Reviews

2

Applying CBT to Children and Adolescents with ADHD

Applying CBT to Children and Adolescents with ADHD

The purpose of this paper is to discuss the application of cognitive behavioral therapy (CBT) to the treatment of children and adolescents with attention-deficit/hyperactivity disorder (ADHD). This paper will thoroughly explore the Diagnostic and Statistical Manual of Mental Disorders, fifth addition, text-revision (DSM-5-TR), diagnostic features of ADHD and the prevalence of ADHD in children and adolescents, including strengths and opportunities associated with the disorder; evidence-based research regarding the use of CBT in treating ADHD; and the application of CBT to treatment of a child with ADHD through the helping process. The helping process consists of six stages: engagement with the client, assessment of the presenting problems, planning for treatment, the intervention process, evaluation of the client’s progress, and the termination of services (Mitchell, 2023). The presenting problem of ADHD in children and adolescents will now be discussed in the following section.

Presenting Problem

According to the DSM-5-TR, ADHD is a neurodevelopmental disorder that is defined by impairing levels of inattention, disorganization, and/or hyperactivity/impulsivity (American Psychiatric Association, 2013). General symptoms of inattention and disorganization are the inability to stay on task, presenting the inability to listen, and losing materials necessary for tasks, at levels that are inconsistent with age or developmental level (American Psychiatric Association, 2013). General symptoms of hyperactivity and impulsivity are overactivity, fidgeting, inability to stay seated, intruding into other people’s activities, and an inability to wait, in which are considered excessive for age or developmental level (American Psychiatric Association, 2013). Specifically in childhood, ADHD can be overlapping with other “externalizing disorders”, such as oppositional defiant disorder (ODD) and conduct disorder (CD) (American Psychiatric Association, 2013). ADHD in childhood typically becomes persistent into adulthood, and can result in impairments in social, academic, and occupational functioning depending on the severity of symptoms (American Psychiatric Association, 2013).

According to the DSM-5-TR criteria on ADHD, the individual must show a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (A1) inattention and/ or (A2) hyperactivity and impulsivity (American Psychiatric Association, 2013). Six or more of the following symptoms must be persistent for at least six months that is inconsistent with developmental level and negatively impacts areas of functioning to meet criteria of (A1) inattention: often fails to give close attention and makes careless mistakes; difficulty paying attention; does not seem to listen when spoken to directly; does not follow through on instructions and fails to finish tasks; disorganization; disengagement due to lack of mental effort; loses things; easily distracted by external stimuli; and forgetful in daily activities (American Psychiatric Association, 2013). Six or more of the following symptoms must be persistent for at least six months that is inconsistent with developmental level and negatively impacts areas of functioning to meet criteria of (A2) hyperactivity and impulsivity: fidgetiness with hands and feet; unable to remain seated when expected to do so; often runs and climbs in inappropriate situations; unable to engage in quiet leisure activities; often “on the go”; talks excessively; blurts out an answer before the question is completed; difficulty waiting a turn; and interrupts or intrudes on others (American Psychiatric Association, 2013).

Other criteria that are included in the diagnosis of ADHD include (B) several inattentive or hyperactive/impulsive symptoms were present prior to age 12; (C) present in two or more settings; (D) interfere with, or reduce the quality of functioning in social, academic, and occupational areas; and (E) other mental disorders are ruled out (American Psychiatric Association, 2013). Specifiers include whether the individual is experiencing only symptoms of inattention, only symptoms of hyperactivity and impulsivity, or both; whether in partial remission; and the severity of the symptoms being mild, moderate, or severe (American Psychiatric Association, 2013).

According to the Centers for Disease Control and Prevention (CDC), the prevalence of ADHD in children and adolescents is estimated to be seven million (11.4%) of U.S. children aged three to seventeen (Centers for Disease Control and Prevention [CDC], n.d.). Out of the estimation, six out of ten of those children have moderate to severe ADHD (CDC, n.d.). An estimate of six percent to sixteen percent of U.S. children are clinically diagnosed with ADHD, and fifty-eight percent to ninety-two percent of those children diagnosed are receiving ADHD treatment (CDC, n.d.). According to the CDC, a higher percentage of those children are being treated with medication versus behavioral therapy (CDC, n.d.).

