Structured skills training for adults with ADHD in an outpatient psychiatric context: an open feasibility trial

Cognitive behavioral therapy for ADHD predominantly inattentive presentation: randomized controlled trial of two psychological treatments

Introduction

Attention-Deficit Hyperactivity Disorder (ADHD) in adults is common and characterized by difficulties in regulation of attention, activity and goal directed behaviors. These challenges are especially associated with inattentive symptoms, why high levels of inattention imply severe impairment in everyday life. CBT for ADHD-inattentive presentation, (CADDI), is designed to treat inattention and incorporates skills training in organization, behavioral activation, and mindfulness. The aim of this study was to compare the effectiveness of CADDI with regular CBT treatment for ADHD.

Methods

A multicenter, pragmatic, two-arm, parallel, randomized controlled trial compared CADDI to Hesslinger's dialectical behavior therapy protocol. The study included 108 participants from six psychiatric outpatient clinics in Stockholm. Self-reported scales were used to assess outcome measures of behavioral activation, procrastination, symptoms of ADHD, depression, quality of life and functional impairment. Data were analyzed for between and within-group effects using multilevel modeling.

Results

Between-group analysis showed that participants in the CADDI group had significantly greater improvement on the primary outcome measure of activation at post assessment (p = .045, d = 0.49). No significant between-group effect was found on the other measures. However, within-group analysis showed larger effect sizes in the CADDI condition relative to the control condition on several measures. Adherence was good and attrition 21.3% despite effects of the pandemic. Participants and therapists reported higher satisfaction with CADDI as compared to the control group.

Discussion

This trial demonstrated that CADDI was more effective regarding behavioral activation and suggests a potential advantage of an intervention specifically targeting ADHD-I over generic CBT for ADHD. However, the trial was underpowered and failed to prove between-group effects in spite of large differences in effect sizes on several measures. Future research with larger samples and long-term follow-ups is recommended to validate and expand upon these results.

Effectiveness of an online dialectical behavior therapy skills training in adults with attention-deficit/hyperactivity disorder: A randomized controlled trial

OBJECTIVE

The current study aims to examine the efficacy of an add-on dialectical behavior therapy skills training (DBT-ST) on adult attention-deficit/hyperactivity disorder (ADHD). The DBT-ST was applied online under the pandemic conditions that occurred after the study had started.

METHODS

The current randomized controlled trial consists of an intervention group to whom the DBT-ST was applied in online setting and a waitlist control group who received treatment as usual (TAU). Data were collected pre-, post-, and mid-treatment. ADHD symptoms (with the sub-dimensions of inattention and hyperactivity), impulsivity, mindfulness, difficulty with emotion regulation, interpersonal effectiveness, distress tolerance, life satisfaction, functionality in daily life, and general psychological symptom levels were measured with self-report scales. The data were analyzed using mixed-design ANOVA.

RESULTS

The global ADHD, inattention, and hyperactivity symptoms of the DBT-ST group significantly decreased more than those in the TAU control group. The DBT-ST group also showed a significant decrease regarding difficulty with emotion regulation and increases in life satisfaction and functionality, though the group × time effect was not significant.

CONCLUSION

DBT-ST was found effective against the participants' ADHD symptoms. The treatment was additionally found to improve their emotion regulation and quality of life. Further investigation is needed to investigate DBT-ST in an online setting.

I've really struggled but it does not seem to work: adolescents' experiences of living with ADHD - a thematic analysis

BACKGROUND

In Attention-deficit/hyperactivity disorder (ADHD) the transition from childhood to adolescence encompass changes in symptom manifestation and related challenges. Given the potential negative impact of ADHD on adolescents, and the increased risk for dropping out from treatment, there is a need to understand more about how adolescents experience their condition. The aim of this study was to explore adolescents' perceptions of how it is to live with ADHD.

METHODS

Twenty adolescents (15-17 years old, 12 girls) diagnosed with ADHD who had completed a skills training group were interviewed. Data was analysed using thematic analysis.

RESULTS

Four themes emerged: 'I find it hard to regulate what I take in and what comes out', 'I've really struggled but it does not seem to work', 'ADHD impacts my vitality and my relationships', and 'I can be successful and things are getting better'.

CONCLUSION

Adolescents with ADHD experience problems with self-regulation with regards to cognitive, emotional and behavioural processes. They describe being either on or off. This difficulty to self-regulate is related to primary and secondary consequences such as stress, anxiety, loss of control, and by extension exhaustion, depressed mood, challenges in social interactions, self-accusations and a tendency of giving up. The experience of 'being on' has positive connotations of vigour and creativity. The challenges related to ADHD can to some extent be overcome with time for recovery, coping strategies, and medical treatment. Symptoms of ADHD can also decrease over time.

