Open Access Review

Article DOI: 10.7759/cureus.32647

Efficacy of Cognitive Behavioral Therapy and

Methylphenidate in the Treatment of Attention
Received 09/24/2022
Deficit Hyperactivity Disorder in Children and
Review began 11/22/2022
Review ended 12/07/2022 Adolescents: A Systematic Review
Published 12/17/2022
Blessing T. Ojinna 1 , Anusha Parisapogu 2 , Mingma L. Sherpa 3 , Silpa Choday 4 , Niriksha Ravi 5 , Sheiniz
© Copyright 2022
Giva 6 , Vivig Shantha Kumar 4 , Nilasma Shrestha 7 , Hadrian Hoang-Vu Tran 4 , Sai Sri Penumetcha 8
Ojinna et al. This is an open access article
distributed under the terms of the Creative
Commons Attribution License CC-BY 4.0., 1. Internal Medicine and Pediatrics, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA 2.
which permits unrestricted use, distribution, Infectious Diseases, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA 3. Neurology,
and reproduction in any medium, provided
California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA 4. Internal Medicine, California Institute
the original author and source are credited.
of Behavioral Neurosciences & Psychology, Fairfield, USA 5. Internal Medicine and Neurology, California Institute of
Behavioral Neurosciences & Psychology, Fairfield, USA 6. Neonatology, California Institute of Behavioral
Neurosciences & Psychology, Fairfield, USA 7. Pathology and Internal Medicine, California Institute of Behavioral
Neurosciences & Psychology, Fairfield, USA 8. General Medicine, California Institute of Behavioral Neurosciences &
Psychology, Fairfield, USA

Corresponding author: Blessing T. Ojinna, bbojinna@yahoo.com

Abstract
The treatment of attention deficit hyperactivity disorder (ADHD) in children and adolescents can be
challenging and involve a combination of pharmacologic and non-pharmacological approaches. Using
recent literature, we aim to identify the effectiveness of cognitive behavioral therapy (CBT) and
methylphenidate (MPH) in reducing the symptoms and improving the quality of life. The investigators
conducted a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) 2020 guidelines. Investigators independently conducted a routine search on PubMed and
Google Scholar for articles published within the last five years through July 30, 2022. Fourteen studies were
identified as generally good quality but with some limitations. The final analysis included 2098 patients with
an age range of three to eighteen. Nine studies reporting the efficacy of MPH in children, adolescents, or
both had different formulations and doses. Six studies documenting the effectiveness of CBT had varying
sessions, duration per therapy, modality of administration, and participants. The diagnostic assessment
measures showed that the parent symptom rating was the highest and appeared in 11 studies, reflecting the
burden on the family. In addition, a structured-self-rated questionnaire rating appeared in eight studies,
and two diagnostic assessment measures, teacher symptom rating and investigators, appeared in six.

The studies demonstrated significant reductions in the primary symptoms of ADHD at assessment, which
led to improved behavioral and functional status with a reduced impact on family and society. Further trials
are needed to understand the benefits of CBT and MPH when combined to reduce psychiatry co-morbidities
and improve learning and overall quality of life in the long term.

Categories: Pediatrics, Psychiatry, Psychology

Keywords: methylphenidate, attention deficit hyperactivity disorder, cognitive behavioral therapy, adolescents,
children

Introduction And Background

Introduction
Attention deficit hyperactivity disorder (ADHD) is a prevalent neurodevelopmental condition in childhood,
affecting approximately 4-6% of children and adolescents [1]. The Diagnostic and Statistical Manual of
Mental Disorders, 5th Edition (DSM-5) includes ADHD under "Neurodevelopmental Disorders" [1]. ADHD is
defined as six or more symptoms of persistent inattention, and/or hyperactivity, and impulsivity, present for
six months in two or more settings that interfere with function and are inappropriate for developmental
level [2]. Children and adolescents diagnosed with this disorder have difficulty focusing, controlling
movements and impulses, and regulating behavior affecting their communication, daily living, and
socialization [3].

