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Adult ADHD and Impulsivity

It is much more than ready-fire-aim..

Posted July 1, 2021 | Reviewed by Lybi Ma

• What Is ADHD?
• Find a therapist to help with ADHD
• Impulsivity is one of the three main diagnostic symptom domains for ADHD.
• Impulsivity is defined as acting without forethought.
• Even though it is a symptom of ADHD, the problems it causes are much more wide-ranging than is typically appreciated.
• Coping with impulsivity and adult ADHD requires thinking ahead and planning for how to avoid or manage risky situations.

Impulsivity numbers among the core symptom domains of ADHD , though it takes up only four of the 18 symptoms in the diagnostic criteria:

• Talks excessively in social situations
• Has difficulty waiting their turn
• Blurts out answers before questions are completely asked, completes others’ sentences, jumps the gun
• Interrupts or intrudes on others (butts into conversations or activities without permission or takes over what others are doing)

Though only comprising a smidge more than 22 percent of the list, impulsivity creates proportionally much more than its share of problems. Like the other official symptoms of ADHD, they are not flawed but they simply do not capture the full array of difficulties faced by those with ADHD. Impulsivity in particular gets short shrift in terms of its role in the struggles of adults with ADHD.

Common problems for adults with ADHD from impulsivity

Impulsivity is considered to be acting without forethought, but this does not do justice to the visceral feeling and emotional dyscontrol driving the impulses in the first place. Coupled with a proneness for disinhibition and its interaction with the emotional dyscontrol central to ADHD, there are many facets of life where adults with ADHD find themselves in trouble due to impulsivity.

Even as listed in DSM-5 , impulsive symptoms seem innocuous and may be annoying to others, but nothing too impairing. In isolation, such miscues represent relatively minor social gaffes that are quickly overlooked or forgiven. However, these lackluster descriptions do not do justice to the negative effects of the more frequent and very public behaviors and accompanying feelings of embarrassment , shame on one’s relationships and social standing among adults with ADHD.

Repeated instances of saying the wrong thing at the wrong time, including indiscrete or hurtful comments, and dominating conversations may lead to the slow withdrawal of people from an adult with ADHD, a slow-motion rejection if not swift a rebuke. Interruptions, completing others’ thoughts, difficulties with impatience and distraction, often sprinkled with missed social cues, defensiveness, and emotional outbursts combine to erode one’s social standing and reputation. It's no surprise that this can be particularly detrimental when tending to a long-term, committed relationship or friendship .

Impulsivity and its emotional correlates also affect other areas of functioning and impairment. Poor impulse control plays a role in imprudent shopping and overspending, impulsive compliance (saying “yes” to any invitation or interesting project), which results in overextending oneself, thereby setting the stage for poor follow through on promises.

Procrastination also has roots in impulsivity: “I know I should work on this now, but I’ll do this other thing first.” Often driven by subtle, but notable emotional aversion (the “ugh” feeling) to a priority task and a drive toward something more enjoyable, or at least anything that is not the have-to chore. Impetuous excitement may set off a stretch of hyper-focus and overdoing even positive activities to the detriment of other priorities. In a similar vein, many addictive behaviors (or merely succumbing to other temptations, including overeating and unsafe sex ) are initiated and maintained by impulsivity. What is the most insidious feature of impulsivity for adults with ADHD is that it may result in acting on suicidal thoughts with tragic consequences.

Coping with ADHD and impulsivity

Medications for ADHD can be helpful with impulsivity as they are for other core symptoms of ADHD. In terms of behavioral coping strategies, a starting point for them is challenging the mindset that one has “no control over impulses.” While the relapse rate for impulsivity is 100 percent—it will happen, at times—there are strategies to reduce its frequency, reduce risks, and deal with slip-ups, which include:

• Recognize situations where you are prone to impulsivity (dinner party, meeting at work, arriving home after work)
• Identify personal risk factors for impulsivity ( alcohol , tiredness, moodiness, anger , medications wearing off)
• Avoid risky situations (avoid temptations; deal with impatience with long line at a coffee shop by going to a less crowded one)
• Prepare a game plan for handling risky situations that cannot be avoided (limit or avoid alcohol at a business dinner, log off of online stores and create a delay before purchasing)
• Create time buffers (24-hour delay on purchases, respond to requests by saying “let me check and get back to you”)
• Have externalized reminders for coping plans (index card with coping reminders, have coping rules, such as a three-sentence rule when talking before pausing to allow others to speak)
• Have daily impulsivity coping goals (Focus on one setting or domain, plan and script how you want to handle a meeting, parenting issue with a child, etc.)
• Normalize slip-ups and make amends ( apologize , undo a situation [“It turns out I will not be able to coordinate the school fundraiser, after all.”], identify the lesson learned from the situation, and create a coping plan)
• Define managing impulsivity as part of an overall treatment and self-care plan for adult ADHD

As with most facets of managing adult ADHD, there are no trade secrets about what works, but the job is the implementation of what works. Impulsivity is a trickier ADHD symptom to manage but with recognizing in advance one’s risk factors and having some plans in place, the problems can be reduced and one’s passions better harnessed and directed towards positive outcomes.

J. Russell Ramsay, Ph.D., is a licensed psychologist with an independent virtual practice. He is retired as a professor of clinical psychology at the University of Pennsylvania’s Perelman School of Medicine.

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Rachael is a New York-based writer and freelance writer for Verywell Mind, where she leverages her decades of personal experience with and research on mental illness—particularly ADHD and depression—to help readers better understand how their mind works and how to manage their mental health.

Claire Eggleston, LMFT-Associate is a neurodivergent therapist and specializes in and centers on the lived experiences of autistic and ADHD young adults, many of whom are also in the queer and disability communities. She prioritizes social justice and intertwines community care into her everyday work with clients.

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The Neurobiology of Impulses and Impulse Control

• Why It's Difficult
• Tips to Improve Impulse Control

ADHD Symptom Spotlight is a series that dives deep into a hallmark or overlooked symptom of ADHD each week. This series is written by experts who also share their tips on managing these symptoms based on firsthand experience and research-backed insights.

Both inattentive and hyperactive subtypes of ADHD are prone to impulse control problems. This impulsivity can come in handy in rare situations where they need to think on their feet, but it generally puts them at risk of making poor choices and taking unnecessary risks.

To understand why impulsivity is a characteristic of ADHD, it’s important to understand the science behind how impulses happen and how the brain typically controls them.

The human brain uses a complex system of “happy” hormones to make decisions about what to do. These hormones reinforce behaviors that make you feel good, but they each function in slightly different ways, triggering different kinds of responses.

When it comes to impulses, the science so far suggests two happy hormones, in particular, are at play: dopamine and serotonin .

In extremely oversimplified terms, dopamine is the “go” signal. It’s the motivational coach in your head encouraging you to do certain activities and to keep going. Meanwhile, serotonin is the “no go” signal. It’s the Zen monk in your head, letting you know when you’ve done enough and it’s time to stop and enjoy the state of contentment you’ve achieved.

In a healthy brain, the balance between the two is relatively stable, where the person gets just enough motivational dopamine to do what they need to do and a healthy amount of serotonin to make them feel satisfied with what they’ve accomplished and avoid making rash decisions.

Then, when the occasion calls for it, each hormone has the ability to override the either. When dopamine overrides serotonin, it’s pushing you to indulge in an impulse and ignore the “no go” signal serotonin is sending you. When serotonin overrides dopamine, it’s practicing impulse control, telling you to ignore that “go” signal the dopamine is giving you.

Both processes have their function. The ability to resist impulses can save you from taking unnecessary risks or making bad choices. Meanwhile, the ability to have and act on impulses can be useful in extreme situations where you need to react quickly and make snap decisions.

Dopamine and Serotonin Imbalances in ADHD Make Impulse Control Difficult

For people with ADHD, that balance is nonexistent. During ordinary tasks, a low number of dopamine receptors in the brain prevent people with ADHD from getting that “go” signal. This lack of motivation means they’re liable to procrastinate , struggle with making decisions , and find it hard to make themselves start or stay on task.

In one study on impulsivity, low activity levels in dopamine receptors were linked to increased impulsive behavior. The reason is that when dopamine release was stimulated, it triggered even higher amounts of the hormone in these normally dopamine-deficient brains than it did in the less impulsive group.

In those unpredictable moments when dopamine release is stimulated, then, a flood of the motivational hormone leaves the person feeling overwhelmed with the need to do the thing that triggered the dopamine flood.

ADHD brains may also have low numbers of serotonin receptors, impairing their ability to resist an impulse. So when those impulses happen, they’re stronger than usual and occur in a brain with a weakened impulse control mechanism.

While the research on exactly how those floods of dopamine are triggered is still scarce, one recent study found a possible link to emotional escalation. Events that trigger sudden and intense emotions—like panic, anger, or euphoria—may trigger higher amounts of dopamine.

What Does Impulsivity Look Like in ADHD?

ADHD-related impulsivity takes a lot of forms, with some impulsive behavior more obvious than others. Some of the most common ways impulsivity manifests in ADHD include:

• Spur-of-the-moment decision-making
• Interrupting people during conversations
• Acting or speaking without thinking first
• Starting tasks without planning first
• Racing thoughts that are hard to control
• Lack of patience
• Difficulty saving money (or generally working toward long-term goals)
• Risky, self-destructive behavior

Impulsiveness feels like this intense, fiery drive to do something. There’s no time to wait, no time to plan, no time to consider whether you actually should do the thing. You just have to go do it. Trying to resist it is like standing in the middle of a bonfire and trying not to leap out of it. The urge is too intense and you feel like you will burn up if you don’t indulge it.

Sometimes, you have the foresight to know the impulse is a bad one, but most of the time you aren’t even really thinking about whether it’s a good or bad idea until after the fact.

Over the long term, your more self-destructive impulses can leave you with heavy guilt and regret. But even the milder forms of impulsivity, like blurting out statements, can strain your friendships, get you in trouble at work, and make it hard to maintain positive, stable relationships in all areas of life.

How to Improve Impulse Control When You Have ADHD

ADHD might make impulses feel stronger and reduce your ability to control them, but with practice, you can get better at managing your impulses. The key is to distinguish between good and bad impulses, and focus most of your energy on resisting the bad ones. Here are a few strategies that can help.

Exercise Regularly

Studies show that regular aerobic exercise can help reduce all symptoms of ADHD, including impulsivity. Find fun activities that get your heart rate up and try to spend around 30 minutes to an hour each day doing those.

This won’t cure your impulse control problems but it can help lessen the intensity so that it’s a little easier to resist.

Do a Personal Inventory to Reflect on Past Impulsive Behavior

Reflect on past moments of impulsivity to figure out what your triggers might be and how you might have acted differently to handle the situation better. It can be tough to think about, but reflecting on past experiences is one of the best ways to figure out a plan for avoiding those mistakes in the future.

Do this regularly until you’ve identified your most problematic impulsive behaviors and grasped some idea of when you’re most likely to become impulsive. This increased self-awareness can help you anticipate high-risk situations and figure out personalized strategies for diffusing those impulses.

Train Your Impulse Endurance

With ADHD, an impaired impulse control mechanism makes resisting impulses feel impossible. But, with practice, you can build up some tolerance. A mental trick you can try is telling yourself that you can act on the impulse but first, you want to see how long you can hold off. Knowing that you can give in when it becomes overwhelming can make it less daunting to try to delay the impulse .

Meanwhile, the more you practice at least delaying those impulses, the better you get at controlling them. Eventually, you’ll be able to use that delay to consider whether this is even an impulse worth indulging. If not, thinking about the consequences can help decrease the desire to do it, eventually allowing the impulse to pass.

Complicate Your Impulse Decisions

ADHD brains often avoid complex or delayed-reward tasks because the motivation isn’t strong enough . So you can leverage one ADHD symptom against the other by making impulsive behaviors harder to execute, thereby forcing your impulsiveness to battle your executive dysfunction for dominance. Here are some ways to do that:

• Enforce a cooling-off period . If you want to buy a new outfit, leave it on the rack for now. Tell yourself you can come back in, say, a week if you still want it.
• Add extra steps . Instead of buying junk food while doing your normal grocery shopping, leave it for when you have the craving. Sure, you can have ice cream. But you have to go all the way back to the store to get it (if possible, enforce a rule that you have to walk instead of drive).
• Bring cash only on nights out . If you tend to overspend when you go out with friends, leave your cards at home and just bring the amount you’ve budgeted for the night in cash.
• Bring a notebook to meetings . If you’re prone to blurting things out in meetings, write those things down in your notes first. That way, you’ll have them there to bring up later when you can speak without interrupting someone. Similarly, in text conversations, you can write out your responses to friends in a notetaking app first during more sensitive or difficult conversations where you don’t want to carelessly hit send before considering how your words will impact the other person.

For each of the impulsive behaviors you identified during that personal inventory, think of similar strategies for complicating them to give you more time to consider your actions.

Accept Some Degree of Impulsivity

To some degree, impulsivity can be healthy, exciting, and productive. There’s nothing wrong with being the spontaneous friend who wants to try new activities or the coworker who proposes a creative change to ineffective processes at work.

The key is learning to recognize good and bad impulses—and doing that requires some honest and thorough self-reflection on your past behavior. When did your impulsiveness lead to good outcomes and when was it disastrous?

Focus your energy on controlling the disastrous impulses and let the positive or neutral ones slide.

Channel Your Impulsivity

Finding ways to let impulsivity exist in life is important for ADHD brains instead of trying to always lessen or "cure" it. You may even be able to use those impromptu actions to your advantage—what's referred to as functional impulsivity. Some hobbies or activities where that functional impulsivity can be an advantage include:

• Gymnastics . In addition to getting you up and moving, gymnastics is an activity that requires the kind of quick and decisive action that someone who’s naturally more impulsive would be good at. You can’t do a backflip in slow motion. You just have to leap into it. If gymnastics doesn’t appeal to you, you could also try martial arts, pole dancing, or figure skating.
• Tennis . Like gymnastics, tennis requires a lot of quick and decisive movements because you’re darting from point to point on the court to strike the ball. Matches are also relatively fast-paced and short, which is good for people who struggle with losing interest in activities too easily. You can play a match or two and then head home for the day before you get bored. Other racket sports like squash, badminton, or table tennis are good options for the same reasons.
• Tabletop role-playing games . For a less physically-demanding option, tabletop RPGs (like the popular Dungeons & Dragons) are great. I really enjoy them because they put you into a fictional world with a constant series of ever-changing high-stakes scenarios (the kind of scenarios ADHD brains thrive in): fighting hordes of angry goblins, negotiating a peace treaty with orcs, or navigating a booby-trapped cave in search of treasures. Often, success hinges on being able to make spur-of-the-moment decisions and adapting quickly when your plans go awry. But even when your impulses lead you astray, the consequences are all in-game, so no real-world harm is done. There are online groups you can join, but you can also check your local hobby shops for regular in-person meetups.
• Arts and crafts. Painting, drawing, woodworking, ceramics, jewelry-making, the list goes on. Any creative hobby you can think of is a great way to channel your impulsivity because you can make what you want, with whatever materials you want, in whatever timeframe you want. Because you’re doing it as a hobby, there are also no external demands or constraints on what you make. You can draw a hyper-realistic cityscape or throw paint wildly at a canvas. Carefully craft a matching set of bowls or free-hand an abstract sculpture. Creative hobbies let you turn impulses into works of art.

Incorporating one of these or a similar hobby into your life is a good way to practice embracing your impulsiveness and learn to recognize how and when it can be beneficial. 

Volkow ND, Wang GJ, Kollins SH, et al. Evaluating dopamine reward pathway in adhd: clinical implications . JAMA . 2009;302(10):1084. doi:10.1001/jama.2009.1308

Buckholtz JW, Treadway MT, Cowan RL, et al. Dopaminergic network differences in human impulsivity . Science . 2010;329(5991):532-532. doi:10.1126/science.1185778

Quist JF, Barr CL, Schachar R, et al. The serotonin 5-HT1B receptor gene and attention deficit hyperactivity disorder . Mol Psychiatry . 2003;8(1):98-102. doi:10.1038/sj.mp.4001244

Monopoli WJ, Evans SW, Benson K, et al. Assessment of a conceptually informed measure of emotion dysregulation: Evidence of construct validity vis a vis impulsivity and internalizing symptoms in adolescents with ADHD . Int J Methods Psychiatr Res . 2020;29(4):1-14. doi:10.1002/mpr.1826

Waldera R, Deutsch J. Adhd and physical activity . TPE . 2021;78(6). doi:10.18666/TPE-2021-V78-I6-10563

Thorell LB. Do delay aversion and executive function deficits make distinct contributions to the functional impact of ADHD symptoms? A study of early academic skill deficits . J Child Psychol & Psychiat . 2007;48(11):1061-1070. doi:10.1111/j.1469-7610.2007.01777.x

Dickman SJ. Functional and dysfunctional impulsivity: personality and cognitive correlates .  J Pers Soc Psychol . 1990;58(1):95-102. doi:10.1037/0022-3514.58.1.95

By Rachael Green Rachael is a New York-based writer and freelance writer for Verywell Mind, where she leverages her decades of personal experience with and research on mental illness—particularly ADHD and depression—to help readers better understand how their mind works and how to manage their mental health.

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Cognitive‐behavioural interventions for attention deficit hyperactivity disorder (ADHD) in adults

Attention deficit hyperactivity disorder (ADHD) is a developmental condition characterised by symptoms of inattention, hyperactivity and impulsivity, along with deficits in executive function, emotional regulation and motivation. The persistence of ADHD in adulthood is a serious clinical problem.

ADHD significantly affects social interactions, study and employment performance.

Previous studies suggest that cognitive‐behavioural therapy (CBT) could be effective in treating adults with ADHD, especially when combined with pharmacological treatment. CBT aims to change the thoughts and behaviours that reinforce harmful effects of the disorder by teaching people techniques to control the core symptoms. CBT also aims to help people cope with emotions, such as anxiety and depression, and to improve self‐esteem.

To assess the effects of cognitive‐behavioural‐based therapy for ADHD in adults.

Search methods

In June 2017, we searched CENTRAL, MEDLINE, Embase, seven other databases and three trials registries. We also checked reference lists, handsearched congress abstracts, and contacted experts and researchers in the field.

Selection criteria

Randomised controlled trials (RCTs) evaluating any form of CBT for adults with ADHD, either as a monotherapy or in conjunction with another treatment, versus one of the following: unspecific control conditions (comprising supportive psychotherapies, no treatment or waiting list) or other specific interventions.

Data collection and analysis

We used the standard methodological procedures suggested by Cochrane.

Main results

We included 14 RCTs (700 participants), 13 of which were conducted in the northern hemisphere and 1 in Australia.

Primary outcomes: ADHD symptoms

CBT versus unspecific control conditions (supportive psychotherapies, waiting list or no treatment)

‐ CBT versus supportive psychotherapies: CBT was more effective than supportive therapy for improving clinician‐reported ADHD symptoms (1 study, 81 participants; low‐quality evidence) but not for self‐reported ADHD symptoms (SMD −0.16, 95% CI −0.52 to 0.19; 2 studies, 122 participants; low‐quality evidence; small effect size).

‐ CBT versus waiting list: CBT led to a larger benefit in clinician‐reported ADHD symptoms (SMD −1.22, 95% CI −2.03 to −0.41; 2 studies, 126 participants; very low‐quality evidence; large effect size). We also found significant differences in favour of CBT for self‐reported ADHD symptoms (SMD −0.84, 95% CI −1.18 to −0.50; 5 studies, 251 participants; moderate‐quality evidence; large effect size).

CBT plus pharmacotherapy versus pharmacotherapy alone : CBT with pharmacotherapy was more effective than pharmacotherapy alone for clinician‐reported core symptoms (SMD −0.80, 95% CI −1.31 to −0.30; 2 studies, 65 participants; very low‐quality evidence; large effect size), self‐reported core symptoms (MD −7.42 points, 95% CI −11.63 points to −3.22 points; 2 studies, 66 participants low‐quality evidence) and self‐reported inattention (1 study, 35 participants).

CBT versus other interventions that included therapeutic ingredients specifically targeted to ADHD : we found a significant difference in favour of CBT for clinician‐reported ADHD symptoms (SMD −0.58, 95% CI −0.98 to −0.17; 2 studies, 97 participants; low‐quality evidence; moderate effect size) and for self‐reported ADHD symptom severity (SMD −0.44, 95% CI −0.88 to −0.01; 4 studies, 156 participants; low‐quality evidence; small effect size).

Secondary outcomes

CBT versus unspecific control conditions : we found differences in favour of CBT compared with waiting‐list control for self‐reported depression (SMD −0.36, 95% CI −0.60 to −0.11; 5 studies, 258 participants; small effect size) and for self‐reported anxiety (SMD −0.45, 95% CI −0.71 to −0.19; 4 studies, 239 participants; small effect size). We also observed differences in favour of CBT for self‐reported state anger (1 study, 43 participants) and self‐reported self‐esteem (1 study 43 participants) compared to waiting list. We found no differences between CBT and supportive therapy (1 study, 81 participants) for self‐rated depression, clinician‐rated anxiety or self‐rated self‐esteem. Additionally, there were no differences between CBT and the waiting list for self‐reported trait anger (1 study, 43 participants) or self‐reported quality of life (SMD 0.21, 95% CI −0.29 to 0.71; 2 studies, 64 participants; small effect size).

CBT plus pharmacotherapy versus pharmacotherapy alone : we found differences in favour of CBT plus pharmacotherapy for the Clinical Global Impression score (MD −0.75 points, 95% CI −1.21 points to −0.30 points; 2 studies, 65 participants), self‐reported depression (MD −6.09 points, 95% CI −9.55 points to −2.63 points; 2 studies, 66 participants) and self‐reported anxiety (SMD −0.58, 95% CI −1.08 to −0.08; 2 studies, 66 participants; moderate effect size). We also observed differences favouring CBT plus pharmacotherapy (1 study, 31 participants) for clinician‐reported depression and clinician‐reported anxiety.

CBT versus other specific interventions : we found no differences for any of the secondary outcomes, such as self‐reported depression and anxiety, and findings on self‐reported quality of life varied across different studies.

Authors' conclusions

There is low‐quality evidence that cognitive‐behavioural‐based treatments may be beneficial for treating adults with ADHD in the short term. Reductions in core symptoms of ADHD were fairly consistent across the different comparisons: in CBT plus pharmacotherapy versus pharmacotherapy alone and in CBT versus waiting list. There is low‐quality evidence that CBT may also improve common secondary disturbances in adults with ADHD, such as depression and anxiety. However, the paucity of long‐term follow‐up data, the heterogeneous nature of the measured outcomes, and the limited geographical location (northern hemisphere and Australia) limit the generalisability of the results. None of the included studies reported severe adverse events, but five participants receiving different modalities of CBT described some type of adverse event, such as distress and anxiety.

Plain language summary

Cognitive‐behavioural therapy for attention deficit hyperactivity disorder (ADHD) in adults

People with ADHD have difficulty paying attention, concentrating, dealing with hyperactivity (e.g. waiting in queues) and acting without thinking (i.e. impulsivity). In adults, ADHD significantly affects social interactions, study and employment performance.

Previous studies suggest that cognitive‐behavioural therapy (CBT) could be effective for treating adults with ADHD, especially when combined with pharmacological (i.e. drug) treatment. CBT aims to change the thoughts and behaviours that reinforce the harmful effects of the disorder by teaching people techniques to control the core symptoms. CBT also aims to help people cope with emotions, such as anxiety and depression, and to improve self‐esteem.

Review question

Does CBT, alone or in combination with pharmacological treatment, reduce the core symptoms of ADHD in adults more than other treatments or no specific treatment?

Search dates

The evidence is current to June 2017.

Study characteristics

We found 14 randomised controlled trials (studies in which participants are randomly assigned to different treatment groups) that described the effects of CBT in 700 adults with ADHD, aged between 18 and 65 years. Thirteen trials took place in the northern hemisphere and one in Australia.

Of the included studies, three compared CBT versus other specific interventions and seven versus unspecific control conditions (unspecific supportive therapy, waiting list or no treatment). Additionally, two compared CBT plus pharmacotherapy versus pharmacotherapy alone. One trial compared CBT to two control groups, one of which was given other specific non‐pharmacological treatment and one of which was a no‐treatment control.

Quality of the evidence

Because of imprecision (i.e. inaccurate results), inconsistency (i.e. results differ across trials) and methodological limitations, we considered the quality of the evidence of the included studies to range from very low to moderate.

Key results

The findings suggest that CBT might improve the core symptoms of ADHD, reducing inattention, hyperactivity and impulsivity.

When combined with pharmacotherapy, there was evidence of an improvement in global functioning (i.e. a person's overall level of functioning in life) and a reduction in depression and anxiety compared to that seen with pharmacotherapy alone.

None of the included studies reported severe adverse events. However, five participants described some type of adverse event, such as distress and anxiety.

Summary of findings

Description of the condition.

According to the Diagnostic and Statistical Manual of Mental Disorders , currently in its fifth edition (DSM‐5), attention deficit hyperactivity disorder (ADHD) is a developmental condition characterised by symptoms of inattention, hyperactivity and impulsivity ( DSM‐5 2013 ). Using these criteria, ADHD can be divided into three types: combined type, predominantly inattentive type and predominantly hyperactive‐impulsive type. The International Classification of Diseases (ICD‐10) offers a similar definition for hyperkinetic disorders ( WHO 1993 ), but the required number of symptoms and the age of onset are different. Along with these three main symptomatic clusters, people with ADHD also present with deficits in executive functions, behaviour and emotion regulation, and motivation ( Brown 2000 ; Davidson 2008 ; Torrente 2011 ; Wender 2001 ). There is a high prevalence of comorbid disorders, estimated at 50% to 75% ( Kessler 2006 ), including anxiety, depression and substance abuse ( Biederman 1993 ; Murphy 1996 ). Epidemiological studies estimate that the prevalence of ADHD is approximately 5% in childhood and around 2.5% in adulthood ( Polanczyk 2014 ; Simon 2009 ).

Evidence on gender differences in ADHD is controversial. Some authors suggest that there are no differences between females and males ( Biederman 2002 ; Seidman 2006 ). Other authors, such as Gershon 2002 , argue that there are quantitative and qualitative differences in executive functions.

Still 1902 is commonly accredited as the first description of a syndrome in children that included some of the characteristics of ADHD. However, the characterisation of the disorder in adults was more recent, with Adler 2002 attributing it to Wood 1976 . Since then, many papers have provided evidence on the diagnostic validity of ADHD in adults ( Spencer 1998 ). The validity of the diagnosis in adulthood is supported by clinical correlates, family history, treatment response and experimental studies ( Faraone 2000 ). Additionally, longitudinal studies have demonstrated the persistence of the disorder in large proportions of adults who were diagnosed with ADHD during childhood ( Barkley 1999 ).   

As Brassett‐Harknett 2007 noted, there are diagnostic difficulties with ADHD in adults because the current diagnostic criteria were originally designed for children. ADHD in adulthood has particular characteristics that differ from the syndrome in childhood. For example, hyperactivity tends to decrease in adulthood ( Achenbach 1998 ), with some studies showing that 90% of adults with ADHD present predominantly with inattentive symptoms ( Millstein 1997 ).

Importantly, different authors have recognised the persistence of ADHD in adulthood as a clinical problem with serious health consequences ( Davidson 2008 ; Wilens 2004 ).  Barkley 2008 highlights the severe occupational consequences of the disorder, such as lower occupational status and annual salaries than in a control group, worse employer‐rated job performance, more job dismissals and frequent changes of job. Those who suffer from ADHD are less capable of fulfilling work demands, less likely to be working independently, completing tasks, and getting along well with supervisors, as rated by employers. They have poorer performance at job interviews and find certain tasks at work too difficult. Additionally, Woods 1986 suggests that people with ADHD experience anger dysregulation as a highly associated psychosocial problem. ADHD also carries psychological consequences since repeated life experiences of frustration undermine self‐concept and self‐esteem, leading to the formation of negative beliefs about the self, which, in turn, affect quality of life and emotional adjustment ( Torrente 2012 ).

