Psychotherapy for Adolescents With Attention-Deficit Hyperactivity Disorder: A Pediatrician’s Guide

Introduction

Attention-deficit hyperactivity disorder (ADHD) is characterized as developmentally inappropriate levels of inattention, impulsiveness, and hyperactivity that surface in childhood and result in multiple impairments. ¹ These core symptoms change as children develop into adolescents. Restlessness replaces hyperactivity and disorganization becomes prominent. ²

For many teens with ADHD, the transition into high school is associated with increased educational and social problems. ³ Difficulties in initiating and completing tasks may hinder academic performance as these students face increasingly complex workloads that require planning and focus.^2,3 Impulsivity persists and manifests in their decision-making style and excessive risky behaviors.^2,4 Additionally, relationships with peers, a critical aspect of adolescent development, are also adversely affected by ADHD symptoms. Coleman reported that peers often view these students as “immature, loners or losers.” ⁵ Problems focusing, following instructions, paying attention, and completing tasks often elicit frustration from their teachers as well. ADHD symptoms lead to decreased functionality in various life domains and contribute to poor academics, behavioral challenges, delayed independence, and strained relationships. The consequences of ADHD can take a huge emotional toll on the individual.^6,7

Optimal ADHD management requires the use of appropriate medications, such as psychostimulants, guanfacine, or atomoxetine.^8-11 Until recently, ADHD pharmacotherapy was routinely discontinued as patients transitioned their care from the pediatrician to the primary care setting. ADHD guidelines currently recommend pharmacotherapy be continued in adolescents and adults as long as it remains effective.^12,13 Clinical trials have documented that stimulant medications significantly reduce core ADHD symptoms in children, adolescents, and adults with ADHD.^11,14-19 Among the stimulants approved by the US Food and Drug Administration (FDA) for adolescent ADHD are lisdexamfetamine, osmotic-release methylphenidate, mixed amphetamine salts extended release, and dexmethylphenidate extended release. Atomoxetine is a nonstimulant medication that also has FDA approval for the treatment of ADHD.^8-10 Adolescents often do not adhere to medication regimens, but the majority of those who are compliant with ADHD pharmacotherapy still show significant residual or comorbid symptoms. In recognition of this issue, the FDA has recently approved guanfacine as an adjunct to psychostimulant therapy. In a multicenter, randomized, double-blind, placebo-controlled dose-optimization study of 455 children and adolescents 6 to 17 years old, the data show that psychostimulants plus adjunctive guanfacine extended release (GXR) considerably reduced comorbid oppositional symptoms. ²⁰ Additional data are available that support the benefits of GXR. Oppositional symptoms are a common comorbidity of ADHD, and GXR is a successful adjunct therapy or monotherapy. However, even after carefully crafted medication management, residual symptoms are common. ²¹

Despite medication, many teens with ADHD continue to experience pervasive failures in their lives due to social and academic struggles. ²² For example, medications may increase a patient’s attention in social interactions but will not increase friendships. Social isolation can contribute to the development of depression and anxiety. ²³ Externalizing disorders, such as oppositional defiant disorder and conduct disorder, are common in these teens and add to their daily challenges. ²⁴ In such cases it is important to address ADHD as well as comorbidities since failure to adequately address both can lead to treatment failure.^25,26 The psychosocial difficulties these patients experience over the course of their adolescent years impair their functioning and treatment outcomes. This article aims to provide a review of the psychotherapeutic interventions available for teens that receive pharmacotherapy but continue to struggle with the residual symptoms of ADHD that interfere with academic function, relationship formation, and psychological development.

Teens With ADHD

Developmental tasks in the teenage years include the effort to gain independence and form friendships. Unfortunately, teens with ADHD typically have difficulty reaching these milestones.^27-29 Inattention, intrusiveness, and quick anger reactions compromise their social relationships. Similarly, behaviors that include problems focusing, following instructions, and completing tasks elicit annoyance from teachers. ³⁰ Over time, the lack of affirmative connections reduces the self-esteem of teens with ADHD.^31,32 Those who internalize criticisms from others suffer from feelings of inadequacy and are predisposed to varying levels of depression and anxiety.^33,34 Alternatively, there are teens with ADHD who overestimate their academic, social, and behavioral competences—a phenomenon called positive illusory bias (PIB).^35,36 Although it is uncertain whether PIB protects against depression, maintaining a positive self-view despite social and academic obstacles does combat demoralization. However, PIB is also associated with fewer social behaviors and aggression. ³⁷ Also, many teens with ADHD have concomitant conduct symptoms (eg, lying, breaking rules) and gravitate toward deviant peers. As a result they are at higher risk for substance abuse, delinquency, and risky behaviors.^38-40

Most parents are cognizant of their child’s social and academic limitations and have a unique perspective on what their teens face every day.^27,41 However, even the parent-child relationship is challenged. ⁴² Risky behaviors, ubiquitous in teens with ADHD, are heightened in those with conduct symptoms and contribute to parental angst. ⁴³ These behaviors are particularly hard to treat.

