Background
The presentation of attention deficit/hyperactivity disorder (ADHD) changes across the life span, with younger children displaying more hyperactivity-impulsive behaviours and adolescents and adults exhibiting more symptoms of inattention [
1]. During adolescence, emotional lability and substance use become a growing problem, as well as comorbid mood and anxiety disorders [
1]. In addition, academic, interpersonal and social problems become more pronounced during this period of life [
2‐
4].
Given the negative impact of ADHD throughout the lifespan, it is imperative to implement treatments that are acceptable and effective for patients of different ages. For children and adolescents, non-pharmacological interventions such as psychoeducation are regarded as the first-line treatment; however, in moderate to severe cases of ADHD a combination of pharmacological and psychosocial treatment is recommended [
5,
6]. Most studies on psychosocial treatment for younger age groups with ADHD have included children or parents to children and only a paucity of studies have included adolescents with ADHD [
7]. However, because adolescence is a period marked by rapid developmental changes with an increased desire for independence and autonomy [
8], it is not evident that treatment methods directed towards children are equally feasible and effective for adolescents. Moreover, compared with children and adults with ADHD, adolescents are more likely to discontinue pharmacological treatment [
9] which further underscores the need to develop non-pharmacological treatment options for this group.
Cognitive behavioural therapy (CBT) has proven to be effective in treating children and adolescents with different psychiatric problems, e.g., anxiety and depression [
10,
11]. CBT is generally characterised by using concrete goals and individual problem analyses, with focus on how emotions, thoughts and behaviours interrelate within a certain context [
12]. A few CBT studies have been conducted in adolescents with ADHD, both delivered individually [
13,
14] and in a group setting [
15]. Preliminary findings indicate that CBT could be an effective treatment for some adolescents with ADHD, even though more studies are needed to draw any definitive conclusions.
As a further development of CBT, dialectical behaviour therapy (DBT) was originally developed for patients with borderline personality disorder (BPD) and suicidal ideation [
16] to specifically target management of interpersonal relations and emotion dysregulation. Within DBT, a strive for balance between change and acceptance within a dialectical framework is emphasised, and techniques such as mindfulness, behavioural analysis, social skills and crises management are continuously practiced in the treatment [
17]. There is symptom overlap between ADHD and BPD with difficulties in emotional regulation, impulse control, interpersonal relations, substance abuse and poor self-esteem [
18]. Given this overlap in symptoms, a structured skills training group (SSTG) with elements of DBT (as well as CBT) has been developed for adult patients with ADHD [
19]. The treatment has thus far yielded mixed results. Using an open study design, the treatment has been associated with a reduction in ADHD symptoms, functional impairment, symptoms of comorbidity and improvement in personal health [
19‐
21]. However, when using a RCT design, a reduction in ADHD symptoms, but not in symptoms of comorbidity, have been reported when compared with a loosely structured discussion group [
22]. In the largest RCT performed, only the blinded clinical global impression ratings supported SSTG to be superior to an individual clinical management [
23]. These mixed findings highlight the importance of the RCT study design. Current recommendations for first-line treatments for ADHD includes psycho-educative interventions [
6]. Therefore, psychoeducation is an appropriate control intervention for future RCT studies.
Although SSTG has not yet been adapted or evaluated regarding its efficacy for adolescents with ADHD, a small pilot study of seven adolescents with ADHD concluded that the treatment was feasible and appreciated by the participants but that the manual needed to be age-adjusted to be more optimal for adolescents [
24]. To increase the prerequisite for adolescents to be engaged in and benefit from treatments originally developed for adults it is necessary that the participants understand, perceive and relate to the content. Therefore, adaptations in the language, materials, examples and activities need to be tailored to fit the age group [
17,
25]. These adaptations may include the use of visual material [
26] to clarify the content, as well as more active and experiential exercises (e.g., role play, discussions and practising skills) to increase engagement [
17,
27]. An active approach is likely to be especially important in working with adolescents with ADHD who have difficulties maintaining concentration in teaching situations.
Aims
The study aims to investigate the efficacy of an age-adapted SSTG based on DBT for adolescents with ADHD in a clinical setting using an RCT design with an active control group based on psychoeducation. The study also aims to investigate whether subgroups (e.g., based on subtype of ADHD and symptoms of comorbidity) respond differently to the treatment, and finally, whether the SSTG is acceptable to adolescents with ADHD. We hypothesise that (i) the SSTG will result in a greater reduction of ADHD symptoms and functional impairment, and an increase in mindfulness and quality of life, than a psychoeducational group treatment, and (ii) the SSTG will lead to a greater reduction of symptoms of comorbidity, perceived stress and sleep problems compared with the psychoeducational group treatment.
Discussion
This study will be the first RCT examining the acceptability and efficacy of a SSTG based on DBT for adolescents with ADHD. Recruitment and treatment ended during 2018, the last post-treatment assessments are now being completed. Treatments based on DBT may be of value for adolescents given that the explicit focus on interpersonal relations and emotional dysregulation corresponds to issues of importance during this age [
1,
3]. Moreover, the group setting per se may be of importance during this phase of life knowing that adolescence is a time when peers’ behaviour and reasoning have a strong impact on the individual [
48]. Thus, the group setting may further reinforce the learning process.
Our study has some limitations. First, the outcome measures are based solely on parental reports and self-reports of the adolescents, which may be subject to reporting bias. Indeed, although rating scales can reliably, validly and efficiently measure DSM-based ADHD symptoms in youths [
49], to add a more objective outcome measure, such as assessment by an independent clinician, would have been preferable. Second, a rather large number of the participants (
n = 32) did not start treatment after being randomised to one of the treatment arms. This pre-treatment drop-out rate may reflect aspects such as not being assigned to the desired treatment or a lack of motivation to participate in the treatment. Given consent to participate may reflect more of an impulsive decision or a willingness to please their parents or the clinician. An attrition analysis will be conducted to further assess potential reasons for attrition and differences between completers and non-completers on the study measures. Third, although we have an active control group, the length of the treatments differs between the two treatment groups, which may have an impact on the outcome measures. More treatment sessions may have a two-fold effect: more attention from the therapist and more time together with the other participants. However, it is not evident that a longer treatment would be perceived as more positive for this group of patients in that participating in a longer treatment is a more time-consuming process. Fourth, some minor adaptations of the treatment manual for the SSTG were conducted after the first round of treatment. However, a comparison between those who received the treatment pre- and post-final adaptations will be calculated for the outcome measures.
The study has some strengths, including being an RCT with an active control setting based on psychoeducation, the recommended first-line treatment. Moreover, data are collected from two information sources, offering the therapists training and supervision and checking adherence to the method. In addition, this study will be carried out at several locations in Sweden, making the sample potentially more representative of the target population. We believe that the study will extend the current knowledge base about psychological treatment for adolescents with ADHD.
Acknowledgements
We are grateful to all adolescents and parents who participated in the study and to the child and adolescent psychiatric outpatient units for their contributions. We also thank Tanja Anca, Elina Arn, Peter Csatlos, Anna Oremark, and Sofia Lantz for their valuable contribution to the work presented in this study.