Some strengths for children that may come with a diagnosis of ADHD are high energy levels, the ability to hyper-focus, creativity, agreeableness, willingness to assist others, and resilience (Miller et al., 2024). These strengths can present children with opportunities to use their strengths in areas where they are needed to succeed. For example, a child may need high energy levels to maintain a level of physical activity, such as playing sports or just simply being active outside. A child may use their creativity and hyper-focus in the classroom to complete projects or be involved in problem-solving or hobbies that require creativity, such as painting and drawing. Resiliency is a huge strength for a child with ADHD to be self-aware of to improve self-confidence and self-esteem, because they experience a lot of adversity while managing symptoms that interfere with functioning. These characteristics can give individuals the opportunities to master the ability to be a leader. Overall, it is important to ensure strengths that come with an ADHD diagnosis are being utilized in the intervention process.

Modality of CBT

Cognitive behavioral therapy is a psychotherapeutic intervention that was developed by Dr. Aaron T. Beck in the 1960s (Fenn & Byrne, 2013). Essentially, the cognitive model hypothesizes that emotions and behaviors are influenced by perceptions of events and experiences (Fenn & Byrne, 2013). Beck conceptualized the cognitive model by outlining three levels of cognition: core beliefs, dysfunctional assumptions, and negative automatic thoughts (Fenn & Byrne, 2013). Core beliefs, or schemas, are deeply held beliefs of the self, world, and others, which are instilled and influenced in early childhood (Fenn & Byrne, 2013). Dysfunctional assumptions are unrealistic, rigid patterns of thoughts that people use to guide their lives (Fenn & Byrne, 2013). Negative automatic thoughts are involuntary, unhealthy thoughts that alter one’s perceptions (Fenn & Byrne, 2013). The cognitive model is used as a framework to understand a person’s mental distress and presenting problems (Fenn & Byrne, 2013).

The key elements of CBT are that it emphasizes collaborative empiricism and is problem-oriented, while focusing on the present (Fenn & Byrne, 2013). Collaborative empiricism aims for the therapist to have a collaborative therapeutic relationship with the client to work together to explore maladaptive cognitions and behavior and identify ways of improving those areas (Fenn & Byrne, 2013). The therapist helps the client focus on the ‘here and now’ of problems and difficulties to improve the current state of mind and behavior contributing to problems (Fenn & Byrne, 2013). Cognitive and behavioral techniques are implemented in the intervention to achieve the established goals (Fenn & Byrne, 2013). Essentially, CBT is a structured, time-limited treatment that consists of five to twenty sessions, and is used to treat mental disorders, such as ADHD, depression, generalized anxiety disorder, OCD, etc. (Fenn & Byrne, 2013).

Evidence Based Approach with Issue

Helping Process

Engagement

Assess

Treatment Plan/Goal Setting

Intervene

Evaluate Process

Terminate

Conclusion

References

Centers for Disease Control and Prevention. (n.d.). Data and statistics on ADHD. https://www.cdc.gov/adhd/data/index.html#:~:text=Millions%20of%20U.S.%20children%20have,parents%20using%20data%20from%202022.

Fenn, K., & Byrne, M. (2013). The key principles of cognitive behavioural therapy. InnovAiT: Education and Inspiration for General Practice, 6(9), 579–585. https://doi.org/10.1177/1755738012471029

Miller, C. L., Jelinkova, K., Charabin, E. C., & Climie, E. A. (2024). Parent and Child-Reported Strengths of Children With ADHD. Canadian Journal of School Psychology. https://doi-org.ezproxy.uta.edu/10.1177/08295735231225261

Mitchell, M. (2023, May 1). The social work “helping process.” Agents of Change Social Work Test Prep. https://agentsofchangeprep.com/blog/the-social-work-helping-process/

Neurodevelopmental Disorders. (2024). Diagnostic and Statistical Manual of Mental Disorders. https://doi.org/10.1176/appi.books.9780890425787.x01_Neurodevelopmental_Disorders

,

Writing

Peer Review Form

Student’s name of paper being reviewed:

Reviewer’s name:

Instructions

Select the button for the rating you would choose and provide written feedback for each criteria listed. Describe overall impressions at the end of the form.

