It is currently recognized that attention deficit/hyperactivity disorder (ADHD) persists into adulthood for more than half of affected individuals. ADHD in adulthood is associated with impairments in most adult roles. Medications are considered an effective treatment for the core symptoms of ADHD. Adjunctive psychosocial treatment, primarily cognitive-behavioral therapy (CBT), is efficacious in cases of residual symptoms and impairments. However, a minority of adults with ADHD may not be able to take medications due to medical contraindications, nonresponse, or intolerable side effects. The goal of this article is to discuss the case of an adult with ADHD who is unable to take medications for ADHD due to cardiac risk. The patient sought a course of CBT for adult ADHD to address difficulties he experienced at work and in his home life. His case illustrates the challenges of and opportunities for CBT for adult ADHD without medications.
AbikoffH.Nissley-TsiopinisJ.GallagherR.ZambenedettiM.SeyffertM.BooradyR.McCarthyJ. (2009). Effects of MPH-OROS on the organizational, time management, and planning behaviors of children with ADHD. Journal of the American Academy of Child and Adolescent Psychiatry, 48, 166-175. doi:10.1097/CHI.ob013e318193062610.1097/CHI.ob013e3181930626
2.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
3.
BarkleyR. A. (1997). ADHD and the nature of self-control. New York, NY: Guilford.
4.
BarkleyR. A. (2010). Deficient emotional self-regulation: A core component of attention-deficit/hyperactivity disorder. Journal of ADHD & Related Disorders, 1, 5-37.
5.
BarkleyR. A.MurphyK. R. (2006). Attention-deficit hyperactivity disorder: A clinical workbook (3rd ed.). New York, NY: Guilford.
6.
BarkleyR. A.MurphyK. R.FischerM. (2008). ADHD in adults: What the science says. New York, NY: Guilford.
7.
BeckA. T.SteerR. A. (1989). Manual for the Beck Hopelessness Scale. San Antonio, TX: The Psychological Corporation.
8.
BeckA. T.SteerR. A. (1990). Beck Anxiety Inventory manual. San Antonio, TX: The Psychological Corporation.
9.
BeckA. T.SteerR. A.BrownG. K. (1996). Beck Depression Inventory—Second edition manual. San Antonio, TX: The Psychological Corporation.
10.
BiedermanJ.FaraoneS. V.SpencerT. J.MickE.MonuteauxM. C.AleardiM. (2006). Functional impairments in adults with self-reports of diagnosed ADHD: A controlled study of 1001 adults in the community. Journal of Clinical Psychiatry, 67, 524-540.
11.
BiedermanJ.PettyC. R.ClarkeA.LomedicoA.FaraoneS. V. (2011). Predictors of persistent ADHD: An 11-year follow-up study. Journal of Psychiatric Research, 45, 150-155. doi:10.1016/ j.jpsychires.2010.06.00910.1016/ j.jpsychires.2010.06.009
12.
BlochM. H.QawasmiA. (2011). Omega-3 fatty acid supplementation for the treatment of children with attention-deficit/hyperactivity disorder symptomatology: Systematic review and meta-analysis. Journal of the American Academy of Child and Adolescent Psychiatry, 50, 991-1000. doi:10.1016/j.jaac.2011.06.00810.1016/j.jaac.2011.06.008
13.
BrownT. E. (1996). Brown attention deficit disorder scales. San Antonio, TX: The Psychological Corporation.
EakinL.MindeK.HechtmanL.OchsE.KraneR.BouffardB.. . . LooperK. (2004). The marital and family functioning of adults with ADHD and their spouses. Journal of Attention Disorders, 8, 1-10.
16.
EmilssonB.GudjonssonG.SigurdssonJ. F.BaldurssonG.EinarssonE.OlafsdottirH.YoungS. (2011). Cognitive behaviour therapy in medication-treated adults with ADHD and persistent symptoms: A randomized controlled trial. BMC Psychiatry, 11, 1-10. doi:10.1186/1471-244X/11-11610.1186/1471-244X/11-116
17.
FaraoneS. V.BiedermanJ.MickE. (2006). The age-dependent decline of attention deficit hyperactivity disorder: A meta-analysis of follow-up studies. Psychological Medicine, 36, 159-165. doi:10.1017/S003329170500471X10.1017/S003329170500471X
18.
FayyadJ.De GraafR.KesslerR.AlonsoJ.AngermeyerM.DemyttenaereK.JinR. (2007). Cross-national prevalence and correlates of adult attention-deficit hyperactivity disorder. British Journal of Psychiatry, 190, 402-409. doi:10.1192/bjp.bp.106.03438910.1192/bjp.bp.106.034389
19.
GawrilowC.GollwitzerP. M. (2008). Implementation intentions facilitate response inhibition in children with ADHD. Cognitive Therapy and Research, 32, 261-280. doi:10.1007/s10608-007-9150-110.1007/s10608-007-9150-1
GouldM. S.WalshB. T.MunfakhJ. L.KleinmanM.DuanN.OlfsonM.CooperT. (2009). Sudden death and use of stimulant medications in youth. American Journal of Psychiatry, 166, 992-1001.
22.
GualtieriC. T.JohnsonL. G. (2008). Medications do not necessarily normalize cognition in ADHD patients. Journal of Attention Disorders, 11, 459-469. doi:10.1177/108705470730531410.1177/1087054707305314
23.
HabelL. A.CooperW. O.SoxC. M.ChanK. A.FiremanB. H.ArbogastP. G.SelbyJ. V. (2011). ADHD medications and risk of serious cardiovascular events in young and middle-aged adults. Journal of the American Medical Association, 306, 2673-2683. doi:10.1001/jama.2011.183010.1001/jama.2011.1830
24.