TRIAL REGISTRATION

This qualitative study was not pre-registered.

Experiences of change following a blended intervention for adults with ADHD and emotion dysregulation: a qualitative interview study

BACKGROUND

Emotion dysregulation commonly co-occurs with attention-deficit hyperactivity disorder (ADHD), leading to a range of negative outcomes. While psychological interventions have shown promise in bringing about positive changes in emotional and cognitive domains, there is still limited knowledge on the subjective experiences of change among the participants in these interventions.

AIM

The present study explores the experiences of adults with ADHD who had participated in a blended digital and face-to-face intervention aimed at improving emotion dysregulation. The study focuses on understanding their experiences of change and identifying contributors to change.

METHODS

A total of 9 adults with ADHD participated in individual semi-structured, in-depth interviews following their participation in the intervention. The interviews were analyzed using thematic analysis.

RESULTS

The thematic analysis resulted in three core themes. The first theme, 'perceiving change', represents changes that the participants experienced, with four subthemes: 1a) being in control, 1b) feeling aware, 1c) accepting oneself and one's emotions and 1d) gaining insight and knowledge. The second theme, 'supporting change', captures factors that supported the participants' changes, with five subthemes: 2a) acquiring skills, 2b) being in it together, 2c) therapist guidance, 2d) finding motivation 2e) putting it into practice. Lastly, the third theme, 'sustaining change', includes aspects important to maintain change, with two subthemes: 3a) working consistently and 3b) giving it time.

CONCLUSIONS

The findings show that the participants experienced various changes related to the management of their emotions following their participation in the intervention. Change was perceived as a multifaceted process, supported by internal factors such as motivation and engagement, along with external factors such as support from the other group members and the therapists. Taken together, the findings from the study could be important to the development of psychological interventions for adults with ADHD and may provide valuable knowledge to clinicians and policymakers.

TRIAL REGISTRATION

Registered on 21st November 2022 at ClinicalTrials.gov.

CLINICALTRIALS

gov ID: NCT05644028.

The State of the Science: Dialectical Behavior Therapy

The first randomized clinical trial of dialectical behavior therapy (DBT) for women with borderline personality disorder was published in 1991. Over the past 30 years, research on DBT has proliferated along with interest by clinicians and the public. In this State of the Science review, we provide a brief description of the treatment paradigm and its conceptual and theoretical underpinnings. We also briefly review the research conducted to date on DBT across populations and settings, the vast majority of which demonstrates that it is effective at treating the behaviors that it targets. We also argue that, although DBT has been established as a "gold-standard" treatment for certain populations and behaviors, there is much more research needed to answer critical questions and improve its efficacy.

Feasibility of the Understanding and Managing Adult ADHD Programme: open-access online group psychoeducation and acceptance and commitment therapy for adults with attention-deficit hyperactivity disorder

BACKGROUND

Psychoeducational interventions are a critical aspect of supporting adults with attention-deficit hyperactivity disorder (ADHD). The Understanding and Managing Adult ADHD Programme (UMAAP) is a six-session, group-based webinar intervention that incorporates psychoeducation with acceptance and commitment therapy. UMAAP relies on self-referrals and is facilitated by a charity, to promote accessibility.

AIMS

The present study aimed to evaluate the feasibility of UMAAP and explore preliminary effectiveness.

METHOD

Adults with formally diagnosed or self-identified ADHD (n = 257) participated in an uncontrolled pre-post design. Feasibility was indicated by attendance, confidence in completing the home practice and satisfaction. Quality of life, psychological flexibility, self-acceptance and knowledge of ADHD were assessed at baseline, 1 week post-intervention and 3 months later, to explore preliminary effectiveness.

RESULTS

Feasibility was demonstrated by the high attendance ratings and satisfaction with the intervention, although there was only moderate confidence in the ability to complete the home practices. Quality of life (mean increase 9.69, 95% CI 7.57-11.80), self-acceptance (mean increase 0.19, 95% CI 0.10-0.28) and knowledge of ADHD (mean increase 1.55, 95% CI 1.23-1.82) were significantly improved post-intervention. The effects were maintained at the 3-month follow-up. Psychological flexibility did not significantly change immediately post-intervention, but increased significantly at the 3-month follow-up (mean increase 0.42, 95% CI 0.26-0.58).