Description of the intervention

Diverse psychological treatments have been developed for for adults with ADHD in recent years ( Knouse 2008 ; Weiss 2008 ). Most have been inspired by cognitive‐behavioural therapy (CBT) and designed as adjunct interventions to pharmacological treatment ( Safren 2006 ). As is usual in CBT treatments, the interventions are organised into relatively brief and focused, structured protocols. Most CBT programmes for adults with ADHD take 8 to 12 sessions and can be delivered on an individual or group basis. The main objectives of the treatment are to change the behaviours that reinforce detrimental effects of the disorder by teaching people techniques to control ADHD's core symptoms, improving emotional adjustment, self‐esteem and common comorbid symptoms such as anxiety and depression. Proposed psychotherapeutic techniques include psychoeducation for increasing awareness and understanding of the disorder and cognitive techniques for restructuring the dysfunctional thoughts and maladaptive beliefs that reinforce emotional maladjustment. Finally, behavioural interventions and cognitive remediation methods intend to provide new, healthy, compensatory strategies and skills for deficient attention, executive functioning, impulse control and emotion regulation ( Ramsay 2010 ).

Investigators have applied variants of the classical CBT approach to this population: Hesslinger 2002 and Philipsen 2007 have experimented with dialectical behavioural therapy and Solanto 2010 with meta‐cognitive therapy. These variants emphasise specific types of interventions such as emotion regulation skills in dialectical behavioural therapy and cognitive training methods in meta‐cognitive therapy, but because they share the general model and procedures of CBT, previous, non‐systematic reviews have usually included these methods within the broad spectrum of CBT interventions ( Knouse 2008 ; Weiss 2008 ). However, no studies have ever directly compared these types of CBTs against each other, so it is unknown if they have different treatment effects. Moreover, comparing CBT versus placebo, waiting list and no treatment could produce different treatment effects for each comparison, and we plan to explore these potential differences in our study.

How the intervention might work

The cognitive‐behavioural approach provides a useful framework for understanding how negative life experiences may reinforce functional impairment and lead to increased emotional disturbance in adults with ADHD. Because of neurobiological deficits in attention, executive function and inhibitory control, failure and underachievement in different domains of function are common occurrences in people with ADHD as they enter adulthood ( Barkley 2006a ;  Biederman 2006 ). According to the CBT model, such repeated life experiences of frustration undermine self‐concept and self‐esteem, leading to the formation of negative beliefs about the self, which, in turn, favour the expression of negative emotions such as depression and anxiety. Negative self‐beliefs can also lead to the adoption of maladaptive behavioural strategies, including negation, procrastination and extreme avoidance as a means of coping with difficult tasks ( Ramsay 2008 ; Safren 2006 ;  Young 2007a ). In addition to emotional disturbances, negative expectations about the future, anticipation of failure and reduced self‐confidence can also affect motivation ( Torrente 2011 ).

The proposed mechanisms of change entail the acquisition of compensatory behavioural and cognitive techniques for improving the core attention and executive deficits of ADHD and modifying distorted negative beliefs to promote emotional maladjustment ( Ramsay 2010 ). CBT programmes are therefore usually organised into several modules with specific techniques for a series of target problems. Most treatments begin with a psychoeducational module in which patients are taught about the disorder and introduced to the rationale for the treatment. This is followed by an organisation module designed to aid the acquisition of different executive techniques such as goal setting, sequencing and prioritising, devising a time schedule, using a calendar or agenda, making 'to do' lists, monitoring progress, and planning breaks and rewards. Patients also learn problem‐solving techniques for articulating problems more clearly, generating a list of potential solutions, evaluating them and finally testing the chosen solution. The distraction management module helps patients to recognise their optimal attention span and organise the tasks according to it, and it introduces skills for dealing with distractions such as writing them down and going back to the task, using cues or alarms, or modifying environmental factors. The impulsivity management module includes strategies for self‐monitoring and self‐control. The self‐monitoring module involves the detection of cues and situations that act as triggers for impulsive behaviour, while self‐control strategies refer to the use of self‐instructions, relaxation techniques or other alternative behaviours. The cognitive restructuring module aims to help patients to become aware of the ideas that reinforce maladaptive behaviours and emotions and replace them with more adaptive thoughts.

Several pilot studies have demonstrated the feasibility and acceptability of the approach ( Knouse 2008 ), and a series of randomised controlled trials have provided evidence for the efficacy of CBT in adults with ADHD ( Safren 2005 ; Safren 2010 ; Solanto 2010 ; Stevenson 2002 ).

Why it is important to do this review

Between 20% and 50% of people with ADHD do not respond to drug treatment ( Wilens 2002 ). Also, pharmacological treatment is frequently associated with relevant side effects in both children and adults ( AJCD 2001 ; Castells 2013 ; Cunill 2013 ; Graham 2011 ; King 2006 ; Lim 2006 ; Morton 2000 ; Perrin 2008 ; Prescrire 2007 ). Due to these concerns, it is important to have non‐pharmacological interventions for treating adults with ADHD.

The consequences of ADHD can also have an important and negative impact on different areas of a person's life, such as poor academic performance, deficits in social and occupational functioning, greater job insecurity and a greater number of legal problems ( Barkley 2002 ; Davids 2004 ). An efficacious psychosocial intervention might be beneficial in one or more of these areas for adults with ADHD.

To our knowledge, three systematic reviews have compared the effects of CBT in adults with ADHD ( Jensen 2016 ; Knouse 2017 ; Young 2016 ). However, there are important methodological differences between them, also with respect to our review. Both Jensen 2016 and Young 2016 employed more restrictive criteria for defining CBT treatments that excluded relevant CBT variants such as mindfulness‐based cognitive therapy and dialectical behavioural therapy. Knouse 2017 did not report grades of quality of evidence of the included studies.

Criteria for considering studies for this review

Types of studies.

Randomised controlled trials (RCTs).

Types of participants

Adults aged 18 years and above diagnosed with ADHD or hyperkinetic disorder according to the established diagnostic criteria, whose medication was stable (less than 10% change in dose) in the two months prior to the initial evaluation.

Types of interventions

Individual and group treatments of CBT in any of its variants such as standard CBT, dialectical behavioural therapy, meta‐cognitive therapy, or mindfulness‐based cognitive therapy.

All included CBT interventions had to fulfil both of the following criteria.

• Treatment was aimed at increasing knowledge on the disorder, identifying and restructuring dysfunctional thinking and maladaptive beliefs, and developing emotional and behavioural compensatory strategies for the core deficits.
• The sequence of treatment modules was clearly defined.

We assessed 'CBT as a monotherapy' separately from 'CBT as part of a combined treatment' because the latter may present interactive effects that are not accounted for by any of the interventions alone. We evaluated these as follows.

• CBT versus unspecific control conditions (supportive psychotherapies, waiting list or no treatment).
• CBT plus pharmacotherapy versus pharmacotherapy alone.
• CBT versus other specific interventions (control interventions that include therapeutic ingredients specifically targeted to ADHD).

We did not impose any restriction with regard to the format of the treatment (that is, the duration, quantity and frequency of sessions).

Types of outcome measures

We considered psychometrically validated self‐report measures or those completed by an independent rater or relative.

We present clinical and self‐reported outcomes separately, as do most studies about this topic, because assessing ADHD is more accurate when symptom information comes from more than one source ( Barkley 1998a ).

We considered the measures as short term (up to 6 months), medium term (6 months to 12 months) and long term (more than 12 months).

We included studies that assessed at least one primary outcome or at least one secondary outcome.

Primary outcomes

We assessed the core symptoms of ADHD (inattention, hyperactivity and impulsivity) as a whole. If the authors of a study reported these symptoms separately, we included the data in the analysis. We assessed the core symptoms using validated measures such as those listed below.

Continuous outcomes (efficacy)

• Current Symptoms Scale ( Barkley 1998a )
• Conners' Adult ADHD Rating Scales ‐ Self‐Report: Long Version ( Conners 1999a )
• Conners' Adult ADHD Rating Scales ‐ Observer Report ( Conners 1999a )

Dichotomous outcomes (safety)

• All‐cause treatment discontinuation (proportion of patients randomised who dropped out from the study due to any cause, such as adverse effects of medication)

We assessed the efficacy variables listed below as secondary outcomes. The listed measures are mentioned only as examples, and the list is not exclusive.

Continuous outcomes

• Beck Depression Inventory II ( Beck 1996 )
• Beck Anxiety Inventory ( Beck 1988 )
• Hamilton Depression Scale ( Hamilton 1960 )
• Hamilton Anxiety Scale ( Hamilton 1959 )
• State‐Trait Anxiety Inventory ( Speilberger 1989 )
• Anger: State‐Trait Anger Expression Inventory ( Spielberger 1988 )
• Self‐esteem: Rosenberg Self‐Esteem Inventory ( Rosenberg 1965a )
• Quality of life: Adult Attention‐Deficit/Hyperactivity Disorder Quality‐of‐Life Scale ( Brod 2005 )

Dichotomous outcomes

• Employment status (for example, working/not working, full‐time/part‐time, as defined by the authors of the study)

Considering that self‐ and clinician‐reported core symptoms are the main targets of CBT, we included them in the 'Summary of findings' tables. We prepared these tables using the GRADE methodology ( Atkins 2004 ; Guyatt 2011 ). To assess the magnitude of effect for continuous outcomes, we used the criteria suggested in section 12.6.2 of the Cochrane Handbook for Systematic Reviews of Interventions ( Re‐expressing SMDs using rules of thumb for effect sizes ): 0.2 represents a small effect, 0.5 a moderate effect, and 0.8 a large effect ( Higgins 2011 ).

Search methods for identification of studies

We used the following search terms and their synonyms: 'attention deficit disorder with hyperactivity', 'cognitive‐behavioural therapy' and 'adults' We used the Cochrane Highly Sensitive Search Strategy to identify RCTs in MEDLINE ( Lefebvre 2011 ). We modified the search strategy as necessary for other databases.

Electronic searches

We searched the following databases in June 2017. We did not limit the searches by date or language (see search strategies in Appendix 1 ).

• Cochrane Central Register of Controlled Studies (CENTRAL; 2017, Issue 6) in the Cochrane Library, which contains the Cochrane Developmental Psychosocial and Learning Problems Group Specialised Register (searched 13 June 2017).
• MEDLINE PubMed, US National Library of Medicine (www.ncbi.nlm.nih.gov/pubmed; 1971 to 13 June 2017).
• Embase Elsevier (1974 to 13 June 2017).
• CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to 27 June 2017).
• PsycINFO EBSCO (1967 to 15 June 2017).
• BIOSIS Previews Web of Science (1926 to 16 June 2017).
• Cochrane Database of Systematic Reviews (CDSR; 2017 Issue 6), part of the Cochrane Library (searched 13 June 2017).
• Database of Abstracts of Reviews of Effects (DARE; 2015 Issue 2), part of the Cochrane Library (searched 13 June 2017).
• LILACS (Latin American and Caribbean Health Sciences Literature; lilacs.bvsalud.org/es; searched 18 June 2017).
• Networked Digital Library of Theses and Dissertations (NDLTD; www.ndltd.org/resources; searched 27 June 2017).
• ClinicalTrials.gov (clinicaltrials.gov; searched 23 June 2017).
• ISRCTN registry BioMed Central (www.isrctn.com; searched 23 June 2017).
• World Health Organization International Clinical Trials Registry Portal (WHO ICTRP; apps.who.int/trialsearch; searched 23 June 2017).

Searching other resources

On 17 June 2017, we handsearched the World Congress of Behavioral and Cognitive Therapies from 1995 to 2016, together with the following websites.

• Association for Behavioural and Cognitive Therapies (ABCT) Convention, 2008 to 2017 (www.abct.org/Conventions/?m=mConvention&fa=PastFutureConvention).
• World Congress on ADHD, organised by the World Federation of ADHD, 2007 to 2017 (www.adhd‐federation.org/congresshistory).
• Annual Meeting ‐ American Psychiatric Association (APA), 1973 to 2016 (www.psychiatry.org/psychiatrists/search‐directories‐databases/library‐and‐archive).

We also consulted experts and researchers in the field, including investigators from all review articles and primary studies identified through searches, about ongoing or unpublished trials.

Selection of studies

Two review authors (PL and FT) independently screened the titles and abstracts using the Early Review Organizing Software (EROS) ( Ciapponi 2011 ; Glujovsky 2011 ; Glujovsky 2010 ). If it was clear from the title and abstract that the study did not meet the eligibility criteria, we rejected it. If it was not clear, then we obtained the full text of the study, and both review authors independently evaluated the paper using EROS to determine if the study should be included or excluded. If there was disagreement, the review authors tried to solve it by reaching a consensus. In the case that these two review authors could not reach a consensus, a third author (AC) independently assessed the study and resolved the disagreement. We recorded the results of this selection process in a PRISMA diagram ( Moher 2009 ).

Data extraction and management

Two review authors (PL and FT) independently extracted data from each included study and entered the information onto a pro‐forma document designed and piloted for this purpose. We extracted information about the 'Risk of bias' criteria and the methods of participant selection. We also extracted information about the populations, interventions, comparisons, outcomes, outcome data, study designs, gender, comorbidity, severity and baseline symptoms. The two review authors resolved any differences in opinion by consensus. If they were unable to do so, a third review author (AC) was included in the decision process, and all three review authors discussed the issue and made a final decision.

Assessment of risk of bias in included studies

We evaluated the risk of bias in each included trial using the seven criteria described in Table 8.5.d ('Criteria for judging risk of bias in the "Risk of bias" assessment tool' ) of the Cochrane Handbook for Systematic Reviews of Interventions ( Higgins 2011 ). Two review authors (PL and FT) independently assessed each included study as being at low, high or unclear (uncertain) risk of bias for each domain, using EROS software ( Ciapponi 2011 ; Glujovsky 2011 ; Glujovsky 2010 ); see Table 4 . If there were discrepancies between their assessments, and the two review authors were unable to reach a consensus, a third review author (AC) joined the decision‐making process. All three review authors discussed the issue and made a final decision.

Measures of treatment effect

Continuous data.

We calculated mean differences (MD) when studies used the same measure and standardised mean differences (SMD) when studies used different measurement scales, and we present these with 95% confidence intervals (CIs). When necessary, we calculated the effect estimates from the P values, t statistics or other available statistics.

We interpreted the magnitude of effect for the SMD using a rule of thumb where we considered 0.2 as a small effect, 0.5 as a moderate effect, and 0.8 as a large effect ( Cohen 1988 ).

For the studies that reported only change scores, we performed separate analyses from the studies that provided only final values. We combined both values using the generic inverse variance method ( Higgins 2011 ).

In cases in which there were at least two studies pooled for the same comparison of results, we used the median change to facilitate readers' understanding.

We provide a table reporting relative effects in order to allow comparisons of effects of interventions across all outcomes (see Appendix 2 ). We reported the absolute and relative changes (95% CI) related to the control central estimates of each outcome (negative percentages indicate a reduction of symptoms).

Dichotomous data

We did not find dichotomous data to include in this review (see Lopez 2013 ; Table 5 ).

CBT : cognitive‐behavioural intervention; CI : confidence interval; ICC : intracluster correlation coefficient; RCT : randomised controlled trial; SD : standard deviation.

See also Lopez 2013 .

Unit of analysis issues

For each included study, we determined the appropriateness of the unit of analysis for the unit of randomisation and the design of each study (the number of observations had to match the number of units that were randomised). We expected to find trials with a simple parallel‐group design, with participants randomly allocated as individuals, and a single measurement collected and analysed for each outcome from each participant.

Cluster‐RCTs and cross‐over trials

We did not find cluster‐RCTs or cross‐over trials (see Lopez 2013 ; Table 5 ).

Multiple treatment groups

For trials with multiple treatment groups, we combined the results across all eligible treatment arms and compared them with the combined results across all eligible control arms, making single, pair‐wise comparisons. Where such a strategy prevented an investigation of the potential sources of heterogeneity, we analysed each treatment arm separately (against a common control group) but divided the sample size of the common comparator groups proportionately across each comparison ( Higgins 2011 , section 16.5.4). This approach prevented inappropriate double‐counting of individuals.

Dealing with missing data

When necessary, we attempted to contact the corresponding authors of the included studies up to three times to collect any unreported data.

We described missing data and dropouts for each included study in the 'Risk of bias' table (beneath the Characteristics of included studies tables), reporting the reasons for missing data and the number and characteristics of dropouts, and we discussed in the 'Quality of the evidence' section the extent to which the missing data could threaten our results due to attrition bias.

We made no assumptions about loss to follow‐up for continuous data, and we based the analyses on those participants who completed the trial.

See Lopez 2013 and Table 5 .

Assessment of heterogeneity

We appraised the extent of clinical heterogeneity among the studies by comparing the distribution of participant characteristics (comorbidity, severity, baseline symptoms, ADHD subtype) and study factors (randomisation, allocation concealment, blinding of outcome assessment, loss to follow‐up, treatment type, type of control group, co‐interventions, different types of outcome measurements). We assessed these variables by subgroup analysis if I 2 was more than 30%. Additionally, we deemed a low P value for the Chi 2 test (< 0.10) as sufficient reason to explore causes of heterogeneity ( Subgroup analysis and investigation of heterogeneity ).

We described the statistical heterogeneity of the intervention effects by calculating the I 2 statistic and using the Chi 2 test. The thresholds used for the interpretation of I 2 can be misleading because the importance of inconsistency depends on several factors. We interpreted it as follows.

• 0% to 40%: might not be important.
• 30% to 60%: may represent moderate heterogeneity.
• 50% to 90%: may represent substantial heterogeneity.
• 75% to 100%: represents considerable heterogeneity.

Assessment of reporting biases

Had there been at least 10 studies in a meta‐analysis, we would have used funnel plots to detect bias. Funnel plot asymmetry can be due to publication bias, but it can also be due to a real relationship between trial size and effect size, such as when larger trials have a lower adherence, and adherence is positively related to effect size. In general, asymmetry may be due to selection biases (publication bias, delayed publication bias, location bias, selective outcome reporting), poor methodological quality leading to spuriously inflated effects in smaller studies (poor methodological design, inadequate analysis, fraud), true heterogeneity or chance ( Egger 1997 ). We used the test proposed by Egger 1997 for continuous outcomes to test for funnel plot asymmetry ( Higgins 2011 ).

Data synthesis

We synthesised the results in a meta‐analysis using Review Manager 5 (RevMan 5) when we considered studies to be sufficiently homogenous in terms of population (regarding sex, age and diagnosis), interventions (comparable modalities of CBT) and comparisons (as a monotherapy or a part of a combined treatment) to avoid clinical heterogeneity, and in terms of outcome measurement methods to avoid methodological heterogeneity ( RevMan 2014 ). Two authors assessed homogeneity independently and solved discrepancies by consensus. In the cases where comparisons had a considerable heterogeneity but the same direction, we present both the global results and the results of each study separately in order to show the range of effects comprised in the comparisons.

We used both a fixed‐effect model and a random‐effects model and compared them to assess the degree of statistical heterogeneity. Because we assumed that clinical heterogeneity was very likely to impact our review results, given the nature of the interventions included, we primarily reported the results of the random‐effects model, regardless of statistical evidence of heterogeneity. We calculated all effects using inverse variance methods. For continuous data, the change in score from baseline to postintervention was the main outcome of interest. We analysed separately continuous data reported as change scores in some studies and as final values in other studies. Additionally, we combined these values using the generic inverse variance method ( Higgins 2011 ).

Subgroup analysis and investigation of heterogeneity

Where it was possible to secure the necessary data, we conducted subgroup analyses, classifying the trials as follows.

• Type of ADHD subtype: inattentive, hyperactive‐impulsive or combined type.
• Type of control group: other specific treatment or unspecific control conditions (supportive psychotherapies, waiting list or no treatment).

We calculated a pooled effect size for each subgroup.

Sensitivity analysis

We used sensitivity analyses to assess the impact of risk of bias on the results of the primary analyses. For this review, we undertook sensitivity analyses to determine the effect of removing from the analysis: studies with high risk of selection bias (associated with sequence generation or allocation concealment); studies with high risk of performance bias (associated with issues of blinding); and studies with high risk of attrition bias (associated with completeness of data). In addition, we assessed the sensitivity of findings to any imputed data within a study.

We investigated the impact of applying a fixed‐effect model on the results compared to that of a random‐effects model. We also compared the impact of using the odds ratio as an effect measure compared to the risk difference.

Summary of findings table

We prepared a 'Summary of findings' table for our three main comparisons (see Types of interventions ) according to GRADE methodology ( Atkins 2004 ; Guyatt 2011 ), using GRADEpro GDT software ( GRADEpro 2015 ). We included our primary outcome, the core symptoms of ADHD (self‐, clinician‐ or observer‐reported), in the tables.

Two review authors (AC and PL) independently assessed the quality of the evidence as high, moderate, low or very low, downgrading the rating according to the presence of study limitations, including the studies' 'Risk of bias' level; imprecision; inconsistency of results; indirectness of evidence; and likely publication bias.

To assess the magnitude of effect for continuous outcomes, we used the criteria suggested in the Cochrane Handbook for Systematic Reviews of Interventions ( Higgins 2011 ): 0.2 represents a small effect, 0.5 a moderate effect, and 0.8 a large effect.

Description of studies

Results of the search.

Our database searches returned 12,088 records (10,306 unique records). We did not find any relevant records by handsearching sources of congress or conference abstracts. After screening titles and abstracts, we deemed 10,237 records to be irrelevant and retrieved 69 full texts for further scrutiny. Of these 69 reports, 14 studies (from 15 reports) met our predefined inclusion criteria ( Criteria for considering studies for this review ); we considered one additional reference to be a secondary reference of Stevenson 2002 because the authors used the same data set and reported the same results. We excluded 49 reports as irrelevant ( Excluded studies ) and identified five ongoing studies. See Figure 1 .

Study flow diagram.

Included studies

Study design.

Authors of the 14 included studies described them as RCTs, with a parallel group design, blinded for participants; each lasted 8 to 15 weeks. We did not find any cluster‐RCTs or cross‐over trials.

Four trials were in outpatients in the USA ( Fleming 2015 ; Safren 2005 ; Safren 2010 ; Solanto 2010 ), and three took place in Sweden ( Hirvikoski 2011 ; Moëll 2015 ; Pettersson 2017 ). The seven remaining trials were carried out in: Australia ( Stevenson 2002 ), China ( Gu 2017 ), Finland ( Virta 2010 ), Iceland ( Emilsson 2011 ), the Netherlands ( Hepark 2015 ; Schoenberg 2014 ), and Spain ( Vidal Estrada 2013 ).

Participants

In total, the 14 trials recruited 700 participants aged 18 to 65 years.

The included trials used three different versions of DSM criteria.

• Third Edition‐Revised ( DSM‐III‐R 1989 ), used in one trial ( Stevenson 2002 );
• Fourth Edition ( DSM‐IV 1994 ), used in eight trials ( Emilsson 2011 ; Hirvikoski 2011 ; Moëll 2015 ; Safren 2005 ; Safren 2010 ; Solanto 2010 ; Vidal Estrada 2013 ; Virta 2010 ); and IV‐Text Revision ( DSM‐IV‐TR 2000 ), used in three trials ( Hepark 2015 ; Pettersson 2017 ; Schoenberg 2014 ).
• Fifth Edition ( DSM‐5 2013 ) used in two trials ( Fleming 2015 ; Gu 2017 ).

Intervention and comparisons

All of the trials reported the effects of CBT‐based treatments on adults with ADHD symptoms. We included studies that assessed mindfulness‐based interventions when authors explicitly stated that the treatment included CBT principles or techniques together with mindfulness procedures. We considered meta‐cognitive therapy and dialectical behaviour therapy as variants of CBT. The trials included the following interventions and comparisons.

• Gu 2017 : mindfulness‐based cognitive therapy versus waiting list.
• Hepark 2015: mindfulness‐based cognitive therapy versus waiting list.
• Hirvikoski 2011 : dialectical behavioural therapy‐based skills training versus structured discussion group.
• Moëll 2015 : CBT‐inspired Internet‐based course with support (Living Smart) versus waiting list.
• Pettersson 2017 : Internet CBT in a self‐help format (iCBT‐S) versus waiting list, and Internet CBT plus weekly group therapy sessions (iCBT‐G) versus waiting list.
• Schoenberg 2014 : mindfulness‐based cognitive therapy versus waiting list.
• Solanto 2010 : meta‐cognitive therapy versus supportive therapy.
• Stevenson 2002 : standard CBT versus waiting list.
• Virta 2010 : standard CBT versus no treatment.
• Emilsson 2011 .
• Safren 2005 .
• Fleming 2015 : dialectical behavioural therapy versus a skills handouts control condition.
• Safren 2010 : standard CBT versus relaxation with educational support.
• Vidal Estrada 2013 : standard CBT plus limited psychoeducation versus psychoeducation.
• Virta 2010 : standard CBT versus cognitive training.

Outcome measures

The included trials used a diversity of outcome measures, which made it difficult to make statistical comparisons between treatment regimens. The outcomes were based on clinical assessments by a physician or by self‐report through the use of validated scales.

We defined treatment efficacy as an improvement in the core symptoms of ADHD, which was evaluated in terms of specific ADHD symptoms, namely hyperactivity, inattentiveness and impulsivity, using clinical, symptom‐specific scales and scores. The authors used a heterogeneous group of scales for each outcome (see details in Table 6 ).

ADHD : attention deficit hyperactivity disorder; DSM‐III‐R : Diagnostic and Statistical Manual of Mental Disorders ‐ Third Edition ‐ Revised ; NIMH : National Institutes of Mental Health.

The authors used a heterogeneous group of scales to assess the secondary outcomes (see details in Table 7 ).

ADHD: attention deficit hyperactivity disorder.

Excluded studies

We excluded 49 full‐text reports as ineligible for this review for the following reasons.

• Not an RCT (n = 8).
• Not CBT (n = 14).
• Comparison not considered in this review (n = 7).
• Others (protocols, or not ADHD in adults) (n = 20).

We described seven of these studies, which initially seemed to merit inclusion but on closer inspection did not, in the Characteristics of excluded studies tables. We excluded one study because it compared group psychotherapy versus individual psychotherapy, thereby affecting the comparability of the intervention of interest of our review ( Philipsen 2015 ). We excluded two studies because the authors explained that their goal was to assess the efficacy of mindfulness, in Mitchell 2013 , and mindfulness plus virtual reality, in Serra‐Pla 2017 , without introducing other treatment modalities such as CBT. We excluded four studies because the comparisons used in these studies did not correspond to the comparisons included in our protocol ( Cherkasova 2016 ; Weiss 2012 ; Young 2015 ; Young 2017 ).

Ongoing studies

We also found five ongoing studies ( ISRCTN03732556 ; {"type":"clinical-trial","attrs":{"text":"NCT02463396","term_id":"NCT02463396"}} NCT02463396 ; {"type":"clinical-trial","attrs":{"text":"NCT02062411","term_id":"NCT02062411"}} NCT02062411 ; {"type":"clinical-trial","attrs":{"text":"NCT02210728","term_id":"NCT02210728"}} NCT02210728 ; {"type":"clinical-trial","attrs":{"text":"NCT02829970","term_id":"NCT02829970"}} NCT02829970 ). See Characteristics of ongoing studies tables.

Risk of bias in included studies

No trial was free from bias across all 'Risk of bias' domains. Authors often described randomisation and allocation concealment processes poorly (See Figure 2 and Figure 3 for 'Risk of bias' graphs). When the authors did not explicitly state the sequence generation method, we asked them for this information through email correspondence ( Emilsson 2011 ; Gu 2017 ; Hepark 2015 ; Hirvikoski 2011 ; Safren 2005 ; Safren 2010 ; Schoenberg 2014 ; Solanto 2010 ; Stevenson 2002 ; Vidal Estrada 2013 ; Virta 2010 ).

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

All included studies were at high risk of performance bias because it is not possible to blind personnel in psychotherapy. For 10 studies, this was the only domain at high risk of bias.

We considered four studies to be at high risk of bias for another domain. Emilsson 2011 was at high risk of attrition and other bias. Pettersson 2017 was at high risk of attrition bias and had conflicts of interest. These two studies had a higher number of domains with high risk of bias. Additionally, we considered Schoenberg 2014 to be at high risk of detection bias because the outcome assessor was not blinded. Finally, we judged Moëll 2015 to be at high risk of other bias.