Introduction

Meets Expectations (1 point)	Approaching Expectations (0.6 point)	Below Expectations (0 points)
Provided a thesis statement about the purpose and scope of the paper.	Section was present but lacked sufficient depth or clarity.	This section was not included or had significant issues with clarity, accuracy or relevance.

Reviewer’s Comments

Select a “mental disorder” classified in the DSM-5-TR or other specific issue.

Meets Expectations (1 point)	Below Expectations (0 points)
Student clearly identified one specific diagnosis classified by the DSM-5-TR. If not a DSM diagnosis, a coherent presenting problem was identified.	Presenting problem was not clearly identified, or was too broad or vague

Reviewer’s Comments

Overview, Prevalence and Diagnostic Features

Describe the prevalence and diagnostic features. Explain this disorder as if the reader is not familiar with it.

Meets Expectations (2 points)	Approaching Expectations (1.2 point)	Below Expectations (0 points)
Provided a clear, concise and comprehensive introduction to this disorder, including a brief summary of symptoms and how common it is in the US.	Section was present but lacked sufficient depth or clarity.	This section was not included or had significant issues with clarity, accuracy or relevance.

Reviewer’s Comments

Presenting Problem Identified

Note strengths or opportunities associated with this condition.

Meets Expectations (1 point)	Approaching Expectations (0.6 point)	Below Expectations (0 points)
Used critical thinking to identify potential strengths, opportunities and resources for clients with this diagnosis.	Section was present but lacked sufficient depth or clarity.	This section was not included or had significant issues with clarity, accuracy or relevance.

Reviewer’s Comments

Modality Overview

Summarize the history and key elements of the approach you selected. Provide a basic overview of this treatment modality.

Meets Expectations (2 points)	Approaching Expectations (1.2 points)	Below Expectations (0 points)
Provided an accurate overview of history and key elements the selected approach (CBT, ACT, REBT, DBT, mindfulness-based CBT, or trauma-informed CBT).	Section was present but lacked sufficient depth or clarity.	This section was not included or had significant issues with clarity, accuracy or relevance.

Reviewer’s Comments

Strengths Perspective

Is the intervention you selected an evidence-based and effective treatment for the problem you identified?

Meets Expectations (1 point)	Below Expectations (0 points)
Summarized empirical literature to support that the selected approach is an effective treatment for the disorder you identified.	This section was not included or had significant issues with clarity, accuracy or relevance.

Reviewer’s Comments

Engagement

In addition to describing general engagement strategies, please specify how your engagement approach will be trauma-informed.

Meets Expectations (1 point)	Approaching Expectations (0.6 point)	Below Expectations (0 points)
Listed specific steps the therapist would take, things the therapist would say, questions to ask, or exercises to employ at this stage of the helping process.	Section was present but lacked sufficient depth or clarity, or did not include information about setting a trauma-informed environment.	This section was not included or had significant issues with clarity, accuracy or relevance.

Reviewer’s Comments

Evidence-Based

Please note what standardized assessment/screening tool you would use to diagnose the condition. Be sure to also consider the biopsychosocial-spiritual perspective.

Meets Expectations (1 point)	Approaching Expectations (0.6 point)	Below Expectations (0 points)
Included a specific instrument or assessment tool to diagnose your selected mental health condition. Listed specific steps the therapist would take, things the therapist would say, or questions to ask at this stage of the helping process. Included person-in- environment considerations.	Section was present but lacked sufficient depth or clarity.	This section was not included or had significant issues with clarity, accuracy or relevance.