Overall, ADHD has an adverse effect on adolescent development. Adolescents with ADHD struggle to succeed academically, socially, and within their family units. ⁴⁴ They are also at increased risk of developing comorbidities such as conduct disorder as they enter puberty. ⁴⁵ Despite these challenges, clinicians treating ADHD are finding innovative, and nonpharmacological, ways of addressing these problems.

Cognitive Behavioral Therapy (CBT)

Traditional strategies for treating adolescents with ADHD include encouraging behavioral training for parents and teachers and teaching problem solving between teens and parents. ² Unfortunately, while behavioral parent training is effective for children, the magnitude of the effect is modest for teens. ⁴⁶ Barkley demonstrated that less than 30% of adolescents respond to behavioral parent training. ⁴⁷ Similar rates of effectiveness were seen for behaviorally based teacher interventions. This is perhaps because there are classroom changes and teacher changes per period in high school. Therefore, it is challenging to maintain consistent behavioral interventions throughout the day. Parent-teen problem-solving strategies also show limited clinical value. ² Since these interventions have not yet provided a robust response in teens with ADHD, there has been a push to develop novel treatment strategies.

Cognitive behavioral therapies, which have been shown to be effective in adults with ADHD, hold some promise for teens. One CBT model designed by Safren et al was tested in adults with ADHD who were already receiving pharmacotherapy but continued to experience residual symptoms. ⁴⁸ Safren and colleagues’ CBT manual consists of 3 “core modules”: (1) psychoeducation and organization, (2) coping with distractibility, and (3) adaptive thinking. Psychoeducation involves teaching the individual about ADHD and facilitating an understanding of the role medications play in treatment. There is also education about the use of CBT in alleviating symptoms. As part of the first module, instruction is given on organization development, such as making a task list and prioritizing responsibilities. The second module teaches how to rate one’s current attention span and simplify tasks into steps to accommodate one’s current focus level. The last module assesses how a teen with ADHD perceives his or her impairments and teaches cognitive restructuring. For example, teens who develop negative self-perceptions (eg, “I mess up everything”) are predisposed to develop cognitive errors that can lead to self-defeating or avoidant behaviors. Cognitive restructuring is applied to assist the teen in identifying the cognitive distortions and reducing maladaptive thoughts. Research studies have demonstrated favorable outcomes with the use of CBT for adolescents with ADHD, especially as an adjunct to medical therapy.

Using an adaptation of the manualized CBT treatment protocol designed and tested by Antshel et al investigated the effect of CBT in 68 adolescents with ADHD and related psychiatric comorbidities in an open-label trial. ⁴⁹ Outcome variables were ADHD symptom rating scales, psychiatric comorbidities (mood, anxiety, conduct) rating scales, and functionality measures (ie, parent-teacher ratings and ecologically real-world measures such as cumulative GPA and school absences or tardiness). In this study, those who used CBT showed improvement in parent reports of medication adherence, self-reports of personal adjustment, parent-teacher ratings of inattentive symptoms, and school attendance. In terms of functioning, there was an effect of CBT on parent report of peer, family, and academic functioning, and teacher report of adolescent relationship with teacher, academic progress, and adolescent self-esteem. Like all interventions, CBT may not benefit all teens with ADHD. In this study, differential responses were seen according to the pattern of ADHD comorbidity. 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. It is also important to note that adolescent functioning did not normalize to that of non-ADHD diagnosed peers. Despite medications and CBT most remained symptomatic and functionally impaired in at least one domain (eg, peers, school, or home).

