The Effect of Different ADHD Comorbidities on CBT Treatment Results for Adolescents

Abstract

Attention deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder affecting over 5% of children and adolescents. In this review, the literature on the effects of conditions commonly comorbid with ADHD on cognitive behavioral therapy (CBT) treatment efficacy for adolescents with ADHD will be analyzed. ADHD is frequently comorbid with the mental health conditions of depression, anxiety, oppositional defiant disorder, and conduct disorder. Given high rates of comorbidity, it is necessary to understand how the outcome of CBT will vary based on each individual’s symptomatology. The results of this review suggest that it is critically important to consider an individual’s demographic background and their comorbidities when prescribing and developing a CBT program. As such, CBT program modules should focus specifically on targeting each individual’s unique set of symptoms to ensure the highest rate of treatment success.

Keywords: cognitive behavioral therapy, adolescent ADHD, comorbidities of ADHD, depression, anxiety, ODD, CD

Introduction

Attention deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder affecting more than 5% of children and adolescents worldwide¹. There are three subtypes of ADHD: ADHD mainly inattentive presentation (ADHD-I), ADHD mainly hyperactive-impulsive presentation (ADHD-H); and ADHD combined presentation (ADHD-C)². 

Diagnosing ADHD relies on observing behavioral symptoms using nosological systems like the Diagnostic and Statistical Manual of Mental Disorders, 5^th edition (DSM-5). According to the DSM-5, ADHD should only be diagnosed when the behavioral symptoms cannot be better explained by some other neurodevelopmental disorder or mental health condition (anxiety or mood disorder, personality disorder, etc.). The DSM-5 lists 9 symptoms of inattention—including having trouble holding attention to tasks or zoning out when being spoken to—and 9 symptoms of hyperactivity/impulsivity—including fidgeting or interrupting/intruding upon others. To be diagnosed as predominantly inattentive or predominantly hyperactive/impulsive, an individual would have to showcase at least 6 symptoms of that subcategory. To be diagnosed with ADHD-C, an individual would have to fulfill both requirements. For children, ADHD symptoms must be present before the age of 12 for at least 6 months and must impair the individual either socially or academically in order to be diagnosed. Diagnostic criteria for adolescents over the age of 17 and adults are slightly different, such that a diagnosis requires at least 5 symptoms to be present³.

While diagnostic criteria for ADHD is well-described,  there is a drop in knowledge regarding adolescent ADHD compared to information on adult or child ADHD. Present literature is also sometimes inconsistent because of the differences in patients’ age, the sample size, and the diagnostics used to assess ADHD and its comorbidities⁴. This is unfortunate as ADHD, though often diagnosed in childhood between the ages of 5 and 12 years, will frequently continue into adolescence and adulthood^5, 6.  During adolescence, the brain is still developing, experiencing hormonal and neurobiological changes that can cause adolescent behaviors and emotions to be erratic or impulsive⁵. The developing and changing brain means that many treatments effective for children or adults may be ineffective or not as effective for adolescents⁵. 

Of the roughly 9% of adolescents in the US with diagnosed ADHD, 40%-80% of children and adolescents with ADHD, also have another comorbid condition. These rates are highest among individuals who were clinically referred⁷.

Common comorbidities include: depression and anxiety disorders (0-45%), oppositional defiant disorder (ODD) and conduct disorder (CD; 27%-55%), and other learning disorders such as reading disorders (15%-50%)⁴. These comorbid conditions may affect the treatment process and negatively influence its effectiveness since the comorbidity may complicate both the clinical presentation and the choice of treatment strategy⁷. As such, it is important to clearly understand present comorbidities and their effect on certain types of treatment.

At present, pharmacological treatment (i.e., stimulants) is the most widely researched and used form of treatment for ADHD. However, 20%-30% of children and adolescents have shown no positive effects from taking these medications or suffer from adverse side effects to stimulants⁶. In addition, in order to prevent the possibility that adolescents may abuse and misuse stimulants, the number of adolescents being prescribed stimulants is less than in children^{5 ,6}. This leads to the need for alternative methods of treatment, facilitating the rise of psychosocial interventions. One of the most common and widely researched psychosocial interventions is cognitive behavioral therapy (CBT) ⁸. 

