (Note that the controls were not available at these follow-ups as they were offered treatment immediately the treatment group had completed their program). In the treatment group (CRP) all outcome measures showed improvement after treatment, when contrasted with controls. This was largely confirmed by the ANOVA (see Table 3), as time (T1 vs T2) by group (Treatment vs Controls) interactions were significant for all measures, excepting trait anger. The trait anger improvement, pre to post-treatment, in the Treatment group, significantly exceeded any reported change in the Control group. Thus, treatment significantly improved reported ADHD symptoms, organizational skills and selfesteem (note improvements here are indicated by an increase in scores in contrast to the other measures). State anger was also significantly reduced. A number of significant main effects are also evident in Table 3, however, the significant interactions described above render these of little interest.
Mean (standard deviation) scores for outcome measures at T1 (pretreatment/week one), T2 (post-treatment/ week eight), T3 (2 months post-treatment) and T4 (one year post-treatment) by group (treatment/control)†
Although the improvements were statistically significant, were they clinically significant? This was examined using criteria published in adult ADHD medication trials, (i.e. that of a 33% reduction in symptoms) [31, 32]. On the ADHD rating scale at T2 (post-treatment) 36% of the participants (n = 8) were responders to treatment in terms of ADHD symptom reduction. This increased to 55% (n = 12) when T3 (2 months post-treatment) was examined and dropped to 50% at T4 (one year post-treatment; n = 11). This degree of improvement is comparable with medication trials where response rates fall between 25 and 78% [32]. For organizational skills, at T2 (week 8) 9% (n = 2) of the participants were responders. This increased to 22% (n = 5) at T3 (2 months post-treatment) and dropped back down to 17% (n = 4) at T4 (one year post-treatment). For the Davidson and Lang Self-Esteem Measure and the STAXI change scores were uniformly small.
Maintenance of treatment gains
The majority of the treatment group was reassessed post-treatment at 2 months and at 12 months. As is evident in Table 2, treatment gains were maintained for all measures, excepting State Anger. This was confirmed by paired t-tests (see Table 3), which indicated significant improvements when the T3 score (at 2 months) was compared to the pretreatment score, T1. Although State Anger score was not maintained, a delayed consequence of treatment appeared to be an improvement in Trait Anger scores.
Significant treatment effects for all outcome measures
At 12 months post-treatment, participants were initially screened using the Life Events Scale [33] to determine if any major disruption had occurred which might influence treatment gains. Nineteen participants completed this measure. The mean score on this measure was (mean = 187.4, SD = 142.8) which is in the normal range for stressful events. Examination of the mean outcome measure scores at 12 months (see Table 2) revealed a similar picture to the 2-month follow-up, with gains apparently preserved. This was confirmed in the analysis, in that all treatment measures significant at the 2 month follow-up, were still significant at 12 months (the paired t-test compared pretreatment scores (T1) with the 12 month follow-up (T4) scores). Finally, three participants had had particularly stressful years and recorded Life Event Scores over 300, a level at which impairment to functioning may occur. However, all three of these participants sustained an improvement in ADHD symptoms of at least 20% at the one-year follow-up. This suggests that extreme levels of stress did not unduly affect the day to day use of the strategies. Finally, some caution should be observed in the interpretation of the one year follow-up data as participants were not asked to maintain their medication status.
Examination of the effect of medication on outcome
A further question that this study addresses is whether medication status had any effect on treatment outcome. All the analyses reported in the ‘effect of treatment’ section were repeated, but with one extra factor included in the ANOVA, that of medication status (Medicated vs Nonmedicated). This factor had no significant effect on any outcome measure. Thus, medication status appeared to exert no obvious effect on the success or otherwise of the CRP.
Examination of the effect of anxiety on outcome
A final question, raised by childhood ADHD literature [34, 35], warrants addressing here, namely, whether adults with ADHD who had problems with anxiety faired better as a results of this psychosocial intervention when compared to non-anxious adults with ADHD. To answer this question, participants in the treatment condition were grouped by their response to a question about anxiety, taken from the semi-structured interview [5]. These groups were then compared to ADHD symptom change between T1 and T2. There was no significant response between anxious and non-anxious participants.
Discussion
This study evaluates a cognitive remediation programme (CRP) for adults with ADHD (some already medicated, some not). Following the treatment programme, participants reported that their ADHD symptoms were less problematic, that their organizational abilities improved, their self-esteem increased and that their anger management improved. Medication was not necessary to benefit from the treatment programme. At the two-month follow-up, all therapeutic gains were either maintained or had continued to improve. Furthermore, at one-year post-treatment, statistically significant improvements in ADHD symptomatology, organizational skills, self-esteem and trait anger remained apparent. These findings suggest that a cognitive remediation approach may provide an effective treatment for adult ADHD.
