Emotion regulation involves effectively managing emotions to enable goal-directed behaviors. Many people with ADHD have deficits in regulating their emotions – difficulties identifying, modulating, and coping with strong emotions.
These regulation problems independently worsen life impairment in those with ADHD such as negatively impacting relationships, work, organization, finances, and driving. Thus targeting emotion dysregulation directly through psychological treatment could improve daily functioning.
Carroll, P., Hirvikoski, T., Lindholm, C., & Thorell, L. B. (2023). Group-based emotion regulation skills training for adults with ADHD: A feasibility study in an outpatient psychiatric setting. Applied Neuropsychology: Adult, 30(1), 71-82. https://doi.org/10.1080/23279095.2021.1910512
Key Points
- The study investigated the feasibility and preliminary effectiveness of Group Therapy for Improving Emotional Acceptance and Regulatory Skills in Adults with ADHD (GEARS), a new 14-session group therapy focused on emotion regulation deficits in adults with ADHD.
- 80% of participants completed treatment, indicating good feasibility. Large improvements were found from pre- to post-treatment in emotion regulation, psychological flexibility, ADHD symptoms, depression, anxiety, and quality of life.
- Treatment effects remained significant at 3-month follow-up. Higher homework completion was associated with greater improvements in emotion regulation and psychological flexibility.
- Limitations include the open trial design and potential sample bias. Further research via randomized controlled trial is warranted to establish efficacy.
Rationale
ADHD persisting into adulthood is associated with negative outcomes in various life domains (Kooij et al., 2019).
While psychoeducation and medication are first-line treatments, many adults continue experiencing functional impairment, underscoring the need for psychotherapy (Cortese, 2020).
Emotion dysregulation has been identified as an important underlying deficit, occurring in 30-70% of adults with ADHD (Shaw et al., 2014).
Despite evidence that medication does not sufficiently improve emotion regulation (Moukhtarian et al., 2017), existing psychological treatments have largely overlooked this aspect.
Targeting the emotion regulation difficulties specifically associated with ADHD could optimize treatment efficacy.
Group Therapy for Improving Emotional Acceptance and Regulatory Skills in Adults with ADHD (GEARS) is a new manualized group therapy developed to address the emotion regulation deficits in this population.
As a feasibility study, this research aimed to evaluate GEARS in terms of treatment completion rate, homework completion, credibility and satisfaction ratings, preliminary treatment effects on emotion regulation and secondary outcomes (e.g., ADHD symptoms), as well as durability of improvements.
Understanding the feasibility and promise of this novel treatment can inform the development of more targeted, effective interventions.
Method
GEARS (Group Therapy for Improving Emotional Acceptance and Regulatory Skills in Adults with ADHD) is a new 14-session group therapy focused specifically on improving emotion regulation deficits in adults with ADHD. Key components include:
- Skills training based in cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), and acceptance and commitment therapy (ACT) to target emotional functioning
- Psychoeducation about emotions, their functions, and strategies for improving awareness, reappraisal, acceptance, and regulation
- Mindfulness exercises, opposite action, communication tactics, and valued living components
The highly structured intervention comprises weekly 2-hour group sessions plus individual coaching sessions every other week. Homework consists mainly of practicing the regulation skills taught in sessions.
Multiple adaptations are incorporated to facilitate compliance among adults with ADHD, such as simplifying paperwork, modeling skills during sessions, and providing audio recordings of mindfulness exercises.
Assessments were conducted pre-treatment, post-treatment, and at 3-month follow-up. Outcomes included emotion regulation, psychological flexibility, ADHD symptoms, depression, anxiety, and quality of life.
Sample
The sample comprised 158 treatment completers (attended ≥9 sessions) with full pre-post data. Mean age was 34.89 years (SD=12.27) and 24.7% were male. Most had combined presentation ADHD (81.6%) and comorbid disorders (74.7%).
Statistical Analysis
Repeated measures ANOVAs analyzed pre-post treatment changes. Follow-up pairwise comparisons examined the maintenance of gains.
Between-groups t-tests compared completers and non-completers on baseline characteristics. Correlations tested the relationship between homework completion and pre-post changes in emotion regulation.
Results
The 80% treatment completion rate demonstrates good feasibility. Participants attended a mean 12 sessions and partially or fully completed most homework assignments. High ratings of treatment credibility (M=8.63-9.14 on a 0-10 scale) and satisfaction (M=3.61-3.90 on a 0-4 scale) were found.
Significant pre-post improvements with large effect sizes occurred on all emotion regulation measures: difficulties in emotion regulation (d=1.18), self-regulation of emotion (d=1.25), and use of cognitive reappraisal (d=0.59). Large gains also emerged for psychological flexibility (d=0.80).
Improvements were medium-sized for ADHD symptoms (d=0.73-0.75) and small for depression (d=0.43); moderate effects were found for anxiety (d=0.57) and quality of life (d=0.68). All treatment effects remained significant at 3-month follow-up.
Higher homework completion correlated with greater gains in emotion regulation (DERS: r = .24, p < .01) and psychological flexibility (r = .26, p < .001).
Insight
This open clinical trial provides preliminary evidence for the feasibility and promise of GEARS as a targeted group therapy for improving emotion regulation abilities in adults with ADHD.
Developing this skills-based treatment addresses an important gap, as existing interventions have overlooked emotion dysregulation despite its detrimental impact on function.