Reviewer’s Comments

Assessment

Meets Expectations (1 point)	Approaching Expectations (0.6 point)	Below Expectations (0 points)
Listed specific steps the	Section was present but	This section was not
therapist would take, things	lacked sufficient depth or	included or had
the therapist would say,	clarity.	significant issues with
questions to ask, or exercises		clarity, accuracy or
to employ at this stage of the		relevance.
helping process.

Reviewer’s Comments

Intervention

Meets Expectations (1 point)	Approaching Expectations (0.6 point)	Below Expectations (0 points)
Provided a detailed	Section was present but	This section was not
explanation of how the	lacked sufficient depth or	included or had
therapist would conduct at	clarity.	significant issues with
least one specific intervention,		clarity, accuracy or
activity or exercise.		relevance.

Reviewer’s Comments

Goal Setting/ Treatment Planning

Meets Expectations (1 point)	Approaching Expectations (0.6 point)	Below Expectations (0 points)
Listed specific steps the therapist would take, things the therapist would say, questions to ask, or exercises to employ at this stage of the helping process.	Section was present but lacked sufficient depth or clarity.	This section was not included or had significant issues with clarity, accuracy or relevance.

Reviewer’s Comments

Termination

Meets Expectations (1 point)	Approaching Expectations (0.6 point)	Below Expectations (0 points)
Listed specific steps the therapist would take, things the therapist would say, questions to ask, or exercises to employ at this stage of the helping process.	Section was present but lacked sufficient depth or clarity.	This section was not included or had significant issues with clarity, accuracy or relevance.

Reviewer’s Comments

Evaluation

Discuss specific modifications or considerations you would apply to promote inclusivity and equity with diverse clients. To make this section more detail and specific, please select one specific demographic to consider (gender, sexuality, race, religion, age, disability, etc.)

Meets Expectations (1 point)	Approaching Expectations (0.6 point)	Below Expectations (0 points)
Provided a thoughtful discussion of how you would plan, adapt, or modify your approach to show cultural competence, respect for diversity, etc.	Section was present but lacked sufficient depth or clarity.	This section was not included or had significant issues with clarity, accuracy or relevance.

Reviewer’s Comments

Diversity and Inclusion

Meets Expectations (1 point)	Approaching Expectations (0.6 point)	Below Expectations (0 points)
Dedicated conclusion section summarized key points from the paper.	Section was present but lacked sufficient depth or clarity.	This section was not included or had significant issues with clarity, accuracy or relevance.

Reviewer’s Comments

Length

Meets Expectations (1 point)	Below Expectations (0 points)
Paper is between 8-10 pages not including title page and references	Paper is less than 8 full pages or more than 10 pages.

Reviewer’s Comments

Conclusion

Your assertions and the information you provided should be supported by literature. Please cite, using both in-text citations and a References section, at least five empirical sources such as peer-reviewed articles or textbooks.

Meets Expectations (1 point)	Below Expectations (0 points)
Paper incorporated course readings and/or any additional applicable academic (empirical) materials (e.g. journal articles). These were cited appropriately, both in-text and in references.	Did not incorporate at least 5 sources.

Reviewer’s Comments

APA

Meets Expectations (1 point)	Approaching Expectations (0.6 point)	Below Expectations (0 points)
Paper follows APA 7 guidelines, including title page, references and section headings.	Student made an effort to follow APA 7 guidelines with some minor errors.	Paper format deviated significantly from APA style.

Reviewer’s Comments

Citing Sources

Demonstrate graduate level writing, including strong organization of ideas and appropriate grammar.

Meets Expectations (1 point)	Approaching Expectations (0.6 point)	Below Expectations (0 points)
Paper is organized, well-written and grammatically appropriate, reflecting graduate-level writing.	Paper contains a small number of minor grammar or spelling errors or organizational issues.	Paper contains numerous organizational issues, grammar or spelling errors that detract from the professionalism of the post or make the writing difficult to understand.

Reviewer’s Comments

Rubric Total 0

Overall, what are the strengths of this paper?