CBT is a psychotherapy administered by a mental health professional such as a psychiatrist, therapist, or other form of mental health counselor⁸. Intervention typically occurs within an 8–12-week time frame, with sessions on a regular basis. This intervention targets specific behaviors or symptoms of ADHD and its comorbidities through a module-based treatment plan. This may entail sessions on combating distractibility or procrastination, learning about organization and planning, or understanding how to think adaptively in order to prevent the negative thoughts associated with anxiety/depression or the overly positive (hyperactive) thoughts associated with ADHD⁹. In addition, CBT is generally more effective in adolescents than children, implying that cognitive development may also affect the results of CBT treatment⁶. 

We chose to focus on CBT as a potential alternate form of treatment instead of other forms of talk therapy or pharmaceuticals because CBT is a generally effective treatment for many mental health conditions, which enables it to broadly help many adolescents with varied conditions¹⁰. As such, CBT is the best treatment to focus on in a paper centering on adolescents with comorbid conditions. 

There is not much information available on CBT treatment for ADHD comorbidities, which leads to a knowledge gap this literature review hopes to help reduce. To expand upon previous findings, this literature review will consolidate and add to information on treatment of adolescents with ADHD and a comorbidity in order to help clinicians and families understand the positive effects CBT treatment can have on adolescents with these combined conditions. To my knowledge, no paper has specifically analyzed and compared the different effects comorbidities have on CBT, so that is what this paper aims to do. 

Based on previous research looking at how comorbidities affect treatment outcomes in individuals with anxiety and bipolar disorders^{11 ,12}, it is hypothesized that the effect of CBT will differ from person to person based on their comorbidity and its symptoms and conditions.

Results

ADHD + ANX

Anxiety is one of the most common comorbidities among individuals with ADHD, affecting about 12% of people living with ADHD¹. In comparison to other comorbidities with ADHD, more research has been conducted on CBT treatment for comorbid anxiety. Therefore, substantial information on how this comorbidity affects outcomes of CBT treatment exists. 

For example, the CBT program called Accessing Campus Connections and Empowering Student Success (ACCESS) targeted both ADHD and other comorbid disorders including anxiety and depression. The program included 88 college students aged 18 to 25 years in successive cohorts over a period of four years, with the CBT program being administered across one semester of active treatment and one semester of maintenance. ACCESS included several sessions targeting behavioral strategies like using a planner or how to study effectively, and other sessions for cognitive therapy, teaching the participants how to recognize and control maladaptive thinking and negative emotions. After a semester of active treatment, ADHD symptoms of inattention and hyperactivity/impulsivity improved significantly, with large effect sizes for inattention and small to medium effect sizes for hyperactivity/impulsivity¹³. The reason for the difference in effectiveness in CBT treatment could be that the behavioral strategies taught were better suited for combatting inattention than for hyperactivity. The vast majority of the strategies included in CBT sessions in this intervention were focused on organization and how to set goals, which are topics designed to help increase attention span and planning ability, thus specifically targeting symptoms of inattention. Perhaps additional sessions on relaxation techniques would have been beneficial in more significantly reducing symptoms of hyperactivity/impulsivity. This variation in effectiveness of CBT for inattention and hyperactivity can likely be attributed to how inattention is more cognitive while hyperactivity is more behavioral. Since CBT targets cognitive processes, it is likely that inattention is more directly addressed through CBT programs. In addition, ACCESS also yielded significant success in reducing symptoms of anxiety, representing a medium effect size¹³. This may also be because the behavioral strategies, as well as the cognitive therapy, targeted changing recognizing maladaptive thoughts to adaptive ones, helpful for combating the negative thoughts and behaviors associated with anxiety. It is important to note, however, that this paper’s participants were limited to only college students, whose brains, at the later end of maturing, are vastly different from early adolescents. Therefore more research on this topic in middle or high schools would be beneficial for the extension of these results to all adolescents. 

