Assessment of the relationship between self-reported cognitive distortions and adult ADHD, anxiety, depression, and hopelessness

Author’s Accepted Manuscript Assessment of the Relationship between SelfReported Cognitive Distortions and Adult ADHD, Anxiety, Depression, and Hopelessness Craig W. Strohmeier, Brad Rosenfield, Robert A. DiTomasso, J. Russell Ramsay www.elsevier.com/locate/psychres

PII: DOI: Reference:

S0165-1781(16)30281-5 http://dx.doi.org/10.1016/j.psychres.2016.02.034 PSY9471

To appear in: Psychiatry Research Received date: 13 May 2015 Revised date: 5 November 2015 Accepted date: 16 February 2016 Cite this article as: Craig W. Strohmeier, Brad Rosenfield, Robert A. DiTomasso and J. Russell Ramsay, Assessment of the Relationship between Self-Reported Cognitive Distortions and Adult ADHD, Anxiety, Depression, and Hopelessness, Psychiatry Research, http://dx.doi.org/10.1016/j.psychres.2016.02.034 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Assessment of the Relationship between Self-Reported Cognitive Distortions and Adult ADHD, Anxiety, Depression, and Hopelessness Craig W. Strohmeiera*, Brad Rosenfield, Robert A. DiTomasso, J. Russell Ramsayb a

Department of Psychology Philadelphia College of Osteopathic Medicine 4170 City Avenue, Philadelphia, PA 19131, USA b

Department of Psychiatry Perelman School of Medicine, University of Pennsylvania 3535 Market St., 2nd Floor Philadelphia, PA 19104, USA

*Corresponding Author. Craig W. Strohmeier Philadelphia College of Osteopathic Medicine. Phone: 215-871-6100. Email: [email protected]

Abstract The current chart review study examined the relationship between self-reported cognitive distortions, attention-deficit/hyperactivity disorder (ADHD) symptoms, and co-occurring symptoms of depression and anxiety in a clinical sample of adults diagnosed with ADHD. Thirty subjects completed inventories measuring cognitive distortions, ADHD, anxiety, depression, and hopelessness as part of the standard diagnostic evaluation protocol used in a university-based outpatient clinic specializing in adult ADHD. A series of correlational analyses were conducted to assess the relationship between self-reported cognitive distortions, ADHD, anxiety, depression, and hopelessness. Results indicated a significant, positive correlation between selfreported cognitive distortions and ADHD. Responses to individual items on the measure of cognitive distortions were tabulated to identify the prevalence of specific cognitive distortion categories, with Perfectionism emerging as the most frequently endorsed. Further clinical implications of these findings are discussed.

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Keywords: Cognitive Behavior Therapy; CBT; Perfectionism; Emotional Reasoning; Avoidance; Procrastination

1. Introduction The term Cognitive Distortion (Beck, 1967; 1970; J. Beck, 1995) refers to a selfstatement that reflects the misinterpretation of an event (J. Beck, 1995). The statement may be verbalized publicly or thought privately, as is the case with the class of behaviors involved in thinking, or cognition. For example, before starting a difficult school assignment an individual may think, “I feel really frustrated with this work, so I won’t do it right now,” while pushing the task aside. This thought aligns with the cognitive distortion Emotional Reasoning, as the feeling of frustration is misinterpreted as a reason for delaying task completion. Behaving in accordance with a cognitive distortion in this way is ultimately maladaptive insofar as an individual persistently treats the cognitive distortion as a rule that may function to alter behavior in a manner counter to one’s ultimate goals (Torneke et al., 2008, p. 152). That is, behaving in accordance with a cognitive distortion may lead to a narrowed behavioral repertoire, fewer opportunities to access new sources of reinforcement, increased emotional distress, and left unchecked, persistent maladaptive behavior. Accordingly, assessment of cognitive distortions in psychotherapy can inform a clinician’s strategies to promote more adaptive cognitions and more flexible responding to the environment, for instance tolerating activities that have historically led to emotional distress and avoidance (see Wilson et al., 2001, p.211-237).

