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Section 17
Cognitive Remediation in Adult ADHD

Question 17 | Test | Table of Contents

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. These include a high incidence of psychiatric problems, lower employment status, relationship problems, poor frustration tolerance and anger dysregulation, low self esteem and a high incidence of drug and alcohol abuse. Most researchers now consider ADHD to be a developmental, neurobiological disorder with a prevalence of between 2 and 6% of the adult population. 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 and one small study has been conducted using a similar approach. 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. The main contribution of this study is to systematically evaluate a cognitive remediation program (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, concentration, listening, impulsivity, organization, anger management and self-esteem. These topics were chosen to cover frequently cited difficulties experienced by adults with ADHD. The multicomponent format ensured the program 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 program by having a cueing or prompting role. 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
DSM-IIIR ADHD checklist. This measure was selected to assess improvements in ADHD symptoms. DSM-IIIR diagnostic criteria for ADHD together with four items from a questionnaire by Gittelman were combined to produce an 18-item checklist. While this checklist was originally designed for adolescents the questions are appropriate for adults. Scaling of DSM-IIIR criteria has previously been used by Barkley.

Adult Organization Scale. This measure was selected to assess day to day improvements in organizational skills. This measure was adapted for adults from the Child Organizational Scale.
Davidson and Lang Self-Esteem Measure. This measure was selected to examine whether the CRP led to improvements in self-evaluation. The Davidson and Lang Self-Esteem Measure has been identified as sensitive for measuring self-esteem in adults with ADHD.
State-Trait Anger Expression Inventory (STAXI). The STAXI was selected to assess whether anger management improved following the CRP. Two subscales of the STAXI were administered; the state and trait anger scales. The STAXI has good psychometric properties. 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 pre and 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.

Discussion
Following the treatment program, 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 program. 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. 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. 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 behavior).

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. Using this criterion, a 50% improvement rate was observed between ratings at T1 and one year post-treatment. This outcome compares favorably with medication trials where the response rate varies between 25 and 78%. 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. 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. 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 program. 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 program was useful for all participants, as it enabled participants to individualize the program by selecting strategies appropriate for their personal needs. In addition, participants had the continuing use of a workbook to review the program. 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. 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. 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.

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.
- Stevenson, Caroline et al; A cognitive remediation program for adults with Attention Deficit Hyperactivity Disorder; Australian & New Zealand Journal of Psychiatry; Oct 2002; Vol. 36 Issue 5, p.610

Personal Reflection Exercise #3
The preceding section contained information about cognitive remediation in adult ADHD.  Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
Goal management training improves executive control in adults
with ADHD: an open trial employing attention network
theory to examine effects on attention

- Jensen, D. A., Lundervold, A. J., Stubberud, J., Halmøy, A., Haavik, J., & Sørensen, L. (2022). Goal management training improves executive control in adults with ADHD: an open trial employing attention network theory to examine effects on attention. BMC psychology, 10(1), 207. https://doi.org/10.1186/s40359-022-00902-9


Peer-Reviewed Journal Article Reference:
Bottini, S., Polizzi, C. P., Vizgaitis, A., Ellenberg, S., & Krantweiss, A. R. (2019). When measures diverge: The intersection of psychometric instruments and clinical judgment in multimodal adult attention-deficit/hyperactivity disorder assessment. Professional Psychology: Research and Practice, 50(6), 353–363.

Courrégé, S. C., Skeel, R. L., Feder, A. H., & Boress, K. S. (2019). The ADHD Symptom Infrequency Scale (ASIS): A novel measure designed to detect adult ADHD simulators. Psychological Assessment, 31(7), 851–860.

Walther, C. A. P., Pedersen, S. L., Gnagy, E., Pelham, W. E., & Molina, B. S. G. (2019). Specificity of expectancies prospectively predicting alcohol and marijuana use in adulthood in the Pittsburgh ADHD longitudinal study. Psychology of Addictive Behaviors, 33(2), 117–127.

QUESTION 17
According to Stevenson, what are the goals of a cognitive remediation program for adults with ADHD? To select and enter your answer go to Test.

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