Boys are two to four times more likely to be diagnosed than girls [4]. In addition, 65% of children diagnosed
with ADHD are symptomatic in adulthood, which suggests that the disease is chronic [2]. The etiology of
ADHD is multi-factorial and a combination of genetic predisposition and environmental factors, such as low
birth weight, prematurity, pregnancy complications, prenatal maternal smoking, intrauterine alcohol
exposure, and lead [5]. Family and twin studies have shown a high percentage of heritability with
approximately 70% to 80% and substantial overlap between hyperactivity/impulsivity and inattention and
with no sex differences in heritability [4]. Although family studies have shown a high heritability and

How to cite this article

Ojinna B T, Parisapogu A, Sherpa M L, et al. (December 17, 2022) Efficacy of Cognitive Behavioral Therapy and Methylphenidate in the Treatment
of Attention Deficit Hyperactivity Disorder in Children and Adolescents: A Systematic Review. Cureus 14(12): e32647. DOI 10.7759/cureus.32647
 multiple candidate genes that may be involved in the disorder, genome‐wide studies have not yet found a
clear association [4].

In addition, over 65% of ADHD patients present with psychiatric comorbidities, including depression,
anxiety, and learning disorders, which affect academic performance and family life, with enormous social
and economic problems when left untreated [2]. In children younger than six, ADHD is the most common
psychiatric reason for referral to a specialist child and adolescent psychiatrist [6]. In addition, parent reports
indicate that more than one in ten school-age children (11%, 6.4 million) in the United States have been
diagnosed with ADHD by their primary care provider [7].

Clinical practice guidelines recommend a combination of pharmacotherapy and cognitive behavioral therapy
(CBT) for treating ADHD in children and adolescents aged six to eighteen years [7]. The psychostimulant,
methylphenidate (MPH), has been approved by the United States Food and Drug Administration (FDA) for
treating ADHD and is considered a part of the standard of care [7]. ADHD imposes a significant financial
burden on families, healthcare systems, and schools [7]. Children and adolescents with ADHD frequently
receive special education services, drop out of school, and achieve a much lower rate of post-high school
education than their peers [8]. Also, more than 40% of preschoolers diagnosed with ADHD are at risk of
suspension, and about 16% are likely to be expelled from school or daycare, compared to only 0.5% of
children without ADHD [6]. Consequently, there have been tremendous efforts to develop pharmacological
treatments to improve their quality of life and evaluate CBT; for example, cognitive restructuring, thought-
stopping, behavioral activation, and exposure techniques to accomplish behavioral management [8].

Research has shown that pharmacological treatments, particularly stimulants and atomoxetine,
psychosocial therapies, and their combination are well-established interventions for children and
adolescents with ADHD [8]. Treatment options for ADHD in adolescents and children are limited and
primarily require prescribing psychostimulant medication as a first-line treatment [3]. Improvements in
behavior, attention, interpersonal interactions, cognition, and executive function reinforce stimulant
medication's short-term efficacy. MPH and dextroamphetamine are the most prescribed [3]. Nevertheless,
the limitations of these medicines (e.g., short-term effects, unknown long-term effects, and adverse effects
such as insomnia and anorexia) have led parents and professionals to seek other treatments. Therefore,
non-pharmacological interventions that decrease ADHD symptomatology, such as cognitive training, have
been considered an excellent potential benefit [3].

The primary care provider roles include diagnosis, medication management, and referrals to other
resources, both educational and behavioral [9]. The American Academy of Pediatrics (AAP) has recently
updated its 2019 guidelines, providing the basis for managing ADHD. First-line treatment for the preschool
age group four to five years is evidence-based parent training in behavior management (PTBM) and teacher-
administered behavioral therapy. If there is no improvement, initiating MPH may be considered. For
elementary school-aged children six to eleven years, approved medications by FDA, along with PTBM and
classroom behavioral interventions, are preferred. For adolescents aged 12-18, FDA-approved medications
are the treatment of choice. Evidence-based training interventions and behavioral interventions should also
be encouraged [9].