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1.1. Cognitive Distortions and Adult Attention Deficit/Hyperactivity Disorder Attention-deficit/hyperactivity disorder (ADHD) is currently classified as a neurodevelopmental disorder characterized by developmentally inappropriate levels of inattention, impulsivity, and/or hyperactivity with the stipulation that at least some symptoms emerge in childhood or adolescence (American Psychiatric Association [APA], 2013). Long thought to be exclusively a childhood disorder, it is currently understood that features of ADHD persist into adulthood for more than half of children with ADHD and that many individuals are not diagnosed until adulthood, with the prevalence of ADHD in the adult population of the United States being estimated at 4.4% (Kessler et al., 2005, 2006). Common symptoms that persist in adult ADHD include deficits associated with working memory, and organizing, sustaining, and completing tasks (Kessler et al., 2010). Additional behavioral deficits include difficulty with self-regulation of emotion and motivation, collectively referred to as Executive Function deficits (See, Barkley, 1997, 2001). Consequently, many adults with ADHD develop cooccurring symptoms of anxiety and depression (Young et al., 2003). Given the potential likelihood that individuals with ADHD will experience more setbacks in their endeavors across the lifespan, along with the prevalence of co-occurring anxiety and depression, it has been assumed that clinic-referred adults with ADHD will be at high risk for exhibiting cognitive distortions that will need to be targeted in psychosocial treatment. Assessment and treatment of cognitive deficits, cognitive distortions, and other behaviors related to emotional distress and maladaptive coping skills have been considered an important feature of comprehensive cognitive-behavioral treatment for adults with ADHD (Safren et al., 2005; Philipsen et al., 2007; Ramsay and Rostain, 2007; Rosenfield et al., 2008;

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Ramsay, 2010; Safren et al., 2010; Solanto, 2010). Nonetheless, while cognitive-behavioral treatments afford the flexibility to target cognitive distortions, limited empirical research addresses the relationship between variants of cognitive distortions and adult ADHD (Abramovitch and Schweiger, 2009; Mitchell et al., 2013). Abramovitch and Schweiger (2009) investigated the relationship between one variation of cognitive distortion, distressing thoughts, and adult ADHD. The authors found significant elevations in scores on the Distressing Thoughts Questionnaire (DTQ; Clark and DeSilva, 1985) for an adult ADHD group when compared to a non-ADHD control group. Mitchell et al. (2013) examined negative automatic thoughts and a measure of adult ADHD. The authors reported a significant positive relationship between the frequency of negative automatic thoughts, measured by the Automatic Thoughts Questionnaire (ATQ; Hollon and Kendall, 1980), and adult ADHD symptoms. Results of these studies provide some support for the inclusion of cognitivebehavioral strategies to target cognitive distortions for adults with ADHD. Nonetheless, the instruments used to measure cognitive distortions in previous studies were intended for the assessment of anxiety-related and depression-related cognitive distortions, thus limiting conclusions that could be drawn regarding possible ADHD-specific cognitive distortions. In the present study, we examined patterns of self-reported cognitive distortions in a clinical sample of adults diagnosed with ADHD. Of note, cognitive distortions were measured with the Inventory of Cognitive Distortions (ICD; Yurica and DiTomasso, 2002). The ICD a) includes 69 items that are factored into 11 different cognitive distortion categories, and b) adopts a transdiagnostic model of cognitive distortions rather than focusing on mood or anxiety symptoms, or personality traits alone (Yurica, 2002; Jager-Hyman et al., 2014). This study

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contributes to the extant literature on cognitive distortions and adult ADHD by providing results of correlational analyses of cognitive distortions and ADHD, and an assessment of specific cognitive distortions, and cognitive distortion categories, endorsed by the clinical sample of adults with ADHD. 2. Method 2.1. Subjects The current chart review study was approved by the Institution Review Boards of each of the institutions with which the authors are affiliated. Archival data were gathered from the clinical charts of participants at a university-based specialty outpatient clinic for adult ADHD in a large northeastern town in the United States. Potential subjects were identified from a subset of individuals who had sought a diagnostic evaluation from the clinic and had completed the requisite scales used in the current study. A clinician at the center reviewed the records to determine eligibility for inclusion or exclusion in the study. Forty-four charts of adults who were diagnosed with ADHD through the clinic were initially reviewed, and 30 met eligibility for inclusion (19 male, 11 female, mean age = 36.7 years, age range = 20 to 60 years). 2.2. Procedures Participant data were considered eligible for the study if a participant was between the ages 18 and 88, and a standard battery of measures to assess cognitive distortions, ADHD, anxiety, and mood disorder symptoms (described below, under “Measures”) was completed upon intake at the clinic. The diagnosis of ADHD was determined through a combination of developmental and clinical interviews, self-report of both childhood and current symptoms, and clinician interview of childhood and current symptoms. In particular, a clinically elevated