Sequence generation

Eight trials were at low risk of bias ( Hepark 2015 ; Pettersson 2017 ; Safren 2005 ; Safren 2010 ; Schoenberg 2014 ; Solanto 2010 ; Vidal Estrada 2013 ; Virta 2010 ). Six trials were at unclear risk of bias because there was no description of the sequence generation process ( Emilsson 2011 ; Fleming 2015 ; Gu 2017 ; Hirvikoski 2011 ; Moëll 2015 ; Stevenson 2002 ).

Allocation concealment

Five trials had an adequate description of the allocation concealment process, and we considered them to be at low risk of bias in this domain ( Hepark 2015 ; Pettersson 2017 ; Safren 2005 ; Schoenberg 2014 ; Stevenson 2002 ).

We considered the remaining nine trials to be at unclear risk of bias. Solanto 2010 affirmed that individuals were stratified by whether or not they were currently receiving medication for ADHD and otherwise randomly assigned to either the CBT or the support group; however, the authors did not describe how they designed this process. Authors of the eight remaining trials provided no information about the randomisation process ( Emilsson 2011 ; Fleming 2015 ; Gu 2017 ; Hirvikoski 2011 ; Moëll 2015 ; Safren 2010 ; Vidal Estrada 2013 ; Virta 2010 ).

Blinding of participants and personnel

We judged all studies to be at high risk of performance bias because, as usual in psychotherapy, it is not possible to blind the personnel ( Emilsson 2011 ; Fleming 2015 ; Gu 2017 ; Hepark 2015 ; Hirvikoski 2011 ; Moëll 2015 ; Pettersson 2017 ; Safren 2005 ; Safren 2010 ; Schoenberg 2014 ; Solanto 2010 ; Stevenson 2002 ; Vidal Estrada 2013 ; Virta 2010 ).

Blinding of outcome assessment

We considered 11 trials to be at low risk of detection bias because the assessors were blinded to group assignment ( Emilsson 2011 ; Fleming 2015 ; Gu 2017 ; Hepark 2015 ; Moëll 2015 ; Pettersson 2017 ; Safren 2005 ; Safren 2010 ; Solanto 2010 ; Vidal Estrada 2013 ; Virta 2010 ).

We considered the risk of detection bias to be unclear in two studies because authors did not adequately describe the blinding of the results ( Hirvikoski 2011 ; Stevenson 2002 ).

Finally, we rated one study, Schoenberg 2014 , at high risk of detection bias because the outcome assessor was not blinded.

Incomplete outcome data

We considered nine trials to be at a low risk of attrition bias since the effect size among the missing outcomes was not enough to have a clinically relevant impact on the observed effect size ( Fleming 2015 ; Gu 2017 ; Moëll 2015 ; Safren 2005 ; Schoenberg 2014 ; Solanto 2010 ; Stevenson 2002 ; Vidal Estrada 2013 ; Virta 2010 ).

We judged two studies to be at high risk of attrition bias because the dropout rate was around 40% ( Emilsson 2011 ; Pettersson 2017 ), and the remaining three were at unclear risk of bias: Hepark 2015 and Safren 2010 performed an intention‐to‐treat (ITT) analysis, but there was unbalanced rate of dropouts, and Hirvikoski 2011 performed ITT analysis, but there was an important rate of dropouts (around 20% per group).

Selective reporting

We considered all trials to be free of reporting bias because the published results corresponded to those expected in these types of studies ( Emilsson 2011 ; Fleming 2015 ; Gu 2017 ; Hepark 2015 ; Hirvikoski 2011 ; Moëll 2015 ; Pettersson 2017 ; Safren 2005 ; Safren 2010 ; Schoenberg 2014 ; Solanto 2010 ; Stevenson 2002 ; Vidal Estrada 2013 ; Virta 2010 ). Five studies prospectively registered the trial, but it was clear that the published reports included all expected outcomes, including those that were pre‐specified ( Emilsson 2011 ; Moëll 2015 ; Safren 2005 ; Safren 2010 ; Solanto 2010 ); we assessed whether the outcome measures described in the Methods of the paper were reported in the Results section.

Other potential sources of bias

We considered 12 trials to be either free of other potential sources of bias or as being at low risk of other bias ( Fleming 2015 ; Gu 2017 ; Hepark 2015 ; Hirvikoski 2011 ; Pettersson 2017 ; Safren 2005 ; Safren 2010 ; Schoenberg 2014 ; Solanto 2010 ; Stevenson 2002 ; Vidal Estrada 2013 ; Virta 2010 ).

We considered two trials to be at high risk of other bias ( Emilsson 2011 ; Moëll 2015 ). Emilsson 2011 did not ask the participants in either condition to refrain from engaging in other interventions during the study period. In Moëll 2015 , the authors reported a lack of confirmed ADHD‐diagnoses for some of the participants, and 12% did not receive an ADHD diagnosis after their previous neuropsychiatric assessment and were thus classified as having sub‐clinical ADHD.

Conflicts of interest

One study had conflicts of interest, and we considered it to be at high risk of bias ( Pettersson 2017 ). We rated all remaining studies at low risk of bias for this domain ( Emilsson 2011 ; Fleming 2015 ; Gu 2017 ; Hepark 2015 ; Hirvikoski 2011 ; Moëll 2015 ; Safren 2005 ; Safren 2010 ; Schoenberg 2014 ; Solanto 2010 ; Stevenson 2002 ; Vidal Estrada 2013 ; Virta 2010 ).

Effects of interventions

See: Table 1 ; Table 2 ; Table 3

Summary of findings for the main comparison

a We downgraded the quality of evidence due to imprecision (considering the width of the CI), methodological limitations (due to high risk of bias in blinding of participants and personnel), and because the evidence is based on a single study. b To assess the magnitude of effect for continuous outcomes, we used the criteria suggested by Cohen 1988 : 0.2 represents a small effect, 0.5 a moderate effect, and 0.8 a large effect. c We downgraded the quality of evidence due to imprecision (considering the width of the CI) and methodological limitations (due to high risk of bias in blinding of participants and personnel and five other domains with unclear risk of bias). d We downgraded the quality of evidence due to imprecision (considering the width of the CI), methodological limitations (due to high risk of bias in blinding of participants and personnel and three other domains with unclear risk of bias) and inconsistency (considering the I 2 of 74%). The estimates of each study was: Hepark 2015 SMD −0.85 lower (−1.30 lower to −0.40 lower) and Stevenson 2002 SMD −1.68 lower (−2.39 lower to −0.98 lower). e We downgraded the quality of evidence due to methodological limitations (considering that two out of the five studies were at high risk of bias in more than one domain other than blinding of participants and personnel).

Summary of findings 2

a We downgraded the quality of evidence due to methodological limitations (high risk of bias in blinding of participants and personnel, and the fact that Emilsson 2011 had a high risk of bias in three domains in one of the two included studies). b We downgraded the quality of evidence due to imprecision (considering the width of the CI). c To assess the magnitude of effect for continuous outcomes, we used the criteria suggested by Cohen 1988 : 0.2 represents a small effect, 0.5 a moderate effect, and 0.8 a large effect.

Summary of findings 3

a We downgraded the quality of evidence because of imprecision (considering the width of the CI) and methodological limitations (due to the high risk of bias in blinding of participants and personnel and three other domains with unclear risk of bias). b To assess the magnitude of effect for continuous outcomes, we used the criteria suggested by Cohen 1988 : 0.2 represents a small effect, 0.5 a moderate effect, and 0.8 a large effect.

CBT versus unspecific control conditions

Adhd symptoms, aggregated adhd symptoms.

Three studies evaluated the effect of CBT on observer‐reported ADHD symptoms against unspecific control conditions (Analysis 1.1). Solanto 2010 compared CBT to supportive therapy for this outcome and found a significant effect of treatment (SMD −0.56, 95% CI −1.01 to −0.12; 81 participants; low‐quality evidence; moderate effect size, see Summary of findings table 1). Two studies (126 participants) comparing CBT to waiting list showed significant effects favouring CBT (SMD −1.22, 95% CI −2.03 to −0.41; I 2 = 74%; very low‐quality evidence; large effect size; (see Summary of findings table 1): Hepark 2015 (SMD −0.85, 95% CI −1.30 to −0.40; 83 participants) and Stevenson 2002 (SMD −1.68, 95% CI −2.39 to −0.98; 43 participants). Considering that the results of Hepark 2015 and Stevenson 2002 are expressed as SMDs, in line with the methods described in Measures of treatment effect , we present the results of Solanto 2010 as an SMD (SMD −0.56, 95% CI −1.01 to −0.12) in the forest plot because it is not possible to present different statistical measures in the same graphic.

Seven studies assessed the effect of CBT versus unspecific control conditions on self‐reported ADHD symptoms ( Analysis 1.2 ). Two studies (122 participants) compared CBT with supportive therapy ( Hirvikoski 2011 ; Solanto 2010 ), finding no significant effect of treatment (SMD −0.16, 95% CI −0.52 to 0.19; I 2 = 0%; low‐quality evidence; small effect size; see Table 1 ). Analysis of the five studies (251 participants) that compared CBT to waiting list revealed a significant effect on this outcome favouring CBT (SMD −0.84, 95% CI −1.18 to −0.50; I 2 = 38%; Gu 2017 ; Hepark 2015 ; Pettersson 2017 ; Schoenberg 2014 ; Virta 2010 ; moderate‐quality evidence; large effect size; see Table 1 ).

Comparison 1 CBT vs unspecific control conditions, Outcome 2 ADHD symptoms (self‐reported).

Disaggregated ADHD symptoms

Two studies evaluated the effect of CBT on clinician‐reported inattention separately ( Analysis 1.3 ). One study, Solanto 2010 , compared CBT to supportive therapy using the Adult ADHD Investigator Symptom Rating Scale (AISRS) Inattention subscale (range 0 (best) to 27 (worst)) (MD −2.47 points, 95% CI −4.43 points to −0.51 points; 81 participants), and the other study, Hepark 2015 , compared CBT to waiting list using Conners' Adult ADHD Rating Scale ‐ Investigator Rated (CAARS‐INV; range 0 (best) to 27 (worst)) (MD −4.10 points, 95% CI −6.00 points to −2.20 points; 83 participants). Both studies showed a significant effect of treatment.

Comparison 1 CBT vs unspecific control conditions, Outcome 3 Inattention (clinician).

Four studies (244 participants) compared the effect of CBT on self‐reported inattention to waiting list ( Gu 2017 ; Hepark 2015 ; Moëll 2015 ; Schoenberg 2014 ). The analysis revealed a significant effect in favour of CBT (SMD −1.10, 95% CI −1.37 to −0.82; I 2 = 0%; large effect size; Analysis 1.4 ).

Comparison 1 CBT vs unspecific control conditions, Outcome 4 Inattention: CBT vs waiting list (self‐reported).

Hepark 2015 assessed clinician‐reported hyperactivity‐impulsivity using the CAARS‐INV (range 0 (best) to 27 (worst)) in the comparison of CBT versus waiting list and found a significant effect of treatment on this outcome (MD −2.50 points, 95% CI −4.63 points to −0.37 points; 83 participants; see the illustrative forest plot in Analysis 1.5 ).

Comparison 1 CBT vs unspecific control conditions, Outcome 5 Hyperactivity‐impulsivity: CBT vs waiting list (clinician).

Four studies (244 participants) compared CBT to waiting list for self‐reported hyperactivity‐impulsivity ( Gu 2017 ; Hepark 2015 ; Moëll 2015 ; Schoenberg 2014 ), finding a significant effect in favour of CBT (SMD −0.60, 95% CI −0.98 to −0.22; I 2 = 53%; moderate effect size; Analysis 1.6 ).

Comparison 1 CBT vs unspecific control conditions, Outcome 6 Hyperactivity‐impulsivity: CBT vs waiting list (self‐reported).

All‐cause treatment discontinuation

Schoenberg 2014 reported excluding two participants because one did not attend the full 12‐week mindfulness‐based cognitive therapy intervention, and the second started extra mindfulness training outside the intervention; nine other participants dropped out of the study due to competing time commitments. Gu 2017 reported that two participants dropped out of mindfulness‐based cognitive therapy after six sessions and did not complete the post‐treatment or follow‐up assessments. There were no dropouts due to adverse events reported for this comparison.

Two of the 21 participants who completed the treatment from a study that evaluated dialectical behavioural therapy reported adverse events to the group leaders at the post‐treatment assessment. Both of them reported anxiety related to separation from the group ( Hirvikoski 2011 ). They had both started pharmacological treatment during the ongoing group treatment. In the control group, two individuals (2/20 who completed the group) reported adverse events to the project leader (TH). These individuals also experienced temporary anxiety due to separation from the group, and they especially missed other participants in the group, rather than group leaders or the sessions themselves. No serious adverse events were reported.

Psychopathology

Six studies assessed self‐reported depression. One study (81 participants) compared CBT to supportive therapy ( Solanto 2010 ), finding no significant differences (SMD 0.07, 95% CI −0.36 to 0.51; small effect size). The remaining five studies (258 participants) compared CBT to waiting list ( Gu 2017 ; Hepark 2015 ; Moëll 2015 ; Pettersson 2017 ; Virta 2010 ), finding a significant effect of treatment on self‐reported depression (SMD −0.36, 95% CI −0.60 to −0.11; I 2 = 0%; small effect size; see Analysis 1.7 ).

Comparison 1 CBT vs unspecific control conditions, Outcome 7 Depression (self‐reported).

One study (81 participants) assessed clinician‐rated anxiety using the Hamilton Anxiety Scale (HAM‐A; range 0 (best) to 56 (worst)) ( Solanto 2010 ), finding no significant effect of CBT compared to supportive therapy (MD −0.81 points, 95% CI −3.21 points to 1.59 points; see the illustrative forest plot in Analysis 1.8 ).

Comparison 1 CBT vs unspecific control conditions, Outcome 8 Anxiety: CBT vs supportive therapy (clinician).

Four studies (239 participants) compared CBT to waiting list for self‐reported anxiety ( Gu 2017 ; Hepark 2015 ; Moëll 2015 ; Schoenberg 2014 ). The analysis revealed a significant effect favouring CBT on this outcome (SMD −0.45, 95% CI −0.71 to −0.19; I 2 = 23%; small effect size; Analysis 1.9 ).

Comparison 1 CBT vs unspecific control conditions, Outcome 9 Anxiety: CBT vs waiting list (self‐reported).

One study (43 participants) compared CBT to waiting list using the State‐Trait Anger Expression Inventory (STAXI; range 0 (best) to 66 (worst)) ( Stevenson 2002 ), finding a significant effect of treatment on self‐reported state anger (MD −3.30 points, 95% CI −5.62 points to −0.98 points; see the illustrative forest plot in Analysis 1.10 ) and a non‐significant effect on self‐reported trait anger (MD −3.80 points, 95% CI −7.63 points to 0.03 points; see the illustrative forest plot in Analysis 1.11 ).

Comparison 1 CBT vs unspecific control conditions, Outcome 10 State anger: CBT vs waiting list (self‐reported).

Comparison 1 CBT vs unspecific control conditions, Outcome 11 Trait anger: CBT vs waiting list (self‐reported).

Self‐esteem

Two studies assessed this outcome ( Analysis 1.12 ). One study, Solanto 2010 , compared CBT to supportive therapy and found no significant effect of treatment (MD 0.00, 95% CI ‐1.85 to 1.85; 81 participants). The other study, Stevenson 2002 , compared CBT to waiting list and found a significant effect favouring CBT (MD 12.40, 95% CI 4.55 to 20.25; 43 participants; large effect size).

Comparison 1 CBT vs unspecific control conditions, Outcome 12 Self‐esteem (self‐reported).

Quality of life

Two studies (64 participants) evaluated CBT versus waiting list ( Pettersson 2017 ; Virta 2010 ), finding no significant effect of treatment on self‐reported quality of life (SMD 0.21, 95% CI −0.29 to 0.71; I 2 = 0%; small effect size; Analysis 1.13 ).

Comparison 1 CBT vs unspecific control conditions, Outcome 13 Quality of life: CBT vs waiting list (self‐reported).

CBT plus pharmacotherapy versus pharmacotherapy alone

Two studies compared CBT plus pharmacotherapy versus pharmacotherapy alone ( Emilsson 2011 ; Safren 2005 ). The analysis revealed a significant effect of treatment on clinician‐reported ADHD symptoms (SMD −0.80, 95% CI −1.31 to −0.30; I 2 = 0%; 65 participants; Analysis 2.1 ; very low‐quality evidence; large effect size) and self‐reported ADHD symptoms (MD −7.42 points, 95% CI −11.63 points to −3.22 points; 66 participants; I 2 = 0%; Analysis 2.2 ; low‐quality evidence), as assessed using the Current Symptoms Scale (CSS; range 0 (best) to 54 (worst)). See Table 2 .

Comparison 2 CBT + pharmacotherapy vs pharmacotherapy alone, Outcome 1 ADHD symptoms (clinician).

Comparison 2 CBT + pharmacotherapy vs pharmacotherapy alone, Outcome 2 ADHD symptoms (self‐reported).

Only one study (35 participants) compared CBT plus pharmacotherapy versus pharmacotherapy alone ( Emilsson 2011 ). The study authors found a significant effect of the combined treatment for self‐reported inattention (MD −4.54 points, 95% CI −7.75 points to −1.33 points; see the illustrative forest plot in Analysis 2.3 ) but no significant effect for self‐reported hyperactivity‐impulsivity (MD −1.70 points, 95% CI −5.29 points to 1.89 points; see the illustrative forest plot in Analysis 2.4 ), as assessed using the CSS (range 0 (best) to 54 (worst)).

Comparison 2 CBT + pharmacotherapy vs pharmacotherapy alone, Outcome 3 Inattention (self‐reported).

Comparison 2 CBT + pharmacotherapy vs pharmacotherapy alone, Outcome 4 Hyperactivity‐impulsivity (self‐reported).

In one study, Emilsson 2011 , one participant in the CBT plus pharmacotherapy condition reported severe distress at the end of treatment due to changes in personal circumstances. This participant then received individual treatment and was not assessed at follow‐up. Emilsson 2011 also described that four participants dropped out during the treatment phase without explanation, one dropped out upon moving out of the area, one due to illness in the family and one due to pregnancy. No dropouts due to adverse events were reported for this comparison, and no other study reported dropouts due to serious adverse events.

Clinical Global Impression

A meta‐analysis of two studies (65 participants) comparing CBT plus pharmacotherapy versus pharmacotherapy alone revealed a significant effect on the Clinical Global Impression scale (CGI; range 1 (best) to 7 (worst)) in favour of the combined treatment (MD −0.75 points, 95% CI −1.21 points to −0.30 points; Emilsson 2011 ; Safren 2005 ; I 2 = 0%; Analysis 2.5 ).

Comparison 2 CBT + pharmacotherapy vs pharmacotherapy alone, Outcome 5 Clinical Global Impression (clinician).

Only one study (31 participants) evaluated clinician‐reported depression using the Hamilton Depression Scale (HAM‐D; range 0 (best) to 52 (worst)) ( Safren 2005 ). The comparison of CBT plus pharmacotherapy versus pharmacotherapy alone showed a significant effect of treatment on this outcome (MD −5.56 points, 95% CI −9.71 points to −1.41 points; Analysis 2.6 ).

Comparison 2 CBT + pharmacotherapy vs pharmacotherapy alone, Outcome 6 Depression (clinician).

Two studies (66 participants) assessed self‐reported depression using the Beck Depression Inventory (BDI; range 0 (best) to 63 (worst)) ( Emilsson 2011 ; Safren 2005 ), reporting a significant effect of CBT plus pharmacotherapy compared to pharmacotherapy alone (MD −6.09 points, 95% CI −9.55 points to −2.63 points; I 2 = 0%; Analysis 2.7 ).

Comparison 2 CBT + pharmacotherapy vs pharmacotherapy alone, Outcome 7 Depression (self‐reported).

One study (31 participants) evaluated clinician‐reported anxiety using the HAM‐A (range 0 (best) to 56 (worst)) ( Safren 2005 ), finding a significant effect favouring combined CBT plus pharmacotherapy compared to pharmacotherapy alone (MD −5.68 points, 95% CI −10.32 points to −1.04 points; Analysis 2.8 ).

Comparison 2 CBT + pharmacotherapy vs pharmacotherapy alone, Outcome 8 Anxiety (clinician).

The analysis of self‐reported anxiety in two studies (66 participants) comparing CBT plus pharmacotherapy versus pharmacotherapy alone revealed a significant effect favouring the combined treatment (SMD −0.58, 95% CI −1.08 to −0.08; I 2 = 0%; moderate effect size; Emilsson 2011 ; Safren 2005 ; Analysis 2.9 ).

Comparison 2 CBT + pharmacotherapy vs pharmacotherapy alone, Outcome 9 Anxiety (self‐reported).

No studies reported data on our other secondary outcomes for this comparison: anger, self‐esteem or quality of life.

CBT versus other specific interventions

Two studies, Safren 2010 and Virta 2010 , assessed CBT compared with other specific non‐pharmacological interventions on clinician‐reported ADHD symptoms. The analysis of this comparison revealed a significant effect favouring CBT (SMD −0.58, 95% CI −0.98 to −0.17; 97 participants; I 2 = 0%; Analysis 3.1 ; low‐quality evidence; moderate effect size; Table 3 ).

Comparison 3 CBT vs other specific interventions, Outcome 1 ADHD symptoms (clinician).

Four studies (156 participants) evaluated the outcome of CBT on ADHD symptoms through self‐reported measures ( Fleming 2015 ; Safren 2010 ; Vidal Estrada 2013 ; Virta 2010 ). The analysis showed a significant effect of CBT on self‐reported ADHD symptom severity when compared with other specific non‐pharmacological interventions (SMD −0.44, 95% CI −0.88 to −0.01; I 2 = 41%; Analysis 3.2 ; low‐quality evidence; small effect size; Table 3 ).

Comparison 3 CBT vs other specific interventions, Outcome 2 ADHD symptoms (self‐reported).

Two studies (65 participants) compared self‐reported inattention symptoms separately ( Fleming 2015 ; Vidal Estrada 2013 ). This comparison showed no significant differences between CBT and other specific interventions (SMD −0.12, 95% CI −0.61 to 0.37; I 2 = 15%; small effect size; Analysis 3.3 ).

Comparison 3 CBT vs other specific interventions, Outcome 3 Inattention (self‐reported).

Only one study (32 participants) compared CBT to psychoeducation using the Conners' Adult ADHD Rating Scale ‐ Self‐Reported (CAARS‐SR; range 0 (best) to 52 (worst)) ( Vidal Estrada 2013 ), finding no significant effect of treatment for self‐reported hyperactivity (MD 1.72 points, 95% CI −4.41 points to 7.85 points; see the illustrative forest plot in Analysis 3.4 ) or self‐reported impulsivity (MD 2.84 points, 95% CI −3.26 points to 8.94 points; Analysis 3.5 ).

Comparison 3 CBT vs other specific interventions, Outcome 4 Hyperactivity: CBT vs psychoeducation.

Comparison 3 CBT vs other specific interventions, Outcome 5 Impulsivity: CBT vs psychoeducation.

One study, Vidal Estrada 2013 , reported that in the psychoeducation group, one participant dropped out after five sessions because of timetable incompatibilities, and one participant was lost to follow‐up because he did not turn up for the post‐treatment assessment. In the CBT group, one participant dropped out because of illness at session six, and three were lost at follow‐up because they missed the post‐treatment evaluation. There were no dropouts due to adverse events reported for this comparison, and no other study reported adverse events for this comparison.

Two studies assessed psychopathology using the clinician‐reported CGI scale (range 1 (best) to 7 (worst)). Safren 2010 , reported no significant effect when comparing CBT to relaxation plus educational support (MD −0.53 points, 95% CI −1.09 points to 0.03 points; 78 participants), nor did Vidal Estrada 2013 , when comparing CBT to psychoeducation (MD 0.18 points, 95% CI −0.19 points to 0.55 points; 32 participants). See Analysis 3.6 .

Comparison 3 CBT vs other specific interventions, Outcome 6 Clinical Global Impression (clinician).

One study (32 participants) assessed psychopathology using the self‐reported CGI scale (range 1 (best) to 7 (worst)) but found no significant effect when comparing CBT to psychoeducation ( Vidal Estrada 2013 ): MD 0.29 points, 95% CI −0.32 points to 0.90 points; see the illustrative forest plot in Analysis 3.7 ).

Comparison 3 CBT vs other specific interventions, Outcome 7 Clinical Global Impression: CBT vs psychoeducation (self‐reported).

Three studies (84 participants) comparing CBT to other specific non‐pharmacological interventions reported non‐significant effects on self‐reported depression (SMD −0.27, 95% CI −0.70 to 0.16; I 2 = 0%; small effect size; Fleming 2015 ; Vidal Estrada 2013 ; Virta 2010 ; Analysis 3.8 ).

Comparison 3 CBT vs other specific interventions, Outcome 8 Depression (self‐reported).

Two studies (65 participants) comparing CBT to other specific non‐pharmacological interventions reported non‐significant effects of treatment on self‐reported anxiety (SMD −0.46, 95% CI −0.95 to 0.04; I 2 = 0%; moderate effect size; Fleming 2015 ; Vidal Estrada 2013 ; Analysis 3.9 ).

Comparison 3 CBT vs other specific interventions, Outcome 9 Anxiety (self‐reported).

Three studies evaluated this outcome through self‐reported measures. One study, Virta 2010 , compared CBT to cognitive training and found a non‐significant effect on self‐reported quality of life (SMD −0.28, 95% CI −1.19 to 0.62; 19 participants; small effect size), as did another study, Vidal Estrada 2013 , which compared CBT to psychoeducation (SMD 0.33, 95% CI −0.37 to 1.03; 32 participants; small effect size). In contrast, Fleming 2015 , which compared CBT to skills handouts, found a significant effect in favour of CBT (SMD 1.17, 95% CI 0.42 to 1.92; 33 participants; large effect size). See Analysis 3.10 .

Comparison 3 CBT vs other specific interventions, Outcome 10 Quality of life (self‐reported).

Sensitivity analyses

Two trials presented with a high risk of attrition bias because they registered an important loss of participants in at least one group and/or no imputation ( Emilsson 2011 ; Pettersson 2017 ).

ADHD symptoms (self‐reported)

Excluding Pettersson 2017 from Analysis 1.2 .2 (subgroup: CBT versus waiting list) did not affect the conclusion (SMD −0.98, 95% CI −1.27 to −0.69; 4 studies, 206 participants; I 2 =0%; large effect size) but did increase the I 2 for the subgroup differences (analysis not shown).

Depression (self‐reported)

Excluding Pettersson 2017 from Analysis 1.7 .2 (subgroup: CBT versus waiting list) did not affect the conclusion (SMD −0.40, 95% CI −0.67 to −0.12; 4 studies, 213 participants; I 2 = 0%; small effect size) but did increase the I 2 for the subgroup differences (analyses not shown).

Anxiety (self‐reported)

Excluding Pettersson 2017 from Analysis 1.9 (CBT versus waiting list) did not affect the conclusion (SMD −0.52, 95% CI −0.81 to −0.23; 3 studies, 194 participants; I 2 = 24%; moderate effect size; analysis not shown).

Quality of life (self‐reported)

Excluding Pettersson 2017 from Analysis 1.13 (CBT versus waiting list) did not affect the conclusion (MD 1.70 points, 95% CI −14.70 points to 18.10 points; rated on Quality of Life Enjoyment and Satisfaction Questionnaire (higher scores indicate greater enjoyment or satisfaction. As Virta 2010 combined the work and school subscale into a work/study subscale, it is difficult to estimate the range) 1 study, 19 participants; analysis not shown).