CONCLUSIONS

Overall, UMAAP is a feasible intervention for adults with ADHD. Findings highlighted the feasibility of delivering psychological interventions online in group settings, to increase access to support for adults with ADHD.

Psychosocial interventions for improving the physical health of young people and adults with attention deficit hyperactivity disorder: a scoping review

BACKGROUND

Young people and adults with ADHD are at risk of a range of physical health problems. There is limited guidance on how to approach health problems in ADHD, and especially around 16-25 year olds who will be transitioning from paediatric to adult care. The aim of this scoping review was to identify psychosocial interventions that target physical health in young people and adults with ADHD.

METHODS

We constructed searches in MEDLINE, PsycInfo, EMBASE of adolescents, young people and adults. Inclusion criteria were; studies of psychosocial interventions examining a component of physical health, applicable to people aged 16-25, with clinical or research diagnoses of ADHD. Data were extracted using a data extraction tool and tabulated, including study intervention framing/aims, population, intervention, and relevant outcomes (including specific statistics where relevant).

RESULTS

Our search identified 22 unique papers covering, psychosocial interventions targeting at least one of sleep (n=7), smoking (n=3), substance/alcohol use (n=4), physical health/exercise (n=6) and general health (n=3). Studies examined psychotherapy/behaviour interventions (n=12), psychoeducation (n=4), digital (n=2) and social interventions (n=4). There was significant heterogeneity in intervention framing, outcome measures and population.

CONCLUSION

Further work on the impact of targeted physical health interventions, with explicit reference to a conceptual framework of poor health in ADHD is required. Furthermore, future work standardising reporting of physical health outcomes in ADHD is crucial for the development of an evidence base in this field.

"It was very nice to be in a room where everyone had ADD-that's kind of VIP": Exploring clients' perceptions of group CBT for ADHD inattentive presentation

OBJECTIVES

This qualitative study explored the perceptions of adult clients participating in a new psychological treatment for attention-deficit/hyperactivity disorder inattentive presentation (ADHD-I, also called "attention deficit disorder", ADD). The study aimed to explore (i) what aspects of treatment the participants found to be helpful, and (ii) if there were areas that ought to be developed to make the protocol more useful to clients with ADHD-I.

METHODS

Participants were recruited from treatment groups following the protocol of cognitive-behavioral therapy for ADHD-I (CADDI), at three psychiatric outpatient units in Stockholm, Sweden. Individual semi-structured interviews, lasting on average 44,6 minutes, were conducted with 14 adults after the completion of CADDI. Interviews explored participants' perceptions of CADDI, its usefulness, and asked for suggestions for improvement. Interviews were conducted by independent interviewers and were transcribed verbatim. The text was analyzed using reflexive thematic analysis.

RESULTS

The analysis generated three themes: "Factors of importance for change", with the subthemes; the group, therapeutic components, structure of treatment, and motivation,"Gains in treatment", with the subthemes; insight and understanding, increased attention, and planning and acting, and "Challenges with ADHD-I and remaining needs", with the subthemes; ADHD as a lifelong condition, maintaining gains in treatment, and wish for further support.

CONCLUSIONS

Participants emphasized the importance of the group setting as a facilitator of therapeutic effects of increased understanding and self-acceptance. Further, they considered the practice of mindfulness to enhance attention and awareness of thoughts, feelings, and activities and considered the structure of treatment as supporting the work in therapy. These findings support the value of the group setting and confirm the usefulness of CADDI. However, participants were concerned about how to maintain gains of treatment after its termination and suggested follow-up sessions to improve the CADDI protocol.

TRIAL REGISTRATION

Preregistered at Clinical Trials: NCT05037903.

A Blended Intervention Targeting Emotion Dysregulation in Adults With Attention-Deficit/Hyperactivity Disorder: Development and Feasibility Study

BACKGROUND

Many adults with attention-deficit/hyperactivity disorder (ADHD) experience difficulties related to emotion regulation. Such difficulties are known to substantially impact quality of life and overall functioning. Yet, there is a lack of treatment interventions specifically designed to address these challenges.

OBJECTIVE

This study aimed to describe the development and assess the feasibility, along with the initial clinical outcomes, of a novel blended intervention for adults with ADHD. The blended intervention combines both face-to-face and digital components and is specifically designed to address emotion dysregulation in ADHD.