CBT has been described as "a form of psychological therapy that uses cognitive and behavioral techniques to
support individuals to change unhelpful behaviors and thought patterns that occur in situations of fear and
to learn better ways of coping with them, thereby relieving their symptoms and becoming more effective in
their lives" [9,10]. CBT is delivered in a series of structured sessions and is effective for depression, anxiety,
eating disorders, and severe mental illness. Results of two studies of adolescents receiving CBT showed
improved parental ratings of ADHD symptoms but found little evidence of benefit for functional impairment
[9]. On the other hand, MPH, a dopamine and noradrenaline reuptake inhibitor, is the recommended first-
line pharmacological treatment for ADHD in many countries, with treatment response rates between 70%
and 90%. As stated previously, MPH is one of the most used psychostimulants and has been the most widely
studied regarding its efficacy in treating ADHD worldwide [11]. Compliance with medication is a common
problem in ADHD treatment. Lack of adherence may lead to reduced effectiveness, increased adverse events,
and other consequential issues, hampering the course of pharmacological treatment. Clinicians should
routinely assess medication compliance during treatment, and potential problems in adherence should be
openly discussed [12]. In deciding whether to initiate pharmacological treatment in school children and
adolescents, the severity of ADHD symptoms, as emphasized by clinical guidelines: cases with low and
moderate severity "can" while severe cases "should" be offered pharmacological treatment. However,
personal factors, for example, the level of suffering, the situation of the patient's family, comorbidities, and
global psychosocial functioning, should also be considered [12].

This review aims to systematically evaluate the effectiveness of MPH and CBT, in treating children and
adolescents with ADHD using available literature. The study also establishes the most efficacious treatment
in the current period.

Review

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 Methods
Guidelines

This systematic review of empirical literature was performed in agreement with Preferred Reporting Items
for Systematic Reviews and Meta-Analyses (PRISMA) 2020 [13].

Search Databases

Three investigators independently searched PubMed, PubMed Central, Medical Literature Analysis and
Retrieval System Online (MEDLINE), and Google Scholar.

Search Strategy

A systematic literature search using boolean logic to perform a database search and boolean search
operators "AND" and "OR" were used to connect the keywords. PubMed search for free full-text
articles, conducted in humans and published in English from 2017 until July 30, 2022, using medical subject
headings (MeSH) terms keywords in the MeSH database are as follows Attention deficit hyperactivity
disorder OR ADHD OR Hyperkinetic syndrome OR ("Attention Deficit Disorder with Hyperactivity/drug
therapy" [Majr] OR "Attention Deficit Disorder with Hyperactivity/therapy" [Majr]) AND Cognitive behavioral
therapy OR Psychotherapy OR Behavioral therapy OR ("Cognitive Behavioral Therapy/methods" [Majr]
OR "Cognitive Behavioral Therapy/organization and administration" [Majr] OR "Cognitive Behavioral
Therapy/statistics and numerical data" [Majr] OR "Cognitive Behavioral Therapy/trends" [Majr]) AND
Methylphenidate OR methylphenidate hydrochloride OR Central nervous system stimulants OR
("Methylphenidate/administration and dosage" [Majr] OR "Methylphenidate/adverse effects" [Majr]
OR "Methylphenidate/pharmacology" [Majr] OR "Methylphenidate/therapeutic use" [Majr]
OR "Methylphenidate/therapy" [Majr]). We also performed a direct search on Google Scholar using the
keywords Attention Deficit Hyperactivity Disorder (ADHD), Hyperkinetic Syndrome, Attention Deficit
Disorder With Hyperactivity, Cognitive Behavioural Therapy (CBT), Psychotherapy, Behavioral Therapy,
Methylphenidate OR Methylphenidate Hydrochloride, Central Nervous System stimulants, treatment,
efficacy, children, and adolescents. The PICO (population, intervention, criteria, outcome) will be
outlined (Table 1).

Headings Definitions

Population Children and adolescents with ADHD, aged 3-18 years old

Intervention Cognitive behavioral therapy and Methylphenidate

Control Healthy controls, placebo, and other treatment options

Outcome ADHD symptomatology and functional outcomes

TABLE 1: PICO criteria.

P - population, I - intervention, C - control, O - outcome, ADHD - attention deficit hyperactivity disorder

Inclusion Criteria

The papers included in this study are within a range of five years, from 2017 to 2022. Only human studies
published in English are part of this study. We included randomized control trials, observational studies,
systematic reviews, or narrative reviews, including the age group of preschools to adolescents who received
MPH and CBT for treating ADHD.

Exclusion Criteria

In our study, the authors excluded studies published before January 2017, studies that were not free full text
on PubMed, studies not published in English, and finally, studies in individuals over 18 years of age.
Furthermore, we excluded clinical guidelines and letters to the editor.