For Analysis 2.1 , when we removed Emilsson 2011 due to its dropout percentage, the difference in favour of CBT and pharmacotherapy treatment became non‐significant (SMD −0.60, 95% CI −1.32 to 0.12; 2 studies, 31 participants; I 2 = 0%; large effect size). However, in Analysis 2.2 (MD −9.12 points, 95% CI −15.69 points to −2.55 points; rated on CSS (range 0 (best) to 54 (worst)); 2 studies, 31 participants; I 2 = 0%), Analysis 2.5 (MD −0.82 points, 95% CI −1.51 points to −0.13 points; rated on CGI (range 1 (best) to 7 (worst)); 2 studies, 31 participants; I 2 = 0%), Analysis 2.7 (MD −4.77 points, 95% CI −9.19 points to −0.35 points; rated on BDI (range 0 (best) to 63 (worst); 2 studies, 31 participants; I 2 = 0%) and Analysis 2.9 (SMD −0.81, 95% CI −1.54 to −0.07; 2 studies, 31 participants; I 2 = 100%; large effect size), removing this study did not have a significant impact on the results of the comparison (analyses not shown).

Following the criteria specified in the Methods section of our protocol ( Lopez 2013 ), we did not perform an analysis of publication bias because the number of included studies per comparison was less than 10 (see Table 5 ).

There were not enough trials at high risk of attrition bias to run a sensitivity analysis for this comparison.

Summary of main results

We identified 14 RCTs that fulfilled the inclusion criteria of this Cochrane Review ( Criteria for considering studies for this review ). We considered that Stevenson 2002 was had two relevant study reports; although the authors mentioned the use of two different samples, the reported data coincided exactly. Of the records we excluded, one study reported a comparison between group psychotherapy versus individual psychotherapy, affecting the comparability of the intervention of interest in our review ( Philipsen 2015 ). We excluded four other studies because the employed comparison did not correspond to the comparisons included in our protocol ( Cherkasova 2016 ; Weiss 2012 ; Young 2015 ; Young 2017 ), plus two more because their goals were to assess the efficacy of mindfulness and mindfulness plus virtual reality respectively, without introducing other treatment modalities such as CBT ( Mitchell 2013 ; Serra‐Pla 2017 ).

The primary outcome of the included trials was the effect of different modalities of CBT‐based treatments on the core symptoms of ADHD in adults. The overall findings of this review suggest that CBT‐based treatments may improve the core symptoms of ADHD as assessed both by clinician‐ and self‐report.

The first main comparison was CBT versus unspecific control conditions. In this analysis, CBT was more effective than a waiting list or supportive therapy for improving observer‐rated core symptoms of ADHD. Additionally, CBT was better than waiting list for reducing self‐reported ADHD symptoms but not more effective than supportive therapy. When analysing symptoms of ADHD separately, we found that CBT was superior to supportive therapy regarding clinician‐reported inattention and superior to the waiting list regarding inattention (clinician‐ and self‐reported) and hyperactivity/impulsivity (clinician‐ and self‐reported). With respect to secondary outcomes, we found significant differences from waiting list in depression (self‐rated), anxiety (self‐rated), state anger (self‐rated) and self‐esteem (self‐rated). There were no differences between CBT and supportive therapy or the waiting list in depression (self‐rated). Additionally, we found no differences between CBT and supportive therapy in anxiety (clinician‐rated) or self‐esteem (self‐rated), or between CBT and waiting list in trait anger (self‐rated), self‐esteem (self‐rated) or quality of life (self‐rated).

The second main comparison was CBT plus pharmacotherapy versus pharmacotherapy alone. The results showed that combined treatment could be more effective than pharmacotherapy alone, not only for improving the core symptoms of ADHD but also for reducing the commonly associated symptoms of depression and anxiety ( Emilsson 2011 ; Safren 2005 ). However, we found no significant differences in self‐reported hyperactivity‐impulsivity when evaluated separately.

The third main comparison of our review was CBT versus other specific interventions. In this comparison, we found that CBT was more effective than the comparison group in terms of improvement in core ADHD symptoms, in both clinician‐ and self‐reported questionnaires. With further analysis, however, we found no significant differences when separately evaluating self‐reported inattention, hyperactivity and impulsivity. Regarding secondary outcomes, we found no differences in self‐reported depression or anxiety and inconsistent results for self‐reported quality of life.

In the first and the third comparisons described above, and with the exception of Moëll 2015 , study authors controlled the proportion of participants who received pharmacological treatment in the different groups.

None of the included studies reported severe adverse events in participants receiving the different modalities of CBT, but five participants described some type of adverse event, such as distress and anxiety.

The sensitivity analysis was limited due to the small number of studies for each outcome. However, the direction of the results was consistent with the primary analysis, except for the comparison between CBT plus pharmacotherapy versus pharmacotherapy alone, for the outcome of clinician‐rated ADHD symptoms.

Overall completeness and applicability of evidence

Our search found studies assessing CBT for adults with ADHD, and their reported results provided findings that could be applicable. However, these studies included heterogeneous clinician‐ and self‐reported measures of ADHD symptoms and associated dimensions. This heterogeneity might have an impact on the interpretation of the results.

Furthermore, our review found few trials, concentrated in the northern hemisphere; there is only one trial from the southern hemisphere and none from low‐ or lower‐middle‐income countries. Because of this, we suggest caution regarding the cross‐cultural applicability of the evidence.

We described the effects of interventions as meta‐analyses when possible and at a study level otherwise.

Important methodological limitations reduced the certainty of the evidence offered by most included trials. Many of the trials were small and included different outcome measures, and selective outcome reporting was occasionally an issue.

We assessed the quality of the evidence using the GRADE approach and presented our ratings in 'Summary of findings' tables (see Table 1 ; Table 2 ; Table 3 ). Considering that self‐ and clinician‐reported core symptoms are the main target of CBT, we included them in the 'Summary of findings' tables.

None of the studies were at high risk of bias for random sequence generation, but six of them were at unclear risk because the authors did not describe the sequence generation process. We were able to record this factor as a low risk only when the study authors responded with more information about this via email.

Similarly, reports did not contain an adequate description of the allocation concealment process. We classified nine studies as being at unclear risk of bias. Five studies were at low risk, and we completed most of the information after contacting the study authors via email.

Due to the inherent characteristics of psychotherapy, we considered all studies to be at high risk of performance bias because it is not possible to blind personnel to this type of intervention.

We considered one trial to be at high risk of detection bias because the study authors described that the outcomes were potentially prone to risk of bias due to lack of blinding of the assessor ( Schoenberg 2014 ).

Additionally, we rated two studies at high risk of attrition bias because the dropout rate was around 40% ( Emilsson 2011 ; Pettersson 2017 ). Three studies were at unclear risk of bias: Hepark 2015 and Safren 2010 performed an ITT analysis, but the number of dropouts was unbalanced between groups; Hirvikoski 2011 performed an ITT analysis, but there was an important rate of dropouts (around 20% per group).

Five studies prospectively registered the trial and reported all planned outcomes ( Emilsson 2011 ; Moëll 2015 ; Safren 2005 ; Safren 2010 ; Solanto 2010 ). We considered all studies as free of the risk of reporting bias because the published reports clearly included all expected outcomes.

Two studies presented a high risk of 'other bias' ( Emilsson 2011 ; Moëll 2015 ). Emilsson 2011 reported not asking participants in either group to refrain from engaging in other interventions during the study period; therefore, they could not establish the impact of a possible second intervention. In Moëll 2015 , the study authors did not confirm the diagnosis of ADHD for some of the participants after their previous neuropsychiatric assessment.

We were unable to assess publication bias as planned ( Lopez 2013 ), as there were fewer than 10 included studies per comparison. However, the search strategy was very sensitive, and the field is not so large. Therefore, we consider that there is no evidence of publication bias.

Finally, we considered one study, Pettersson 2017 , to be at high risk of bias due to conflicts of interest, because the main author was a partner and shareholder in the company that constructed and owned the rights to the Internet‐based treatment programme, In Focus. This author was also involved in the design and construction of the programme.

Potential biases in the review process

We designed the search process in conjunction with a specialised librarian, and the Cochrane Developmental, Psychosocial and Learning Problems Information Specialist supervised it with the objective of minimising bias in the compilation of potentially relevant references.

In all cases, we repeatedly tried to contact the authors of the included studies by email to obtain more information, when needed. In five cases, we did not receive a reply. The replies we did receive helped us to describe the random allocation process and the random sequence generation.

The high number of outcomes analysed could generate type 1 errors, but the consistency in the direction of most results reduces this possibility.

Finally, we did not identify other significant potential biases in the review process.

Agreements and disagreements with other studies or reviews

According to Chandler 2013 , there is a need for a meta‐analysis of CBT versus other psychotherapies. To our knowledge, there are three meta‐analyses of RCTs on psychotherapy for adults with ADHD. In the first one ( Jensen 2016 ), the authors only included studies that evaluated the effects of standard CBT, using a more restrictive criteria for CBT treatments. With respect to search results, these authors found a smaller number of studies, and, after full‐text evaluation, they only included two ( Emilsson 2011 ; Safren 2005 ). The results of their review are similar to the results of our comparison between CBT with pharmacotherapy versus pharmacotherapy alone (which includes these two studies), except for clinician‐reported ADHD symptoms. This difference might be because Jensen 2016 only reported the data from Safren 2005 , leaving out the data from Emilsson 2011 . When only considering Safren 2005 , the results were not significant, but as a whole (including Emilsson 2011 ), the results were significant.

The second meta‐analysis reported similar findings even though the eight included studies and comparison groups differed from the present review ( Young 2016 ). The first difference between our reviews was that Young 2016 did not include mindfulness‐based cognitive therapy or dialectical behavioural therapy. Second, those authors defined the control conditions as 'inactive' (waiting list or treatment as usual) or 'active' (alternative treatment to CBT). These categories resemble the ones employed in our review (unspecific control conditions and other specific interventions), but the inclusion of studies was not homologous (i.e. Young 2016 classified supportive therapy as an active control, while we considered it an unspecific control condition). Finally, Young 2016 did not discriminate between studies based on whether or not they employed CBT as an adjunctive treatment to pharmacotherapy. Beyond these differences, the overall findings point to the same conclusions.

The third meta‐analysis included controlled and uncontrolled studies, but the authors meta‐analysed controlled and uncontrolled (pre‐ to‐post) effect sizes separately ( Knouse 2017 ). They also included controlled studies that did not use random assignment. Even though the global results were similar, these authors failed to assess the quality of the evidence, limiting the findings of the review.

Additionally, previous non‐systematic reviews on this topic such as Knouse 2010 and Mongia 2012 showed similar results to our findings.

Our results agree with Antshel 2011 and Ramsay 2007 , who stated that CBT plus pharmacotherapy improved treatment outcomes more than medication alone; however, these authors found only limited evidence that CBT was efficacious on its own.

In contrast to Philipsen 2012 , our results did not clearly show whether specific treatment for ADHD in adults significantly reduced the commonly associated symptoms (depression, anxiety and anger).

Implications for practice

Cognitive‐behavioural‐based treatments may be efficacious in the short term for treating the core symptoms of ADHD in adults. Compared with unspecific control conditions and when combined with pharmacotherapy (compared with pharmacotherapy alone), CBT may also improve common comorbid disturbances in adults with ADHD such as depression, anxiety and anger. Additionally, we did not find any severe adverse effects of this psychological treatment.

However, the scarcity of outcomes from long‐term studies, the divergent efficacy measures and designs, and the limited geographical location, mostly confined to high‐income countries in the northern hemisphere, limit the generalisability of the results.

Implications for research

Further research is needed to precisely determine the efficacy of cognitive‐behavioural therapy for adults with ADHD, particularly in the long term, and, if possible, through multicentre studies that include cost‐effectiveness analyses. Additionally, there is a need to establish consensus‐based standards for study design and efficacy measures of psychotherapy treatments for this population, as the Research Forum on Psychological Treatment of Adults with ADHD noted ( Weiss 2008 ). Although the situation has improved in past decades, it is still necessary to determine which types of psychological treatment are more effective. In particular, according to Philipsen 2012 , it is necessary to increase the number of studies that evaluate the effects of therapy on adaptive functioning. We consider that these studies should report participants' employment status and measures of daily functioning.

Acknowledgements

To the members of the Cochrane Developmental, Psychosocial and Learning Problems Editorial Team, for their time dedicated to reviewing and commenting on the draft protocol and review. To Daniel Comandé, for his invaluable collaboration in the search strategy design. To Andrés Rumboll, for his collaboration in reviewing the phrasing of the draft protocol and review. To Marta Roqué Figuls, for her assistance and guidance in the final stages of the full revision.

Appendix 1. Search strategies

Cochrane central register of controlled trials (central), the cochrane database of systematic review s (cdsr) and database of abstracts of reviews of effectiveness (dare).

1202 records

1. MeSH descriptor: [Attention Deficit and Disruptive Behavior Disorders] this term only 2. MeSH descriptor: [Attention Deficit Disorder with Hyperactivity] explode all trees 3. Attention Deficit:ti,ab,kw 4. Hyperactivity Disorder*:ti,ab,kw 5. Deficit Disorder*:ti,ab,kw 6. Oppositional Defiant*:ti,ab,kw 7. Defiant Disorder*:ti,ab,kw 8. Disruptive Behavi*:ti,ab,kw 9. ADHD:ti,ab,kw 10. ADDH:ti,ab,kw 11. ADHS:ti,ab,kw 12. AD‐HD:ti,ab,kw 13. HKD:ti,ab,kw 14. Hyperkinetic*:ti,ab,kw 15. Hyperkines*:ti,ab,kw 16. Impulsiv*:ti,ab,kw 17. Inattentiv*:ti,ab,kw 18. Inattention*:ti,ab,kw 19. #1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11 or #12 or #13 or #14 or #15 or #16 or #17 or #18 20. MeSH descriptor: [Behavior Therapy] explode all trees 21. MeSH descriptor: [Cognitive Therapy] explode all trees 22. MeSH descriptor: [Psychotherapy, Rational‐Emotive] explode all trees 23. MeSH descriptor: [Imagery (Psychotherapy)] explode all trees 24. MeSH descriptor: [Desensitization, Psychologic] explode all trees 25. MeSH descriptor: [Biofeedback, Psychology] explode all trees 26. Cognitive Behavio*:ti,ab,kw (Word variations have been searched) 27. Cognitive therap*:ti,ab,kw (Word variations have been searched) 28. Metacognitive Therap*:ti,ab,kw (Word variations have been searched) 29. Meta‐Cognitive Therap*:ti,ab,kw (Word variations have been searched) 30. Behavior Therap*:ti,ab,kw (Word variations have been searched) 31. Behavioral Therap*:ti,ab,kw (Word variations have been searched) 32. Behavioral Psychotherap*:ti,ab,kw (Word variations have been searched) 33. Behaviour Therap*:ti,ab,kw (Word variations have been searched) 34. Cognitive Psychotherap*:ti,ab,kw (Word variations have been searched) 35. Behavior Psychotherap*:ti,ab,kw (Word variations have been searched) 36. Behaviour Psychotherap*:ti,ab,kw (Word variations have been searched) 37. Dialectical Behavio*:ti,ab,kw (Word variations have been searched) 38. Rational‐Emotive*:ti,ab,kw (Word variations have been searched) 39. Rational Psychotherap*:ti,ab,kw (Word variations have been searched) 40. Guided Imager*:ti,ab,kw (Word variations have been searched) 41. Reverie Therap*:ti,ab,kw (Word variations have been searched) 42. Imageries:ti,ab,kw (Word variations have been searched) 43. Imagery:ti,ab,kw (Word variations have been searched) 44. False Physiological:ti,ab,kw (Word variations have been searched) 45. Myofeedback*:ti,ab,kw (Word variations have been searched) 46. Psychophysiologic Feedback*:ti,ab,kw (Word variations have been searched) 47. Desensitization*:ti,ab,kw (Word variations have been searched) 48. Desensitisation*:ti,ab,kw (Word variations have been searched) 49. Mindfulness:ti,ab,kw (Word variations have been searched) 50. Biofeedback*:ti,ab,kw (Word variations have been searched) 51. CBT:ti,ab,kw (Word variations have been searched) 52. DBT:ti,ab,kw (Word variations have been searched) 53. #20 or #21 or #22 or #23 or #24 or #25 or #26 or #27 or #28 or #29 or #30 or #31 or #32 or #33 or #34 or #35 or #36 or #37 or #38 or #39 or #40 or #41 or #42 or #43 or #44 or #45 or #46 or #47 or #48 or #49 or #50 or #51 or #52 54. MeSH descriptor: [Adult] explode all trees 55. Adult*:ti,ab,kw (Word variations have been searched) 56. #54 or #55 57 #19 AND #53 and #56

MEDLINE via PubMed US National Library of Medicine

2186 records

1. Search (Attention Deficit and Disruptive Behavior Disorders[Majr]) 2. Search Attention Deficit Disorder with Hyperactivity[Mesh] 3. Search Attention Deficit[tiab] 4. Search Hyperactivity Disorder*[tiab] 5. Search Deficit Disorder*[tiab] 6. Search Oppositional Defiant*[tiab] 7. Search Defiant Disorder*[tiab] 8. Search Disruptive Behavi*[tiab] 9. Search ADHD[tiab] 10. Search ADDH[tiab] 11. Search ADHS[tiab] 12. Search AD‐HD[tiab] 13. Search HKD[tiab] 14. Search Hyperkinetic*[tiab] 15. Search Hyperkines*[tiab] 16. Search Impulsiv*[tiab] 17. Search Inattentiv*[tiab] 18. Search Inattention*[tiab] 19. Search (#1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17 OR #18) 20. Search Behavior Therapy[Mesh] 21. Search Cognitive Therapy[Mesh] 22. Search Psychotherapy, Rational‐Emotive[Mesh] 23. Search "Imagery (Psychotherapy)"[Mesh] 24. Search Desensitization, Psychologic[Mesh] 25. Search Biofeedback, Psychology[Mesh] 26. Search Cognitive Behavio*[tiab] 27. Search Cognitive therap*[tiab] 28. Search Metacognitive Therap*[tiab] 29. Search Meta‐Cognitive Therap*[tiab] 30. Search Behavior Therap*[tiab] 31. Search Behavioral Therap*[tiab] 32. Search Behavioral Psychotherap*[tiab] 33. Search Behaviour Therap*[tiab] 34. Search Cognitive Psychotherap*[tiab] 35. Search Behavior Psychotherap*[tiab] 36. Search Behaviour Psychotherap*[tiab] 37. Search Dialectical Behavio*[tiab] 38. Search Rational‐Emotive*[tiab] 39. Search Rational Psychotherap*[tiab] 40. Search Guided Imager*[tiab] 41. Search Reverie Therap*[tiab] 42. Search Imageries[tiab] 43. Search Imagery[tiab] 44. Search False Physiological[tiab] 45. Search Myofeedback*[tiab] 46. Search Psychophysiologic Feedback*[tiab] 47. Search Desensitization*[tiab] 48. Search Desensitisation*[tiab] 49. Search Biofeedback*[tiab] 50. Search CBT[tiab] 51. Search DBT[tiab] 52. Search Mindfulness[tiab] 53. Search (#20 OR #21 OR #22 OR #23 OR #24 OR #25 OR #26 OR #27 OR #28 OR #29 OR #30 OR #31 OR #32 OR #33 OR #34 OR #35 OR #36 OR #37 OR #38 OR #39 OR #40 OR #41 OR #42 OR #43 OR #44 OR #45 OR #46 OR #47 OR #48 OR #49 OR #50 OR #51 OR #52) 54. Search ((Adult[Mesh] OR Adult*[tiab])) 55. Search (#19 AND #53 AND #54)

Embase Elsevier

5483 records

#57 #55 AND #56 #56 'randomized‐controlled‐trial'/de OR 'randomization'/de OR 'controlled‐study'/de OR 'multicenter study'/de OR 'phase‐3‐clinical‐trial'/de OR 'phase‐4‐clinical‐trial'/de OR 'double‐blind‐procedure'/de OR 'single blind‐procedure'/de OR random$:ab,ti OR crossover$:ab,ti OR 'cross over$':ab,ti OR factorial$:ab,ti OR placebo$:ab,ti OR volunteer$:ab,ti OR (singl$:ab,ti OR doubl$:ab,ti OR trebl$:ab,ti OR tripl$:ab,ti AND (blind$:ab,ti OR mask$:ab,ti)) NOT ('animals'/exp NOT ('humans'/exp AND 'animals'/exp)) #55 #53 AND #54 #54 'adult'/exp OR adult$:ab,ti #53 #18 AND #52 #52 #19 OR #20 OR #21 OR #22 OR #23 OR #24 OR #25 OR #26 OR #27 OR #28 OR #29 OR #30 OR #31 OR #32 OR #33 OR #34 OR #35 OR #36 OR #37 OR #38 OR #39 OR #40 OR #41 OR #42 OR #43 OR #44 OR #45 OR #46 OR #47 OR #48 OR #49 OR #50 OR #51 #51 dbt:ab,ti #50 cbt:ab,ti #49 biofeedback*:ab,ti #48 'mindfulness':ab,ti #47 desensitisation*:ab,ti #46 desensitization*:ab,ti #45 'psychophysiologic feedback':ab,ti #44 myofeedback*:ab,ti #43 'false physiological':ab,ti #42 'imagery':ab,ti #41 'imageries':ab,ti #40 'reverie therapy':ab,ti #39 'guided imagery':ab,ti OR 'guided imageries':ab,ti #38 'rational psychotherapy':ab,ti OR 'rational psychotherapies':ab,ti #37 'rational‐emotive':ab,ti #36 'dialectical behavior':ab,ti OR 'dialectical behaviour':ab,ti #35 'behaviour psychotherapy':ab,ti OR 'behaviour psychotherapies':ab,ti #34 'behavior psychotherapy':ab,ti OR 'behavior psychotherapies':ab,ti #33 'cognitive psychotherapy':ab,ti OR 'cognitive psychotherapies':ab,ti #32 'behaviour therapy':ab,ti OR 'behaviour therapies':ab,ti #31 'behavioral psychotherapy':ab,ti OR 'behavioral psychotherapies':ab,ti #30 'behavioral therapy':ab,ti OR 'behavioral therapies':ab,ti #29 'behaviour therapy':ab,ti OR 'behaviour therapies':ab,ti #28 'behavior therapy':ab,ti OR 'behavior therapies':ab,ti #27 'meta‐cognitive therapy':ab,ti #26 'metacognitive therapy':ab,ti #25 'cognitive therapy':ab,ti #24 'cognitive behavior':ab,ti OR 'cognitive behaviour':ab,ti #23 'psychophysiology'/exp #22 'desensitization'/exp #21 'guided imagery'/exp #20 'cognitive therapy'/exp #19 'behavior therapy'/exp #18 #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17 #17 inattention*:ab,ti #16 'inattentiv*':ab,ti #15 'impulsiv*':ab,ti #14 'hyperkines*':ab,ti #13 'hyperkinetic':ab,ti #12 'hkd':ab,ti #11 'ad‐hd':ab,ti #10 'adhs':ab,ti #9 'addh':ab,ti #8 'adhd':ab,ti #7 'disruptive behavior':ab,ti OR 'disruptive behaviour':ab,ti #6 'defiant disorder':ab,ti OR 'defiant disorders':ab,ti #5 'oppositional defiant':ab,ti #4 'deficit disorder':ab,ti OR 'deficit disorders':ab,ti #3 'hyperactivity disorder':ab,ti OR 'hyperactivity disorders':ab,ti #2 'attention deficit':ab,ti #1 'attention deficit disorder'/exp

CINAHL EBSCO

S1. (MH "Attention Deficit Hyperactivity Disorder") S2. TI Attention Deficit OR AB Attention Deficit S3. TI Hyperactivity Disorder* OR AB Hyperactivity Disorder* S4. TI Deficit Disorder* OR AB Deficit Disorder* S5. TI Oppositional Defiant* OR AB Oppositional Defiant* S6. TI Defiant Disorder* OR AB Defiant Disorder* S7. TI Disruptive Behavi* OR AB Disruptive Behavi* S8. TI ADHD OR AB ADHD S9. TI ADDH OR AB ADDH S10. TI ADHS OR AB ADHS S11. TI AD‐HD OR AB AD‐HD S12. TI HKD OR AB HKD S13. TI Hyperkinetic* OR AB Hyperkinetic* S14. TI Hyperkines* OR AB Hyperkines* S15. TI Impulsiv* OR AB Impulsiv* S16. TI Inattentiv* OR AB Inattentiv* S17. TI Inattention* OR AB Inattention* S18. S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8 OR S9 OR S10 OR S11 OR S12 OR S13 OR S14 OR S15 OR S16 OR S17 S19. (MH "Behavior Therapy+") S20. (MH "Cognitive Therapy+") S21. (MH "Psychotherapy, Brief") S22. (MH "Guided Imagery") S23. (MH "Desensitization, Psychologic+") S24. (MH "Biofeedback") S25. TI Cognitive Behavio* OR AB Cognitive Behavio* S26. TI Cognitive therap* OR AB Cognitive therap* S27. TI Metacognitive Therap* OR AB Metacognitive Therap* S28. TI Meta‐Cognitive Therap* OR AB Meta‐Cognitive Therap* S29. TI Behavior Therap* OR AB Behavior Therap* S30. TI Behavioral Therap* OR AB Behavioral Therap* S31. TI Behavioral Psychotherap* OR AB Behavioral Psychotherap* S32. TI Behaviour Therap* OR AB Behaviour Therap* S33. TI Cognitive Psychotherap* OR AB Cognitive Psychotherap* S34. TI Behavior Psychotherap* OR AB Behavior Psychotherap* S35. TI Behaviour Psychotherap* OR AB Behaviour Psychotherap* S36. TI Dialectical Behavio* OR AB Dialectical Behavio* S37. TI Rational‐Emotive* OR AB Rational‐Emotive* S38. TI Rational Psychotherap* OR AB Rational Psychotherap* S39. TI Guided Imager* OR AB Guided Imager* S40. TI Reverie Therap* OR AB Reverie Therap* S41. TI Imageries OR AB Imageries S42. TI Imagery OR AB Imagery S43. TI False Physiological OR AB False Physiological S44. TI Myofeedback* OR AB Myofeedback* S45. TI Psychophysiologic Feedback* OR AB Psychophysiologic Feedback* S46. TI Desensitization* OR AB Desensitization* S47. TI Desensitisation* OR AB Desensitisation* S48. TI Biofeedback* OR AB Biofeedback* S49. TI CBT OR AB CBT S50. TI DBT OR AB DBT S51. TI Mindfulness OR AB Mindfulness S52. S19 OR S20 OR S21 OR S22 OR S23 OR S24 OR S25 OR S26 OR S27 OR S28 OR S29 OR S30 OR S31 OR S32 OR S33 OR S34 OR S35 OR S36 OR S37 OR S38 OR S39 OR S40 OR S41 OR S42 OR S43 OR S44 OR S45 OR S46 OR S47 OR S48 OR S49 OR S50 OR S51 S53. S18 AND S52 S54. (MH "Clinical Trials+") S55. PT Clinical trial S56. TX clinic* n1 trial* S57. TX ( (singl* n1 blind*) or (singl* n1 mask*) ) or TX ( (doubl* n1 blind*) or (doubl* n1 mask*) ) or TX ( (tripl* n1 blind*) or (tripl* n1 mask*) ) or TX ( (trebl* n1 blind*) or (trebl* n1 mask*) ) S58. TX randomi* control* trial* S59. (MH "Random Assignment") S60. TX random* allocat* S61. TX placebo* S62. (MH "Placebos") S63. (MH "Quantitative Studies") S64. TX allocat* random* S65. S54 OR S55 OR S56 OR S57 OR S58 OR S59 OR S60 OR S61 OR S62 OR S63 OR S64 S66. S53 AND S65