The sample selected for this study can be considered representative of adults with ADHD. A clear set of diagnostic criteria and appropriate measures for clinical assessment were used. Diagnoses made by psychiatrists who specialize in treating adult ADHD were confirmed in the majority of cases. Furthermore, the clinical and demographic characteristics of this sample were similar to the findings of overseas studies [3, 19]. Participants with commonly co-occurring conditions such as anxiety, depression and learning disabilities were included, reflecting the reality that the majority of adults with ADHD have comorbid conditions [36]. Outcomes from this study can therefore be expected to generalize to typical clinical samples (albeit those who do not have substance abuse problems or antisocial behaviour).
The improvement in ADHD symptomatology was substantial following the CRP. While direct comparison with medication trials is difficult because of differing entry criteria across studies, it is suitable to use the criterion of a 33% reduction in ADHD symptoms as an indication of satisfactory response to treatment. This criterion has been used in two adult ADHD medication trials [31, 32]. Using this criterion, a 50% improvement rate was observed between ratings at T1 and one year post-treatment. This outcome compares favourably with medication trials where the response rate varies between 25 and 78% [32]. Furthermore, the CRP may have the advantage of being used as either an adjunct to existing medication treatment or as an alternative to medication.
The success of the CRP in reducing symptom expression may be explained in a number of ways. First, strategies may act to partially circumvent the primary deficits associated with ADHD. Similar findings have been observed in the brain injury literature, where adults have been taught to use skills, such as self-instructional training and problem solving to compensate for organic deficits [37, 38]. Second, improvements in self-esteem and anger management may contribute to the perception of improvement in primary symptoms. Third, the use of compensatory strategies may place less demands on attention and memory systems thus decreasing the impact of ADHD symptoms overall. In all probability, these mechanisms combine to improve symptomatology, suggesting that a multimodal, multistrategy skill approach is useful for adults with ADHD.
Disappointingly, there were not more substantial gains in self-esteem and state and trait anger. There is no doubt that both self-esteem and anger management are important issues for adults with ADHD. However, separate interventions may be required to obtain more substantial improvements in these domains.
The therapeutic effects of stimulant medication are known to enhance concentration and reduce hyperactivity [32, 39, 40, 41]. These improvements in symptomatology could be expected to make learning new skills easier for those on medication. It might therefore be hypothesized that outcomes would be maximized if medication were used in conjunction with the CRP. However, non-medicated participants responded to the treatment as well as medicated participants. This may be an indication that those in the medicated group were non-responders or tolerant to their medication. An alternative explanation is that medicated participants had more severe symptoms prior to medication. However, this argument is weakened when childhood measures of ADHD symptomatology (WURS and PRS) are considered, as no difference was found between groups in the severity of childhood symptoms suggesting that they were not more severely affected by ADHD. It is therefore probable that the medicated group were somewhat unusual, representing either a group who had become tolerant to medication or who had not responded.
During the skill acquisition phase, participants reported that the coaches/support people were helpful in enabling them to keep on track of the programme. Improvements on all rating scales were found to be maintained or continued to improve, at two months posttreatment, suggesting the strategies taught were used after the withdrawal of the support person. Furthermore, improvements in ADHD symptomatology and organizational skills were maintained one year later. The multimodal approach ensured the programme was useful for all participants, as it enabled participants to individualize the programme by selecting strategies appropriate for their personal needs. In addition, participants had the continuing use of a workbook to review the programme. Thus, maintenance of improvements is best explained by on-going skills use.
While these results are very encouraging, some caveats are necessary. First, outcome was restricted to self-report ratings that may be influenced by participant expectation. It was not possible to include independent clinical assessments in this preliminary study, due to resource constraints. However, a less objective but equally important means of assessing treatment is to elicit anecdotal information from family or friends about a clients performance on day-to-day tasks [40]. Where possible the first author informally discussed progress with a relative or friend of each participant. In most cases, improvements were apparent to the significant other. In addition, feedback was obtained from psychologists and psychiatrists involved with the participants. This was equally encouraging in terms of observed improvements. While this information is anecdotal, it suggests that improvement ratings are reliable. This is consistent with the findings of other authors where adults with ADHD are reported as appropriate reporters of their own condition [36]. A second caveat is that there are limitations to the interpretation of findings when a waiting list group is used, in that, contact time with the mental health service is not controlled for. However, the use of an attention placebo group (i.e. ‘a tea and sympathy group’) is controversial both ethically and from a research perspective [42].
As ADHD in adults becomes increasingly recognized, it is important that safe, effective treatments are trialled. Teaching cognitive remediation strategies provides one method of assisting adults in making a successful adjustment. While this study is only preliminary, the findings suggest that a cognitive remediation approach is an effective way of intervening to reduce the impact of ADHD on daily functioning and also that the approach warrants further investigation.
Footnotes
Acknowledgements
Special thanks to J. Ellard, S. Metcalfe, D. Nasser and G. Wilkins and Addult NSW, Northern Beaches Learning Difficulties Support Group and New South Wales Learning Difficulties Coalition for referring patients. This research was supported by a grant from the Department of Psychology at Sydney University.