METHODS

This intervention was an 8-week blended intervention combining weekly face-to-face group sessions with a supplementary digital companion app. The intervention is based on elements from dialectic behavioral therapy skills training and positive psychology. To evaluate its feasibility, we performed a 10-week feasibility study with an uncontrolled pre-post study design, including 16 adults with ADHD and co-occurring emotion dysregulation. The feasibility measures encompassed adherence, satisfaction, and perceived credibility of the intervention. Clinical outcomes were evaluated by self-reported symptoms of emotion dysregulation, inattention, hyperactivity-impulsivity, executive function, depression, anxiety, and a measure of quality of life. Paired sample 2-tailed t tests were used to analyze clinical outcomes with a Bonferroni-corrected significance level.

RESULTS

Both treatment credibility and treatment satisfaction were rated favorably by the majority of the participants. In particular, the participants emphasized meeting others with ADHD as beneficial. In terms of adherence, 3 participants withdrew before initiating the intervention, while another 4 participants did not complete the intervention. On average, the participants who enrolled in the intervention attended 6.2 of the 8 group sessions and completed 6.7 of the 8 skills training modules in the companion app. In terms of clinical outcomes, there was a reduction in symptoms of emotion dysregulation from before to after the intervention (d=2.0). Significant improvements were also observed in measures of inattention (d=1.1) and hyperactivity-impulsivity (d=0.9). However, no significant improvements were found in the domains of depression, anxiety, quality of life, and executive functioning.

CONCLUSIONS

The results are encouraging, both in terms of feasibility and the preliminary clinical results on emotion dysregulation. The blended format, combining digital and face-to-face elements, may also seem to offer some advantages: the group-based format was valued as it facilitated peer interaction, while a rather high completion of modules in the companion app highlights its potential to enhance skills training between the group sessions. Future randomized controlled trials are called for to further evaluate the clinical effectiveness of the intervention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05644028; https://clinicaltrials.gov/study/NCT05644028.

Exploring the efficacy of dialectical behaviour therapy and methylphenidate on emotional comorbid symptoms in adults with attention Deficit/Hyperactivity disorder: Results of the COMPAS multicentre randomised controlled trial

This study evaluated the efficacy of dialectical behaviour group therapy (GPT) vs. individual clinical management (CM) and methylphenidate (MPH) vs. placebo (PLB) on emotional symptoms in adults with ADHD. This longitudinal multicentre RCT compared four groups (GPT+MPH, GPT+PLB, CM+MPH, and CM+PLB) over five assessment periods, from baseline to week 130. Emotional symptomatology was assessed using SCL-90-R subscales. Of the 433 randomised participants, 371 remained for final analysis. At week 13, the GPT+MPH group showed smaller reductions in anxiety symptoms than the CM groups, but the differences disappeared at subsequent assessments. Improvements in emotional symptom were significantly predicted by reductions in core ADHD symptoms in all groups except the GPT+MPH group. The unexpected lack of between-group differences may be explained by a "floor effect", different intervention settings (group vs. individual), and psychotherapy type. Multiple regression analyses suggest a more specific effect of combined interventions (GPT+MPH). Implications for clinical practice are discussed. Clinical trial registration: ISRCTN54096201 (Current Controlled Trials).

Digital Cognitive Training for Children with Attention Deficit Hyperactivity Disorder

The present article used a pilot study to determine the effectiveness of digital cognitive mindfulness training developed based on dialectical behavioral therapy (DBT) in reducing attention deficit hyperactivity disorder (ADHD) symptoms in children. The sample consisted of 90 children (8-10 years old) diagnosed with ADHD. The participants were randomized into two groups: an experimental group (n = 45) and a control group (n = 45). Results were assessed at three time points: before, after the study, and one month after the end of the study. Regarding ADHD symptoms, the ANCOVA results showed that there were no statistically significant differences between the study groups for inattention and hyperactivity/impulsivity after testing. One month after completion of the program, there was a significant alleviation in symptoms of inattention, executive functioning, learning problems, aggression, and peer relationships. Hyperactivity was the only variable that showed a decrease both post-test and during follow-up. These results suggest that a DBT-based mindfulness program is a promising method of reducing ADHD symptoms in children.

Adult ADHD Treatment Based on Combination of Dialectical Behavior Therapy (DBT) and Transcranial Direct Current Stimulation (tDCS) as Measured by Subjective and Objective Scales

Almost 30% of ADHD adults do not respond to standard pharmaceuticals. Transcranial direct current stimulation (tDCS) is a method for modulation of cortical excitability. On the other hand, dialectical behavioral therapy (DBT) is a cognitive-behavioral approach that might be utilized for adults with ADHD. The effects of integration of these interventions are only beginning to be explored. In the present work, we used both subjective and objective measures to investigate the effects of tDCS, DBT, and the integration of the two in treating adult ADHD symptoms. A total of 80 adults with ADHD (63 females, 17 males) participated in the study and were grouped into control, DBT, tDCS, and combined groups. Based on the observed results, the combination of DBT and tDCS was significantly effective in improving the mentioned variables compared to administration of each method in isolation. The results are discussed in terms of neurophysiological and psychological aspects of treatment methods.