Furthermore, when targeting specific moments of the day in which symptoms of anxiety may peak, CBT treatment can significantly reduce the effect the increased symptoms may have on adolescents with ADHD and comorbid anxiety. This specific targeting, rather than a more general approach, may have contributed to the CBT program’s overall success. This is because this format helps provide participants with specific moments to practice the skills taught during their sessions, such as learning how to identify different emotions and using relaxation techniques to combat anxiety¹⁴. Identifying times during the time when anxiety typically peaks and specifically targeting those moments can help maximize the effectiveness of the strategies taught during CBT interventions. In a recent study Houghton and colleagues did on CBT treatment targeting specific times during the day, the researchers split 9 participants into two groups and targeted 4 anxiety-arousing times: a period of time prior to leaving home for school, a period of time prior to recess, a period of time prior to leaving school for home, and a period of time prior to starting homework. Group 1 experienced statistically significant reductions in mean levels of anxiety for 3 of the 4 identified times following CBT treatment, while there was only one time for which Group 2 experienced statistically significant reductions. However, as this study was conducted with only 9 participants, the variability in results may be due to individual differences in participants or other pharmacological variables¹⁴. Ultimately, though, as seen in multiple studies, the positive effect of CBT treatment was still present post-treatment at the follow-up assessment, although to a lesser degree^{13 ,14}. It is important to acknowledge that this study was conducted with a small sample, leaving the generalizability of the study in question. However, this study does serve as a foundation for further studies, with larger sample sizes, to research whether this type of CBT targeting specific times of the day is a feasible way of conducting CBT treatment.

While CBT is an effective alternative treatment for ADHD + ANX, creating long lasting reductions in symptoms post-treatment, it is also important to consider the different anxiety disorders and how the difference diagnoses may influence CBT outcomes. In a study analyzing the different anxiety disorders (generalized anxiety disorder, social anxiety disorder, separation anxiety disorder, obsessive-compulsive disorder (OCD), and posttraumatic stress disorder (PTSD) present in individuals with ADHD, it was noted that the CBT treatment program differed slightly between disorders. For disorders such as general anxiety disorder, social anxiety disorder, and separation anxiety disorder, more emphasis needs to be placed on the cognitive restructuring process. However, for disorders such as OCD and PTSD, a more exposure-based treatment can be more effective². Houghton et al. noted that some of the participants in their study had social anxiety or separation anxiety, and, in their final results, found that the symptoms of social anxiety improved more than the symptoms of separation anxiety, though they both improved enough to be statistically significant¹⁴. As such, the results show that CBT treatment is an effective way to combat ADHD and anxiety in individuals.

ADHD + DEP

CBT was originally created for the treatment of depression, and over time, its uses have expanded to treating other mental health challenges, including anxiety and sleep disorders¹⁰. Yet, different CBT treatments that focus on different symptoms may result in different effects on symptoms of ADHD and depression. 

In the study on ACCESS that Anastopoulos and colleagues conducted, comorbid symptoms of depression, if present, were also tracked in the college students receiving CBT treatment. While the effect size was not as large for symptoms of depression as compared to symptoms of anxiety, ACCESS still succeeded in helping to reduce depression symptoms significantly, representing a small effect size¹³. This may be because, though anxiety and depression are often present together¹⁵, the behavioral strategies taught during this CBT intervention may target anxiety specifically, rather than both anxiety and depression. Implementing sessions on behavioral activation or increasing motivation may be more beneficial to targeting and treating the symptoms of depression while also having a positive effect on ADHD symptoms as well. The study did not specifically state individual differences in symptom severity for either depression or ADHD, but the results showed the average decrease in symptoms, which was statistically significant, showcasing the general effectiveness of this CBT program. 