Study Selection and Quality Check

The studies we shortlisted were then imported into the EndNote software (Clarivate, London, UK) and
transferred to the excel sheet, where we removed duplicates. In addition, we performed a manual check to
remove any article to which the topic was non-related. Three reviewers independently reviewed papers

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 based on title, keywords, and abstract. In addition, two reviewers thoroughly reviewed full-text articles that
passed the initial screening to determine their suitability for inclusion in the systematic review. The quality
of the paper included in the study was assessed by the primary author and two secondary authors using the
Cochrane risk of bias tool for randomized controlled trials. We interpreted the result from the biases using
the agency for healthcare research and quality (AHRQ) standards. Finally, the papers selected were of good
quality. Finally, the investigators used the PRISMA diagram to check the quality of systematic reviews for
inclusion.

Additionally, we used the scale for assessing narrative review articles (SANRA) checklist to determine if a
narrative review was of good quality. Finally, in the event of disagreement, we reached a consensus after
discussing it with a fourth author. The PRISMA flow diagram is below in Figure 1 [13].

FIGURE 1: Preferred Reporting Items for Systematic Reviews and Meta-

Analysis (PRISMA) 2020 flow diagram depicting the study selection
process.
Reference [13]

Results
After a strategic search of various electronic databases, the total number of articles found was 10438
(PubMed - 10432, Google Scholar - six). Records were removed before screening by PubMed filter inclusion
criteria = 9722. We removed 52 duplicates with excel. The authors manually screened by title 664 studies and
removed 619 articles with a non-related topic. We retrieved 45 records and excluded 21 studies after
reviewing abstracts and full text using the eligibility criteria. The investigators identified 24 studies, and 10

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 did not meet the inclusion criteria after the quality assessment. Finally, we included 14 articles in our
review. The PRISMA flow diagram is in the methods section (Figure 1) above. Finally, we outlined the type
and number of studies used in this review article (Table 2).

Type of Study Number of Studies

Randomized Control Trial 11

Systematic Reviews 2

Narrative Reviews 1

TABLE 2: Type and number of studies included in the analysis.

General Study Characteristics

Study participants: The studies included were performed in seven countries; the United States, Taiwan,
Norway, Australia, the Netherlands, Denmark, and France [6,7,11,14-24]. The total number of participants
recorded was 2,098. The age ranged from 3 to 18 years old, and the mean age observed from the review was
11. However, only one study in this review did not specify the sample size and age range [21]. Therefore, we
will explore the essential characteristics of the studies included in this review (Table 3).

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 Study Diagnostic No. of Age
Reference Frequency of Sample Type of
Author, Study Design Country Assessment Reviewed Range Dosage Duration Outcome Efficacy
Number Assessment Size Treatment
Year Measures Articles (years)

Stable-
Duric et al., Randomized 11.6 (6-
[14] Norway 1, 2, and 3 3 130, # NA MPH 1 mg/kg/day 6 months a, b throughout
2017 controlled trial 18)
the study

Wigal et al., Randomized United

[7] 1, 7, 8, 9 Varies hourly 90 NA 6-12 MPH 20-60 mg 7 weeks a, b, c yes
2017 controlled trial States

Goode et Systematic United 3rd and 12 th

[15] 10, 11, 12 298 2 for CBT <17 CBT ND 12 months a c, f, h yes
al., 2018 Review States month

Novik et al., Randomized 12 weeks 9

[16] Norway 1, 2, 3, 9 4 99 NA 14-18 CBT ND f Limited
2019 controlled trial months

Sciberras Randomized Baseline, 5 th, 5 months 12 Study

[17] Australia 1, 3, 4, 9 228 NA 8-12 CBT ND NA
et al., 2019 controlled trial and 12th month months protocol

Childress et Randomized United 14-16 weeks

[6] 1, 3, 9 ND 119 NA 4-6 MPH 10-40 mg varied a, b, c Yes
al., 2019 controlled trial States 12 months

Huang et Randomized 22, 33, and 44

[11] Taiwan 1, 2, 9 3 100 NA 6-18 MPH 10-12 weeks a, b, c Yes
al., 2020 controlled trial mg

Coles et al., Randomized United

[18] 1, 2, 3 9 127 NA 5-13 CBT MPH ND varied 9 weeks e NA
2020 controlled trial States

Wigal et al., Systematic and United Mainly 1 and 2, 255 79 4-7 3-4 4 years 2
[19] ND NA MPH IR ND a, b Short-term
2020 clinical review States varied varied varied years Varied

Rosenau et Randomized
[20] Netherlands 1 and 5 ND 94 NA 8-18 MPH Varied >2 years d uncertain
al., 2021 controlled trial