PsycINFO EBSCO

710 records

S1. DE "Attention Deficit Disorder" S2. DE "Attention Deficit Disorder with Hyperactivity" S3. TI Attention Deficit OR AB Attention Deficit S4. TI Hyperactivity Disorder* OR AB Hyperactivity Disorder* S5. TI Deficit Disorder* OR AB Deficit Disorder* S6. TI Oppositional Defiant* OR AB Oppositional Defiant* S7. TI Defiant Disorder* OR AB Defiant Disorder* S8. TI Disruptive Behavi* OR AB Disruptive Behavi* S9. TI ADHD OR AB ADHD S10. TI ADDH OR AB ADDH S11. TI ADHS OR AB ADHS S12. TI AD‐HD OR AB AD‐HD S13. TI HKD OR AB HKD S14. TI Hyperkinetic* OR AB Hyperkinetic* S15. TI Hyperkines* OR AB Hyperkines* S16. TI Impulsiv* OR AB Impulsiv* S17. TI Inattentiv* OR AB Inattentiv* S18. TI Inattention* OR Inattention* S19. S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8 OR S9 OR S10 OR S11 OR S12 OR S13 OR S14 OR S15 OR S16 OR S17 OR S18 S20. DE "Behavior Therapy" OR DE "Aversion Therapy" OR DE "Conversion Therapy" OR DE "Dialectical Behavior Therapy" OR DE "Exposure Therapy" OR DE "Implosive Therapy" OR DE "Reciprocal Inhibition Therapy" OR DE "Response Cost" OR DE "Systematic Desensitization Therapy" S21. DE "Cognitive Therapy" S22. DE "Imagery" OR DE "Conceptual Imagery" OR DE "Spatial Imagery" S23. MM "Biofeedback" S24. TI Cognitive Behavio* OR AB Cognitive Behavio* S25. TI Cognitive therap* OR AB Cognitive therap* S26. TI Metacognitive therap* OR AB Metacognitive therap* S27. TI Meta‐Cognitive Therap* OR AB Meta‐Cognitive Therap* S28. TI Behavior Therap* OR AB Behavior Therap* S29. TI Behavioral Therap$ OR AB Behavioral Therap$ S30. TI Behavioral Psychotherap* OR AB Behavioral Psychotherap* S31. TI Behaviour Therap* OR AB Behaviour Therap* S32. TI Cognitive Psychotherap* OR AB Cognitive Psychotherap* S33. TI Behavior Psychotherap* OR AB Behavior Psychotherap* S34. TI Behaviour Psychotherap* OR AB Behaviour Psychotherap* S35. TI Dialectical Behavio* OR AB Dialectical Behavio* S36. TI Rational‐Emotive OR AB Rational‐Emotive S37. TI Rational Psychotherap* OR AB Rational Psychotherap* S38. TI Guided Imager* OR AB Guided Imager* S39. TI Reverie Therap* OR AB Reverie Therap* S40. TI Imageries OR AB Imageries S41. TI Imagery OR AB Imagery S42. TI False Physiological OR AB False Physiological S43. TI Myofeedback* OR AB Myofeedback* S44. TI Psychophysiologic Feedback* OR AB Psychophysiologic Feedback* S45. TI Desensitization* OR AB Desensitization* S46. TI Desensitisation* OR AB Desensitisation* S47. TI Mindfulness OR AB Mindfulness S48. TI DBT OR AB DBT S49. TI CBT OR AB CBT S50. TI Biofeedback* OR AB Biofeedback* S51. S20 OR S21 OR S22 OR S23 OR S24 OR S25 OR S26 OR S27 OR S28 OR S29 OR S30 OR S31 OR S32 OR S33 OR S34 OR S35 OR S36 OR S37 OR S38 OR S39 OR S40 OR S41 OR S42 OR S43 OR S44 OR S45 OR S46 OR S47 OR S48 OR S49 OR S50 S52. TI Adult$ OR AB Adult$ S53. S19 AND S51 AND S52 S54. MM "Clinical Trials" S55. MD treatment outcome clinical trial S56. MD treatment outcome clinical trial S57. MD treatment outcome clinical trial S58. MD treatment outcome clinical trial S59. (TI Randomized OR TI Randomized OR AB Randomized OR AB Randomised) AND (TI Trial* OR AB Trial*) S60. ( TI single OR TI doubl* OR TI tripl* OR TI Treb* OR AB single OR AB doubl* OR AB tripl* OR AB Treb* ) AND ( TI blind* OR AB blind* OR TI mask* OR AB mask* ) S61. ( TI controlled OR TI clinical OR AB controlled OR AB Clinical ) AND ( TI Trial* OR AB Trial* ) S62. S54 OR S55 OR S56 OR S57 OR S58 S63. S53 AND S59

BIOSIS Previews Web of Science

766 records

1. TS=(Attention Deficit) 2. TS=(Disruptive Behavior) 3. TS=(Hyperactivity) 4. TI=(Attention Deficit) 5. TI=(Disruptive Behavior) 6. TI=(Hyperactivity) 7. TI=(Defiant Disorder*) 8. TI=(Disruptive Behavi*) 9. TI=ADHD 10. TI=(ADDH) 11. TI=(ADHS) 12. TI=(AD‐HD) 13. TI=(Hyperkinetic*) 14. TI=(Hyperkines*) 15. TI=(Impulsiv*) 16. TI=(Inattentiv*) 17. TI=(Inattention*) 18. #17 OR #16 OR #15 OR #14 OR #13 OR #12 OR #11 OR #10 OR #9 OR #8 OR #7 OR #6 OR #5 OR #4 OR #3 OR #2 OR #1 19. TS=(Behavior Therapy) 20. TS=(Cognitive Therapy) 21. TS=(Imagery) 22. TS=(Desensitization) 23. TS=(Biofeedback) 24. TI=(Cognitive Behavio*) 25. TI=(Metacognitive Therap*) 26. TI=(Meta‐Cognitive Therap*) 27. TI=(Behavior Therap*) 28. TI=(Behavioral Therap*) 29. TI=(Behavioral Psychotherap*) 30. TI=(Behaviour Therap*) 31. TI=(Cognitive Psychotherap*) 32. TI=(Behavior Psychotherap*) 33. TI=(Behaviour Psychotherap*) 34. TI=(Dialectical Behavio*) 35. TI=(Rational‐Emotive*) 36. TI=(Rational Psychotherap*) 37. TI=(Guided Imager*) 38. TI=(Reverie Therap*) 39. TI=(Imageries) 40. TI=(Imagery) 41. TI=(False Physiological) 42. TI=(Myofeedback*) 43. TI=(Psychophysiologic Feedback*) 44. TI=(Desensitization*) 45. TI=(Desensitisation*) 46. TI=(Biofeedback*) 47. TI=(CBT) 48. TI=(DBT) 49. TI=(Mindfulness) 50. #49 OR #48 OR #47 OR #46 OR #45 OR #44 OR #43 OR #42 OR #40 OR #39 OR #38 OR #37 OR #36 OR #35 OR #34 OR #33 OR #32 OR #31 OR #30 OR #29 OR #28 OR #27 OR #26 OR #25 OR #24 OR #23 OR #22 OR #21 OR #20 OR #19 51. #50 AND #18 52. TS=(Adults) OR TI=(Adult*) 53. #52 AND #51 54. (#53) AND Notas taxonómicas: (Humans)

LILACS (Latin American and Caribbean Health Sciences Literature)

lilacs.bvsalud.org/en

122 records

(MH Attention Deficit and Disruptive Behavior Disorders OR MH Attention Deficit Disorder with Hyperactivity OR Hyperactivity OR Defiant OR Attention OR Disruptive OR Hyperkinetic$ OR Hyperkines$ OR Inattentiv$ OR Inattention$ OR ADHD OR ADDH OR ADHS OR AD‐HD OR HKD) AND (MH Behavior Therapy OR MH Cognitive Therapy OR MH Psychotherapy, Rational‐Emotive OR MH Desensitization, Psychologic OR MH Biofeedback, Psychology OR Cognitive OR Metacognitive OR Behavioral OR Imager$ OR Rational‐Emotive OR Myofeedback OR Desensitization$ OR Desensitisation$ OR Biofeedback$ OR CBT OR DBT OR Mindfulness OR Reverie OR Dialectical) [Words] and (PT Ensayo Clínico Controlado Aleatorio OR PT Ensayo Clínico Controlado OR MH Ensayo Clínico Controlado Aleatorio OR MH Distribución Aleatoria OR MH Método Doble Ciego OR MH Método Simple‐Ciego OR PT Ensayo Clínico OR MH Ensayo Clínico OR (clinical trial OR ensayo clinico OR Ensaio clínico OR ((singl$ OR simpl$ OR doubl$ OR trebl$ OR tripl$)))) [Words]

Networked Digital Library of Theses and Dissertations

www.ndltd.org/resources

407 records

"(attention deficit OR inattention) AND (behavior OR cognitive) AND (trial) AND (adult)"

ClinicalTrials.gov

clinicaltrials.gov

195 records

Attention Deficit OR Disruptive Behavior OR Hyperactivity OR Attention Deficit OR Defiant Disorder OR Hyperkinetic* OR Impulsiv* OR Inattentiv* OR Inattention* | Behavior OR Cognitive OR Desensitization OR Biofeedback OR Metacognitive OR Behavioral OR Dialectical OR Rational‐Emotive OR Rational Psychotherap* OR Imager* OR Reverie OR Myofeedback* OR Psychophysiologic Feedback* OR Mindfulness | Adult, Senior

ISRCTN registry

www.isrctn.com

"(Condition: Attention Deficit OR Disruptive Behavior OR Hyperactivity OR Attention Deficit OR Defiant Disorder OR Hyperkinetic* OR Impulsiv* OR Inattentiv* OR Inattention* AND Interventions: Behavior OR Cognitive OR Desensitization OR Biofeedback OR Metacognitive OR Behavioral OR Dialectical OR Rational‐Emotive OR Rational Psychotherap* OR Imager* OR Reverie OR Myofeedback* OR Psychophysiologic Feedback* OR Mindfulness)"

World Health Organization International Clinical Trials Registry Portal (WHO ICTRP)

apps.who.int/trialsearch

(Inattention OR Attention) AND (Behavior OR Cognitive)

Appendix 2. Percentage change in effect sizes

We reported the absolute and relative changes (95% CI) related to the control central estimates of each outcome (negative percentages indicate a reduction of symptoms).

Data and analyses

Comparison 1.

Comparison 1 CBT vs unspecific control conditions, Outcome 1 ADHD symptoms (observer).

Comparison 2

Comparison 3, characteristics of studies, characteristics of included studies [ordered by study id].

ADHD : attention deficit hyperactivity disorder; ANCOVA : analysis of covariance; ASRS : Adult ADHD Self‐Report Scale; CBT : cognitive‐behavioural therapy; CGI‐S : Clinical Global Impressions ‐ Severity; DBT : dialectical behaviour therapy; DSM : Diagnostic and Statistical Manual of Mental Disorders ; ITT : intention‐to‐treat; LOCF : last observation carried forward; MBCT : mindfulness‐based cognitive therapy; SD : standard deviation; SH : skills handout; WL : waiting list.

Characteristics of excluded studies [ordered by study ID]

CBT : cognitive‐behavioural therapy; TAU : treatment as usual.

Characteristics of ongoing studies [ordered by study ID]

ADHD : attention deficit hyperactivity disorder; AUDIT : Alcohol Use Disorders Identification Test; CBT : cognitive‐behavioural therapy; DSM : Diagnostic and Statistical Manual of Mental Disorders ; IQ : intelligence quotient; MBCT : mindfulness‐based cognitive therapy; SD : standard deviation; TAU : treatment as usual.

Differences between protocol and review

• We pointed out the differences between ICD‐10 and DSM‐5, and we updated the reference about the prevalence of ADHD in childhood.
• Where we argued that between 20% and 50% of people with ADHD do not respond to drug treatment, we added a sentence about the side effects of psychopharmacological treatment.
• When the protocol was published, no systematic review on this topic existed. At the time of publication of this review, we found three systematic reviews. We added this information.
• We modified the comparisons that considered CBT was considered as monotherapy to clarify the different types of control groups. In the protocol ( Lopez 2013 ), we considered: "monotherapy (CBT versus control (supportive psychotherapies, placebo interventions, waiting list or no treatment) and CBT versus usual treatment (other specific psychotherapies for ADHD)); and combined therapy (CBT combined with pharmacotherapy versus pharmacotherapy alone)". In the review, we redefined the comparison as follows: CBT versus unspecific control conditions (supportive psychotherapies, waiting list or no treatment); CBT plus pharmacotherapy versus pharmacotherapy alone; CBT versus other specific interventions (control interventions that include therapeutic ingredients specifically targeted to ADHD).
• To clarify the analysis of the outcomes, we added the following paragraph: "We presented clinical and self‐reported outcomes separately, as do most studies about this topic, because assessing ADHD is more accurate when symptom information comes from more than one source ( Barkley 1998a )."
• We stated in the protocol that we planned to include studies that assessed at least one primary outcome or secondary outcome ( Lopez 2013 ), but in the full review we clarified that we included studies that assessed at least one primary outcome or at least one secondary outcome.
• The safety outcome 'All‐cause treatment discontinuation', which we considered a secondary outcome in the protocol ( Lopez 2013 ), is now considered a primary outcome in the full review.
• We included the criteria to assess the magnitude of effect for continuous outcomes using the suggestions in section 12.6.2 'Re‐expressing SMDs using rules of thumb for effect sizes' of the Cochrane Handbook for Systematic Reviews of Interventions ( Higgins 2011 ): 0.2 represents a small effect, 0.5 a moderate effect, and 0.8 a large effect.
• We planned to use MEDLINE Ovid but we used MEDLINE PubMed because of the availability of this interface.
• We replaced the meta Register of Controlled Trials ( m RCT), which was reported as "under review", with the World Health Organization International Clinical Trials Registry Portal (WHO ICTRP).
• We added the World Congress of Behavioral and Cognitive Therapies to search for conference abstracts.
• If the studies did not report the standard deviation (SD), we planned to calculate it from the P value, t values, CIs or standard errors (as described in section 7.7.3.3 of the Cochrane Handbook for Systematic Reviews of Interventions ; Higgins 2011 ). If this information was not reported or was unattainable, we planned to impute the SD from the study with the highest SD for that outcome and assess the effects of this assumption on the analysis by conducting a sensitivity analysis. If the outcome data were reported as a median, a range or as a mean without a variance, we planned to report the data in additional tables. Since these situations did not happen, we did not apply these planned approaches.
• We revised the bands that we reported for I 2 from "0% to 30%: might not be important; 30% to 60%: may represent moderate heterogeneity; more than 60%: may represent substantial or considerable heterogeneity" ( Lopez 2013 ), to "0% to 40%: might not be important; 30% to 60%: may represent moderate heterogeneity; 50% to 90%: may represent substantial heterogeneity; and 75% to 100%: represents considerable heterogeneity".
• We explained the conditions for consideration of homogeneity in more detail.
• We also included a new subsection named 'Summary of findings' beneath this section, to explain the criteria we used to rate the quality of evidence according to the GRADE methodology.
• We decided to remove 'type of CBT' as a possible subgroup analysis after the comparisons were redefined (see 'Types of interventions' above).
• As we did not include cluster‐RCTs, we did not perform sensitivity analyses to assess the potential biasing effects of inadequately controlled cluster‐RCTs ( Donner 2001 ), or the effect of different values of the ICC.
• We did not conduct, as planned, a sensitivity analysis comparing the results of the analyses with our imputed 'highest SD' versus analyses that used an SD imputed from the study with the lowest SD.
• We did not conduct, as planned, a sensitivity analysis to assess the effects of eventual missing dichotomous data on our primary meta‐analyses by assuming, on the one hand, that all missing data were successes and, on the other hand, that all missing data were failures (best‐ versus worst‐case scenario analyses).
• While we did not foresee the transformation of the continuous results to relative percentage changes in the protocol, we included it in Appendix 2 to facilitate the readers' understanding.

We describe all modifications in the Additional Methods Table ( Table 11 ).

Contributions of authors

Pablo López: overall responsibility for the review, protocol writing, trial selection, data extraction and assimilation, statistical analysis and review writing. Fernando Torrente: protocol writing, trial selection, data extraction and assimilation, statistical analysis and review writing. Agustín Ciapponi: protocol writing, trial selection, data extraction and assimilation, statistical analysis and review writing. Alicia Graciela Lischinsky: protocol and review writing. Marcelo Cetkovich‐Bakmas: protocol and review writing. Juan Ignacio Rojas: protocol and review writing. Marina Romano: protocol and review writing. Facundo F Manes: overall supervision of the review.

Sources of support

Internal sources.

• None, Other.

External sources

Declarations of interest.

Pablo Luis Lopez ‐ none known. Fernando Manuel Torrente ‐ none known. Agustín Ciapponi ‐ none known. Alicia Graciela Lischinsky received payment as an invited speaker at Ely Lilly and Jannsen Cilag Labs. Marcelo Cetkovich‐Bakmas ‐ none known. Juan Ignacio Rojas ‐ none known. Marina Romano received payment from Novartis Argentina for review preparation and funds for travel/accommodation/meeting expenses from Boehringer‐Ingelheim. MR declares no conflict of interest related to this review. Facundo F Manes ‐ none known.

References to studies included in this review

Emilsson 2011 {published data only}.

• Emilsson B, Gudjonsson G, Sigurdsson JF, Baldursson G, Einarsson E, Olafsdottir H, et al. Cognitive behaviour therapy in medication‐treated adults with ADHD and persistent symptoms: a randomized controlled trial . BMC Psychiatry 2011; 11 :116. [DOI: 10.1186/1471-244X-11-116; ACTRN12611000533998; PMC3155481; PUBMED: 21787431] [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Fleming 2015 {published data only}

• Fleming AP, McMahon RJ, Moran LR, Peterson AP, Dreessen A. Pilot randomized controlled trial of dialectical behavior therapy group skills training for ADHD among college students . Journal of Attention Disorders 2015; 19 ( 3 ):260‐71. [DOI: 10.1177/1087054714535951; PUBMED: 24874347] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Gu 2017 {published data only}

• Gu Y, Xu G, Zhu Y. A randomized controlled trial of mindfulness‐based cognitive therapy for college students . Journal of Attention Disorders 2016 Dec 1 [Epub ahead of print]. [DOI: 10.1177/1087054716686183; PUBMED: 28038496] [ PubMed ] [ CrossRef ]

Hepark 2015 {published data only}

• Hepark S, Janssen L, Vries A, Schoenberg PLA, Donders R, Kan CC, et al. The efficacy of adapted MBCT on core symptoms and executive functioning in adults with ADHD: a preliminary randomized controlled trial . Journal of Attention Disorders 2015 Nov 20 [Epub ahead of print]. [DOI: 10.1177/1087054715613587; PUBMED: 26588940] [ PubMed ] [ CrossRef ]

Hirvikoski 2011 {published data only}

• Hirvikoski T, Waaler E, Alfredsson J, Pihlgren C, Holmström A, Johnson A, et al. Reduced ADHD symptoms in adults with ADHD after structured skills training group: results from a randomized controlled trial . Behaviour Research and Therapy 2011; 49 ( 3 ):175‐85. [DOI: 10.1016/j.brat.2011.01.001; PUBMED: 21295767] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Moëll 2015 {published data only}

• Moëll B, Kollberg L, Nasri B, Lindefors N, Kaldo V. Living SMART – A randomized controlled trial of a guided online course teaching adults with ADHD or sub‐clinical ADHD to use smartphones to structure their everyday life . Internet Interventions 2015; 2 ( 1 ):24‐31. [DOI: 10.1016/j.invent.2014.11.004] [ CrossRef ] [ Google Scholar ]

Pettersson 2017 {published data only}

• Pettersson R, Söderström S, Edlund‐Söderström K, Nilsson KW. Internet‐based cognitive behavioral therapy for adults with ADHD in outpatient psychiatric care . Journal of Attention Disorders 2017; Vol. 21, issue 6:508‐21. [DOI: 10.1177/1087054714539998; PUBMED: 24970720] [ PubMed ] [ CrossRef ]

Safren 2005 {published data only}

• Safren SA, Otto MW, Sprich S, Winett CL, Wilens TE, Biederman J. Cognitive‐behavioral therapy for ADHD in medication‐treated adults with continued symptoms . Behaviour Research and Therapy 2005; 43 ( 7 ):831‐42. [DOI: 10.1016/j.brat.2004.07.001; PUBMED: 15896281] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Safren 2010 {published data only}

• Safren SA, Sprich S, Mimiaga MJ, Surman C, Knouse L, Groves M, et al. Cognitive behavioral therapy vs relaxation with educational support for medication‐treated adults with ADHD and persistent symptoms: a randomized controlled trial . JAMA 2010; 304 ( 8 ):875‐80. [DOI: 10.1001/jama.2010.1192; NCT00118911; PMC3641654; PUBMED: 20736471] [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Schoenberg 2014 {published data only}

• Schoenberg PL, Hepark S, Kan CC, Barendregt HP, Buitelaar JK, Speckens AE. Effects of mindfulness‐based cognitive therapy on neurophysiological correlates of performance monitoring in adult attention‐deficit/hyperactivity disorder . Clinical Neurophysiology 2014; 125 ( 7 ):1407‐16. [DOI: 10.1016/j.clinph.2013.11.031; PUBMED: 24374088] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Solanto 2010 {published data only}

• Solanto MV, Marks DJ, Wasserstein J, Mitchell, Abikoff H, Alvir JM, et al. Efficacy of meta‐cognitive therapy (MCT) for adult ADHD . American Journal of Psychiatry 2010; 167 ( 8 ):958‐68. [DOI: 10.1176/appi.ajp.2009.09081123; NIHMS439495; PMC3633586] [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Stevenson 2002 {published data only}

• Stevenson CS, Stevenson RJ, Whitmont S. A self‐directed psychosocial intervention with minimal therapist contact for adults with attention deficit hyperactivity disorder . Clinical Psychology & Psychotherapy 2003; 10 ( 2 ):93‐101. [DOI: 10.1002/cpp.356] [ CrossRef ] [ Google Scholar ]
• Stevenson CS, Whitmont S, Bornholt L, Livesey D, Stevenson RJ. A cognitive remediation programme for adults with attention deficit hyperactivity disorder . Australian and New Zealand Journal of Psychiatry 2002; 36 ( 5 ):610‐6. [DOI: 10.1046/j.1440-1614.2002.01052.x; PUBMED: 12225443] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Vidal Estrada 2013 {published data only}

• Vidal R, Bosch R, Nogueira M, Gómez‐Barros N, Valero S, Palomar G, et al. Psychoeducation for adults with attention deficit hyperactivity disorder vs cognitive behavioral group therapy: a randomized controlled pilot study . Journal of Nervous and Mental Disease 2013; 201 ( 10 ):894‐900. [DOI: 10.1097/NMD.0b013e3182a5c2c5; PUBMED: 24080677] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Virta 2010 {published data only}

• Virta M, Salakari A, Antila M, Chydenius E, Partinen M, Kaski M, et al. Short cognitive behavioral therapy and cognitive training for adults with ADHD – a randomized controlled pilot study . Neuropsychiatric Disease and Treatment 2010; 6 ( 1 ):443‐53. [DOI: 10.2147/NDT.S11743; PMC2938293; PUBMED: 20856608] [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

References to studies excluded from this review

Cherkasova 2016 {published data only}.

• Cherkasova MV, French LR, Syer CA, Cousins L, Galina H, Ahmadi‐Kashani Y, et al. Efficacy of cognitive behavioral therapy with and without medication for adults with ADHD: a randomized clinical trial . Journal of Attention Disorders 2016 Oct 6 [Epub ahead of print]. [10.1177/1087054716671197] [ PubMed ]

Mitchell 2013 {published data only}

• Mitchell JT, McIntyre EM, English JS, Dennis MF, Beckham JC, Kollins SH. A pilot trial of mindfulness meditation training for ADHD in adulthood: impact on core symptoms, executive functioning,and emotion dysregulation . Journal of Attention Disorders 2017; 21 ( 13 ):1105‐20. [DOI: 10.1177/1087054713513328; PMC4045650; PUBMED: 4305060] [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Philipsen 2015 {published data only}

• Philipsen A, Jans T, Graf A, Matthies S, Borel P, Colla M, et al. Effects of group psychotherapy, individual counseling, methylphenidate, and placebo in the treatment of adult attention‐deficit/hyperactivity disorder: a randomized clinical trial . JAMA Psychiatry 2015; 72 ( 12 ):1199‐210. [DOI: 10.1001/jamapsychiatry.2015.2146; ISRCTN54096201; PUBMED: 26536057] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Serra‐Pla 2017 {published data only}

• Serra‐Pla JF, Pozuelo M, Richarte V, Corrales M, Ibáñez Pol, Bellina M, et al. Treatment of attention deficit hyperactivity disorder in adults using virtual reality through a mindfulness programme [Tratamiento del trastorno por déficit de atención/hiperactividad en la edad adulta a través de la realidad virtual mediante un programa de mindfulness]. Revista de Neurología 2017; 64 ( s01 ):S117‐22. [PUBMED: 28256698] [ PubMed ] [ Google Scholar ]

Weiss 2012 {published data only}

• Weiss M, Murray C, Wasdell M, Greenfield B, Giles L, Hechtman L. A randomized controlled trial of CBT therapy for adults with ADHD with and without medication . BMC Psychiatry 2012; 12 :30. [DOI: 10.1186/1471-244X-12-30] [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Young 2015 {published data only}

• Young S, Khondoker M, Emilsson B, Sigurdsson JF, Philipp‐Wiegmann F, Baldursson G, et al. Cognitive‐behavioural therapy in medication‐treated adults with attention‐deficit/hyperactivity disorder and co‐morbid psychopathology: a randomized controlled trial using multi‐level analysis . Psychological Medicine 2015; 45 ( 13 ):2793–804. [DOI: 10.1017/S0033291715000756; PMC4595859; PUBMED: 26022103] [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Young 2017 {published data only}

• Young S, Emilsson B, Sigurdsson JF, Khondoker M, Philipp‐Wiegmann F, Baldursson G, et al. A randomized controlled trial reporting functional outcomes of cognitive‐behavioural therapy in medication‐treated adults with ADHD and comorbid psychopathology . European Archives of Psychiatry and Clinical Neuroscience 2017; 267 ( 3 ):267‐76. [DOI: 10.1007/s00406-016-0735-0; PMC5357275] [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

References to ongoing studies

Isrctn03732556 {published data only}.

• Dittner AJ, Rimes KA, Russell AJ, Chalder T. Protocol for a proof of concept randomized controlled trial of cognitive‐behavioural therapy for adult ADHD as a supplement to treatment as usual, compared with treatment as usual alone . BMC Psychiatry 2014; 14 :248. [DOI: 10.1186/s12888-014-0248-1] [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

{"type":"clinical-trial","attrs":{"text":"NCT02062411","term_id":"NCT02062411"}} NCT02062411 {unpublished data only}

• NCT02062411. A randomized controlled study of cognitive behavioral therapy for adults with attention deficit disorder [A randomized controlled study of cognitive behavioral therapy for adults with attention deficit disorder]. clinicaltrials.gov/ct2/show/study/NCT02062411 (first received 12 February 2014).

{"type":"clinical-trial","attrs":{"text":"NCT02210728","term_id":"NCT02210728"}} NCT02210728 {unpublished data only}

• NCT02210728. Efficacy of cognitive behavioral therapy in treatment of adults with attention deficit hyperactivity disorder [Efficacy of cognitive behavioral therapy in treatment of adults with attention deficit hyperactivity disorder]. clinicaltrials.gov/ct2/show/NCT02210728 (first received 31 July 2014).

{"type":"clinical-trial","attrs":{"text":"NCT02463396","term_id":"NCT02463396"}} NCT02463396 {published data only}

• Janssen L, Kan CC, Carpentier PJ, Sizoo B, Hepark S, Grutters J, et al. Mindfulness based cognitive therapy versus treatment as usual in adults with attention deficit hyperactivity disorder (ADHD) . BMC Psychiatry 2015; 15 :216. [DOI: 10.1186/s12888-015-0591-x; PMC4572448] [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

{"type":"clinical-trial","attrs":{"text":"NCT02829970","term_id":"NCT02829970"}} NCT02829970 {unpublished data only}

• NCT02829970. Helping college students with ADHD lead healthier lifestyles [Behavioral activation to reduce problem alcohol use In college students with ADHD]. clinicaltrials.gov/ct2/show/record/NCT02829970 (first received 7 July 2016).

Additional references

Achenbach 1998.