As adolescents spend most of their time in school, it is also beneficial to examine the effect of CBT interventions that take place at school on individuals with ADHD and comorbid depression. A recent case study evaluated an adolescent boy with comorbid ADHD and depression. In this study a CBT intervention was developed to target the boy’s unique symptoms. This CBT program was conducted through a three-tier intervention system at a school. The program involved sessions with a specialist covering social skills training and behavioral and emotional self-regulation, including teaching relaxation techniques and anger management strategies¹⁶. Through this intervention, symptoms of depression lowered from clinically significant to average, while the symptoms of ADHD were mixed. Inattention symptoms remained in the at-risk range post-intervention, perhaps because CBT sessions targeted emotional regulation over organizational strategies. In contrast, symptoms of hyperactivity fell to barely at the clinical range, likely because controlling erratic behaviors was a goal of this CBT program¹⁶. This case study centered around an individual with ADHD, oppositional behaviors, and explosive anger. Therefore, the CBT program Parker and colleagues created was likely designed to help combat these symptoms specifically. In contrast, this CBT program may not be as effective on another individual with different symptoms or comorbidities. As such, it is important for clinicians to understand each individual’s symptoms and prescribe treatment as necessary. 

Given that pharmaceutical medications are often the first line of treatment for individuals with depression and ADHD, it is also important to see how CBT treatment compares to pharmacological treatment. The Treatment for Adolescents with Depression Study (TADS) compares the effectiveness of CBT treatment and fluoxetine in adolescents with ADHD and depression. Kratochvil and colleagues conducted a study using TADS. They randomly split participants into four groups: CBT treatment, fluoxetine (FLX), CBT and fluoxetine (COMB), and placebo (PBO). After 12-weeks of receiving treatment, those who received PBO had their treatment discontinued, while the others continued treatment for another 24 weeks. The results showed that CBT, fluoxetine, and a method that combined both treatments yielded similar results at both the end of the 12-week active treatment period and the 36-week treatment period¹⁷. This suggests that there is no significant difference between CBT treatment and this antidepressant, signifying that CBT may be a viable alternative to traditional pharmacological treatment. There is potential for uncontrolled variables in this study, such as the individual differences in treatment response, as well as differences in initial symptom severity, which should be acknowledged. However, as a whole, the conclusion that CBT treatment effectiveness is similar to pharmacological treatment effectiveness is in line with previous research¹⁸,¹⁹. With this in mind, it is imperative to emphasize the necessity for clinicians to create individual-based treatment plans. 

ADHD + OTHERS

There are many other conditions which are commonly comorbid with ADHD, including ODD and CD. However, the available literature on CBT treatment for these comorbidities is limited in comparison to anxiety and depression.          

Overall, symptoms of ADHD, CD, and ODD, appearing individually or comorbidly, decrease significantly as a result of CBT treatment²⁰,²¹. Most meta-analyses on the effect of behavioral interventions show only small to medium effect sizes, but a few papers that include both randomized controlled trials and open trials in their analysis found that the results show a large effect size post-treatment²⁰. This difference could be because some meta-analyses were smaller than others, therefore having a smaller sample size and resulting in skewed data towards a specific population. 

In some cases, the presence of CD seemed to moderate the effect of behavioral intervention. For symptoms of ADHD, hyperactivity/impulsivity, and ODD, more severe CD symptoms led to larger treatment effects. This may be because those with more severe CD symptoms experience a faster deterioration in symptoms of ADHD and other behavioral problems over time. This in turn highlights the importance of individualized treatment²¹.

Beyond the CBT program itself, demographic variables also may affect the outcome of CBT. For instance, symptoms of ODD in youth from single-parent families with ADHD and comorbid ODD did not improve significantly after treatment²¹. An adolescent’s ODD symptoms only improved significantly after their parent received specific behavioral training targeted towards single-parents, an effect not observed when the parent received standardized parent behavioral training²¹. This suggests that individuals of this subgroup may require treatments tailored to their specific circumstances and needs, signifying that treatment modules need to be adjusted to help the individual better combat their situation. It could also suggest that CBT for the individual may not be a particularly effective method of treatment for those in this specific subgroup. 

It is also important to consider additional factors which might impact CBT intervention success, such as the level of parent or teacher involvement. For example, as adolescence is a time when many youth begin to develop independence, parental involvement/interference may prevent individuals from learning how to rely on their own use of the cognitive skills taught through CBT²². However, including parents in interventions may not only assist with improving the relationship between the adolescent and parent as they walk through the treatment process together, but can also reduce “nagging” from the parents when they think their adolescent is being difficult²². Thus, it is important to identify the appropriate level of parental participation in the CBT program for each individual. The clinician should therefore keep in mind that this will depend on the individual’s past experiences and background. 

