Sprich, S. E., Safren, S. A., Finkelstein, D., Remmert, J. E., & Hammerness, P. (2016). A randomized controlled trial of cognitive behavioral therapy for ADHD in medication-treated adolescents. Journal of child psychology and psychiatry, and allied disciplines, 57(11), 1218–1226. https://doi.org/10.1111/jcpp.12549

Randomized Controlled Trial

Objective: To test cognitive behavioral therapy (CBT) for persistent attention-deficit hyperactivity disorder (ADHD) symptoms in a sample of medication-treated adolescents.

Methods: Forty-six adolescents (ages 14-18), with clinically significant ADHD symptoms despite stable medication treatment were randomly assigned to receive CBT for ADHD or wait list control in a cross-over design. Twenty-four were randomized to CBT, 22 to wait list, and 15 crossed-over from wait list to CBT. A blind independent evaluator (IE) rated symptom severity on the ADHD Current Symptom Scale, by adolescent and parent report, and rated each subject using the Clinical Global Impression Severity Scale (CGI), a global measure of distress and impairment. These assessments were performed at baseline, 4-months (post-CBT or post wait list), and 8-months (post-treatment for those originally assigned to the wait list condition and 4-month follow-up for those originally assigned to CBT).

Results: Using all available data, mixed effects modeling, and pooling for the wait list cross-over, participants who received CBT received a mean score 10.93 lower on the IE-rated parent assessment of symptom severity (95% CI: -12.93, -8.93; p < .0001), 5.24 lower on the IE-rated adolescent assessment of symptom severity (95% CI: -7.21, -3.28; p < .0001), and 1.17 lower IE-rated CGI (95% CI: -1.39, -.94; p < .0001). Results were consistent across 100 multiple imputations (all p < .0001). There was a greater proportion of responders after CBT by parent (50% vs. 18%, p = .00) and adolescent (58% vs. 18% p = .02) report.

Conclusion: This study demonstrates initial efficacy of CBT for adolescents with ADHD who continued to exhibit persistent symptoms despite medications.

• Participants in the study were already treated with medication prior to receiving CBT treatment.
• Blind independent evaluators rated symptom severity which the article states affect school performance, social relationships, relationships at home, repeating grades. The bold are directly related to social outcomes.
• The study showed that adolescents with ADHD not controlled by medications benefited form CBT therapy.

I chose this article because I felt it was directly answering my PICO question. It dealt directly with the population I wanted to research (adolescents with ADHD), the intervention (CBT), comparison (medication alone), and the outcomes were symptom severity which is related to social outcomes as I mentioned in my key points. The results were also measured at baseline, 4 months, and 8 months which answers the long term aspect of my PICO question. It is also a randomized controlled trial which has a high level of evidence and mitigates bias.

Antshel, K. M., Faraone, S. V., & Gordon, M. (2014). Cognitive behavioral treatment outcomes in adolescent ADHD. Journal of attention disorders, 18(6), 483–495. https://doi.org/10.1177/1087054712443155

Extension of previous Randomized Controlled trial

Objective: To assess the efficacy of cognitive behavioral therapy (CBT) for managing adolescent ADHD

Method: A total of 68 adolescents with ADHD and associated psychiatric comorbidities completed a manualized CBT treatment protocol. The intervention used in the study was a downward extension of the Safren et al. program for adults with ADHD who have symptoms unresolved by medication. Outcome variables consisted of narrow band (ADHD) and broadband (e.g., mood, anxiety, conduct) symptom measures (Behavior Assessment System for Children–2nd edition and ADHD–Rating Scales) as well as functioning measures (parent/teacher ratings and several ecologically real-world measures).

Results: Treatment effects emerged on the medication dosage, parent rating of pharmacotherapy adherence, adolescent self-report of personal adjustment (e.g., self-esteem), parent and teacher ratings of inattentive symptoms, school attendance, school tardiness, parent report of peer, family and academic functioning and teacher report of adolescent relationship with teacher, academic progress, and adolescent self-esteem. Adolescents with ADHD with oppositional defiant disorder were rated by parents and teachers as benefiting less from the CBT intervention. Adolescents with ADHD and comorbid anxiety/depression were rated by parents and teachers as benefiting more from the CBT intervention.

Conclusion: A downward extension of an empirically validated adult ADHD CBT protocol can benefit some adolescents with ADHD.

•  This study was a downward extension of a previous randomized controlled trial that was conducted in adults, now being conducted in adolescents.
• This study also discusses how ADHD is often a comorbid disorder with other forms of psychopathology.
• CBT sessions focused on psychoeducation about ADHD as well as training in organizing and planning skills, adolescent learning skills to reduce distractibility, reducing procrastination, improving communication skills, and improving anger/frustration management.
• Post treatment ratings from parents and teachers showed that those suffering from ADHD & ODD benefited less. It also showed that those suffering from ADHD & anxiety and those suffering from ADHD & depression benefited more from CBT. Those with just ADHD seemed to benefit less than those with ADHD & depression and those with ADHD and anxiety.

I chose this article because the objective was related to my PICO research question. It also looked at a different aspect of the test subjects which was comorbidity. After reading this article it was clear how prevalent other psychopathologies were in those who were diagnosed with ADHD. The other articles I was considering using didn’t mention much about comorbidities. It was important to me not to have very similar articles, as that could narrow down the research and make it less valid.

Sprich, S. E., Burbridge, J., Lerner, J. A., & Safren, S. A. (2015). Cognitive-Behavioral Therapy for ADHD in Adolescents: Clinical Considerations and a Case Series. Cognitive and behavioral practice, 22(2), 116–126. https://doi.org/10.1016/j.cbpra.2015.01.001

Case Series

Although ADHD in adolescents is an impairing and prevalent condition, with community prevalence estimates between 2% and 6%, psychosocial treatments for adolescents compared to younger children are relatively understudied. Our group has successfully developed an evidence base for cognitive-behavioral therapy (CBT) for ADHD in medication-treated adults with ADHD with clinically significant symptoms. In the current paper, we describe an adaptation of this treatment to adolescents, and provide case reports on 3 adolescents who participated in an open pilot trial. The results suggest that the treatment approach was well tolerated by the adolescents and that they experienced clinical benefit. This early report of the approach in adolescents is promising and requires further efficacy testing.

• Case series on 3 adolescents who had been on stable ADHD medication for 2 months.
• Doctoral level psychologists carried out the behavioral therapy weekly.
• In case 1, Jane and her parents reported “having a few close friends and no being involved in many social activities.
• In case 2, Tylers mother reported how his ADHD symptoms have affected his relationships with his family.
• In case 3, Sally’s ADHD and problems in school affected her relationship with her mother which caused arguing.
• All above cases had symptoms of ADHD which affected their social relationships with family/friends.
• Baseline assessments/post treatment assessments of ADHD symptom severity were conducted and showed a clinically significant decrease in all 3 studies after behavioral therapy.

I chose this article because I thought it was a well-organized case series. I had not used a case series in any of my other previous articles. It also was appropriately related to my PICO question. I thought that there maybe could have been a better assessment of social outcomes then just an examination on symptoms but the symptoms displayed in ADHD directly were affecting the patients social relationships. It was interesting reading about each of the three adolescents being examined and the differing ways that CBT had a positive effect on each of them.