Group-based emotion regulation skills training for adults with ADHD: A feasibility study in an outpatient psychiatric setting

The aim of this open non-controlled clinical trial was to investigate the feasibility and preliminary treatment effects of a new group-based skills training program for adult ADHD: Group Therapy for Improving Emotional Acceptance and Regulatory Skills in Adults with ADHD (GEARS). Out of the 226 allocated patients, 213 initiated the treatment and 170 (80%) were considered treatment completers (i.e., attending at least 9 out of 14 sessions). A total of 158 of the completers also completed pre- and post-treatment assessments, and 126 provided assessments at the 3-month follow-up. Treatment credibility received high ratings, as did treatment satisfaction. Preliminary treatment effects showed significant improvements in emotion regulation with large effect sizes. Significant effects were also found for all secondary outcome variables: ADHD symptom levels, depression, anxiety, and quality of life. All significant effects remained at the 3-month follow-up. In conclusion, GEARS should be considered a feasible treatment in an outpatient psychiatric setting. The results also indicate that GEARS could be an effective treatment for adults with ADHD who are also experiencing problems with emotion regulation. However, a randomized controlled trial is needed to further evaluate the effectiveness of this new treatment.

Dialectical behavioral therapy-based group treatment versus treatment as usual for adults with attention-deficit hyperactivity disorder: a multicenter randomized controlled trial

BACKGROUND

Studies on structured skills training groups have indicated beneficial, although still inconclusive, effects on core symptoms of ADHD in adults. This trial examined effects of Dialectical Behavioral Therapy-based group treatment (DBT-bGT) on the broader and clinically relevant executive functioning and emotional regulation in adults with ADHD.

METHODS

In a multicenter randomized controlled trial, adult patients with ADHD were randomly assigned to receive either weekly DBT-bGT or treatment as usual (TAU) during 14 weeks. Subsequently, participants receiving TAU were offered DBT-bGT. All were reassessed six months after ended DBT-bGT. Primary outcomes were the Behavior Rating Inventory of Executive Function (BRIEF-A) and the Difficulties in Emotion Regulation Scale (DERS). Secondary outcomes included self-reported ADHD-symptoms, depressive and anxiety symptoms, and quality of life. We used independent samples t- tests to compare the mean difference of change from pre- to post-treatment between the two treatment groups, and univariate linear models adjusting for differences between sites.

RESULTS

In total, 121 participants (68 females), mean age 37 years, from seven outpatient clinics were included, of whom 104 (86%) completed the 14-week trial. Entering the study, 63% used medication for ADHD. Compared to TAU (n = 54), patients initially completing DBT-bGT (n = 50) had a significantly larger mean reduction on the BRIEF-A (-12.8 versus -0.37, P = 0.005, effect size 0.64), and all secondary outcomes, except for symptoms of anxiety. All significant improvements persisted at 6 months follow-up. Change on DERS did not differ significantly between the groups after 14 weeks, but scores continued to decrease between end of group-treatment and follow-up.

CONCLUSIONS

This DBT-bGT was superior to TAU in reducing executive dysfunction, core symptoms of ADHD and in improving quality of life in adults with ADHD. Improvements sustained six months after ended treatment. The feasibility and results of this study provide evidence for this group treatment as a suitable non-pharmacological treatment option for adults with ADHD in ordinary clinical settings.

TRIAL REGISTRATIONS

The study was pre-registered in the ISRCTN registry (identification number ISRCTN30469893, date February 19^th 2016) and at the ClinicalTrials.gov (ID: NCT02685254, date February 18^th 2016).

Associated predictors of functional impairment among adolescents with ADHD-a cross-sectional study

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) in adolescence is associated with functional impairment in several domains of life. To enable development of interventions that more effectively target functional impairment in this age group, the associations between clinical characteristics and impairment need to be clarified. The aim of this study was to investigate the associations between ADHD and functional impairment, if they varied by sex, and the potential impact of comorbid psychiatric symptoms on the associations.

METHODS

This was a cross-sectional study including adolescents with ADHD (n = 164) and a reference group of adolescents without ADHD (n = 106). Self-ratings and parental ratings of functional impairment in different life domains were used as outcomes in all analyses. Differences between groups were investigated with comparative analyses. General linear models (GLMs) were used to explore associations between ADHD symptoms and functional impairment in adolescents with ADHD, while adjusting for of comorbid symptoms, sex, and medication.