Discussion

This literature review sought to understand how different conditions frequently comorbid with ADHD impact the efficacy and structure of CBT treatment on adolescents with ADHD. The results suggest that while overall CBT treatment is an effective alternative to pharmaceutical medications¹⁷, the treatment program itself has a large impact on the effectiveness of symptom reduction. Regardless, the positive effects of CBT intervention are usually still present at follow-up, though to a lesser degree^{13 ,14}. Therefore, previous work supports the use of CBT treatment for individuals with ADHD, regardless of comorbidity status.

The ACCESS CBT program demonstrated that covering techniques that increase attention span and planning ability are effective in reducing symptoms of inattention and anxiety significantly. Sessions on transforming maladaptive thoughts into adaptive ones are also beneficial in recognizing the negative thoughts and behaviors associated with anxiety and reducing their severity. While ACCESS succeeded in reducing depression symptoms significantly, it was to a lesser degree than for anxiety symptoms¹³. This may be because the behavioral strategies and cognitive therapy were better suited for combatting symptoms of anxiety rather than depression. Including sessions on behavioral activation or increasing motivation may be more beneficial to targeting the symptoms of depression while also making a positive impact on symptoms of ADHD as well. In addition, CBT treatment for adolescents with ADHD and comorbid anxiety that targets specific moments of the day where individuals feel more anxiety is also effective in reducing symptom severity. This may be because this approach gives participants specific times during the day to apply what has been taught to them¹⁴. There are also many different anxiety disorders, and their presence may also affect CBT outcomes. The CBT program content will differ slightly between disorders. For general anxiety disorder, social anxiety disorder, and separation anxiety disorder, more emphasis should be placed on cognitive restructuring sessions, while for OCD and PTSD, more exposure-based therapy may be more effective². Therefore, CBT has been shown to be an effective form of treatment for individuals with ADHD and comorbid anxiety, and the CBT program should be designed with the individual’s specific symptoms and needs in mind.

CBT interventions that take place at school, a place adolescents spend most of their day in, also prove effective. When a school establishes an intervention system so that students with ADHD can meet with a specialist and receive support, students are more inclined to rely on school resources and learn more effectively¹³. A specific CBT treatment targeting an adolescent with ADHD, oppositional behaviors, and explosive anger reduced symptoms of depression and hyperactivity significantly, while making a minimal impact on symptoms of inattention. This program targeted emotional and behavioral regulation over organization strategies, resulting in the above reductions in some symptoms’ severity. Another CBT program targeted towards an individual with different symptoms would focus on other topics that better address their symptoms. 

In addition, the presence of CD in individuals with ADHD and other comorbidities seems to moderate the effect of CBT treatment. This moderation seems to be linked to the fact that individuals with more baseline symptoms/diagnosis of CD have more symptoms of ADHD. More severe CD symptoms led to greater treatment effects for symptoms of ADHD, hyperactivity/impulsivity, and ODD, likely because individuals with more severe CD symptoms experience a faster deterioration in other behavioral problems²¹. Demographic variables also play a key part in determining what type of CBT program best suits each individual. For example, youth with ADHD and comorbid ODD from single-parent families did not improve significantly after receiving CBT treatment, though some behavioral interventions specifically targeting single parents resulted in significant reductions in the adolescent’s symptoms²¹. Another factor that impacts CBT intervention success includes the level of parent or teacher involvement. Including parents can not only help improve the relationship between adolescent and adult, but also reduce parent “nagging” towards the adolescent. However, reduced parental involvement may prevent individuals from learning how to rely on their own use of the cognitive skills taught through CBT²². Even the most minute variations towards a CBT program can affect the treatment outcome depending on an individual’s unique diagnosis. Therefore, clinicians should carefully consider all of these factors when designing and prescribing CBT as treatment for these adolescents with ADHD. 