• Achenbach TM, Howell C, McConaughy SH, Stanger C. Six‐year predictors of problems in a national sample: IV. Young adult signs of disturbance . Journal of the American Academy of Child and Adolescent Psychiatry 1998; 37 ( 7 ):718‐27. [DOI: 10.1097/00004583-199807000-00011; PUBMED: 9666627] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Adler LA, Chua HC. Management of ADHD in adults . Journal of Clinical Psychiatry 2002; 63 ( Suppl 12 ):29‐35. [PUBMED: 12562059] [ PubMed ] [ Google Scholar ]
• Adler LA, Spencer T, Biederman J. Adult ADHD Investigator Symptom Rating Scale–AISRS . Boston (MA); New York (NY): Massachusetts General Hospital; New York University School of Medicine, 2003. [ Google Scholar ]
• America Journal of Clinical Dermatology. Cutaneous drug reaction case reports: from the world literature . American Journal of Clinical Dermatology 2001; 2 ( 4 ):267‐74. [PUBMED: 11817970] [ PubMed ] [ Google Scholar ]

Amador‐Campos 2014

• Amador‐Campos JA, Gómez‐Benito J, Ramos‐Quiroga JA. The Conners' Adult ADHD Rating Scales ‐‐ short self‐report and observer forms: psychometric properties of the Catalan version . Journal of Attention Disorders 2014; 18 ( 8 ):671‐9. [DOI: 10.1177/1087054712446831; PUBMED: 22771453] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Antshel 2011

• Antshel KM, Hargrave TM, Simonescu M, Kaul P, Hendricks K, Faraone SV. Advances in understanding and treating ADHD . BMC Medicine 2011; 9 :72. [DOI: 10.1186/1741-7015-9-72] [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Atkins 2004

• Atkins D, Eccles M, Flottorp S, Guyatt GH, Henry D, Hill S, et al. Systems for grading the quality of evidence and the strength of recommendations I: critical appraisal of existing approaches The GRADE Working Group . BMC Health Services Research 2004; 4 ( 1 ):38. [DOI: 10.1186/1472-6963-4-38; PMC545647; PUBMED: 15615589] [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Barkley 1998a

• Barkley RA, Murphy KR. Attention‐Deficit Hyperactivity Disorder: A Clinical Workbook . 2nd Edition. New York (NY): Guilford Press, 1998. [ Google Scholar ]

Barkley 1998b

• Barkley RA. Attention Deficit‐Hyperactivity Disorder: A Handbook for Diagnosis and Treatment . 2nd Edition. New York (NY): Guilford Press, 1998. [ Google Scholar ]

Barkley 1999

• Barkley RA. Niños Hiperactivos: Cómo Comprender y Atender sus Necesidades Especiales. Guía Completa del Trastorno por Déficit de Atención con Hiperactividad [Hyperactive Children: How to Understand and Address their Special Needs: Complete Guide to Attention Deficit Hyperactivity Disorder] . Barcelona (ES): Paidós, 1999. [ Google Scholar ]

Barkley 2002

• Barkley RA. Major life activity and health outcomes associated with attention‐deficit/hyperactivity disorder . Journal of Clinical Psychiatry 2002; 63 ( Suppl 12 ):10‐5. [PUBMED: 12562056] [ PubMed ] [ Google Scholar ]

Barkley 2006a

• Barkley RA, Fischer M, Smallish L, Fletcher K. Young adult outcome of hyperactive children: adaptive functioning in major life areas . Journal of the American Academy of Child and Adolescent Psychiatry 2006; 45 ( 2 ):192‐202. [DOI: 10.1097/01.chi.0000189134.97436.e2; PUBMED: 16429090] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Barkley 2006b

• Barkley RA, Murphy KR. Attention‐Deficit Hyperactivity Disorder: A Clinical Workbook . 3rd Edition. New York (NY): Guilford Press, 2006. [ Google Scholar ]

Barkley 2008

• Barkley RA, Murphy KR, Fischer M. ADHD in Adults: What the Science Says . New York (NY): Guilford Press, 2008. [ Google Scholar ]

Barkley 2011

• Barkley RA. Barkley Adult ADHD Rating Scale‐IV (BAARS‐IV) . New York (NY): Guilford Press, 2011. [ Google Scholar ]
• Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression . Archives of General Psychiatry 1961; 4 :561‐71. [PUBMED: 13688369] [ PubMed ] [ Google Scholar ]
• Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: psychometric properties . Journal of Consulting and Clinical Psychology 1988; 56 ( 6 ):893–7. [PUBMED: 3204199] [ PubMed ] [ Google Scholar ]
• Beck AT, Steer RA. Beck Anxiety Inventory Manual . San Antonio (TX): Psychological Corporation, 1993. [ Google Scholar ]
• Beck AT, Steer RA, Brown GK. Manual for the Beck Depression Inventory‐II . San Antonio (TX): Psychological Corporation, 1996. [ Google Scholar ]
• Beck AT, Steer RA, Järvå H. BAI – Beck Anxiety Inventory: Manual, Svensk Version . Stockholm (SE): Pearson, 2012. [ Google Scholar ]

Biederman 1993

• Biederman J, Faraone SV, Spencer T, Wilens T, Norman D, Lapey KA, et al. Patterns of psychiatric comorbidity, cognition, and psychosocial functioning in adults with attention deficit hyperactivity disorder . American Journal of Psychiatry 1993; 150 ( 12 ):1792‐8. [DOI: 10.1176/ajp.150.12.1792; PUBMED: 8238632] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Biederman 2002

• Biederman J, Mick E, Faraone SV, Braaten E, Doyle A, Spencer T, et al. Influence of gender on attention deficit hyperactivity disorder in children referred to a psychiatric clinic . American Journal of Psychiatry 2002; 159 ( 1 ):36‐42. [DOI: 10.1176/appi.ajp.159.1.36; PUBMED: 11772687] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Biederman 2006

• Biederman J, Monuteaux MC, Mick E, Spencer T, Wilens TE, Silva JM, et al. Young adult outcome of attention deficit hyperactivity disorder: a controlled 10‐year follow‐up study . Psychological Medicine 2006; 36 ( 2 ):167–79. [DOI: 10.1017/S0033291705006410; PUBMED: 16420713] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Brassett‐Harknett 2007

• Brassett‐Harknett A, Butler N. Attention‐deficit/hyperactivity disorder: an overview of the etiology and a review of the literature relating to the correlates and lifecourse outcomes for men and women . Clinical Psychology Review 2007; 27 ( 2 ):188‐210. [DOI: 10.1016/j.cpr.2005.06.001; PUBMED: 16081194] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Brod M, Perwien A, Adler L, Spencer T, Johnston J. Conceptualization and assessment of quality of life for adults with attention deficit disorder . Primary Psychiatry 2005; 12 ( 6 ):58‐64. [www.researchgate.net/profile/Meryl_Brod/publication/232471361_Conceptualization_and_Assessment_of_Quality_of_Life_for_Adults_with_Attention‐DeficitHyperactivity_Disorder/links/53d26cf00cf220632f3c9993/Conceptualization‐and‐Assessment‐of‐Quality‐of‐Life‐for‐Adults‐with‐Attention‐Deficit‐Hyperactivity‐Disorder.pdf] [ Google Scholar ]
• Brod M, Johnston J, Able S, Swindle R. Validation of the adult attention‐deficit/hyperactivity disorder quality‐of‐life scale (AAQoL): a disease‐specific quality‐of‐life measure . Quality of Life Research 2006; 15 ( 1 ):117‐29. [DOI: 10.1007/s11136-005-8325-z; PUBMED: 16411036] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Brown TE. Attention‐Deficit Disorder Scales Manual . San Antonio (TX): Psychological Corporation, 1996. [ Google Scholar ]
• Brown TE. Attention Deficit Disorders and Comorbidities in Children, Adolescents and Adults . Washington (DC): American Psychiatric Press, 2000. [ Google Scholar ]

Campbell 2000

• Campbell M, Grimshaw J, Steen N. Sample size calculations for cluster randomised trials. Changing Professional Practice in Europe Group (EU BIOMED II Concerted Action) . Journal of Health Services Research & Policy 2000; 5 ( 1 ):12‐6. [DOI: 10.1177/135581960000500105; 10787581] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Castells 2013

• Castells X, Cunill R, Capellà D. Treatment discontinuation with methylphenidate in adults with attention deficit hyperactivity disorder: a meta‐analysis of randomized clinical trials . European Journal of Clinical Pharmacology 2013; 69 ( 3 ):347‐56. [DOI: 10.1007/s00228-012-1390-7; PUBMED: 22983311] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Chandler 2013

• Chandler ML. Psychotherapy for adult attention deficit/hyperactivity disorder: a comparison with cognitive behavior therapy . Journal of Psychiatric and Mental Health Nursing 2013; 20 ( 9 ):814‐20. [DOI: 10.1111/jpm.12023; PUBMED: 23506050] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Ciapponi 2011

• Ciapponi A, Glujovsky D, Bardach A, García Martí S, Comande D. EROS: A new software for early stage of systematic reviews . HTAi 2011 Conference, 2011 June 27‐29; Rio de Janeiro . 2011.
• Cohen J. Statistical Power Analysis in the Behavioural Sciences . 2nd Edition. Hillsdale (NJ): Lawrence Erlbaum Associates, Inc, 1988. [ Google Scholar ]

Conners 1999a

• Conners CK, Erhardt D, Sparrow E. Conners CAARS Adult ADHD Rating Scales: Technical Manual . New York (NY): Multi‐Health Systems Inc., 1999. [ Google Scholar ]

Conners 1999b

• Conners CK, Erhardt D, Epstein JN, Parker JDA, Sitarenios G, Sparrow E. Self‐ratings of ADHD symptoms in adults I: factor structure and normative data . Journal of Attention Disorders 1999; 3 ( 3 ):141‐51. [DOI: 10.1177/108705479900300303] [ CrossRef ] [ Google Scholar ]

Conners 1999c

• Conners CK, Erhardt D, Sparrow E. Conners' CAARS Adult ADHD Rating Scales: Technical Manual . Toronto (ON): Multi‐Health Systems, 1999. [ Google Scholar ]

Conners 2008

• Conners CK, Erhardt D, Sparrow EP. Conners’ Adult ADHD Rating Scale ㅡ Self: Screening Version (CAARS‐S:SV) . New South Wales (AU): Psychological Assessments, 2008. [ Google Scholar ]

Cunill 2013

• Cunill R, Castells X, Tobias A, Capellà D. Atomoxetine for attention deficit hyperactivity disorder in the adulthood: a meta‐analysis and meta‐regression . Pharmacoepidemiology and Drug Safety 2013; 22 ( 9 ):961‐9. [DOI: 10.1002/pds.3473; PUBMED: 23813665] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Davids 2004

• Davids E, Krause DA, Specka M, Gastpar M. Analysis of a special consultation for attention deficit/hyperactivity disorder in adults [Analyse einer Spezialsprechstunde für die Aufmerksamkeitsdefizit‐/Hyperaktivitätsstörung bei Erwachsenen]. Gesundheitswesen 2004; 66 ( 7 ):416–22. [DOI: 10.1055/s-2004-813327; PUBMED: 15314733] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Davidson 1960

• Davidson HH, Lang G. Children's perceptions of their teachers feelings towards them related to self perception, school achievement and behavior . Journal of Experimental Education 1960; 29 ( 2 ):107‐18. [DOI: 10.1080/00220973.1960.11010675] [ CrossRef ] [ Google Scholar ]

Davidson 2008

• Davidson MA. ADHD in adults: a review of the literature . Journal of Attention Disorders 2008; 11 ( 6 ):628‐41. [DOI: 10.1177/1087054707310878; 18094324] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Donner 2001

• Donner A, Piaggio G, Villar J. Statistical methods for the meta‐analysis of cluster randomization trials . Statistical Methods in Medical Research 2001; 10 ( 5 ):325‐38. [DOI: 10.1177/096228020101000502; PUBMED: 11697225] [ PubMed ] [ CrossRef ] [ Google Scholar ]

DSM‐5 2013

• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM‐5) . 5th Edition. Arlington (VA): American Psychiatric Association, 2013. [ Google Scholar ]

DSM‐III‐R 1989

• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM‐III‐R) . 3rd Edition. Washington (DC): American Psychiatric Association, 1989. [ Google Scholar ]

DSM‐IV 1994

• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM‐IV) . 4th Edition. Washington (DC): American Psychiatric Association, 1994. [ Google Scholar ]

DSM‐IV‐TR 2000

• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM‐IV‐TR) . 4th Edition. Washington (DC): American Psychiatric Association, 2000. [ Google Scholar ]

DuPaul 1990

• DuPaul G. The ADHD Rating Scale: normative data, reliability and validity . Unpublished manuscript of the University of Massachussetts Medical School ca 1990 .

DuPaul 1998

• DuPaul GJ, Power TJ, Anastopoulos AD, Reid R. ADHD Rating Scale‐IV: Checklists, Norms, and Clinical Interpretation . New York (NY): Guilford Press, 1998. [ Google Scholar ]
• Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta‐analysis detected by a simple, graphical test . BMJ 1997; 315 ( 7109 ):629‐34. [9310563; PMC2127453] [ PMC free article ] [ PubMed ] [ Google Scholar ]

Endicott 1993

• Endicott J, Nee J, Harrison W, Blumenthal R. Quality of Life Enjoyment and Satisfaction Questionnaire: a new measure . Psychopharmacology Bulletin 1993; 29 ( 2 ):321‐6. [PUBMED: 8290681] [ PubMed ] [ Google Scholar ]

Erhardt 1999

• Erhardt D, Epstein JN, Conners CK, Parker JDA, Sitarenios G. Self‐ratings of ADHD symptoms in adults: II. Reliability, validity, and diagnostic sensitivity . Journal of Attention Disorders 1999; 3 ( 3 ):153‐8. [DOI: 10.1177/108705479900300304] [ CrossRef ] [ Google Scholar ]

Faraone 2000

• Faraone SV, Biederman J, Spencer T, Wilens T, Seidman LJ, Mick E, et al. Attention‐deficit/hyperactivity disorder in adults: an overview . Biological Psychiatry 2000; 48 ( 1 ):9‐20. [PUBMED: 10913503] [ PubMed ] [ Google Scholar ]

Gershon 2002

• Gershon J. A meta‐analytic review of gender differences in ADHD . Journal of Attention Disorders 2002; 5 ( 3 ):143‐54. [DOI: 10.1177/108705470200500302; PUBMED: 11911007] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Gittelman 1985

• Gittelman R. Self‐evaluation (teenager's) self‐reports . Psychopharmacology Bulletin 1985; 21 :925‐6. [ Google Scholar ]

Glujovsky 2010

• Glujovsky D, Bardach A, García Martí S, Comande D, Ciapponi A. New software for early stage of systematic reviews . Abstracts of the Joint Cochrane and CampbellColloquium; 2010 Oct 18‐22; Keystone (CO) . Chichester (UK): Wiley‐Blackwell, John Wiley & Sons, 2010:P95. [DOI: 10.1002/14651858.CD000002; P90] [ CrossRef ]

Glujovsky 2011

• Glujovsky D, Bardach A, García Martí S, Comande D, Ciapponi A. EROS: A new software for early stage of systematic reviews . ISPOR 3rd Latin America Conference: Building Networks Across Institutions for Access to Health Care in Latin America; 2011 Sep 8‐10; Mexico City (MX) . Mexico City (MX): IPSOR (International Society for Pharmacoecomics and Outcomes Research), 2011:111.

GRADEpro 2015 [Computer program]

• McMaster University (developed by Evidence Prime). GRADEpro GDT . Version accessed 12 December 2017. Hamilton (ON): McMaster University (developed by Evidence Prime), 2015.

Graham 2011

• Graham J, Banaschewski T, Buitelaar J, Coghill D, Danckaerts M, Dittmann RW, et al. European guidelines on managing adverse effects of medication for ADHD . European Child & Adolescent Psychiatry 2011; 20 ( 1 ):17–37. [DOI: 10.1007/s00787-010-0140-6; PMC3012210] [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Guy W, National Institute of Mental health (US), Psychopharmacology Research Branch. Division of Extramural Research Programs. ECDEU Assessment Manual for Psychopharmacology, Revised . Rockville (MD): US Department of Health, Education, and Welfare, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute of Mental Health, Psychopharmacology Research Branch, Division of Extramural Research Programs, 1976. [ Google Scholar ]

Guyatt 2011

• Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J, et al. GRADE guidelines: 1. Introduction‐GRADE evidence profiles and summary of findings tables . Journal of Clinical Epidemiology 2011; 64 ( 4 ):383‐94. [DOI: 10.1016/j.jclinepi.2010.04.026; PUBMED: 21195583] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Hamilton 1959

• Hamilton M. The assessment of anxiety states by rating . British Journal of Medical Psychology 1959; 32 ( 1 ):50‐5. [DOI: 10.1111/j.2044-8341.1959.tb00467.x] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Hamilton 1960

• Hamilton M. A rating scale for depression . Journal of Neurology, Neurosurgery and Psychiatry 1960; 23 :56‐62. [PMC495331; PUBMED: 14399272] [ PMC free article ] [ PubMed ] [ Google Scholar ]

Hesslinger 2002

• Hesslinger B, Tebartz Van Elst L, Nyberg E, Dykierek P, Richter H, Berner M, et al. Psychotherapy of attention deficit hyperactivity disorder in adults ‐‐ a pilot study using a structured skills training program . European Archives of Psychiatry and Clinical Neuroscience 2002; 252 ( 4 ):177‐84. [DOI: 10.1007/s00406-002-0379-0; PUBMED: 12242579] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Higgins 2011

• Higgins JPT, Green S (Editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011 . Available from www.cochrane‐handbook.org .

Jensen 2016

• Jensen CM, Amdisen BL, Jorgensen KJ, Arnfred SM. Cognitive behavioural therapy for ADHD in adults: systematic review and meta‐analyses . Attention Deficit and Hyperactivity Disorders 2016; 8 ( 1 ):3‐11. [DOI: 10.1007/s12402-016-0188-3; PUBMED: 26801998] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Kaufman 1996

• Kaufman J, Birmaher B, Brent D, Rao U, Ryan N. Kiddie‐SADS‐Present and Lifetime Version (K‐SADS‐PL) . Available from www.psychiatry.pitt.edu/sites/default/files/Documents/assessments/ksads‐pl.pdf (accessed 12 December 2017).

Kessler 2005

• Kessler RC, Adler L, Ames M, Demler O, Faraone S, Hiripi E, et al. The World Health Organization Adult ADHD Self‐Report Scale (ASRS): a short screening scale for use in the general population . Psychological Medicine 2005; 35 ( 2 ):245‐56. [PUBMED: 15841682] [ PubMed ] [ Google Scholar ]

Kessler 2006

• Kessler RC, Akiskal HS, Ames M, Birnbaum H, Greenberg P, Hirschfeld RM, et al. Prevalence and effects of mood disorders on work performance in a nationally representative sample of US workers . American Journal of Psychiatry 2006; 163 ( 9 ):1561‐8. [DOI: 10.1176/ajp.2006.163.9.1561; PMC1924724; PUBMED: 16946181] [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• King A, Harris P, Fritzell J, Kurlan R. Syncope in children with Tourette's syndrome treated with guanfacine . Movement Disorders 2006; 21 ( 3 ):419–20. [DOI: 10.1002/mds.20738; 16229000] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Knouse 2008

• Knouse LE, Cooper‐Vince C, Sprich S, Safren SA. Recent developments in the psychosocial treatment of adult ADHD . Expert Reviews of Neurotherapeutics 2008; 8 ( 10 ):1537‐48. [10.1586/14737175.8.10.1537; NIHMS75098; PMC2628311] [ PMC free article ] [ PubMed ] [ Google Scholar ]

Knouse 2010

• Knouse LE, Safren SA. Current status of cognitive behavioral therapy for adult attention‐deficit hyperactivity disorder . Psychiatric Clinics of North America 2010; 33 ( 3 ):497‐509. [DOI: 10.1016/j.psc.2010.04.001; NIHMS213647; PMC2909688] [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Knouse 2017

• Knouse LE, Teller J, Brooks MA. Meta‐analysis of cognitive–behavioral treatments for adult ADHD . Journal of Consulting and Clinical Psychology 2017; 85 ( 7 ):737‐50. [DOI: 10.1037/ccp0000216; 28504540] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Landgraf 2007

• Landgraf JM. Monitoring quality of life in adults with ADHD: reliability and validity of a new measure . Journal of Attention Disorders 2007; 11 ( 3 ):351‐62. [DOI: 10.1177/1087054707299400; PUBMED: 17494834] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Lefebvre 2011

• Lefebvre C, Manheimer E, Glanville J. Chapter 6: Searching for studies. In: Higgins JP, Green S, editor(s). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011 . Available from handbook.cochrane.org .
• Lim JR, Faught PR, Chalasani NP, Molleston JP. Severe liver injury after initiating therapy with atomoxetine in two children . Journal of Pediatrics 2006; 148 ( 6 ):831–4. [DOI: 10.1016/j.jpeds.2006.01.035; PUBMED: 16769398] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Millstein 1997

• Millstein RB, Wilens TE, Biederman J, Spencer TJ. Presenting ADHD symptoms and subtypes in clinically referred adults with ADHD . Journal of Attention Disorders 1997; 2 ( 3 ):159‐66. [DOI: 10.1177/108705479700200302] [ CrossRef ] [ Google Scholar ]
• Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta‐analyses: the PRISMA statement . PLOS Medicine 2009; 6 ( 7 ):e1000097. [DOI: 10.1371/journal.pmed.1000097; PMC2707599; PUBMED: 19621072] [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Mongia 2012

• Mongia M, Hechtman L. Cognitive behavior therapy for adults with attention‐deficit/hyperactivity disorder: a review of recent randomized controlled trials . Current Psychiatry Reports 2012; 14 ( 5 ):561‐7. [DOI: 10.1007/s11920-012-0303-x; PUBMED: 22878974] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Morton 2000

• Morton WA, Stockton GG. Methylphenidate abuse and psychiatric side effects . Primary Care Companion to The Journal of Clinical Psychiatry 2000; 2 ( 5 ):159‐64. [PMC181133] [ PMC free article ] [ PubMed ] [ Google Scholar ]

Murphy 1996

• Murphy K, Barkley RA. Attention deficit hyperactivity disorder adults: comorbidities and adaptive impairments . Comprehensive Psychiatry 1996; 37 ( 6 ):393‐401. [PUBMED: 8932963] [ PubMed ] [ Google Scholar ]
• National Institute of Mental Health. CGI (Clinical Global Impression) Scale — NIMH . Psychopharmacology Bulletin 1985; 21 :839‐44. [ Google Scholar ]

Perrin 2008

• Perrin JM, Friedman RA, Knilans TK, Black Box Working Group, Section on Cardiology, Cardiac Surgery. Cardiovascular monitoring and stimulant drugs for attention‐deficit/hyperactivity disorder . Pediatrics 2008; 122 ( 2 ):451–3. [DOI: 10.1542/peds.2008-1573] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Philipsen 2007

• Philipsen A, Richter H, Peters J, Alm B, Sobanski E, Colla M, et al. Structured group psychotherapy in adults with attention deficit hyperactivity disorder: results of an open multicenter study . Journal of Nervous and Mental Disease 2007; 195 ( 12 ):1013‐9. [DOI: 10.1097/NMD.0b013e31815c088b; PUBMED: 18091195] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Philipsen 2012

• Philipsen A. Psychotherapy in adult attention deficit hyperactivity disorder: Implications for treatment and research . Expert Review of Neurotherapeutics 2012; 12 ( 10 ):1217‐25. [DOI: 10.1586/ern.12.91; PUBMED: 23082738] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Polanczyk 2014

• Polanczyk GV, Willcutt EG, Salum GA, Kieling C, Rohde LA. ADHD prevalence estimates across three decades: an updated systematic review and meta‐regression analysis . International Journal of Epidemiology 2014; 43 ( 2 ):434‐42. [DOI: 10.1093/ije/dyt261; PMC4817588; PUBMED: 24464188] [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Prescrire 2007

• Prescrire International. Modafinil: serious skin reactions . Prescrire International 2007; 16 ( 88 ):71. [PUBMED: 17465032] [ PubMed ] [ Google Scholar ]

Ramsay 2007

• Ramsay JR. Current status of cognitive‐behavioral therapy as a psychosocial treatment for adult attention‐deficit/hyperactivity disorder . Current Psychiatry Reports 2007; 9 ( 5 ):427‐33. [PUBMED: 17915084] [ PubMed ] [ Google Scholar ]

Ramsay 2008

• Ramsay JR, Rostain AL. Cognitive‐Behavioral Therapy for Adult ADHD: An Integrative Psychosocial and Medical Approach . New York (NY): Routledge, 2008. [ Google Scholar ]

Ramsay 2010

• Ramsay JR. CBT for adult ADHD: adaptations and hypothesized mechanisms of change . Journal of Cognitive Psychotherapy 2010; 24 ( 1 ):37‐45. [DOI: 10.1891/0889-8391.24.1.37] [ CrossRef ] [ Google Scholar ]

RevMan 2014 [Computer program]

• Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan) . Version 5.3. Copenhagen: Nordic Cochrane Centre, The Cochrane Collaboration, 2014.

Rosenberg 1965a

• Rosenberg M. The association between self‐esteem and anxiety . Journal of Psychiatric Research 1962; 1 :135‐52. [PUBMED: 13974903] [ PubMed ] [ Google Scholar ]

Rosenberg 1965b

• Rosenberg M. Society and the Adolescent Self‐Image . Princeton (NJ): Princeton University Press, 1965. [ Google Scholar ]

Safren 2006

• Safren SA. Cognitive‐behavioral approaches to ADHD treatment in adulthood . Journal of Clinical Psychiatry 2006; 67 ( Suppl 8 ):46‐50. [PUBMED: 16961430] [ PubMed ] [ Google Scholar ]

Safren 2014 [pers comm]

• Safren SA. Random sequence generation and allocation concealment [personal communication] . Email to: S Safren 12 June 2014.

Seidman 2006

• Seidman LJ. Neuropsychological functioning in people with ADHD across the lifespan . Clinical Psychology Review 2006; 26 ( 4 ):446‐85. [DOI: 10.1016/j.cpr.2006.01.004; PUBMED: 16473440] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Shear MK, Vander Bilt J, Rucci P, Endicott J, Lydiard B, Otto MW, et al. Reliability and validity of a structured interview guide for the Hamilton Anxiety Rating Scale (SIGH‐A) . Depression and Anxiety 2001; 13 ( 4 ):166‐78. [PUBMED: 11413563] [ PubMed ] [ Google Scholar ]
• Simon V, Czobor P, Bálint S, Mészáros A, Bitter I. Prevalence and correlates of adult attention‐deficit hyperactivity disorder: meta‐analysis . British Journal of Psychiatry 2009; 194 ( 3 ):204‐11. [DOI: 10.1192/bjp.bp.107.048827; PUBMED: 19252145] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Solanto 2014 [pers comm]

• Solanto MV. Random sequence generation and allocation concealment [personal communication] . Email to: M V Solanto 11 June 2014.