RESULTS

Adolescents with ADHD displayed higher levels of functional impairment than peers without ADHD, and girls with ADHD rated higher impairment than their male counterparts. The combined ADHD presentation was associated with the highest levels of self-reported impairment, while parental ratings indicated comparable levels of overall impairment across presentations. In the adjusted GLMs, symptoms of inattention were strongly associated with self- and parent-rated impairment in school, but symptoms of hyperactivity/impulsivity were not, whereas symptoms of both inattention and hyperactivity/impulsivity were modestly associated with self-rated impairment with friends. Further, both emotional and conduct problems were associated with impairment in daily life.

CONCLUSIONS

Our results suggest that attention difficulties, in particular, seem to impair academic functioning in adolescents with ADHD, and interventions targeting such difficulties are warranted. In addition, comorbid symptoms need to be assessed and treated, and self-reports of functioning should be included in research and clinical practice involving adolescents.

Evaluation of a structured skills training group for adolescents with attention-deficit/hyperactivity disorder: a randomised controlled trial

Attention-deficit/hyperactivity disorder (ADHD) in adolescence is associated with behavioural, emotional and interpersonal problems, and non-pharmacological treatments targeting these difficulties have been requested. The objective of this study was to evaluate the effectiveness and acceptance of an age-adapted structured skills training group (SSTG) for adolescents with ADHD. Adolescents (n = 184, ages 15-18 years) with a diagnosis of ADHD were randomly assigned to either the SSTG, which is based on dialectical behavioural therapy, or an active control group based on psychoeducation. Symptoms of ADHD, behavioural and emotional problems, functional impairment, and health-related outcomes were assessed with self-ratings and parental ratings two weeks before, two weeks after, and six months after treatment. All participants who completed the pre-treatment measurements (n = 164) were included in the main analyses, which were conducted using a linear mixed model. Our results demonstrated no significant group differences in favour of the SSTG for any of the study outcomes. A majority of the participants in both groups reported that they had increased their knowledge about ADHD, improved their ability to manage problems related to the diagnosis, and would recommend the treatment to others. We conclude that the SSTG seems to be acceptable for adolescents with ADHD in a clinical context. However, the treatment was not proved to be more effective or more acceptable than the psychoeducational control intervention.Trial registration: http://www.isrctn.com/ISRCTN17366720,11/05/2016 , retrospectively registered.

Psychoeducational groups for adults with ADHD and their significant others (PEGASUS): A pragmatic multicenter and randomized controlled trial

Objective:

To examine the feasibility, efficacy, and effectiveness of PEGASUS, a group-based structured psychoeducation for adults with ADHD and their significant others.

Method:

A pragmatic parallel group add-on design multicenter randomized controlled trial was conducted, comparing an 8-session treatment with PEGASUS (allocated n = 97; 48 with ADHD and 49 with significant others) to treatment as usual (TAU, allocated n = 82; 39 with ADHD and 43 significant others). Participants (individuals with ADHD and significant others) were recruited from five psychiatric outpatient departments and block randomized to PEGASUS or TAU. Knowledge about ADHD was measured using the ADHD 20 scale pre- and post-intervention and served as primary outcome.

Results:

Knowledge about ADHD (d = 0.97 [95% CI: 0.61–1.31]) increased following PEGASUS participation compared to TAU. Improvements were also observed in secondary outcomes e.g. global life satisfaction (d = 0.25 [95% CI: from –0.09 to 0.59]). Overall treatment satisfaction was good. Over 90% of the participants completed the program. Post-intervention data was obtained from n = 89 in PEGASUS group and n = 70 in TAU group and analyses were conducted per protocol. No important adverse effects or side effects were observed.

Conclusions:

Group-based structured psychoeducation PEGASUS for adults with ADHD and their significant others is a feasible, efficacious, and effective treatment option to increase ADHD knowledge and general life satisfaction in psychiatric outpatient care.