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total score (i.e., T > 65) on the clinician administered Brown Attention Deficit Disorders Scale for Adults (Brown, 1996) combined with meeting DSM-IV (APA, 1994) diagnostic criteria (including childhood onset of symptoms) provided the operational definition of a diagnosis of ADHD. Structured clinical interview of DSM-IV symptoms (to assess for comorbidity or other psychiatric diagnosis that may better explain presenting problems) as well as review of corroborative information (including past records and observer reports of childhood and current symptoms, whenever available) were used to further make a differential diagnosis. For charts that were identified as appropriate for inclusion in the study, the data relevant to the study were extracted and de-identified, and each participant was assigned a unique identification. The de-identified data were transferred to a password-protected electronic database used by the first author for data analysis. 2.3 Measures 2.3.1. Assessment of Anxiety, Depression, Hopelessness, and ADHD 1) Beck Anxiety Inventory (BAI). The BAI is a 21 item self-report scale designed to assess primary physiological/somatic and panic symptoms related to anxiety (Beck and Steer, 1990). The severity of each symptom is rated on a 4-point scale ranging from 0 (not at all) to 3 (severely, I could barely stand it). A total score from 0 to 63 is calculated by adding the severity ratings for all 21 items. Research suggests the BAI possesses high internal consistency (Cronbach’s α = 0.92) and adequate test-retest reliability (r = 0.75) and strong discriminant validity (Beck et al., 1988). When compared with a measure of depression, the Hamilton Rating Scale for Depression-Revised (HAM-D: Hamilton, 1960), the instrument demonstrated strong discriminant validity (r = 0.25) (Beck et al. 1988)

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2) Beck Depression Inventory, Second Edition (BDI – II). The BDI-II is a 21 item self-report scale designed to assess common symptoms of depression. Items are rated on a 4-point scale from 0 to 3 (Beck et al., 1996). A total score from 0 to 63 is calculated by adding the ratings for each of the 21 items. In regard to psychometric properties of the BDI-II, Beck et al., (1996) reported high internal consistency (Cronbach’s α = 0.91), and high test-retest reliability (r = 0.93). When compared with a measure of anxiety, the Hamilton Anxiety Rating Scale-Revised (HAM-A; Hamilton, 1959) the instrument demonstrated adequate discriminant validity (r = 0.47). 3) Beck Hopelessness Scale (BHS). The BHS is a 20 item self-report scale that asks true or false questions about an individual’s perceived level of hopelessness (Beck et al., 1989). Items are scored as “1” (true) or “0” (false) based on agreement or disagreement with the item. Beck et al., (1974) examined the psychometric properties of the BHS and found high internal consistency (Cronbach’s α = 0.93). 4) Brown Attention Deficit Disorder Scale (BADDS)-Adult Version. The BADDS is a 40-item selfreport questionnaire (Brown, 1996) that is clinician administered as part of the initial diagnostic evaluation. A clinically elevated total score on the BADDS (i.e., T > 65) was used a criterion for the diagnosis of ADHD along with fulfilling DSM-IV diagnostic criteria. BADDS items are organized into five clusters, each related to a class of symptoms consistent with Brown’s (1996) executive dysfunction model of ADHD. The BADDS utilizes self-reported symptoms, rated on a scale from 0 (never) to 3 (almost daily). Psychometric evaluation of the BADDS suggests high internal consistency (Cronbach’s α = 0.96) and adequate test-retest reliability (r = 0.87) (Brown and Whiteside, 2003).

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5) Conners’ Adult ADHD Rating Scale (CAARS) Self-Report: Long Version. The CAARS is a 66-item self-report instrument that measures a wide variety of symptoms of ADHD in adult patients (Conners et al., 1999). Respondents rate each item on a four-point scale of the occurrence of symptoms ranging from “Not at all, never” to “Very much, very frequently” The CAARS yields a total score and subscale scores (i.e., Inattention/Memory Problems, Hyperactivity/Restlessness, Impulsivity/Emotional Lability, Problems with Self-Concept) measuring a variety of deficits commonly associated with ADHD. Among the subscale scores are three devoted to DSM criteria (DSM-IV Inattentive Symptoms, DSM-IV Hyperactive-Impulsive Symptoms, and DSM-IV ADHD Symptoms Total) and an additional ADHD Index score that are helpful in corroborating clinical data gathered during interviews. The current study used the CAARS DSM-IV Inattentive Symptoms subscale as the measure of adult ADHD.