Ribeiro et
[21] Narrative review Denmark ND ND varied 24 Varied MPH ND ND Uncertain NA
al., 2021

Wilens et Randomized United 9.3 DR/ER 3.7 mg/kg/day a, b, and

[22] 3, 6 2 163 NA 5 weeks yes
al., 2022 controlled trial States (mean) MPH 68.1 mg (mean) c

Vacher et Randomized
[23] France 1, 2, 3, and 4 3 68 NA 7-13 CBT ND 6 months c long-term
al., 2022 controlled trial

5months
Crouzet et Randomized a, b, c, d,
[24] France 1, 3, 9 3 248 NA 7-15 CBT ND 8months follow hypothetical
al., 2022 controlled trial g
up

TABLE 3: Detailed information about studies included in the review.

Detailed information about studies we included in the review.

Note: access to the patient during the study determined the sample size#.

Diagnostic assessment measures: 1 = parent symptoms rating; 2 = teacher symptom ratings; 3 = structured self-rated questionnaire; 4 = structured parent
interview; 5 = performance-based neurological measures; 6 = baseline score as a covariate; 7 = Swanson, Kotkin, Agler, M-Flynn, and Pelham (SKAMP)
scale rating; 8 = permanent product measure of performance (PERMP); 9 = investigators; 10 = CGI-S (Clinical Global Impression-Severity, self-report or
clinician); 11 = child behavior checklist (CBCL); 12 = child depression inventory and screen for child anxiety.

Outcome: improvement in the ADHD core symptoms: a = attention deficit, b = hyperactivity, c = impulsivity/aggressiveness, d = improvement in working
memory (accuracy), e = reduction in medication, f = change in symptoms scores on the ADHA rating scale-IV, g = improvement of self-esteem, emotional
regulation, and social integration, h = depression/anxiety.

DR/ER = delay release/early release, N/A = not applicable, ND = not defined, NFT = neurofeedback is behavioral therapy

No. = number, CBT = cognitive behavioral therapy, MPH = methylphenidate

Review of Diagnostic Assessment Measures

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 Two essential treatment modalities, CBT and MPH, were used to assess the primary efficacy outcome:
reduced symptoms and improved function in patients with ADHD. The study outcomes were measured using
diagnostic assessment measures, which were different in all studies and were undefined in two studies. The
"parent symptom rating," the highest applied diagnostic assessment measure, was used in 11 studies. In
contrast, eight studies showed that the "structured-self-rated questionnaire" is the second most used
diagnostic assessment measure. The other diagnostic assessment measure, "teacher symptom rating" and
"investigators," the third most utilized, appeared in six studies.

Type of Treatment Considered Dosage and Duration

The authors analyzed the treatment type, dose, duration of therapy, frequency of assessment, and patient
response to demonstrate whether the administration of CBT and MPH is effective. One study assessed MPH
and CBT in the included articles [18]. Six studies centered on CBT [15-18,23,24], while nine researchers
centered on MPH administration [6,7,11,14,18-22]. The dosage of MPH was different in each of the nine
studies. In addition, the duration of the interventions ranged from five weeks to four years, while the
frequency of assessment varied extensively.

Review Findings

Our findings showed an improvement in core ADHD symptoms. We observed that eight studies recorded a
reduction in inattention, and seven reported a decrease in hyperactivity and impulsivity/aggressiveness.
Two more studies also reported improvements in the change in symptom scores using the ADHD rating scale
and improved working memory. Nonetheless, Sciberras et al. [17] randomized control trial study outcomes
were undefined, and Ribeiro et al. [21] didn't find enough evidence regarding the benefits of MPH on
treatment outcomes.

Discussion
A research review, including 11 random controlled trials, two systematic reviews, and one narrative review
(Table 2), was used to assess the effects of either CBT or MPH on core ADHD symptoms and function in
children and adolescents. This review differs from previously published reviews, intending to focus on the
effect of non-pharmacologic therapy (CBT) and stimulant therapy (MPH) as interventions for treating
children and adolescents with diagnosed ADHD. In addition, the author's included the established rating
scales used in assessing ADHD symptoms in children, as shown in (Table 4) for better understanding [19].