Overall, what are the most important things for your colleague to work on?

image3.png

image1.png

image2.png

,

Introduction

Attention-deficit Hyperactivity Disorder (ADHD) is a developmental disorder often first observed in childhood which persists into adulthood. Symptoms of ADHD can have a pervasive and negative effect on the lives of those diagnosed with the disorder, particularly in areas pertaining to academics, career and finances. As of this writing, pharmacotherapy is seen as the most common and effective form of ADHD treatment, however there is a growing body of evidence to suggest psychosocial treatments, particularly Cognitive Behavioral Therapy (CBT), may be an effective alternative/addition to medication when treating symptoms of ADHD. This paper will discuss ADHD and CBT and how CBT may be used as a form of treatment to manage ADHD in adults.

Presenting Problem

Characteristics of ADHD include a pervasive inability to focus on tasks or activities, forgetfulness, a lack of attention to detail, excessive talking, and impatience. A diagnosis of ADHD can only occur if these characteristics cause difficulty in academic, job, social and familial settings. ADHD is most commonly seen in males, though there is anecdotal discourse among social media personalities and influencers suggesting the prevalence in males versus females has more to do with gender bias than anything scientific. ADHD diagnoses have higher rates in children than adults. As of the most recent publishing of the DSM-V-TR, there are no specific biological markers to indicate the presence of ADHD. Though there have been a few neuroimaging studies to indicate differences in brain wave functions in children with ADHD, the data is inconsistent, and more studies must be conducted in order to establish neuroimaging as a form of diagnostic measure to determine the presence of ADHD.

Individuals with ADHD may have co-occurring diagnoses of anxiety, major depression, oppositional defiance, learning disorders, autism spectrum disorder, substance abuse, obsessive-compulsive disorder and sleep difficulties. These comorbidities are not always present; however rates of oppositional defiance disorder and specific learning disorder are higher in individuals diagnosed with ADHD. Thoughts of suicide, suicidal ideation, and attempted suicide are higher in individuals diagnosed with ADHD.

As of this writing, there is a robust online community of individuals diagnosed with ADHD colloquially known as ADHDers, with a sub-community of late diagnosed individuals, predominantly those who identify as female. A late diagnosis can be relieving and frustrating and because of this, community resources and support are shared which give those with the diagnosis (early or late) a sense of connection they may not have enjoyed in childhood as those with ADHD are more likely to experience social impairment and rejection. Anecdotally speaking, ADHD provides affected individuals with a unique set of skills and interests due to their desire and need for novel experiences making ADHDers jacks of all trades, and masters of some. For ADHDers with hyperactivity, they are able to work in fast paced environments that require individuals to wear many hats. An individual with experience in multiple industries and the ability to be many things in one setting is a valuable asset in the commerce industry and retail sector. There are no citations to support these assertions as they are anecdotal, and the information has been acquired over the course of many hours consuming ADHD specific social media and message boards, as well as first-hand experience with a late diagnosis.

Modality

Cognitive Behavioral Therapy (CBT) is rooted in the belief that our thoughts (cognitions) and behaviors affect our emotions/feelings. CBT is a term that encompasses a multitude of techniques that are focused on identifying maladaptive thought processes and finding ways to alter or restructure those thoughts to produce healthy thought patterns and behaviors. Some techniques used in CBT are identification and modification of core beliefs, cognitive restructuring, mindfulness practices, self-monitoring and psychoeducation, to name a few.

Evidence Base

There is evidence to support the effectiveness of Cognitive Behavioral Therapy (CBT) on the treatment of ADHD symptoms. A literature review found CBT was the more effective nonpharmacological mode of therapy versus Dialectical Behavioral Therapy, Mindfulness Based Cognitive Therapy, and Neurofeedback. Additionally, the research suggests that individual therapy is more effective than group therapy. Though meta-analytic reviews found CBT to be the most effective therapy to manage ADHD symptoms, the researchers are careful to point out the limitations of their findings due to the number of studies done on the efficacy of CBT and other psychosocial treatments for ADHD. Reviewers suggest more studies must be conducted to provide a larger body of evidence to draw from in order to fully support CBT as an effective treatment for ADHD.