2.3.2. Measure of Cognitive Distortions 6) Inventory of Cognitive Distortions (ICD). The ICD is a 69-item self-report inventory (Yurica and DiTomasso, 2002). ICD items are comprised of various statements designed to reflect 11 different cognitive distortion categories, organized through factor analysis. ICD items are scored on a 5 point scale ranging from 1 (never) to 5 (always) to reflect a respondent’s level of agreement with each statement, i.e., cognitive distortion. The sum of the ratings for each of the 69 items provides the total ICD score, ranging from 69 to 345. The higher total scores reflect a higher endorsement of cognitive distortions. Yurica’s (2002) psychometric evaluation of the ICD indicated that the instrument possessed excellent content and construct validity, excellent testretest reliability (r = 0.998) and internal consistency (Cronbach’s α = 0.98). Strong correlations

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were demonstrated between the ICD and other measures of problematic thought patterns (i.e. the Dysfunctional Attitudes Scale [DAS; Weissman and Beck, 1978]), suggesting good concurrent validity (r = 0.70) (Yurica, 2002).

2.4 Statistical Analyses The Statistical Package for Social Sciences (SPSS), version 18.0 was used for the correlational analyses. Two-tailed Pearson correlation analyses (alpha level 0.05) were conducted to examine the relationship between total scores on the BADDS, BAI, BDI-II, BHS, and ICD.

2.5 Assessment of Cognitive Distortion Endorsement The degree of endorsement of cognitive distortions was calculated by adding ICD item scores that corresponded to each separate cognitive distortion category included in the ICD and then dividing by the total number of statements associated with that particular cognitive distortion category in the instrument, i.e., Perfectionism, Emotional Reasoning, etc.. The most strongly endorsed individual cognitive distortion for the sample was calculated by dividing the total score for each of the cognitive distortions measured by the ICD by the total number of participants.

3. Results Results of the correlational analyses indicated a significant positive relationship between cognitive distortions (total ICD score) and ADHD (total BADDS score) (r = 0.487, p <

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0.05). Significant relationships were also identified between cognitive distortions and depression (BDI-II score) (r = 0.650, p < 0.05), and cognitive distortions and hopelessness (BHS score) (r = 0.533, p < 0.05), and depression and hopelessness (r = 0.677, p < 0.05). No significant relationship emerged between ADHD and anxiety, ADHD and depression, or ADHD and hopelessness (See Table). --INSERT TABLE HERE-Review of the endorsement of specific cognitive distortion categories indicated that Perfectionism was the most frequently endorsed cognitive distortion theme (55%), followed by Emotional Reasoning and Decision Making (17.5%), Comparison to Others, and Emotional Reasoning (7.5%), Magnification, Mind Reading, and Minimization (5%), and Arbitrary Inference/Jumping to Conclusions (2.5%). Externalization of Self-Worth, Fortune-Telling, and Labeling were cognitive distortion themes that were not endorsed by any participants (See Figure). --INSERT FIGURE HERE-4. Discussion This study found a significant positive relationship between total self-reported cognitive distortions, and ADHD. Additionally, similar to previous studies using the ICD, significant relationships were identified between total self-reported cognitive distortions and depression, and hopelessness (Yurica, 2002; Rosenfield, 2004). These findings are consistent with previous lines of research that directly assessed problematic thinking patterns in adults with ADHD (Abramovitch and Schweiger, 2009; Mitchell et al., 2013). The findings from the current study are also in line with studies of the influence of cognitive distortions on the experience of adults

