Cognitive-Functional Intervention for Adults With ADHD (Cog-Fun-A): An Extreme Case Series Analysis.

Three adult men (ages 25, 43, and 34) with confirmed ADHD and clinically significant executive-function difficulties (BRIEF-A T-score ≥65) were purposefully selected from a pilot trial of 14 adults. Two were chosen because they improved substantially; one because he improved the least. Each received 15 weekly 1-hour individual sessions of Cog-Fun-A, a metacognitive, occupation-based intervention delivered by the same occupational therapist. The intervention had four units: building relationship and psychoeducation, analysing recent daily activities, expanding strategy use to more routines, and consolidating learning. Outcomes were measured at baseline and post-intervention with the BRIEF-A, SRSI, COPM, AAQoL, and MOHOST-v2. Data were analysed descriptively at the individual level and qualitatively from therapist session logs; no statistical tests were performed.

Participant 1 (25, supermarket worker, unmedicated): BRIEF-A T-scores dropped from a range of 55–82 to 39–76; SRSI scores decreased across all dimensions; AAQoL total rose from 55.8 to 70.6; COPM performance and satisfaction each gained more than 5 points; MOHOST ratings improved in motivation, process skills, and environmental support. Participant 2 (43, married, scientific-instrumentation worker, inconsistently medicated): BRIEF-A subscale scores shifted toward or within the normative range; SRSI scores decreased; AAQoL total rose from 32.5 to 76.6; COPM performance and satisfaction each gained more than 7 points; MOHOST ratings improved. Participant 3 (34, unemployed, never consistently medicated): BRIEF-A showed minimal change with some subscales worsening (Inhibition, Self-monitor); he did not complete the post-intervention SRSI due to irregular attendance; AAQoL total was unchanged (psychological health rose from 29.1 to 66.6, productivity from 45.4 to 47.7, outlook fell from 71.4 to 46.4, relationships fell from 65 to 56.2); no clinically meaningful COPM improvement; MOHOST ratings showed restricted motivation, limited process skills, and insufficient environmental support with no notable improvement.

This paper is written for and about occupational therapy practice. The authors suggest that before or alongside metacognitive strategy work, an OT might attend to a client's attribution style (does the person see their difficulties as modifiable or as personal failure?), motivation, stability of daily routines, and the level of environmental support. In the one non-responder, these factors were all adverse. However, this is a description of three men with no control group and no statistical testing; it generates hypotheses for clinical reasoning, not a practice guideline. It does not tell you whether Cog-Fun-A is effective, only what the authors think may have helped two of the three.

Only three participants, all men, so nothing can be said about women or about the full range of adult ADHD presentations. Cases were selected retrospectively from a single pilot trial specifically because two improved and one did not; they are not a random or representative sample. No control group, no statistical analyses, and no blinding; any observed change could reflect time, expectancy, or other factors. The non-responder did not complete the post-intervention SRSI, so his metacognitive change is unmeasured. The authors themselves state the findings are descriptive and hypothesis-generating, not evidentiary, and that larger controlled studies are needed.

The authors received no financial support and declared no conflicts of interest.

Do not read the improvements in two of the three men as evidence that Cog-Fun-A is an effective treatment for adult ADHD. The three cases were chosen after the fact specifically because two improved and one did not, there was no control group, no statistical testing was performed, and all participants were men. This is a description of three individuals' experiences, not a test of whether the intervention works, and it cannot support a treatment decision for a specific patient.