Why therapy – not just medication – is important for adults with ADHD

Stimulant medications have been used for several decades to treat attention-deficit / hyperactivity disorder (ADHD). Methylphenidate (e.g. Ritalin, Concerta) has been prescribed since the mid-20th century for disorders characterised by inattention and hyperactivity, with modern amphetamine-based medications developed and approved in later decades.

But medications are not the whole story for treating adults with ADHD. Dr Steven Safren is a leading expert on ADHD. According to him, while drugs can usually reduce the symptoms, they should be used together with cognitive behavioral therapy:

“ADHD is a neurobiological disorder that affects attention, activity levels, and related cognitive domains. Although it begins in childhood, many individuals continue to experience clinically significant symptoms into adulthood.

“ADHD is most commonly treated with medication, which can be very helpful in reducing symptom intensity. However, medication does not inherently provide people with the skills needed to manage difficulties such as problems with executive functioning [skills that we use to manage everyday tasks]. As a result, many adults who are treated pharmacologically continue to experience impairments, even when medication has effectively ‘turned down the volume’ on their symptoms.

“One of the key findings from our work is that core cognitive behavioral skills can further reduce ADHD symptoms, particularly when they are taught alongside or following medication treatment. Skills such as problem solving, organizing and planning, coping with distractibility, and developing more adaptive thinking patterns can make a meaningful difference for many adults with ADHD.”

What problems do people with ADHD face?

To meet the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) criteria for adult ADHD, an individual must have at least five out of the nine possible inattention symptoms (such as difficulty sustaining attention in tasks or difficulties with organisation) and/or five out of the nine possible hyperactive/impulsive symptoms. These include fidgeting, feelings of restlessness and frequently interrupting.

They must have significant difficulties with some aspect of their life, such as work or relationships (a thorough assessment is needed to rule out other disorders that could be causing the impairments).

“We often see people leaving jobs that are objectively going well, due to impulsivity or a sense that ‘the grass is greener’ elsewhere,” notes Dr Safren. “Others are able to compensate with high intelligence up to a point, but as job demands increase, particularly in higher-level roles, they may struggle unless they put effective organizational systems in place.”

How can therapy help?

A randomized controlled trial (RCT) by Dr Safren and his team (published in the Journal of the American Medical Association in 2010), found that adults with ADHD who completed a 12-week cognitive behavioral therapy (CBT) course on top of their medication had significantly better symptom control than those who received relaxation training alongside their medications. A standard rating scale for ADHD symptoms showed a 30 percent reduction for more than two thirds of the CBT group but in only one third of the relaxation group. These gains were maintained at 6-month and 12-month follow-up.

Meta-analyses have supported these findings: one published in the Journal of Attention Disorders in 2023 found that CBT plus medication was more effective in improving ADHD symptoms than medication alone – an advantage that lasted for at least three months after treatment. Another, published in the Journal of Attention Disorders in 2016, found that CBT was superior to waiting list with a moderate to large effect size.

So, when doing therapy with someone with ADHD, what are the main things to consider?

“It’s especially important to use core CBT structures, such as setting a clear agenda and actively following it,” says Dr Safren. “Sessions can easily become sidetracked by whatever issues emerged during the past week, so therapists need to be intentional about making sure relevant skills are taught and practiced. In particular, helping clients establish effective organizational systems for calendars and task lists is often essential.

“Incorporating motivational interviewing can be very helpful, as can being careful not to introduce new skills until the client is genuinely ready to make changes. With ADHD, having a core set of skills for organizing and planning is needed as a foundation before other CBT skills. In our approach, for example, adaptive thinking (i.e. cognitive restructuring) comes last in the manual, because we first address core compensatory skills.” In this final part of the therapy, the client learns how to identify and dispute negative and ‘overly positive’, thinking patterns. This is useful as adult clients with ADHD will often overestimate their ability to accomplish a task (or complete it within a specified time) and then have negative thoughts when they haven’t met their unrealistic goals.

The prevalence of ADHD

ADHD is often mislabeled as a child’s condition. Indeed, its original name, ‘hyperkinetic reaction of childhood’ was only changed by the American Psychiatric Association in 1980. But 2-5% of adults worldwide have ADHD symptoms, according to the U.S. Centers for Disease Control and Prevention (CDC). Based on self-report, 6% of U.S. adults (around 15.5 million) have ADHD.

It's becoming a more common concurrent issue that clients are bringing into the therapy room. Dr Safren observes that for those working on depression, anxiety, or OCD with someone who has ADHD, “it’s often necessary to establish a foundation of organizational and planning skills before moving on to other CBT interventions.”

The question of how society needs to respond to the growing awareness of neurodiversity in the population is a difficult one. Dr Safren comments: “Greater openness and understanding are clearly important, but we also need to be careful not to create new forms of stigma or scapegoating. I’m concerned, for example, about the spread of misinformation around the causes of autism, and about what appears to be a growing backlash against neurodiversity more broadly. As awareness increases, it’s important that it’s grounded in accurate information and genuine respect.”

What next?

Many therapists are also increasingly interested in how AI (artificial intelligence) can be used to augment treatment.

“Future research should aim to identify who might benefit from more automated interventions, and who is likely to need a live therapist to achieve meaningful change,” explains Dr Safren. “Even when technology is used, it often works best when combined with a ‘human touch’, particularly for accountability.”

If you would like to hear more of Dr Safren’s insights, he has co-authored Mastering Your Adult ADHD, which is part of the Treatments That Work^TM series available through Psychology Tools. Dr Safren is also holding a CBT workshop at the World Congress of CBT (WCCBT) in San Francisco in June 2026.