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with ADHD in terms of depressive symptoms and a depression diagnosis (Knouse et al., 2013). For example, Knouse et al. (2013) identified significant correlations between adult ADHD symptom severity and depressive symptom severity in their clinical sample. Furthermore, the authors reported that dysfunctional attitudes and behavioral avoidance mediated the correlation. Therefore, interventions that target both the dysfunctional attitudes and behavioral avoidance associated with both adult ADHD and depression may functionally address cognitive and behavioral processes involved in the maintenance of both disorders. More specific to the clinical relevance of the current study, on average, the cognitive distortion category of Perfectionism was endorsed most frequently within the sample. Some research suggests a relationship between maladaptive perfectionism and problem problemsolving deficits (Argus and Thompson, 2008), which would be consistent with organization and problem-solving being one of the executive function domains assessed in adults with ADHD (Barkley, 2011). Therefore, among adults with ADHD, cognitive distortions related to perfectionism may co-occur with persistent task avoidance stemming from deficits in taskrelated problem-solving skills (Young, 2005). Additionally, although going beyond the available data, clinical conjecture suggests that this sort of “ADHD perfectionism” may manifest itself as an individual stating the need to be “perfectly ready” before engaging in a task. Falling short of this ideal state of “perfect readiness” can be used to rationalize procrastination. Treatment may proceed by helping an individual modify their dichotomous self-statements to reflect standards more accepting of imperfection, so as to encourage behaviors associated with approaching, rather than avoiding a task.

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Emotional Reasoning and Decision Making, Comparison with Others, and Emotional Reasoning were the next three most commonly endorsed cognitive distortions, respectively. The role of emotions and more specifically deficient emotional self-regulation (DESR; Barkley, 2010; Surman et al., 2011) is increasingly recognized as a core component of ADHD despite not being included in the official diagnostic criteria. DESR reflects the fact that individuals with ADHD report greater difficulty than individuals without ADHD in managing the typical emotional stressors and emotional demands of daily life. An adult with ADHD may verbalize this deficit through cognitive distortions that reflect emotional reasoning and decision making, which may co-occur with behaviors aimed at avoiding emotionally stressful events, rather than adaptively enduring the related distress (Knouse and Mitchell, 2015). Lastly, judging oneself in comparison with others is commonly observed in clinicreferred adults diagnosed with ADHD. Individuals may judge themselves in a negative light based on various setbacks experienced while navigating through life’s typical demands, compared to others, which may further contribute to seemingly self-defeating and/or avoidant behavior patterns, akin to Knouse et al.’s (2013) discussion of the relationship between adult ADHD, depression, and cognitive-behavioral avoidance as a coping pattern, with its potential impact on functioning.

4.1 Limitations The current study is limited by the small sample size (N = 30). Therefore, the significant correlations identified should be interpreted with caution. In addition, generalizability of the findings should be scrutinized carefully due to the idiosyncratic characteristics of the sample.

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The sample was comprised of mostly high functioning, college educated individuals, albeit who were experiencing a clinically significant degree of impairment at the time of assessment. Moreover, 90% of the sample identified as Caucasian, 7% identified as African American, and 3% did not report this information. Therefore, future studies should examine similar variables within a larger, more culturally, economically, and educationally diverse sample. A larger sample size would allow for more refined statistical analyses to identify potential mediating variables among cognitive distortions, adult ADHD, anxiety, depression, and hopelessness. Additionally, future studies may consider gathering more data on the specific characteristics of ADHD in the sample. This would allow for an analysis of cognitive distortion categories across various characteristics of adult ADHD. Finally, the majority of the archival data for the current study was generated by self-report inventories. Therefore, future studies should utilize direct observations of behavior to corroborate the self-reported information.

4.2 Conclusions and Implications Our results support recommendations by clinicians and researchers that encourage the use of cognitive-behavioral therapy techniques, including those focused specifically on cognitive distortions, for the psychosocial treatment of adults with ADHD (Ramsay and Rostain, 2007; Rosenfield et al., 2008; Ramsay, 2010). Several manuals that describe empirically supported psychosocial treatments for adult ADHD underscore the importance of incorporating an individual’s cognitive experience into treatment for ADHD (e.g. Safren 2005; Solanto, 2011; Ramsay and Rostain, 2015). One specific strategy, relevant to the current study, is Ramsay’s (2010) recommendation for the inclusion of interventions directed at cognitive distortions to