Instrument Age, Years Type of Scale

Preschool Age Psychiatric Assessment, Egger The psychiatric symptom/function scale incorporating DSM-IV-TR and
2-5
et al. (2006a) RDC-PA diagnostic criteria includes an ADHD module

Conners Parent Rating Scale-Revised,

Conners et al. (1998a) Conners Teacher 3-17 Validated ADHD-specific rating scale
Rating Scale-Revised, Conners, et al. (1998b)

ADHD Rating Scale–5, parent and teacher

5-17 Validated DSM-5–referenced, ADHD-specific rating scale
versions, DuPaul et al. (2016)

Early Childhood Inventory–4, Sprafkin et al. Validated DSM-IV–referenced screening instrument includes subscales for
3-6
(2002) ADHD inattention and hyperactive-impulsive subtypes

The validated behavioral symptom checklist includes attention problems

Child Behavior Checklist 11⁄2–5, de la Osa et
1.5-5 and attention-deficit/hyperactivity problems subscale (including
al. (2016)
hyperactive-impulsive and inattentive types)

Vanderbilt ADHD Teacher and Parent Rating Validated DSM–referenced, ADHD-specific rating scale, includes items
Scales, Wolraich et al. (1998, 2003), and 6-12 related to oppositional-defiant/conduct and anxiety/depressive disorders;
DuPaul et al. (2016) validated in children 6–12 years of age, but applicable to preschoolers

ADD-H Comprehensive Teacher Rating Scale,

Kindergarten The validated Likert response scale with Attention, Hyperactivity, Social
Ullmann et al. (1984) and Carlini and Parks
to Grade 8 Skills, and Oppositional Behavior sections
(1993)

TABLE 4: Rating scales for assessment of ADHD symptoms in children and adolescents.
ADHD - attention deficit hyperactivity disorder; DSM-IV-TR - Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revisions; DSM-5 -
Diagnostic and Statistical Manual of Mental Disorders, fifth edition; RDC-PA - Research Diagnostic Criteria-Preschool Age [19].

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 Several behavioral assessment scales have been specifically designed for this patient population to enable
physicians to identify patients with ADHD better while excluding those showing developmentally normal
behavior. These include the Conners Parent Rating Scale-Revised (Conners et al. 1998a) and Conners
Teacher Rating Scale-Revised (Conners et al. 1998b), the AD/HD Rating Scale-5 parent and teacher versions
(DuPaul et al. 2016), the Early Childhood Inventory-4 (Sprafkin et al. 2002), and the Child Behavior
Checklist (de la Osa et al. 2016). The Preschool Age Psychiatric Assessment (Egger et al. 2006a) was
developed based on the Child and Adolescent Psychiatric Assessment (Angold and Costello 1995) for
children two to five years of age. Still, no validation reports in that population have been published to date.
The Vanderbilt ADHD Teacher and Parent Rating Scales have been validated in children aged six to twelve
but are also applicable to preschool children (Wolraich et al. 1998, 2003; American Academy of Pediatrics
2019). The Conners scales and AD/HD Rating Scale-5 are specific to ADHD behaviors and based on the
Diagnostic and Statistical Manual of Mental Disorders (DSM) ADHD criteria. In contrast, the Child Behavior
Checklist and Preschool Age Psychiatric Assessment assess a wide range of behaviors and do not reflect
criteria for ADHD alone (Conners et al. 1998a, 1998b; Egger et al. 2006a; de la Osa et al. 2016; DuPaul et al.
2016). Physicians must remain cautious in diagnosing ADHD in preschool children, monitoring very young
children for the emergence of symptoms and impairments over time [19].

CBT Intervention

The CBT interventions in six studies included in this review had different measures of assessing the
effectiveness of the ADHD treatment [15-18,23,24]. The study observed that CBT improved ADHD symptoms
(Table 3). However, CBT can be time-limited and resource-intensive. The variations in CBT treatments could
be the mode and duration of CBT sessions. Most studies had weekly clinician-led sessions, and the number of
sessions varied. The duration of each session also varied between studies lasting an hour long and beyond,
and the sessions can be either with individual children/parents [17] or combined [24]. Finally, we will detail
the CBT sessions reviewed in our study (Table 5).