The high treatment completion rate, attendance level, homework adherence, and participant ratings signify that emotion regulation-focused group therapy is engaging, acceptable, and perceived as beneficial by adults with ADHD, lending support for feasibility in a psychiatric outpatient setting.
Critically, GEARS demonstrated efficacy specifically for its primary targets of enhancing emotion regulation capacities and psychological flexibility.
The large pre-post gains were durable over 3-month follow-up. Homework practice was directly associated with the degree of improvement. Together, these indicators of specificity substantiate the premise that directly remediating emotion regulation deficits can optimize treatment outcomes in this population.
The medium effects on broader ADHD impairment (symptoms, quality of life) offer encouraging signals about the wider benefits of ameliorating dysfunctional emotional processes.
As emotion dysregulation likely interacts with ADHD to worsen comorbid conditions like depression and anxiety, improvements here may arise indirectly from enhancing regulatory abilities.
This line of research warrants further development. While these initial findings are notable given the sample’s challenges, a randomized controlled trial is imperative to demonstrate the efficacy of GEARS above usual care or active controls.
Understanding moderators (e.g., ADHD presentation, baseline severity) can refine the intervention. In all, specialized emotion regulation treatment shows promise for more effectively assisting adults with ADHD to gain functional improvements.
Strengths
- Used thorough diagnostic process (psychiatric evaluation, interviews, cognitive testing, symptom scales, general psychopathology and substance screening)
- Stringent eligibility criteria ensured sample had clinical ADHD and moderate-severe emotion regulation issues
- Structured GEARS protocol combined evidence-based CBT, DBT, ACT components
- Comprehensive assessments pre-, post-, and follow-up with validated scales evaluating both treatment targets and functional outcomes
- Included 3-month follow-up period to evaluate durability of gains
- Analyzed multiple indicators of feasibility and acceptability from participant and therapist perspectives
- Accounted for homework completion rates in analyses
Limitations
- Lack of control condition limits causal claims about effectiveness
- Self-selected sample could be biased towards higher motivation
- Sample not fully representative of adult ADHD heterogeneity (more combined presentation, highly functioning, less comorbidity)
- Under-inclusion of men should be addressed in future studies
- Lack of blinded outcome assessors could inflate perceived benefits
- Single specialized clinic setting restricts generalizability
Implications
The high completion rates and satisfaction scores show that an emotion regulation skills group therapy is engaging and helpful for adults with ADHD who have problems managing emotions. This suggests the treatment is practical for real-world psychiatric clinics.
The large improvements specifically in emotion regulation abilities and psychological flexibility indicate the treatment successfully targeted these areas. Gains were maintained at follow-up, further supporting the benefits.
Moderate reductions in broader ADHD symptoms and improvements in quality of life imply enhancing emotion regulation capacities may also lessen other areas of impairment.
However, more research is still needed through controlled studies comparing GEARS to other treatments. This can confirm whether GEARS leads to better outcomes.
Studying whether the treatment works well for different types of ADHD presentations would expand its usefulness. Adaptations like adding smartphone support may also improve outcomes.
Overall, GEARS seems a promising therapy for improving emotion regulation difficulties in adults with ADHD. Showing proven advantages over other approaches would move towards making the treatment ready for widespread clinical use.
References
Primary reference
Carroll, P., Hirvikoski, T., Lindholm, C., & Thorell, L. B. (2023). Group-based emotion regulation skills training for adults with ADHD: A feasibility study in an outpatient psychiatric setting. Applied Neuropsychology: Adult, 30(1), 71-82. https://doi.org/10.1080/23279095.2021.1910512
Other references
Cortese, S. (2020). Pharmacologic treatment of attention deficit–hyperactivity disorder. New England Journal of Medicine, 383(11), 1050-1056. 10.1056/NEJMra1917069
Kooij, J. J. S., Bijlenga, D., Salerno, L., Jaeschke, R., Bitter, I., Balazs, J., Thome, J., Dom, G., Kasper, S., Nunes Filipe, C., Stes, S., Mohr, P., Leppämäki, S., Casas, M., Bobes, J., Mccarthy, J. M., Richarte, V., Kjems Philipsen, A., Pehlivanidis, A., … Asherson, P. (2019). Updated European Consensus Statement on diagnosis and treatment of adult ADHD. European Psychiatry, 56, 14–34.
Moukhtarian, T. R., Cooper, R. E., Vassos, E., Moran, P., & Asherson, P. (2017). Effects of stimulants and atomoxetine on emotional lability in adults: A systematic review and meta-analysis. European Psychiatry, 44, 198–207.
Shaw, P., Stringaris, A., Nigg, J. T., & Leibenluft, E. (2014). Emotion dysregulation in attention deficit hyperactivity disorder. American Journal of Psychiatry, 171(3), 276–293. https://doi.org/10.1176/appi.ajp.2013.13070966
Keep Learning
Here are some suggested Socratic questions for students to critically analyze and discuss this research paper further:
- How might someone’s gender or cultural background influence whether they would be willing to participate in group therapy focused on emotion regulation? What adaptations could make the treatment more inclusive?
- If emotion dysregulation is common across many psychiatric disorders, could GEARS potentially help patients with conditions like depression or anxiety even if they don’t have ADHD? What might this imply about the overlap between diagnoses?
- The study found that doing more homework was linked to better emotion regulation improvements. Why might practicing skills outside of sessions increase treatment benefits? What barriers might patients face applying new coping strategies to real-world situations?