Efficacy of Nonpharmacological Treatments on Comorbid Internalizing Symptoms of Adults With Attention-Deficit/Hyperactivity Disorder: A Meta-Analytic Review

Background: Attention-deficit/hyperactivity disorder (ADHD) is highly comorbid in adulthood. This meta-analysis was aimed at ascertaining the efficacy of different psychotherapies in improving comorbid internalizing symptoms in adults with ADHD. Method: Twenty randomized controlled trials and 12 uncontrolled pretest-posttest studies were included and combined using the inverse variance method. Risk of bias and heterogeneity assessment and moderator analyses were performed. Results: Cognitive-behavioral therapy (CBT) improved quality of life (QoL), emotional dysregulation (ED), depression, and anxiety symptoms, particularly at follow-up, which was predicted by core symptoms reduction. A significant between-group effect was obtained only on QoL, ED, and self-esteem for dialectical behavior therapy (DBT), mindfulness-based therapies (MBTs), and neurofeedback, respectively. Conclusion: Results support CBT efficacy for treating comorbid internalizing symptoms. More research is needed to determine the effectiveness of DBT, MBT, and neurofeedback. The small number of studies evaluating some therapies and the high risk of bias observed might limit these results.

How do adolescents with ADHD perceive and experience stress? An interview study

Background: Attention-deficit/hyperactivity disorder (ADHD) is linked to high levels of perceived stress in adult populations. Thus, it is not surprising that stress managing techniques are being included in treatment protocols for adults with ADHD. There is, however, a paucity of studies on perceived stress in adolescents with ADHD.Aims: This study aims to explore how adolescents with ADHD perceive and experience stress (and stressors) using a qualitative approach.Methods: Explorative interviews were conducted with 20 adolescents (Mean age: 16.30) diagnosed with ADHD in conjunction with group treatment therapy. Data were analysed using qualitative content analysis.Results: Stress and ADHD, as well as stress, anxiety and ill-health, were described as closely intertwined. The result is presented in four categories: stress is often present, triggers of stress, stress affects daily life, and stress can be handled and prevented. A relation was found between stress and feelings of helplessness, ill-health and anxiety. Stress was viewed as being out of proportion with reality and was driven by such factors as ADHD symptoms, school demands, unpredictable situations and relational problems. Several negative consequences of stress were reported, including postponing schoolwork and the tendency to give up. Some participants also reported performing better when stressed. Accepting help from others, practising acceptance, settling down and controlling oneself, and planning in advance were seen as helpful stress managing techniques.Conclusions: Stress should be considered among other problems related to ADHD. Psychoeducation about stress, stress managing techniques and coaching should be included in the treatment of adolescents with ADHD.

Evaluation of a structured skills training group for adolescents with attention deficit/hyperactivity disorder (ADHD) - study protocol of a randomised controlled trial

BACKGROUND

Attention deficit/hyperactivity disorder (ADHD) has a negative impact on several domains of life. However, there is a shortage of evidence-based non-pharmacological treatments for adolescents with ADHD. A structured skills training group (SSTG) based on dialectical behaviour therapy (DBT) has been used in adult patients with ADHD with some promising results, although the treatment has not yet been adapted or evaluated for adolescents with ADHD. This study protocol describes how this treatment was adapted for an adolescent population and how the efficacy of the SSTG will be evaluated using a randomised controlled trial (RCT) design.

METHODS

A sample of 184 adolescents (15-18 years of age) with a diagnosis of ADHD has been recruited from seven child and adolescent psychiatric outpatient units and randomised to either the SSTG or an active control group based on psychoeducation. Measures are conducted weekly during the treatment, as well as 2 weeks before treatment and 2 weeks and 6 months after treatment. The primary outcome measures are ADHD symptoms, functional impairment, quality of life and mindfulness. Secondary outcome measures are symptoms of comorbid psychopathology, perceived stress and sleep problems. This article describes the design, methods and analysis plan for evaluating the efficacy of the SSTG.

DISCUSSION

The study will be the first RCT to examine the acceptability and efficacy of a SSTG based on DBT adapted for adolescents with ADHD. We believe that the study will extend the current knowledge base about psychological treatment for adolescents with ADHD.

TRIAL REGISTRATION

ISRCTN registry ( ISRCTN17366720 ). Retrospectively registered May 112,016.

Behavioral and Cognitive Impacts of Mindfulness-Based Interventions on Adults with Attention-Deficit Hyperactivity Disorder: A Systematic Review