Reference
Study Session Led Number of Sessions Duration Participants
Number

Goode et
[15] Not applicable Not applicable Not applicable Children
al., 2018

Psychologist,
Novik et
[16] psychiatrist, Weekly sessions for 12 weeks 90 minutes Adolescents
al., 2019
special educator

Sciberras 8 * 1 hour long weekly

Children and
[17] et al., Psychologist 10 sessions over 12 weeks sessions, 2* 1 hour long
parents together
2019 fortnightly sessions

Children daily for three weeks varied no;

Coles et Clinician,
[18] low high behavioral treatment crossed with School year follow up Children, parents
al., 2020 teacher
MPH. Parents 8 weeks

Vacher et Psychologist, Once weekly for 15 weeks, children

[23] 1 hour Children, parents
al., 2022 Nurse, Educator sessions and 8 parent sessions

Children and
Crouzet
Psychiatrist, parents
[24] et al., Children 16 sessions Parents 16 sessions 75 minutes weekly
Psychologist performed
2022
separately

TABLE 5: Details of CBT sessions.

CBT - cognitive behavioral therapy

MPH Treatment

The nine studies included in this review have different formulations of MPH [6,7,11,14,18-22]. Since the
advent of MPH in the 1960s, MPH has been the drug of choice for ADHD worldwide and has proven to
improve ADHD core symptoms. Pharmacological treatment optimization poses challenges, including careful
dose adjustments and the risk of drug abuse during treatment [14]. The study reported marked improvement
in ADHD core symptoms six months after treatment completion by parents, teachers, and participants, with
significant improvement in inattention [14]. However, the study did not witness a significant improvement
in hyperactivity or academic performance [14]. Furthermore, treatment with MPH ERCT (extended-release

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 chewable tablet) showed a significant improvement in ADHD symptoms compared with placebo at two to
eight hours post-dose, with a good safety and tolerability profile [7]. In the first multicenter, phase three
study of the efficacy and safety of MPH ERCT formulations, the results showed a statistically significant
improvement in behavior impairment in children aged six to twelve with ADHD [7].

Additionally, in the first randomized, placebo-controlled trial of an ER MPH formulation for preschool
children aged four to six years, doses of up to 40 mg were effective and well tolerated [6]. It is like the known
safety profile in older children [6]. Another study, a placebo-controlled crossover trial looking into the
clinical efficacy and tolerability of ORADUR-MPH, reported that it significantly reduced symptoms of
inattention, hyperactivity, and impulsivity within two weeks of treatment regardless of informants [11].
ORADUR-MPH is efficacious, safe, and well-tolerated for treating ADHD without serious side effects [11].

Limitations
This study has some critical limitations. The major one is the limited number of articles documenting the
use of MPH and CBT alone to treat ADHD. Furthermore, a systematic, non-descriptive review of CBT
sessions was included [15] and provided limited measures for the discussion. In addition, we included an
unresolved research protocol, which can be controversial due to the lack of an evident result. Some studies
lacked information on the study characteristics, and we did not contact the authors. This insufficiency in
knowledge may have affected the quality of the outcome of the result. Also, our studies used different CBT
session approaches and varying formulations and dosages for MPH; therefore, this needs to be considered
for overt improvement.

Finally, our search strategy excluded studies published before the last five years and not freely available full
text on PubMed. The inclusion of these might have provided more clarity.

Conclusions
The purpose of this review is to critically evaluate the efficacy of CBT and MPH in treating ADHD in children
and adolescents to improve their core symptoms and functional capacity from published literature. The
findings from the review of 2098 patients undergoing either or both treatment interventions showed
significant reductions in the primary symptoms of ADHD at assessment, which led to improved behavior
and functional status with an overall reduced impact on family and society. Additionally, accurate diagnosis
by physicians using the rating scales is key to treatment choice. We observed how CBT helps with behavior
management and the role of psychologists, parents, and teachers in ensuring effective therapy. Further
trials are needed to understand the benefits of CBT and MPH when combined to reduce psychiatry co-
morbidities and improve learning and overall quality of life in the long term.

Additional Information
Disclosures
Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the
following: Payment/services info: All authors have declared that no financial support was received from
any organization for the submitted work. Financial relationships: All authors have declared that they have
no financial relationships at present or within the previous three years with any organizations that might
have an interest in the submitted work. Other relationships: All authors have declared that there are no
other relationships or activities that could appear to have influenced the submitted work.

Acknowledgements
We want to thank Dr. Hassaan Tohid, California Institute of Behavioral Neurosciences and Psychology,
Fairfield, USA, for his guidance and mentoring in writing this article and Emeka B Ekwenna, Ph.D., Durham
University, Durham, UK for reading this manuscript.

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