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enhance the rationale for behavioral activation and exposure strategies. For example, the therapist can reframe cognitive distortions related to emotional reasoning and avoidance (i.e. “Things ought to feel just right before I get started on them…”) and establish statements that alter the client’s likelihood of engaging in a task (i.e. “Even if this doesn’t feel just right, I can stick with it for ten minutes.”). Each successive experience, incrementally closer to the terminal goal, provides an opportunity to contact a reinforcing event that will maintain future adaptive responses, while simultaneously building tolerance for unpleasant emotional experiences that may occur when engaging in a less preferred task. Our finding that perfectionism was the most commonly endorsed cognitive distortion category aligns with contemporary perspectives on the function of Overly Positive cognition for adults with ADHD (Knouse and Mitchell, 2015). Although statements related to perfectionism may be regarded as positive, likely due to connotations associated with confidence and a high quality of work, perfectionism may be maladaptive if procrastination and task avoidance are the functional consequences, resulting in perfectionism actually working in opposition to task engagement. We reiterate Knouse and Mitchell (2015), suggesting that, “…excessively ‘positive’ thoughts observed in adults with ADHD become problematic when they reduce aversive emotions in the short term but increase avoidant behavior and reduce compensatory skill use in the long term” (p. 8). From a clinical standpoint, then, there may be a functional difference between topographically similar forms of cognitive distortions related to perfectionism. On the one hand, there can be an excessive meticulousness in the performance of a task that does not interfere with getting started on it, but rather manifests as problems accepting that a finished

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product is adequate enough to be considered complete, such as can be observed in obsessivecompulsive personality disorder. On the other hand, clinical observation would suggest that ADHD-related perfectionism is better conceptualized as problems with procrastination and avoidance of tasks due to a history of frustration, poor results not commensurate with efforts, and resulting emotional discomfort associated with various tasks. Thus, adults with ADHD will verbalize their recognition of the importance of a task, its relevance for a larger objective, and the awareness that they will be better off for completing it, but still justify delaying it until ”everything is just right” to begin to perform it, or some other precondition for engaging in the task. As noted by Mitchell and Knouse (2015), these rationalizations provide immediate relief from facing an uncomfortable task but reinforce avoidance and run the risk of being selfhandicapping, defeating, and potentially creating perpetual setbacks (see Knouse et al., 2013; Ramsay and Rostain, 2015). Therefore, cognitive-behavioral interventions for adult ADHD target the cognitions about initiating a task, and promote the management of emotional reactions and developing a feasible behavioral plan to increase the likelihood of task implementation and follow through (Ramsay, 2011). In conclusion, the current study contributes to the increased attention to the cognitive experience of adults with ADHD. Based on the results of this and other recent studies, we suggest that assessment of a client’s cognitive distortions with instruments similar to the ICD is a practical method for gaining information regarding problematic self-statements that co-occur with, and may contribute to, characteristic ADHD-related functional difficulties beyond those explained by the core features of the disorder. Overall, the present study and other similar studies (i.e. Knouse et al., 2013; Mitchell et al., 2013; Knouse and Mitchell, 2015; Torrente et

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al., 2014) provide encouraging direction for future research in the assessment and psychosocial treatment of cognitive distortions related to adult ADHD.

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Running head: COGNITIVE DISTORTIONS AND ADHD

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Figure 1 Percentage of participant endorsement for the 11 cognitive distortion categories.

Percentage of Participants 0

10

20

30

40

50

60

70

80

90

100

Cognitive Distortion Category

Perfectionism Emotional Reasoning and Decision Making Comparison to Others Emotional Reasoning Magnification Mind Reading Minimization Arbitrary Inference/Jumping to Conclusions Externalization of Self-Worth Fortune-Telling Labeling

Table 1 Correlation matrix for ADHD, Cognitive Distortions, Depression, Anxiety, and Hopelessness.

ADHD

ADHD

______

Cognitive Distortions

0.487**

Depression

0.306

Anxiety

0.268

Cognitive Distortions

0.487**

Depression

Anxiety

Hopelessness

0.306

0.268

0.202

0.650**

0.259

0.533**

0.650**

______

0.114

0.677**

0.259

0.114

______

______

0.114

Running head: COGNITIVE DISTORTIONS AND ADHD

Hopelessness

0.202

0.533**

23

0.677**

0.114

______

**. Correlation is significant at the 0.01 level (2-tailed).

Highlights   

Limited empirical research addresses the role of targeting cognitive distortions in the psychosocial treatment of adult ADHD. Correlational analyses indicated a significant positive relationship between cognitive distortions and ADHD for the adults in the clinical sample. Commonly endorsed cognitive distortion categories included Perfectionism, Emotional Reasoning and Decision Making, and Comparison to Others.