HesslingerB.van ElstL. T.NybergE.DykierekP.RichterH.BernerM.EbertD. (2002). Psychotherapy of attention deficit hyperactivity disorder in adults: A pilot study using a structured skills training program. European Archives of Psychiatry and Clinical Neuroscience, 252, 177-184.
25.
KesslerR. C.AdlerL. A.BarkleyR. A.BiedermanJ.ConnersC. K.DemlerO.ZaslavskyA. M. (2006). The prevalence and correlates of adult ADHD in the United States: Results from the national comorbidity survey replication. American Journal of Psychiatry, 163, 716-723.
26.
KesslerR. C.GreenJ. G.AdlerL. A.BarkleyR. A.ChatterjiS.FaraoneS. V.. . . Van BruntD. L. (2010). Structure and diagnosis of adult attention-deficit/hyperactivity disorder: Analysis of expanded diagnostic criteria from the adult ADHD clinical diagnostic scale. Archives of General Psychiatry, 67, 1168-1178.
27.
PhilipsenA.GrafE.van ElstL. T.JansT.WarnkeA.HesslingerB.BergerM. (2010). Evaluation of the efficacy and effectiveness of a structured tailored psychotherapy in ADHD in adults: Study protocol of a randomized controlled multicentre trial. Attention Deficit Hyperactivity Disorder, 2, 203-212. doi:10.1007/s12402-010-0046-710.1007/s12402-010-0046-7
28.
PhilipsenA.RichterH.PetersJ.AlmB.SobanskiE.CollaM.HesslingerB. (2007). Structured group psychotherapy in adults with attention deficit hyperactivity disorder. Journal of Nervous and Mental Disease, 195, 1013-1019.
29.
PolanczykG.LimaM. S.HortaB. L.BiedermanJ.RohdeL. A. (2007). The worldwide prevalence of attention deficit/hyperactivity disorder: A systematic review and meta-regression analyses. American Journal of Psychiatry, 164, 942-948.
30.
ProchaskaJ. O.NorcrossJ. C. (2001). Stages of change. Psychotherapy, 38, 443-448.
31.
RamsayJ. R. (2010). Nonmedication treatments for adult ADHD: Evaluating impact on daily functioning and well-being. Washington, DC: American Psychological Association.
32.
RamsayJ. R.RostainA. L. (2008). Cognitive-behavioral therapy for adult ADHD: An integrative psychosocial and medical approach. New York, NY: Routledge.
33.
RamsayJ. R.RostainA. L. (2011). CBT without medications for adult ADHD: An open pilot study of five patients. Journal of Cognitive Psychotherapy: An International Quarterly, 25, 277-286. doi:10.1891/0889-8391.25.4.27710.1891/0889-8391.25.4.277
34.
RobinA. L.PaysonE. (2002). The impact of ADHD on marriage. ADHD Report, 10(3), 9-11, 14.
35.
RostainA. L.RamsayJ. R. (2006). A combined treatment approach for adults with attention-deficit/hyperactivity disorder: An open study of 43 patients. Journal of Attention Disorders, 10, 150-159. doi:10.1177/108705470628811010.1177/1087054706288110
36.
SafrenS. A.OttoM. W.SprichS.WinettC. L.WilensT. E.BiedermanJ. (2005). Cognitive-behavior therapy for ADHD in medication-treated adults with continued symptoms. Behaviour Research and Therapy, 43, 831-842.
37.
SafrenS. A.PerlmanC. A.SprichS.OttoM. W. (2005). Mastering your adult ADHD: A cognitive-behavioral treatment program—Therapist guide. Oxford, UK: Oxford University Press.
38.
SafrenS. A.SprichS.MimiagaM. J.SurmanC.KnouseL.GrovesM.OttoM. W. (2010). Cognitive behavioral therapy vs relaxation with educational support for medication-treated adults with ADHD and persistent symptoms: A randomized controlled trial. Journal of the American Medical Association, 304, 875-880. doi:10.1001/jama.2010.119210.1001/jama.2010.1192
39.
SolantoM. V. (2011). Cognitive-behavioral therapy for adult ADHD: Targeting executive dysfunction. New York, NY: Guilford.
40.
SolantoM. V.MarksD. J.MitchellK. J.WassersteinJ.KofmanM. D. (2008). Development of a new psychosocial treatment for adults with AD/HD. Journal of Attention Disorders, 11, 728-736.
41.
SolantoM. V.MarksD. J.WassersteinJ.MitchellK.AbikoffH.AlvirJ. M.KofmanM. D. (2010). Efficacy of meta-cognitive therapy for adult ADHD. American Journal of Psychiatry, 167, 958-968. doi:10.1176/appi.ajp.2009.0908112310.1176/appi.ajp.2009.09081123
42.
TcheremissineO. V.SalazarJ. O. (2008). Pharmacotherapy of adult attention deficit/hyperactivity disorder: Review of evidence-based practices and future directions. Expert Opinion in Pharmacotherapy, 9, 1299-1310. doi:10.1517/1465656080209824610.1517/14656560802098246
43.
VitielloB. (2009). ADHD psychopharmacology across the lifespan. Current Attention Disorders Reports, 1, 69-74.
44.
WilensT. E.BiedermanJ.SpencerT. J. (2002). Attention deficit/hyperactivity disorder across the lifespan. Annual Review of Medicine, 53, 113-131.
45.
WilensT. E.SpencerT. J.BiedermanJ. (2000). Pharmacotherapy of attention-deficit/hyperactivity disorder. In BrownT. E. (Ed.), Attention deficit disorders and comorbidities in children, adolescents, and adults (pp. 509-535). Washington, DC: American Psychiatric Press.