Limitations

The small number of papers that could be found on this topic proved to be a limitation in this study. We could not find many papers that contained information on CBT treatment for ADHD and a single comorbidity that we wanted to examine, and we could not find any specifically for ADHD and ODD or ADHD and CD. In addition, this was a recent literature review and not a comprehensive systematic review, so some pieces of literature were not included in the data. The majority of papers included in this review had small sample sizes, thereby leaving some of the results in question. In addition, several papers tracked results using individual self-report, which leaves room for personal bias. Thus, given the various types of methodological approaches used across studies, it’s important to do further research on this topic to minimize bias in the results. 

In addition, because ADHD presents on a spectrum, with each individual having varying degrees of ADHD symptom severity, the results from person-to-person may differ. Similar to conditions like anxiety or depression, this variation in severity may affect the results and effect of CBT, further emphasizing the need for an individual-based treatment approach by clinicians.     Thus, for CBT treatment to be most effective in a clinical setting, it’s important for the clinician to understand the severity of ADHD and comorbidities in order to most effectively tailor a treatment plan for the individual.

Future Directions

Future research should focus on close-up analysis of frequent comorbidities, especially ODD and CD, as these two comorbidities are less frequently studied than anxiety or depression. This will help give clinicians a better idea regarding which modules of CBT are particularly effective for individuals with that specific comorbidity. In addition, many of the papers reviewed focused on late adolescence (aged 15-24 years), creating a need for more research to be conducted with a focus on how ADHD comorbidities in younger adolescents affects CBT outcomes. Also, in order to test the effectiveness of the many CBT programs, more randomized controlled trials should be conducted, with larger sample sizes, in order to test the results of prior randomized controlled trials and open clinical trials. Furthermore, despite the increase in research conducted on CBT for adolescents, there is still a general lack of information on this topic. More research is necessary to explore the effect of different variables on the result, an example being if an individual is on medication prior to, and during, CBT will affect the result.

The results of this review strongly suggest that CBT is an effective treatment for ADHD and comorbidities, with some variability regarding the severity of the symptoms; however, because of the general lack of large sample sizes in the studies reviewed, future research should focus on a more in-depth exploration of these psychopathologies as well as the effect CBT has on their treatment. 

Conclusion 

Here we reviewed papers assessing the effect of CBT treatment on adolescents aged 10 to 24 who have ADHD and comorbid anxiety, depression, oppositional defiant disorder (ODD), or conduct disorder (CD). The primary results suggest that an individual’s demographic background and comorbidities should be taken into consideration when prescribing a CBT program as treatment for ADHD. The CBT program modules should focus on targeting each comorbidities’ symptoms collectively rather than independently, and because this may differ person to person, an individualized treatment approach is recommended to clinicians. Clinicians should consider the information outlined in this review when examining adolescents with ADHD and deciding which treatment option they should prescribe and developing CBT modules.

Methods

To identify research papers assessing the effect of CBT intervention on ADHD with comorbidities, a literature search was conducted in Google Scholar. The search keywords “cognitive behavioral therapy for adolescent ADHD and comorbidities”, and more specific search terms in which the term “comorbidities” was replaced with “depression”, “anxiety”, or “externalizing disorders” were used, with search results limited to papers published prior to August 2023 and after 2003. Because this is not a systematic review of literature, to ensure the reliability of the studies included, as well as limit potential biases as much as possible, only the studies that populated on the first five Google Scholar pages were reviewed. There was no study that we identified that met criteria that wasn’t included. Given the focus on adolescent ADHD, studies were only included if they had participants ages 10 to 25 years. To make analyzing the information easier, the identified papers were then sorted into the following categories based on the target of CBT treatment: ADHD, ADHD with comorbid anxiety disorder (ADHD + ANX), ADHD with comorbid depressive disorder (ADHD + DEP), and ADHD with other comorbidities (ADHD + OTHER). Papers assessing multiple comorbidities were included in multiple categories. Exclusion criteria was: if the paper included participants under the age of 10 and over the age of 25, only mentioned ADHD without comorbidities, or only mentioned the conditions of anxiety, depression, ODD, and CD, without reference to its comorbidity with ADHD in participants. The 13 papers selected were the first few papers that populated the Google Scholar database that fit these criteria. 

Acknowledgements

I’d like to thank my mentor, Kathryn Wall, for all her help and advice during this process.

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