Additional insights into the use of CBT for adolescents with ADHD come from Belgium.^50,51 In a multicenter study, 159 adolescents 12 to 17 years old with ADHD were randomly assigned to 1 of 2 nonspecific CBT treatments: Plan My Life (PML) or Solution-Focused Treatment (SFT). Both are individual, manualized treatments that aim to improve planning skills in adolescents with ADHD. The intervention PML was designed to develop and improve planning skills by identifying organizational strategies, such as “to do” lists. Barriers such as maladaptive thinking were also identified and corrected. A total of 8 weekly adolescent sessions were held with discussion of the strategies practiced by the adolescent for each week. At each session areas of success or areas of modification were identified. Additionally, a daily planner and “to do” list was reviewed with the therapist. Two parental sessions were held that focused on creating and enforcing rules, encouraging positive communications, and reducing power struggles between parent and adolescent. PML was compared to SFT, which did not have any set skills or content. During SFT, the adolescent or parent was responsible for having problems to discuss and was guided by the therapist through fixed questioning toward a solution. Fixed questioning includes describing a selected topic, defining how it is a problem, and determining the adolescent’s desired outcome. In addition, it is focused on identifying solutions that have been previously used along with new alternatives, planning the implementation of an alternative, and providing justifications for newly chosen alternative solutions. Throughout the process the therapist provides positive feedback to the adolescent and identifies specific strengths in the adolescent’s problem-solving strategy. Each CBT approach was used in conjunction with motivational enhancement therapy to achieve better treatment adherence. Attrition was low in both treatments (5%). Pre-, post-, and 3-month follow-up data were collected on parent-rated ADHD, planning problems and executive functioning (primary outcomes), neuropsychological measures of planning, comorbid symptoms, general functioning, and teacher measures. All domains demonstrated considerable improvement pre- to posttest and remained stable or continued to improve from posttest to follow-up. The results were controlled for use of stimulant medications. The PML strategy was evaluated more positively by parents and therapists and revealed a marked reduction of parent-rated planning problems when compared to SFT. The preference of PML established a promising possibility of reducing the gap in the therapies currently available for the management of ADHD. When combined with motivational interviewing, both PML and SFT were proven to be feasible, acceptable, and beneficial for adolescents with ADHD. These initial improvements remained stable or continued to grow when patients were followed-up 1 year later. Unlike the 3-month follow-up, the 1-year follow-up revealed no preference differences between PML and SFT. The 1-year outcomes demonstrate that treatments focused on the development of predetermined planning skills is not necessary to relive symptoms and advance functioning in teens with ADHD.

Mongia and Hechtman also conducted a trial of the efficacy of CBT for adolescents with ADHD in Canada in 2012. ⁵² The 18 adolescents included in the trial received 14 CBT sessions in addition to treatment with medications. Similar to other CBT methods, this CBT focused on psychoeducation, organization, stress management, and focus training. The novel aspect of this CBT program was the involvement of coaching calls to the teens throughout the intervention period and during follow-up. The objective of the calls was to improve motivation, remind them to apply their skills, review progress, and continue goal planning. Participants reported positive experience of this CBT technique. Participants also reported feeling they learned a lot about ADHD and a greater understanding of the skills addressed through the study. According to the adolescent self-report assessment measures, there was an improvement in restlessness and impulsivity, increased awareness of ADHD and its management, and heightened confidence. These improvements were reported to be maintained at the 3-month follow-up. Blinded clinicians, parents, and teachers also completed assessments and reported similarly positive outcomes. Parents noticed improvements in adolescents’ knowledge of ADHD and acceptance of its treatment, motivational level, social behavior, self-esteem, distractibility, impulsivity, and stress management. The improvements were maintained at follow-up. Limitations of this study included a small sample size and lack of a control group. Strengths included that it is a hypothesis-generating trial that suggests promise with future research.

In 2015, Vidal et al reported the results of a multicenter, randomized, rater-blind controlled trial looking at outcomes of group CBT treatment (N = 89). The adolescents with ADHD in the trial also received medication treatment. ⁵³ Compared to the control group, adolescents on a waitlist for group CBT, those who were a part of group CBT had significant reduction in ADHD symptoms, and a substantial improvement in functional impairments based on scales filled by the adolescents, parents, and blinded evaluators. Similar to other studies, this study was limited by its small sample size. However, group therapy clearly demonstrated the benefit of CBT in improving ADHD symptoms and functional impairment when used in addition to pharmacotherapy.

Emerging data suggest that CBT can be beneficial to some teens with ADHD. Given the heterogeneity of the clinical presentations, it is unlikely that a single intervention will help all teens with ADHD. Moreover, sufficient high-quality, replicated, and controlled studies demonstrating CBT efficacy for teens with ADHD are not yet available.

Dialectical Behavioral Therapy (DBT)

Given the limitations of existing psychotherapeutic treatment approaches to teen ADHD and the adverse impact of ADHD on development, it is important to explore novel interventions. Existing therapies such as CBT focus on key clinical manifestations of ADHD in adolescence, including difficulty planning, completing tasks, problem solving, adaptive thinking, and disruptive behaviors. However, emotional dysregulation and peer difficulties such as conflict and rejection have been neglected despite their contributions to impairments and interference with development. More recently, there has been interest in identifying factors that promote positive interpersonal communications in teens with ADHD. ⁵⁴ For example, adolescents with ADHD are more likely to encounter peer rejection through negative interactions as well as chronic stigma from childhood due to long-term social malfunctioning.^29,55 The quality of peer relationships and identification of factors that affect it could be viewed as core treatment issues that could further therapeutic efforts given their prominence in this developmental stage. Particular areas that contribute to the interpersonal problems are reckless behaviors, managing negative emotions (such as irritability, anger), and difficulty with empathy and reciprocity.