Speilberger 1989

• Spielberger CD. State‐Trait Anxiety Inventory: A Comprehensive Bibliography . 2nd Edition. Palo Alto (CA): Consulting Psychologists Press, 1989. [ Google Scholar ]

Speilberger 1991

• Spielberger CD. State‐Trait Anger Expression Inventory: Revised Research Edition: Professional Manual . Odessa (FL): Psychological Assessment Resources, 1991. [ Google Scholar ]

Spencer 1998

• Spencer T, Biederman J, Wilens TE, Faraone SV. Adults with attention‐deficit/hyperactivity disorder: a controversial diagnosis . Journal of Clinical Psychiatry 1998; 59 ( S7 ):59‐68. [PUBMED: 9680054] [ PubMed ] [ Google Scholar ]

Spielberger 1986

• Spielberger CD, Gorsuch RL, Lushene RE. STAI: State‐Trait Anxiety Inventory: Manual [STAI: cuestionario de ansiedad estado‐rasgo: Manual] . Madrid (ES): TEA Ediciones, 1986. [ Google Scholar ]

Spielberger 1988

• Spielberger CD. State‐Trait Anger Expression Inventory: Professional Manual . Odessa (FL): Psychological Assessment resources, 1988. [ Google Scholar ]
• Still GF. The Goulstonian lectures on some abnormal psychical condition in children . Lancet 1902; 159 ( 4104 ):1163‐8. [DOI: 10.1016/S0140-6736(01)74901-X] [ CrossRef ] [ Google Scholar ]

Torrente 2011

• Torrente F, Lischinsky A, Torralva T, López P, Roca M, Manes F. Not always hyperactive? Elevated apathy scores in adolescents and adults with ADHD . Journal of Attention Disorders 2011; 15 ( 7 ):545‐56. [DOI: 10.1177/1087054709359887; PUBMED: 20207850] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Torrente 2012

• Torrente F, López P, Alvarez Prado D, Kichic R, Cetkovich‐Bakmas M, Lischinsky A, et al. Dysfunctional cognitions and their emotional, behavioral, and functional correlates in adults with attention deficit hyperactivity disorder (ADHD): is the cognitive‐behavioral model valid? . Journal of Attention Disorders 2014; 18 ( 5 ):412‐24. [DOI: 10.1177/1087054712443153; PUBMED: 22628149] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Van der Ploeg 2000

• Ploeg HM, Defares PB, Spielberger CD. Handleiding bij de Zelf‐Beoordelings Vragenlijst ZBV. Een Nederlandse bewerking van de Speilberger State‐Trait Anxiety Inventory STAI‐DY [Manual for the Self‐Assessment Questionnaire ZBV. A Dutch Version of the Speilberger State‐Trait Anxiety Inventory STAI‐DY] . Amsterdam (NLD): Pearson Assessment and Information BV, 2000. [ Google Scholar ]

Virta 2014 [pers comm]

• Virta M. Random sequence generation and allocation concealment [personal communication] . Email to: M Virta 17 June 2014.
• Weiss M, Safren SA, Solanto MV, Hechtman L, Rostain AL, Ramsay JR, et al. Research forum on psychological treatment of adults with ADHD . Journal of Attention Disorders 2008; 11 ( 6 ):642‐51. [DOI: 10.1177/1087054708315063; PUBMED: 18417729] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Wender 2001

• Wender PH, Wolf LE, Wasserstein J. Adults with ADHD. An overview . Annals of the New York Academy of Sciences 2001; 931 :1‐16. [PUBMED: 11462736] [ PubMed ] [ Google Scholar ]
• World Health Organization. The ICD‐10 Classification of Mental and Behavioural Disorders. Diagnostic Criteria for Research . Geneva: World Health Organization, 1993. [ Google Scholar ]

Wilens 2002

• Wilens TE, Biederman J, Spencer TJ. Attention deficit/hyperactivity disorder across the lifespan . Annual Review of Medicine 2002; 53 :113‐31. [DOI: 10.1146/annurev.med.53.082901.103945; PUBMED: 11818466] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Wilens 2004

• Wilens TE, Dodson W. A clinical perspective of attention‐deficit/hyperactivity disorder into adulthood . Journal of Clinical Psychiatry 2004; 65 ( 10 ):1301‐11. [PUBMED: 15491232] [ PubMed ] [ Google Scholar ]
• Wood DR, Reimherr FW, Wender PH, Johnson GE. Diagnosis and treatment of minimal brain dysfunction in adults: a preliminary report . Archives of General Psychiatry 1976; 33 ( 12 ):1453‐60. [DOI: 10.1001/archpsyc.1976.01770120057005; PUBMED: 793563] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Woods D. The diagnosis and treatment of attention deficit disorder, residual type . Psychiatric Annals 1986; 16 ( 1 ):23‐8. [DOI: 10.3928/0048-5713-19860101-06] [ CrossRef ] [ Google Scholar ]

Young 2007a

• Young S, Bramham J. ADHD in Adults: A Psychological Guide to Practice . Chichester (UK): John Wiley and Sons, 2007. [ Google Scholar ]

Young 2007b

• Young S, Ross RR. R&R2 for ADHD Youths and Adults: A Prosocial Training Program . Ottawa (ON): Cognitive Centre of Canada, 2007. [ Google Scholar ]

Young 2014 [pers comm]

• Young S. Random sequence generation and allocation concealment [personal communication] . Email to: Susan Young 18 June 2014.
• Young Z, Moghaddam N, Tickle A. The efficacy of cognitive behavioral therapy for adults with ADHD: a systematic review and meta‐analysis of randomized controlled trials . Journal of Attention Disorders 2016 Aug 22 [Epub ahead of print]. [DOI: 10.1177/1087054716664413; PUBMED: 27554190] [ PubMed ] [ CrossRef ]

Zigmond 1983

• Zigmond AS, Snaith RP. The hospital anxiety and depression scale . Acta Psychiatrica Scandinavica 1983; 67 ( 6 ):361‐70. [PUBMED: 6880820] [ PubMed ] [ Google Scholar ]

References to other published versions of this review

• Lopez PL, Torrente FM, Ciapponi A, Lischinsky AG, Cetkovich‐Bakmas M, Rojas JI, et al. Cognitive‐behavioural interventions for attention deficit hyperactivity disorder (ADHD) in adults . Cochrane Database of Systematic Reviews 2013, Issue 11 . [DOI: 10.1002/14651858.CD010840] [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Header menu - Mobile | United Kingdom

Header menu - drawer | united kingdom, attention deficit hyperactivity disorder (adhd).

This content discusses substance abuse or addiction (which may include mentions of alcohol or drug use), depression and anxiety, which some people may find triggering.

What are the symptoms of ADHD?

Adhd and other mental health problems, what causes adhd, getting a diagnosis, getting support, ways you can look after yourself.

Studies show that ADHD may affect certain areas of the brain that allow us to solve problems, plan ahead, understand others’ actions, and control our impulses.

Most cases are diagnosed in childhood, but it’s possible to be diagnosed as an adult. ADHD can’t develop for the first time in adults, but you may have had it as a child and not been diagnosed.

The symptoms of ADHD fall into two groups: inattentiveness, hyperactivity and impulsiveness. You may have difficulties that fall into one or both categories.

Symptoms of ADHD may present themselves differently. For example, boys with ADHD may be more disruptive in the classroom than girls. Adults are less likely to show hyperactivity.

ADHD in children and teenagers

The main symptoms of inattentiveness include:

• a short attention span
• making careless mistakes
• being forgetful or losing things
• being unable to stick to boring tasks
• difficulty listening or carrying out instructions
• constantly changing activity
• difficulty organising tasks

The main symptoms of hyperactivity and impulsiveness include:

• fidgeting or being unable to sit still
• lots of physical movement or talking
• being unable to wait your turn
• acting impulsively or recklessly
• interrupting conversations

Many children have phases where they’re restless or can’t concentrate. This doesn’t necessarily mean they have ADHD. But, if you think your child’s behaviour is different to most children their age, speak to their teacher or GP about your concerns.

ADHD in adults

While you can’t develop ADHD as an adult, your symptoms may have been missed as a child. Some children grow out of ADHD, while others continue to have symptoms.

Adult symptoms tend to be more subtle than those seen in children. They include:

• difficulty paying attention or focusing
• being easily distracted by things other people are able to ignore
• daydreaming or zoning out
• struggling to complete tasks
• lack of attention to detail
• poor listening skills
• losing things and being forgetful
• quickly getting bored and seeking out new experiences
• impatience, mood swings and irritability
• risk-taking (for example, dangerous driving)

If you have undiagnosed ADHD as an adult, you may find life overwhelming but not know why. You may be stressed out and have problems with work, money and relationships as a result of your ADHD.

If you have ADHD, you’re more likely to experience a mental health problem. These include anxiety , depression , sleep problems , conduct disorder (showing aggressive or antisocial behaviour) and substance abuse .

The causes of ADHD aren’t fully known, but a combination of factors – including genetics and brain chemistry – are likely responsible. Some people may be more likely to develop ADHD, including those born prematurely or with low birth weights or with epilepsy or brain damage.

If you think you or your child could have ADHD, speak to your GP . They can’t formally diagnose you, but they can talk about your concerns and refer you for a specialist assessment if necessary.

The NHS website has more information about getting a diagnosis .

If there’s a long waiting list to see a specialist, you may be able to speed this up by using your right to choose . This lets you choose the organisation that provides your NHS care when you’re referred to a specialist.

If you live in an area where they have an NHS contract, you can be assessed for adult ADHD through Psychiatry UK . As an online service, they have a larger group of specialists to deliver assessments and, therefore, a shorter waiting list than many other services. They have more information on how to get an assessment on their website.

There are lots of different types of treatment for ADHD. While it can’t be cured, treatment can help relieve the symptoms and make daily life much easier.

ADHD is often treated with stimulant medication. It can help you concentrate better, be less impulsive and feel calmer.

You may be offered:

• psychoeducation. You discuss how ADHD affects you and how you can cope
• with behaviour therapy. Children are rewarded for trying to control ADHD and show good behaviour
• parent training and education programmes. You learn how to talk to and work with your child to improve their attention and behaviour
• Cognitive Behavioural Therapy (CBT). Talking therapy can help you manage your problems by changing your thoughts and behaviour

The NHS website has more information about  treatment for ADHD .

Different things work for different people with ADHD. You could try physical activity , eating well , get enough sleep , and reducing  alcohol . The ADHD And You website have other tips to help you organise your day , such as using checklists and breaking up bigger tasks into smaller chunks.

You could also join a support group. ADHD charity ADHD Information Services  has a list of groups for children and adults with ADHD – click on your nation to see them.

ADHD (youngminds.org.uk)

ADHD and you

ADHD: diagnosis and management (NICE)

ADHD in Adults - HelpGuide.org

Attention deficit hyperactivity disorder (ADHD) - NHS (www.nhs.uk)

If you feel affected by the content you have read, please see our get help page for support.

* Last updated: 9 June 2021

Was this content useful, related content, autism and mental health.

ADHD Impulsivity: Its Types, Effects, and Management Tips

• Updated: 9.01.2023

Rabia Khaliq

ADHD is a diverse cognitive condition that manifests behaviorally in many ways, including impulsivity. It is a common symptom among those adults diagnosed with predominantly hyperactive ADHD . Even though the prevalence of hyperactivity in adults is lower since it tends to decline with age, it can still occur.

It’s vital to carefully assess if you have this symptom because ADHD impulsivity can affect the functionality and the quality of your life in different ways. Read on to learn more.

Over the course of your life, your symptoms of ADHD may change. Consult a professional for ADHD treatment online .

What Does Impulsiveness Mean?

Impulsivity is the tendency to act without thought or planning and without considering the potential consequences. Impulsivity reveals itself in a range of behaviors in children and adults with attention-deficit/hyperactivity disorder (ADHD).

Of course, some people may experience impulsiveness more severely than others, particularly if they are more likely to have the hyperactive-impulsive subtype of the disorder than the inattentive subtype.

Types of Impulsivity

ADHD impulse control issues can be divided into four main types depending on how the action develops and the motivations behind the impulsive activity. Here is a little explanation to give you some background information on this:

• Motor impulsivity . This kind is connected to an individual’s unexpected acts or outbursts. People with this type are restless and need help sitting still or frequently perform behaviors that are likely to draw attention.
• Emotional impulsivity . Individuals do this when they base a choice on their feelings. This kind of impulsivity increases one’s tendency to be impatient, irritable, or easily angered. Emotional dysregulation, one of the symptoms of ADHD , should be addressed in this case.
• Sensory impulsivity . Individuals struggle to digest information when dealing with this type of impulsivity. They need help sifting through unimportant information and need to be more focused .
• Cognitive impulsivity. It typically entails a lack of clarity of thought or attention to detail. It also makes a person more likely to act hastily, act without thinking, or forget things , all of which might lead to future issues.

Adult ADHD and Impulse Control Issues: The Connection Explained

The thalamus region [1*] of the brain regulates response inhibition. It functions like a gate, providing signals to permit or prohibit certain behaviors. The limbic-hippocampal connections of the brain transmit a warning from the thalamus to the frontal cortex when it notices a red flag. That is the part of the brain that regulates problem-solving and emotional expression.

This thalamus gate might be impaired in people with ADHD. As a result, a person can find it difficult to restrain short-term urges, such as the desire to eat an extra candy or spend more money than planned.

ADHD comes in many forms. Consider getting professional help if you want to manage the symptoms effectively.

How Impulsivity Can Impact One's Life

Symptoms of impulsive ADHD issues in adults might include but are not limited to actions like:

• Making impulsive decisions
• Pursuing dangerous activities
• Requiring immediate fulfillment of needs
• Being loud in voice or actions
• Having a generally rowdy behavior, possibly even destructive
• Willing to finish tasks and projects before moving on to other ones

Beneficial outcomes do not always follow impulsive actions. Regular and recurrent impulsivity is frequently seen as a sign of a more serious problem, especially when it results in injury to oneself or others.

As a result of impulsive behavior, the following effects are most frequently observed:

• Uncontrollable urges. Impulsive behavior can result in an inability to control an urge, temptation, or desire. It can also occur in the form of an obsessive need to engage in a particular action damaging to oneself or others.
• Heightened stress. ADHD and impulse control problems can lead to stress. Before conducting the act, impulsivity can heighten the sense of arousal.
• Antisocial personality. According to research [2*] , impulsivity is linked to antisocial personality. It can also increase the risk of developing an antisocial personality disorder. This disorder is characterized by a total disregard for the consequences of one’s actions and the feelings of other people.
• Temperament issues. Impulsive people are sometimes characterized as hot-headed, rash, and unstable. The feelings of inadequacy that surface with unstable emotions, behaviors, and relationships can be difficult for impulsive people to deal with. They could be quick to react angrily to perceived injustices and frequently fail to realize when their feelings are unjustified or exaggerated.
• Unacceptable behaviors. Adults with poor impulse control may be prone to exhibit behaviors such as unrestricted gaming, the compulsion to shop, pyromania (an impulse to set fires without considering consequences), internet addiction, or hypersexuality.
• Bipolar disorder
• Obsessive-compulsive disorder (OCD)
• Substance abuse

Consult a competent doctor in your area to receive a personalized treatment plan.

Managing Impulsivity

Although impulsivity can be difficult to control sometimes, it is manageable with the correct tools and some effort. You can learn how to recognize your triggers and how to control impulsivity caused by ADHD by using the following tactics:

• Recognize and accept your impulsiveness.
• Develop your self-awareness.
• Limit or prevent risks.
• Communicate more with loved ones.
• Notice your impulsive behaviors to change them.
• Consult a professional.

Final Words

Even though it can occasionally seem quite difficult, controlling ADHD impulsivity is possible. Seeking the assistance of a mental health professional who can help you develop a treatment plan is the first step to managing your impulses. The ADHD specialists at MEDvidi are at your convenience at any time.

• Thalamic inhibition: diverse sources, diverse scales. (2016) Source link
• The Role of Impulsivity in Antisocial and Violent Behavior and Personality Disorders Among Incarcerated Women. (2007) Source link

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• Adult attention-deficit/hyperactivity disorder (ADHD)

Adult attention-deficit/hyperactivity disorder (ADHD) is a mental health disorder that includes a combination of persistent problems, such as difficulty paying attention, hyperactivity and impulsive behavior. Adult ADHD can lead to unstable relationships, poor work or school performance, low self-esteem, and other problems.

Though it's called adult ADHD , symptoms start in early childhood and continue into adulthood. In some cases, ADHD is not recognized or diagnosed until the person is an adult. Adult ADHD symptoms may not be as clear as ADHD symptoms in children. In adults, hyperactivity may decrease, but struggles with impulsiveness, restlessness and difficulty paying attention may continue.

Treatment for adult ADHD is similar to treatment for childhood ADHD . Adult ADHD treatment includes medications, psychological counseling (psychotherapy) and treatment for any mental health conditions that occur along with ADHD .

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Some people with ADHD have fewer symptoms as they age, but some adults continue to have major symptoms that interfere with daily functioning. In adults, the main features of ADHD may include difficulty paying attention, impulsiveness and restlessness. Symptoms can range from mild to severe.

Many adults with ADHD aren't aware they have it — they just know that everyday tasks can be a challenge. Adults with ADHD may find it difficult to focus and prioritize, leading to missed deadlines and forgotten meetings or social plans. The inability to control impulses can range from impatience waiting in line or driving in traffic to mood swings and outbursts of anger.

Adult ADHD symptoms may include:

• Impulsiveness
• Disorganization and problems prioritizing
• Poor time management skills
• Problems focusing on a task
• Trouble multitasking
• Excessive activity or restlessness
• Poor planning
• Low frustration tolerance
• Frequent mood swings
• Problems following through and completing tasks
• Trouble coping with stress

What's typical behavior and what's ADHD?

Almost everyone has some symptoms similar to ADHD at some point in their lives. If your difficulties are recent or occurred only occasionally in the past, you probably don't have ADHD . ADHD is diagnosed only when symptoms are severe enough to cause ongoing problems in more than one area of your life. These persistent and disruptive symptoms can be traced back to early childhood.

Diagnosis of ADHD in adults can be difficult because certain ADHD symptoms are similar to those caused by other conditions, such as anxiety or mood disorders. And many adults with ADHD also have at least one other mental health condition, such as depression or anxiety.

When to see a doctor

If any of the symptoms listed above continually disrupt your life, talk to your doctor about whether you might have ADHD .

Different types of health care professionals may diagnose and supervise treatment for ADHD . Seek a provider who has training and experience in caring for adults with ADHD .

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While the exact cause of ADHD is not clear, research efforts continue. Factors that may be involved in the development of ADHD include:

• Genetics. ADHD can run in families, and studies indicate that genes may play a role.
• Environment. Certain environmental factors also may increase risk, such as lead exposure as a child.
• Problems during development. Problems with the central nervous system at key moments in development may play a role.

Risk factors

Risk of ADHD may increase if:

• You have blood relatives, such as a parent or sibling, with ADHD or another mental health disorder
• Your mother smoked, drank alcohol or used drugs during pregnancy
• As a child, you were exposed to environmental toxins — such as lead, found mainly in paint and pipes in older buildings
• You were born prematurely

Complications

ADHD can make life difficult for you. ADHD has been linked to:

• Poor school or work performance
• Unemployment
• Financial problems
• Trouble with the law
• Alcohol or other substance misuse
• Frequent car accidents or other accidents
• Unstable relationships
• Poor physical and mental health
• Poor self-image
• Suicide attempts

Coexisting conditions

Although ADHD doesn't cause other psychological or developmental problems, other disorders often occur along with ADHD and make treatment more challenging. These include:

• Mood disorders. Many adults with ADHD also have depression, bipolar disorder or another mood disorder. While mood problems aren't necessarily due directly to ADHD , a repeated pattern of failures and frustrations due to ADHD can worsen depression.
• Anxiety disorders. Anxiety disorders occur fairly often in adults with ADHD . Anxiety disorders may cause overwhelming worry, nervousness and other symptoms. Anxiety can be made worse by the challenges and setbacks caused by ADHD .
• Other psychiatric disorders. Adults with ADHD are at increased risk of other psychiatric disorders, such as personality disorders, intermittent explosive disorder and substance use disorders.
• Learning disabilities. Adults with ADHD may score lower on academic testing than would be expected for their age, intelligence and education. Learning disabilities can include problems with understanding and communicating.
• Attention-deficit/hyperactivity disorder. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. Arlington, Va.: American Psychiatric Association; 2013. https://dsm.psychiatryonline.org. Accessed Jan. 26, 2019.
• Attention-deficit/hyperactivity disorder. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorder-adhd/index.shtml. Accessed Jan. 26, 2019.
• AskMayoExpert. Attention-deficit/hyperactivity disorder. Rochester, Minn.: Mayo Foundation for Medical Education and Research; 2017.
• What is ADHD? American Psychiatric Association. https://www.psychiatry.org/patients-families/adhd/what-is-adhd. Accessed Jan. 26, 2019.
• ADHD. National Alliance on Mental Illness. https://www.nami.org/Learn-More/Mental-Health-Conditions/ADHD/Overview. Accessed Jan. 26, 2019.
• Adult ADHD (attention deficit hyperactive disorder). Anxiety and Depression Association of America. https://adaa.org/understanding-anxiety/related-illnesses/other-related-conditions/adult-adhd. Accessed Feb. 11, 2019.
• Geffen J, et al. Treatment of adult ADHD: A clinical perspective. Therapeutic Advances in Psychopharmacology. 2018;8:25.
• Adult ADHD. American Association for Marriage and Family Therapy. https://www.aamft.org/Consumer_Updates/Adult_ADHD.aspx. Accessed Feb. 11, 2019.
• Kooij JJS, et al. Updated European consensus statement on diagnosis and treatment of adult ADHD. European Psychiatry. 2019;56:14.
• Fields SA, et al. Adult ADHD: Addressing a unique set of challenges. Journal of Family Practice. 2017;66:68.
• Mitchell JT, et al. Mindfulness meditation training for attention-deficit/hyperactivity disorder in adulthood: Current empirical support, treatment overview, and future direction. Cognitive and Behavioral Practice. 2015;22:172.
• Bhagia J (expert opinion). Mayo Clinic, Rochester, Minn. June 13, 2019.
• Hyperthyroidism (overactive). American Thyroid Association. https://www.thyroid.org/hyperthyroidism/. Accessed June 13, 2019.
• Low blood glucose (hypoglycemia). National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/low-blood-glucose-hypoglycemia. Accessed June 13, 2019.

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Impulse Control Disorders: Everything to Know

Signs and symptoms, frequently asked questions.

Impulse control disorders (ICD) are a group of mental health disorders that involve problems with self-control.  

People with ICDs fail to resist the impulse to behave in harmful ways, often without thought of the consequences. These urges typically involve disruptive behaviors —such as stealing, cheating, lying, risk-taking, rule breaking, and violence—that violate the rights, well-being, and/or safety of others.  

There are several different types of impulse control disorders. This article will discuss the five main types of impulse control disorders, as well as causes, symptoms, and how to treat them.

KatarzynaBialasiewicz / Getty Images

Types of Impulse Control Disorders

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition ( DSM-5 ) lists five types of impulse control disorders. They are oppositional defiant disorder , intermittent explosive disorder, conduct disorder, kleptomania , and pyromania . All five ICDs involve problems with self-control in terms of behavior and emotions.  

People with ICDs may find it difficult to resist the temptation to perform a certain action. In many cases, these urges are related to “acting out” in some way through aggressive, dishonest, rule breaking, or unsafe behavior.

How Common Are Impulse Control Disorders?

Current estimates suggest that about 3.3% of the population meets the criteria for oppositional defiant disorder, and up to 3.4% of people meet the criteria for conduct disorder. Intermittent explosive disorder is the most common impulse disorder, as around 7% of people will meet the diagnostic criteria for IED at some point during their lifetime.

Pyromania and kleptomania are rarer, with prevalence estimates hovering at around 1% of the population.

Oppositional Defiant Disorder

Oppositional defiant disorder (ODD) is a condition that involves a long-lasting pattern of defiance, disobedience, and hostility toward parents, teachers, and other authority figures. It is diagnosed in children and teens, usually older than the age of 8. However, younger children and adolescents may also receive an ODD diagnosis.

Some of the most common signs and symptoms of ODD are:

• Frequent temper tantrums
• Irritability, anger, argumentativeness, and/or vindictiveness
• Refusal to obey adults’ rules or follow directions
• Difficulty making and keeping friends
• Frequently getting in trouble at school

To be diagnosed with ODD, a child must have exhibited these signs and symptoms on a consistent basis for at least six months with at least one person other than their sibling. Their disruptive behaviors must go beyond typical, developmentally appropriate rule breaking.

Some, but not all, young people with ODD later develop antisocial personality disorder (ASPD). ASPD is a mental health disorder that involves a lack of empathy (the ability to feel along with others) and a long-lasting pattern of manipulative, reckless, and/or criminal behavior.

Conduct Disorder

Conduct disorder (CD) is a condition that involves a chronic pattern of violating social norms and the rights and well-being of others. Conduct disorder is only diagnosed in children and teens up to age 18, and symptoms usually appear during early adolescence.

Common signs and symptoms of CD include:

• Frequent rule-breaking
• Angry outbursts 
• Aggression towards others, including bullying, fighting, and/or sexual assault
• Mistreating children or animals
• Dishonesty, including lying and cheating
• Excessive substance use
• Running away from home
• Truancy (skipping school)
• Criminal behavior, such as theft, vandalism, or arson

Many children with ODD eventually develop conduct disorder, which is usually considered more severe. Some people have both ODD and CD, while others meet the criteria for only one or the other. Many people with CD are diagnosed with ASPD as adults.

Intermittent Explosive Disorder

Intermittent explosive disorder (IED) is an impulse control disorder that involves repeated episodes of angry outbursts that are extremely disproportionate to the situation.  

During these impulsive episodes, a person with IED may:

• Be verbally aggressive
• Start arguments
• Physically assault others
• Destroy property or possessions
• Threaten others

To meet the DSM-5 criteria for IED, these angry outbursts can’t be related to any other mental health disorder or medical condition. They also can’t occur while someone is taking a particular medication, drinking, or using drugs.

Kleptomania

People with kleptomania , also called compulsive stealing, fail to resist the urge to steal things they don’t want or need.  

Kleptomania doesn’t involve stealing for monetary or personal gain, for revenge, or out of necessity. Instead, people with kleptomania feel an intense buildup of tension before stealing. After they steal, they feel an immediate sense of relief and/or pleasure.

Pyromania is an impulse control disorder that involves repeatedly and deliberately setting fires. 

Like people with kleptomania, people with pyromania don’t have political, personal, or vindictive motivations for following through with their urges. For example, someone who sets a fire to destroy an ex-partner’s property or as part of a political protest doesn’t meet the DSM-5 criteria for pyromania.

People with pyromania are often fascinated by fire and anything related to fire. They may feel “pent up” and anxious before setting a fire, followed by an intense release of tension while watching it burn.

There is no single known cause of impulse control disorders. In many cases, multiple factors interact to increase the likelihood that someone will develop an ICD. Contributing factors may include:

• Genetics : Research suggests that genetics plays a role in the development of impulse control disorders. Oppositional defiant disorder, for example, is inherited in approximately 61% of cases. Meanwhile, twin studies suggest that conduct disorder is passed down in families about 50% of the time.
• Trauma : Children with impulse control disorders like ODD or CD are significantly more likely than others to have been abused, neglected, harshly punished, or exposed to substance abuse or violence in the home. Certain environmental factors, such as childhood poverty, significantly increase the risk that someone will later be diagnosed with an impulse control disorder.
• Personality traits : Certain personality traits may make someone more likely to develop an ICD. Research indicates that people with kleptomania are more prone to novelty-seeking behaviors (pursuit of new experiences with intense emotional sensations) and are less likely to relate to others.
• Brain function : Imaging tests and cognitive assessments have revealed impairments in brain structure, thinking, and cognitive function among people with impulse control disorders. For example, studies suggest that people with pyromania may have problems with memory , executive functioning (thinking skills in planning, memory, and self-control), and attention.
• Parkinson’s disease (PD): Parkinson’s disease is a neurodegenerative disorder that causes symptoms like stiffness, slowness, balance and coordination problems, and tremors. Dopamine agonists (common medications prescribed to people with PD) can increase the risk of impulse control disorders and other disruptive, compulsive, and/or repetitive behaviors.  
• Attention deficit hyperactivity disorder (ADHD): Attention deficit hyperactivity disorder involves hyperactivity , impulsivity, and inattentiveness. ADHD is often comorbid with (exists alongside) ODD. Up to 30%–50% of people with oppositional defiant disorder also meet the criteria for ADHD.  
• Comorbid mental health conditions: Many people with impulse control disorders have comorbid mental health conditions, including personality disorders , substance use disorders , mood disorders , depression , and anxiety . For example, up to 60% of people with kleptomania also meet the criteria for obsessive-compulsive disorder (OCD). Meanwhile, people with IED have higher-than-average rates of generalized anxiety disorder (GAD) and bipolar disorder .