Mindfulness-based interventions (MBIs) are becoming increasingly popular as treatments for physical and psychological problems. Recently, several studies have suggested that MBIs may also be effective in reducing symptoms of attention-deficit hyperactivity disorder (ADHD). Most studies have examined the effectiveness in children, but there are now a sufficient number of individual treatment trials to consider a systematic review in adults. Majority of existing systematic reviews and meta-analyses only consider ADHD symptoms as an outcome, and most of them do not fully report potential biases of included studies, thus limiting considerably their conclusions. This is an important facet because some studies could be found ineligible to be included in future analysis due to their low quality. In this systematic review, we followed the PRISMA/PICO criteria and we thoroughly assessed the risks of bias for each of the selected studies according to Cochrane guidelines. We searched the available literature concerning MBIs in adult participants with ADHD using PsycINFO, PubMed, Scopus, and ERIC databases. In total, 13 studies conducted with 753 adults (mean age of 35.1 years) were identified as eligible. Potential moderators such as participants' age, ADHD subtypes, medication status, comorbidity, intervention length, mindfulness techniques, homework amount, and training of therapists were carefully described. Aside from measuring the symptoms of ADHD, outcome measures were categorized into executive/cognitive functioning, emotional disturbances, quality of life, mindfulness, and grade point average at school. According to presented descriptive results, all the studies (100%) showed improvement of ADHD symptoms. In addition, mindfulness meditation training improves some aspects of executive function and emotion dysregulation. Although these are promising findings to support treatment efficacy of MBIs for ADHD, various biases such as absence of randomization and lack of a control group may affect the actual clinical value and implications of the studies. Moreover, the relatively low quality of selection and performance criteria in several studies, as well as relatively high attrition bias across studies, call for caution before considering conducting further analysis.

Identifying novel applications of dialectical behavior therapy: considering emotion regulation and parenting

Dialectical behavior therapy (DBT) is an effective treatment for an increasing number of mental disorders. Its increased application to a range of disorders has been prompted by the recognition that DBT targets emotion dysregulation, which is a transdiagnostic feature underlying several forms of psychopathology. More recently, DBT has been used to target additional clinically relevant domains that are outside diagnostically bound categories, such as improving parenting quality as a means of preventing psychopathology in children of parents with psychopathology. As the ability to regulate emotions is critical to parenting, this paper uses the connection between DBT, emotion regulation, and parenting as an illustration of how focusing on mechanistic features by which DBT is effective aids in strategically identifying areas by which DBT may be a highly useful treatment option.

Long-Term Efficacy of Psychosocial Treatments for Adults With Attention-Deficit/Hyperactivity Disorder: A Meta-Analytic Review

Background: Recent evidence suggests that psychosocial treatments, particularly cognitive-behavioral therapy (CBT), are effective interventions for adult attention deficit hyperactivity disorder (ADHD). The objective of this review was to determine the long-term efficacy of psychosocial interventions in improving clinically relevant variables, including ADHD core symptoms, clinical global impression (CGI), and global functioning. Methods: In total, nine randomized controlled trials and three uncontrolled single-group pretest-posttest studies were included. The data from these studies were combined using the inverse variance method. Heterogeneity and risk of bias were assessed. Subgroup analyses and meta-regressions were performed, to determine the influence of different potential moderator variables (risk of bias, medication status, follow-up length, therapy type and setting, and control group type) on effect size (ES) estimates. Results: Up to 680 of a total of 1,073 participants assessed pre-treatment were retained at follow-up. Treatment groups showed greater improvement than control groups in self-reported total ADHD symptoms, inattention, and hyperactivity/impulsivity, in addition to CGI and global functioning. Blind assessors also reported a large ES in within-subject outcomes. Studies using dialectical behavioral therapy (DBT) in a group setting, with active control matching, and that were rated as having an unclear risk of bias, achieved significantly lower ES estimates for most outcomes. Treatment effectiveness, according to the CGI measure, and global functioning were significantly increased when the percentage of medicated participants was greater. Conclusions: Our results indicate that the post-treatment gains reported in previous reviews are sustained for at least 12 months. Nevertheless, these results must be interpreted with caution, because of a high level of heterogeneity among studies and the risk of bias observed in the majority of outcomes. Thus, these findings indicate that psychological interventions are a highly valuable and stable clinical tool for the treatment of core symptoms and global functioning in adults with ADHD.

Treatment of adult ADHD: a clinical perspective

Adult attention deficit/hyperactivity disorder (ADHD) has moved from the blurred edge of clinical focus to clear recognition as a prevalent and significant disorder in its own right. It is a relatively common comorbidity which if identified and treated may open the door to better outcomes for hard-to-treat patients. Conversely, failure to identify and treat adult ADHD is linked to negative outcomes. The recognition of the importance of adult ADHD in a subset of our patients challenges us to overcome our anxiety about this diagnosis and prevent the societal marginalization of vulnerable patients. Adult ADHD responds well to integrated pharmacological and psychotherapeutic intervention. Its treatment responsiveness reduces disability and allows the comorbidity which is typically present to be addressed. Mastering this challenge can make the diagnosis and treatment of adult ADHD a rewarding experience.