Dialectical behavior therapy is an evidence-based treatment initially developed for borderline personality disorder (BPD) patients with impulsivity, chaotic interpersonal relationships, and emotional regulation difficulties. ⁵⁶ In recent years, there have been studies indicating the efficacy of DBT in adolescents who have difficulties with self-regulation across a number of psychiatric disorders. ⁵⁷ The core components of DBT entail mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. Mindfulness is a technique of focusing attention that is derived from Eastern meditation practices. It has been defined as “bringing one’s complete attention to experience the present moment.” Over the past few years mindfulness training has been adapted for use in clinical populations including adolescents who have difficulties regulating their emotions and behaviors. ⁵⁸ Distress tolerance skills require the application of mindfulness techniques and are designed to provide patients with the ability to accept oneself and the current situation one is in without judgment; this acceptance is not equivocal to approval of the reality. Emotion regulation skills also require utilization of mindfulness skills in noticing and describing one’s emotional state without judgment. Specific emotion regulation skills include identifying and labeling affect, identifying obstacles to changing emotions, reducing vulnerability to the “emotional mind,” increasing positive emotional events, increasing mindfulness to current emotion, taking opposite action, and applying distress tolerance skills . Interpersonal effectiveness skills aim to improve communication, listening, boundary enforcement, and empathy skills.

Contemporary views of DBT include the notion that this treatment is generally appropriate for individuals who have difficulties regulating emotions irrespective of the diagnosis. Indeed, several adaptations have been made to the original DBT protocol targeting interpersonal and emotional difficulties in both adults and adolescents. ⁵⁹ The efficacy of DBT has been supported by the literature, especially when used for complex disorders with deficits in the domain of emotion regulation. The available adolescent literature suggests that DBT may be equally effective in adolescents as it is in adults, particularly for those with oppositional features. ⁶⁰ While randomized control trials have not been conducted in the ADHD adolescent population, emerging literature in Germany and Sweden suggested positive effects of DBT in adults with ADHD.^54,61 The rationale for these studies is that adult ADHD shares some similar clinical features with borderline personality disorder such as impulsivity and emotional dysregulation, which can be effectively addressed by DBT. More recently in 2015, a pilot randomized controlled trial evaluated DBT group skills training adapted for college students with ADHD. ⁶² For 8 weeks, 33 undergraduates with ADHD were randomized to receive either DBT group skill training or skill handouts. ADHD symptoms, executive functioning, and quality of life were assessed at baseline, posttreatment, and at a 3-month follow-up. Although the study was small, it suggested that DBT group skill training combined with short individual coaching sessions may benefit college students with ADHD by reducing inattentive symptoms and improving executive functioning and quality of life.

Much like CBT, limitations of DBT training for the treatment of ADHD are the scarcity of large magnitude, randomized controlled trials. However, the available data suggest that DBT is a promising area of research for the interpersonal difficulties and oppositionality of adolescents with ADHD.

Conclusion

ADHD is common among adolescents and associated with a range of impairments in academic, social, and family functioning. Unlike earlier grade levels, high school presents expectations of detailed project completion as well as complex tasks that require planning and create major challenges for teens with ADHD. Furthermore, adolescent developmental milestones such as establishing a sense of autonomy and peer affiliation are often compromised in these teens. Despite the negative impact of ADHD in adolescent development, there is little research to guide the use of psychosocial strategies in this population. Clinical trials have documented that stimulants significantly reduce core ADHD symptoms in adolescents with ADHD. However, medication adherence drops during adolescence, and residual symptoms and persistent impairments are the rule even when the teens are compliant with medication. In the treatment of adolescents with ADHD, traditional psychosocial interventions (eg, problems, solving, behaviorally based methods) have shown limited efficacy; and multiple countries have initiated studies employing CBT as a strategy, hopefully giving these patients additional tools to utilize toward academic success. Nevertheless, available studies are small and assess more feasibility than efficacy. CBT focuses more on planning and organization and less on interpersonal and emotional symptoms. While there is a need for randomized control trials to develop an empiric basis for the role of CBT in adolescent ADHD, it is also important to study the possible use of DBT in this population targeting emotional dysregulation and interpersonal distress. How adolescents interact with others and handle situations that trigger strong emotions are just as critical to teen development as academic performance, planning, and organization. With the combination of CBT, DBT, and pharmacotherapy, all aspects of ADHD may be addressed and hopefully result in improved outcomes for these adolescents.

Author Contributions

VML and VC wrote the majority of the first draft. PF wrote the majority of the second draft including an addition on the use of dialectical behavioral therapy skills for this population.