Complications of Impulse Control Disorders

If left untreated, impulse control disorders can lead to serious negative consequences, including:

• Legal problems, including incarceration
• Impaired or broken relationships
• Poor performance in school 
• Job loss and/or chronic unemployment
• Substance abuse

Impulse control disorders typically involve a severe, long-lasting pattern of disruptive, harmful, and/or risky behaviors. Common signs and symptoms of ICDs include:

• Argumentativeness
• Threatening to harm others
• Verbal or physical outbursts
• Irritability
• Vindictiveness
• Breaking rules and/or the law
• Taking unnecessary risks
• Cruel treatment of animals  
• Lack of empathy
• Skipping school or work
• Excessive drug or alcohol use
• Using or trying to get weapons
• Deliberately setting fires

The first-line treatment for impulse control disorders is psychotherapy (talk therapy). Types of psychotherapy that have been found to be effective in treating people with ICDs include:

• Cognitive behavioral therapy (CBT) : CBT can help people with ICDs improve their problem-solving and decision-making skills. Research suggests that CBT may help people with pyromania to identify and resist their urges. CBT is also commonly used to treat people with kleptomania. A 2018 study found that people with IED were able to control their anger more effectively after undergoing CBT in a group setting.
• Family therapy : In many cases, family therapy is the preferred treatment for children and adolescents with ODD and/or CD. Functional family therapy aims to assess how interactions between different family members may contribute to a child’s disruptive behaviors. Brief strategic family therapy, a similar short-term behavioral intervention, also works to identify repetitive patterns of thinking, relating, and interacting within the family in order to improve relationships and prevent harmful behaviors.
• Parental management training (PMT) : Parental management training can help to repair the relationship between parent and child in order to reinforce positive behaviors. Typically used to treat ODD, CD, or both, PMT focuses on improving parenting skills and promoting quality time.
• Multisystemic therapy (MST) : Multisystemic therapy is a holistic behavioral intervention program that addresses impulse control disorder symptoms in all areas of a child’s or adolescent’s life. Many key figures—including parents and other relatives, peers, teachers, and therapists—collaborate to promote positive behaviors and prevent harmful ones. MST may take place in foster care, juvenile detention centers, school, and home with the help of social workers and mental health professionals .
• Social skills training : Social skills training can help children and youth with ODD and/or CD to improve their relationships and everyday interactions, respond appropriately to situations, and communicate more effectively.

In some cases, a healthcare provider may prescribe psychiatric medication to manage particular symptoms of an impulse control disorder. They may also prescribe medication to help with comorbid mental health conditions like anxiety, ADHD , or depression.  

Under the supervision of their medical team, people with Parkinson’s disease may need to lower their current dose of dopamine agonists to reduce their ICD-related symptoms.

Impulse control disorders (ICDs) are a group of mental and behavioral disorders that involve a lack of self-control and a failure to resist the urge to perform harmful actions. The five main types of impulse control disorders are oppositional defiant disorder, conduct disorder, intermittent explosive disorder, pyromania, and kleptomania. 

Oppositional defiant disorder (ODD) is a condition in children and adolescents that involves a pattern of defying authority figures. Some children and adolescents with ODD are later diagnosed with conduct disorder (CD), which is characterized by a more severe pattern of violence, substance use , and/or criminal activity.

People with intermittent explosive disorder (IED) have a pattern of angry, aggressive outbursts. People with pyromania have trouble suppressing their urge to start fires, while people with kleptomania fail to resist their impulse to steal.

Researchers have not identified a single known cause of impulse control disorders. Genetics, social and environmental factors, brain structure , past trauma, and comorbid medical conditions (such as Parkinson’s disease) may all contribute to the likelihood that someone will develop an ICD.

Treatment for impulse control disorders typically involves psychotherapy, medication, or a combination of both.

A Word From Verywell

If you or your child has an impulse control disorder, you are far from alone. Fortunately, there are effective treatments available for impulse control disorders. Reach out to your healthcare provider to discuss your options.

Researchers haven’t identified one definitive cause of impulse control disorders (ICDs). Biological, social, environmental, psychological, and neurological factors all play a role.

People with comorbid medical conditions, such as Parkinson’s disease or ADHD, have a higher risk of developing an ICD. Other risk factors include a history of abuse or neglect, living in poverty, and early exposure to violence.

Impulse control disorders are categorized as a group of psychiatric conditions in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). People with ICDs fail to resist their impulses and urges, even if they violate the rights, well-being, and/or safety of themselves or others.

This category of disorders includes oppositional defiant disorder (ODD), conduct disorder (CD), intermittent explosive disorder (IED), kleptomania, and pyromania within this category.

According to estimates, intermittent explosive disorder is the most common impulse control disorder. In the general population, intermittent explosive disorder has a lifetime prevalence of about 7%. In comparison, pyromania and kleptomania are relatively rare.

Impulse control disorders are unlikely to go away on their own. Effective treatments for impulse control disorders include cognitive behavioral therapy (CBT) and social skills training. For children and adolescents with conduct disorder or oppositional defiant disorder, family therapy and parent management training may help.

American Psychiatric Association. What are disruptive, impulse control and conduct disorders? .

Silva B, Canas-Simião H, Cavanna AE. Neuropsychiatric aspects of impulse control disorders .  Psychiatr Clin North Am . 2020;43(2):249-262. doi:10.1016/j.psc.2020.02.001

American Psychological Association. Impulse-control disorder .

Virginia Commission on Youth. Disruptive, impulse-control, and conduct disorders .

American Psychiatric Association. Disruptive, impulse-control and conduct disorders .

MedlinePlus. Oppositional defiant disorder .

American Psychological Association. Oppositional defiant disorder .

MedlinePlus. Antisocial personality disorder .

American Psychological Association. Conduct disorder .

MedlinePlus. Conduct disorder .

American Psychological Association. Intermittent explosive disorder .

National Institutes of Health. Intermittent explosive disorder affects up to 16 million Americans .

American Psychological Association. Kleptomania .

Sipowicz J, Kujawski R. Kleptomania or common theft - diagnostic and judicial difficulties .  Psychiatr Pol . 2018;52(1):81-92. doi:10.12740/PP/82196

American Psychological Association. Pyromania .

Blum AW, Odlaug BL, Grant JE. Cognitive inflexibility in a young woman with pyromania .  J Behav Addict . 2018;7(1):189-191. doi:10.1556/2006.7.2018.09

Ghosh A, Ray A, Basu A. Oppositional defiant disorder: current insight .  Psychol Res Behav Manag . 2017;10:353-367. doi:10.2147/PRBM.S120582

Salvatore JE, Dick DM. Genetic influences on conduct disorder .  Neurosci Biobehav Rev . 2018;91:91-101. doi:10.1016/j.neubiorev.2016.06.034

Lin X, Li L, Chi P, et al. Child maltreatment and interpersonal relationship among Chinese children with oppositional defiant disorder .  Child Abuse Negl . 2016;51:192-202. doi:10.1016/j.chiabu.2015.10.013

Peisch V, Breslend NL, Jones DJ, MacFarlane M, Forehand R. Young children with behavior disorders in low-income families: the role of clinic observations in the assessment of parenting .  Evid Based Pract Child Adolesc Ment Health . 2017;2(3-4):201-211. doi:10.1080/23794925.2017.1393638

Saluja B, Chan LG, Dhaval D. Kleptomania: a case series .  Singapore Med J . 2014;55(12):e207-e209. doi:10.11622/smedj.2014188

MedlinePlus. Parkinson's disease .

Augustine A, Winstanley CA, Krishnan V. Impulse control disorders in Parkinson's disease: from bench to bedside .  Front Neurosci . 2021;15:654238. doi:10.3389/fnins.2021.654238

MedlinePlus. Attention deficit hyperactivity disorder .

Scott KM, de Vries YA, Aguilar-Gaxiola S, et al. Intermittent explosive disorder subtypes in the general population: association with comorbidity, impairment and suicidality .  Epidemiol Psychiatr Sci . 2020;29:e138. doi:10.1017/S2045796020000517

Costa AM, Medeiros GC, Redden S, Grant JE, Tavares H, Seger L. Cognitive-behavioral group therapy for intermittent explosive disorder: description and preliminary analysis .  Braz J Psychiatry . 2018;40(3):316-319. doi:10.1590/1516-4446-2017-2262

Christianini AR, Conti MA, Hearst N, Cordás TA, de Abreu CN, Tavares H. Treating kleptomania: cross-cultural adaptation of the Kleptomania Symptom Assessment Scale and assessment of an outpatient program .  Compr Psychiatry . 2015;56:289-294. doi:10.1016/j.comppsych.2014.09.013

Szapocznik J, Muir JA, Duff JH, Schwartz SJ, Brown CH. Brief strategic family therapy: implementing evidence-based models in community settings .  Psychother Res . 2015;25(1):121-133. doi:10.1080/10503307.2013.856044

Sagar R, Patra BN, Patil V. Clinical practice guidelines for the management of conduct disorder .  Indian J Psychiatry . 2019;61(Suppl 2):270-276. doi:10.4103/psychiatry.IndianJPsychiatry_539_18

Gatto EM, Aldinio V. Impulse control disorders in Parkinson's disease: a brief and comprehensive review .  Front Neurol . 2019;10:351. doi:10.3389/fneur.2019.00351

By Laura Dorwart Laura Dorwart is a health journalist with particular interests in mental health, pregnancy-related conditions, and disability rights. She has published work in VICE, SELF, The New York Times, The Guardian, The Week, HuffPost, BuzzFeed Reader, Catapult, Pacific Standard, Health.com, Insider, Forbes.com, TalkPoverty, and many other outlets.

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Problem solving, impulse control and planning in patients with early- and late-stage Huntington's disease

Affiliations.

• 1 Department of Psychiatry, Medical University of Graz, Auenbruggerplatz 31/1, 8036, Graz, Austria.
• 2 Department of Psychiatry, Medical University of Graz, Auenbruggerplatz 31/1, 8036, Graz, Austria. [email protected].
• 3 Behavioral Neurology Unit, National Institute of Neurological Disorders and Stroke, National Institutes of Health, 10 Center Dr., MSC 1440, Bethesda, MD, 20892-1440, USA.
• PMID: 27372072
• PMCID: PMC5037143
• DOI: 10.1007/s00406-016-0707-4

Sub-domains of executive functions, including problems with planning, accuracy, impulsivity, and inhibition, are core features of Huntington's disease. It is known that the decline of cognitive function in Huntington's disease is related to the anatomical progression of pathology in the basal ganglia. However, it remains to be determined whether the severity of executive dysfunction depends on the stage of the disease. To examine the severity of sub-domains of executive dysfunction in early- and late-stage Huntington's disease, we studied performance in the Tower of London task of two groups of Huntington's disease patients (Group 1: early, n = 23, and Group 2: late stage, n = 29), as well as a third group of age, education, and IQ matched healthy controls (n = 34). During the task, we measured the total number of problems solved, total planning time, and total number of breaks taken. One aspect of executive function indexed by the number of solved problems seems to progress in the course of the disease. Late-stage Huntington's disease patients scored significantly worse than early-stage patients and controls, and early-stage patients scored significantly worse than controls on this measure of accuracy. In contrast, late- and early-stage HD patients did not differ in terms of planning time and number of breaks. Early- and late-stage HD pathology has a different impact on executive sub-domains. While accuracy differs between early- and late-stage HD patients, other domains like planning time and number of breaks do not. Striatal degeneration, which is a characteristic feature of the disease, might not affect all aspects of executive function in HD.

Keywords: Disease severity; Executive function; Huntington’s disease; Neuropsychology; Tower of London.

• Cognitive Dysfunction / etiology
• Cognitive Dysfunction / physiopathology*
• Executive Function / physiology*
• Huntington Disease / complications
• Huntington Disease / physiopathology*
• Impulsive Behavior / physiology*
• Inhibition, Psychological*
• Middle Aged
• Problem Solving / physiology*
• Severity of Illness Index

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Middle East crisis — explained

The conflict between Israel and Palestinians — and other groups in the Middle East — goes back decades. These stories provide context for current developments and the history that led up to them.

Biden wants a two-state solution for Israeli-Palestinian peace. Is it still possible?

Rachel Treisman

An Israeli settler stands with an Israeli flag before a man holding up a Palestinian flag during a demonstration in the East Jerusalem neighborhood of Sheikh Jarrah in February 2022. Ahmad Gharabli/AFP via Getty Images hide caption

An Israeli settler stands with an Israeli flag before a man holding up a Palestinian flag during a demonstration in the East Jerusalem neighborhood of Sheikh Jarrah in February 2022.

Israel continues to respond to Hamas' unprecedented attack on its people, bombarding Gaza and preparing for a ground offensive. Humanitarian groups and some foreign leaders are calling for a cease-fire. But what are the prospects for long-term peace?

President Biden said Wednesday that there is no going back to the status quo before Oct. 7 — meaning in part that when the crisis is over, there must be a view of what comes next.

Consider This from NPR

Will war between israel and hamas end hopes for two-state solution.

"In our view, it has to be a two-state solution," he said, reiterating a comment he made during his visit to Israel. "And that means a concentrated effort for all the parties — Israelis, Palestinians, regional partners, global leaders — to put us on a path toward peace."

The two-state solution calls for establishing an independent state for Palestinians alongside that of Israel. And U.S. support for it is nothing new: For decades, it has been the primary proposed framework for resolving the Israeli-Palestinian conflict.

But failed peace talks, logistical questions, expanded Israeli settlements, Palestinian attacks and recurring clashes have kept it from becoming a reality. The two-state solution has seen dwindling support from both Palestinians and Israelis over the years. And its prospects now seem dimmer than ever, in light of Hamas' attack on Israel and Israel's response.

The space for peace and Jewish-Arab solidarity is shrinking in wartime Israel

Dennis Ross, who was the chief U.S. negotiator at the 2000 Camp David summit between Israeli and Palestinian leaders, told NPR that as heartbreaking as the situation is in the Middle East right now, eventually "there needs to be a day after."

"We have to understand: Israelis aren't going anyplace, and Palestinians aren't going anyplace," Ross said. "Somehow, given that, we have to find a way towards coexistence, and obviously, we're not there now."

Where did the two-state solution come from?

Tel Aviv residents celebrate the U.N. decision to create a Jewish state by dividing Palestine into two states on Nov. 29, 1947. AFP via Getty Images hide caption

Tel Aviv residents celebrate the U.N. decision to create a Jewish state by dividing Palestine into two states on Nov. 29, 1947.

The Israeli-Palestinian conflict is long running and complex but primarily rooted in a dispute over land with immense historical and religious significance to Jews and Muslims (as well as Christians).

Jewish proponents of the Zionist movement began moving to Ottoman Palestine — which was predominantly Arab — in the late 19th century, seeking safety from European antisemitism in their ancient homeland. Many more followed suit after the Holocaust.

Tensions grew between the two groups. And Britain — which had governed Palestine since 1922 — referred the issue to the United Nations. The U.N. General Assembly voted in 1947 to divide Palestine into two states, one Jewish and one Arab.

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The partition plan was rejected by the Arab community, in part due to concerns about how much land and access to resources it would get. But the plan was embraced by the Jewish community as legal justification for the establishment of Israel.

Israel declared independence in May 1948. Five Arab nations immediately invaded the new country, prompting a major Israeli offensive and many months of fighting. That resulted in the permanent displacement of thousands of Palestinians, which some refer to as the Nakba , meaning "catastrophe" in Arabic.

Another major turning point came in 1967, with Israel's decisive victory in the Six-Day War against Egypt, Syria and Jordan.

Israel gained territory four times its original size , taking control of the Sinai Peninsula, the Golan Heights, the West Bank, the Gaza Strip and East Jerusalem.

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Those territories have been a major point of contention and peace negotiations ever since. The U.N. issued a resolution in 1967 calling for Israeli troops to withdraw from areas it captured, though the resolution's meaning has been disputed .

That set up the current occupation of the West Bank and Gaza, which are collectively home to some 5 million Palestinians . (Israel pulled troops and settlers out of Gaza in 2005, but it's still considered an occupied territory because the withdrawal was done without any agreement and Israel still exerts control over it.)

The two-state solution was baked into Israel's creation but didn't necessarily play out as planned, says Jon Alterman, director of the Middle East Program at the Center for Strategic and International Studies.

"What started off in the U.N.'s mind as a 50-50 split of Mandatory Palestine, after the 1948 war — which was initiated by the Arab armies — it was more than 50 percent for Israel. After 1967, it was 100 percent-plus for Israel," he says. "And now Israel is, I think, the only country that's hard to draw on a map."

Has the two-state solution ever come close to reality?

U.S. President Bill Clinton stands between PLO leader Yasser Arafat (right) and Israeli Prime Minister Yitzhak Rabin at the White House as the latter two shake hands for the first time after signing the Oslo Accords on Sept. 13, 1993. J. David Ake/AFP via Getty Images hide caption

U.S. President Bill Clinton stands between PLO leader Yasser Arafat (right) and Israeli Prime Minister Yitzhak Rabin at the White House as the latter two shake hands for the first time after signing the Oslo Accords on Sept. 13, 1993.

U.S. President Bill Clinton brought Palestine Liberation Organization (PLO) leader Yasser Arafat and Israeli Prime Minister Yitzhak Rabin together in 1993 to negotiate the agreement that came to be known as the Oslo Accords .

In it, Israel officially recognized the PLO as the representative of the Palestinian people and a partner in future negotiations, and the PLO renounced terrorism and recognized Israel's right to exist.

The deal raised expectations for a two-state solution. But it quickly began to unravel after a series of events, including a 1994 attack on a mosque in Hebron by an American Jewish settler and Rabin's assassination in 1995 by an Israeli settler opposed to the agreement.

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Almost immediately after the Oslo Accords were signed, Israel enhanced its policy of fragmenting Gaza from the West Bank and East Jerusalem, says Atalia Omer, a professor of religion, conflict and peace studies at the Keough School of Global Affairs at the University of Notre Dame.

At the same time, Israeli settlements continued to proliferate in the West Bank — on occupied land that the Palestinians hoped would be part of their state.

And that has continued in the years since. The population of Israeli settlers in the occupied West Bank, including East Jerusalem, grew from 520,000 to more than 700,000 between 2012 and 2022, according to the U.N. Office of the High Commissioner for Human Rights .

"Settlements continue to eat into Palestinian spaces," Omer says. "And over the course of the 30 years since the Oslo Accords — signed in the White House in September 1993 — the settlements completely prevented the possibility of a contiguous sovereign Palestinian state within that two-state framework."

What are the other obstacles?

A road extends between the Jewish settlement of Givat Zeev (in the background) and Palestinian villages near the Israeli-occupied West Bank city of Ramallah in September. Ahmad Gharabli/AFP via Getty Images hide caption

A road extends between the Jewish settlement of Givat Zeev (in the background) and Palestinian villages near the Israeli-occupied West Bank city of Ramallah in September.

Discussions of a two-state solution center on a number of core issues, as the Council on Foreign Relations explains.

One is how exactly the borders would be drawn. Most international diplomacy favors Israel reverting to a version of its pre-1967 borders, without a consensus on how that would account for the Palestinians living within those borders or the Jewish Israelis beyond them.

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Israel has annexed the whole city of Jerusalem as its capital, while Palestinians claim East Jerusalem for the capital of their state — which makes for another logistical question.

There's also the major question of Palestinian refugees of the wars of 1948 and 1967. The survivors and their descendants live mostly in Jordan, Lebanon and Syria and claim the right to return to Israel based on a 1948 U.N. General Assembly resolution . Israel views that right to return as a threat to its existence as a Jewish state and believes those refugees should go to the Palestinian state instead.

Security looms large, too. Israel views certain Palestinian militant groups as existential threats — including Hamas, which governs Gaza and whose founding charter called for the obliteration of Israel — and wants them to disarm. Israel wants to maintain the ability to act in Palestinian areas against security threats. Palestinians want an end to Israel's military occupation and full control over their own security.

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Both sides want recognition of their respective states by the other and the international community. Palestinians also want acknowledgment of and redress for their forced displacement, Omer says.

"There needs to be a recognition and kind of naming, and then put in place mechanisms to redress — how can Palestinians be compensated for historical injustice they experienced — and then figure out ways of respecting Jewish citizens in the space through principles of equality and democracy," Omer says.

Where did peace negotiations stand before this war?

Demonstrators protest against the Israeli government's judicial overhaul plan in Tel Aviv on Sept. 23. Jack Guez/AFP via Getty Images hide caption

Demonstrators protest against the Israeli government's judicial overhaul plan in Tel Aviv on Sept. 23.

There has been little progress since the turn of the millennium. The collapse of the 2000 peace process fueled the Second Intifada , a major Palestinian uprising in the Israel-occupied Palestinian territories and Israel.

It ended in 2005 with some 1,000 Israelis and 3,200 Palestinians dead, along with heightened skepticism of the peace process on both sides. Those feelings seem to have prevailed in the years since, which have been marked by terrorist attacks, military raids, rocket fire, border clashes and other incidents .

"As a fundamental proposition, it's hard to have productive peace talks when no side sees either urgency or necessity to reach an agreement," says Alterman, of the Center for Strategic and International Studies.

He says that from an Israeli perspective, security was improving, Palestinian demands were diminishing and it would be politically divisive to make concessions to them. Palestinians, meanwhile, had a sense that they couldn't make an agreement with the right-wing government of Prime Minister Benjamin Netanyahu and that it wasn't worth giving up rights when demographics are in their favor in the long run.

The State Of Israeli Politics

All the while, support for a two-state solution has shrunk considerably among both Israelis and Palestinians .

A Gallup poll released last week — conducted before Hamas' attack on Israel — found that just 24% of Palestinians living in the West Bank, Gaza and East Jerusalem supported a two-state solution. That figure is down from 59% in 2012.

A Pew Research Center poll released in September found that only 35% of Israelis think "a way can be found for Israel and an independent Palestinian state to coexist peacefully," a decline of 15 percentage points since 2013.

"A decent number of Israelis and Palestinians have come to conclude that it's not a solution, that the nature of Israeli behavior, especially in the West Bank, makes a Palestinian state unviable," says Alterman, noting that many members of the Israeli government want to annex the West Bank altogether.

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He says it's too early to say where the current conflict will go, though many Israelis believe Israeli politics are more likely to move to the right than the left in the wake of Hamas' attack, which killed some 1,400 people in Israel and resulted in more than 220 hostages taken.

"When I talk to Israeli officials, I don't get any sense that part of the strategy is providing a political horizon for Palestinians," he added, "which is what a peace agreement would ostensibly be."

That doesn't mean Israeli citizens aren't pushing for peace at all. Sally Abed is a member of Standing Together , an organization that aims to improve Arab-Jewish relations within Israel, and she's also a Palestinian.

"I really don't want to think that we needed to endure such loss, such atrocities here in Israel," she told NPR . "But maybe now I really hope that from this dark corner, we can have this shift in the paradigm on how we actually look at these wars and how, actually, we look at the Israeli control over Gaza and over the West Bank, and really have a different outlook on what our leadership actually should look like."

What are the alternatives?

A monument in the West Bank town of Jenin bears the outline of Mandatory Palestine. Jaafar Ashtiyeh/AFP via Getty Images hide caption

A monument in the West Bank town of Jenin bears the outline of Mandatory Palestine.

There are alternatives to a two-state solution — including a one-state solution, a confederation, annexation and maintaining the status quo — at least in theory.

Rand Corp. focus groups conducted in 2018 and 2019 found that none of those was acceptable to a majority of both Israelis and Palestinians, underscoring the deep complexities and emotions involved.

Alterman says one of the biggest challenges for Israelis is balancing the need for a Jewish state and a democratic state.

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"If you have a one-state solution that gives citizenship to all of the natural-born residents of Mandatory Palestine — which includes Gaza and the West Bank — you don't have a Jewish majority," he explained. "A substantial line of thought [in Israel] is that it's more important that Israel be Jewish than democratic."

In contrast, most Americans — 73% — would choose a democratic over a Jewish Israel, according to a University of Maryland and Ipsos poll conducted this year.

Omer is one of many who see the current reality as that of a single state. She points to the exclusionary practices and annexationist policies of the right-wing Netanyahu government, like a 2018 law that demoted Arabic as one of Israel's official languages, and the recent findings of human rights groups in and beyond Israel that its practices toward Palestinians amount to apartheid .

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She says some Israeli and Palestinian activists support a one-state solution, but in different formats and for different reasons.

Some leftists and Palestinians support the creation of a democratic, secular country in which Arab Muslims would outnumber Jews. But some rightists and Israelis would prefer to see Israel annex the West Bank — either forcing out Palestinians or denying them the right to vote — which is illegal under international human rights law.

Some activists, like the group A Land for All , argue that solutions based on separation have failed in the past, and they are instead pushing for a confederal framework , with two sovereign states sharing the capital of Jerusalem and an open border.

Omer says there are "historical examples of life together in this space that is not within the paradigm of domination." She acknowledges that it's hard to imagine those kinds of possibilities in this moment but says the need for change is clear.

"What we can see depends on, also, an expression of how the paradigm that had been there before Oct. 7 is completely collapsing," she says. "And all these contradictions just cannot be sustained anymore."

• israel palestinian conflict
• two-state solution
• Middle East peace process
• U.S. foreign policy

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“I Know! I Know!” Self-Control Solutions for Kids Who Blurt Out

Children with adhd don’t blurt out answers or talk over people to be purposely rude. their impulse-control problems are neurological and tough for them to see. but with these tips (and lots of practice) they can learn to stop interrupting..

The problem: Students with ADHD can’t stop interrupting their teachers and classmates by calling out answers or commenting while others are speaking.

The reason: Children with ADHD have difficulty controlling their impulses. Scientists believe that lower levels of dopamine, a neurotransmitter in the brain, leads them to respond immediately and reflexively to their environment — whether the stimulus is a question, an idea, or a treat. That’s why they often seem to act or talk before thinking, and suffer as a result.

The obstacles: Children with ADHD don’t always realize that they are interrupting or that their behavior is disturbing to others. Simply telling students with ADHD their behavior is wrong doesn’t help. Even though they know they’re acting out of turn, their impulsivity overrides their self-control. Many children with ADHD can’t understand nonverbal reprimands, like frowning, either.

Solutions in the Classroom

Kids with ADHD need classroom behavior reminders to stay on track. But reminding them verbally in front of other students may damage the fragile self-esteem of a child with ADHD. Instead, try visual reminders as part of a secret “contract” you set up with the student.

Have a secret signal. Decide on a gesture or signal that will convey to the student that he is interrupting and needs to stop. For example, one teacher had success with a “wind it down” hand signal in the shape of a descending spiral staircase.

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Post a list of rules. Be sure each ADHD student is familiar with the class rules and can clearly see them from his seat. You can also try highlighting “No Interrupting” on the list for an added reminder.

Have an on-desk reminder. Tape a note to the child’s desk with the letters “N.I.” written on it to stand for “No Interrupting.” None of the other students need to know that the initials don’t mean something like “New Inventions.”

Keep a visual count. Show the student how much he’s been interrupting by calling attention to it through visuals. One teacher uses an abacus where she can silently slide over a bead every time her ADHD student talks out of turn. No one else knew what she was counting and this repetitive visual cue helped the ADHD student curb his behavior.

Solutions at Home

Do “No Interrupting” training. Tell your child that you’re going to be doing an activity that can’t be interrupted (say, talking on the phone). Set your child up with a task that will hold his attention while you’re talking, and then take breaks every few minutes to visit with your child and praise him for not interrupting. You also can do a little behavior therapy by using the abacus method, but as part of a reward system.

[ Free Handout: Solving Challenges in the Classroom ]

Add incentives. Begin the week with a pot of $5. Assign a value — say 10 cents — to each bead on the abacus or other visual counter. Each time you have to slide a bead because of an interruption, 10 cents should be removed from the pot. At the end of the week, your child gets to keep what’s left.

If your child doesn’t respond well to the “negative” method, reverse the system to provide positive rewards. Slide a bead for every time your child does not interrupt, to reinforce good behavior. At the end of the week, the child keeps what’s been earned.

In both cases, take your child out to purchase a treat with his earned money. The one-on-one attention will cap his sense of achievement and provide additional reinforcement for not interrupting.

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