Group-Based DBT Trial for Adults with ADHD

Dialectical Behavior Therapy (DBT) is a cognitive-behavioral treatment that emphasizes building skills in mindfulness, emotional regulation, distress tolerance, and interpersonal effectiveness. Through structured individual and group sessions, DBT helps individuals identify and change problematic thoughts and behaviors.

For ADHD, DBT skills like mindfulness and organization can target inattention and impulsivity, while emotional regulation strategies address mood lability and stress management.

By teaching practical coping tools and promoting self-awareness, DBT can help adults with ADHD better manage their symptoms and improve overall functioning and quality of life.

While originally developed for borderline personality disorder, DBT’s focus on concrete skill-building and its validation-plus-change approach fit well with the challenges faced by many with ADHD.

Halmøy, A., Ring, A. E., Gjestad, R., Møller, M., Ubostad, B., Lien, T., Munkhaugen, E. K., & Fredriksen, M. (2022). Dialectical behavioral therapy-based group treatment versus treatment as usual for adults with attention-deficit hyperactivity disorder: a multicenter randomized controlled trial. Bmc Psychiatry, 22(1), 738. https://doi.org/10.1186/s12888-022-04356-6

Key Points

• This multicenter randomized controlled trial found that a 14-week dialectical behavioral therapy-based group treatment (DBT-bGT) was superior to treatment as usual (TAU) in improving self-reported executive functioning, core ADHD symptoms, and quality of life in adults with ADHD. Effect sizes were moderate to large.
• The DBT-bGT did not have a significant effect on emotional regulation immediately after treatment compared to TAU, but emotional regulation scores continued to improve at 6-month follow-up after DBT-bGT.
• Improvements from DBT-bGT were maintained 6 months after treatment. The study, while enlightening, has limitations such as lack of clinician-based outcome measures and non-standardization of the TAU control condition.
• Effective non-pharmacological treatments for ADHD in adults are important given the broad impacts of the disorder.

Rationale

Previous research has indicated potential benefits of structured skills training groups for core ADHD symptoms in adults, but evidence remains inconclusive (Bramham et al., 2009; Philipsen et al., 2007).

Adults with ADHD often experience difficulties beyond core symptoms, such as problems with executive functioning, emotional regulation, and quality of life (Newark & Stieglitz, 2010).

Dialectical behavior therapy (DBT) targets emotional regulation and executive functioning, which are important mediators of differences in adult ADHD (Halleland et al., 2019; Skirrow & Asherson, 2013), making DBT a promising approach.

A pilot study found DBT-based group treatment improved self-reported executive functioning in college students with ADHD (Fleming et al., 2015). However, the effects of DBT-based treatment on executive functioning and emotional regulation have not been thoroughly examined in larger clinical trials of adults with ADHD.

Examining these broader measures of functioning is important for capturing clinically relevant treatment effects.

This multicenter randomized controlled study aimed to evaluate the efficacy of a manualized DBT-based group treatment compared to treatment as usual on self-reported executive functioning, emotional regulation, core ADHD symptoms, mood symptoms, and quality of life in a naturalistic clinical sample of adults with ADHD.

Method

Procedure

• 121 adults with ADHD were randomly assigned 1:1 to DBT-based group treatment (DBT-bGT) or treatment as usual (TAU) for 14 weeks
• DBT-bGT consisted of weekly 2-hour group sessions following a structured manual plus individual coaching
• TAU was non-standardized and consisted of the individual’s usual care
• After the RCT phase, the TAU group was offered DBT-bGT and all participants were reassessed 6 months post-treatment

Sample

• 121 adults with ADHD, mean age 37, 56% female
• Diagnosed with ADHD according to DSM-IV criteria
• Recruited from 7 outpatient psychiatric clinics in Norway

Measures

• Behavior Rating Inventory of Executive Function-Adult Version (BRIEF-A): Assesses everyday executive functioning behaviors (inhibition, shifting, emotional control, self-monitoring, planning/organizing, working memory)
• Difficulties in Emotion Regulation Scale (DERS): Measures emotion dysregulation (nonacceptance of emotions, difficulties with goal-directed behavior, impulse control, emotional awareness/clarity, limited regulation strategies)
• Secondary outcomes: Adult ADHD Self-Report Scale (ASRS): Assesses frequency of inattentive and hyperactive-impulsive ADHD symptoms
• Beck Depression Inventory (BDI): Evaluates affective, cognitive, and somatic aspects of depression
• Beck Anxiety Inventory (BAI): Measures common cognitive and physiological symptoms of anxiety
• Adult ADHD Quality of Life Scale (AAQoL): Covers quality of life domains (life productivity, psychological health, life outlook, relationships)

Statistical Analysis

• Independent t-tests compared mean change from pre- to post-treatment between groups
• Univariate linear models controlled for site effects
• Paired t-tests and repeated measures ANOVA examined follow-up effects

Results

• DBT-bGT showed significantly greater improvements than TAU on the BRIEF-A (p=.002, d=0.64), ASRS (p<.001, d=1.01), AAQoL (p=.004, d=0.63) and BDI (p=.005, d=0.58)
• No significant difference between groups on the DERS or BAI post-treatment
• All improvements in the DBT-bGT group were maintained at 6-month follow-up
• The TAU group showed significant improvements after later receiving DBT-bGT

Insight

This study demonstrates that a structured, intensive DBT-based group treatment can lead to meaningful improvements in executive functioning, ADHD symptoms, depressive symptoms, and quality of life compared to treatment as usual for adults with ADHD.

Interestingly, while emotional regulation did not differ between groups immediately post-treatment, improvements in this domain emerged at 6-month follow-up, suggesting potential delayed or continuing effects of the DBT skills training.

The large effect on core ADHD symptoms is particularly notable given that most participants were already on stable medication treatment. This supports DBT group treatment as an effective adjunctive intervention for medicated patients with residual symptoms.

The naturalistic, multicenter design with few exclusion criteria suggests good generalizability of the findings to real-world clinical practice. Sustained effects at 6-month follow-up indicate the DBT skills may be incorporated into patients’ longer-term coping.

However, the lack of effect on anxiety symptoms suggests DBT in this format may not sufficiently address co-occurring anxiety. Longer-term follow-up would help determine if the delayed improvements in emotional regulation continue to develop.

Overall, this study provides strong evidence for DBT-based group treatment as a feasible and efficacious treatment option for adults with ADHD, addressing not only core symptoms but also the critical domains of executive and emotional functioning.

With its emphasis on skills acquisition and rehearsal, DBT appears well-suited to the learning needs of ADHD. Examining mediators and moderators of treatment response could help further refine and target the intervention.

Strengths

The study had many methodological strengths, enhancing the reliability and generalizability of the findings:

1. It utilized a randomized controlled design, the gold standard for evaluating treatment efficacy.
2. The sample size (N=121) was relatively large for a psychotherapy study, providing sufficient statistical power to detect treatment effects.
3. The multicenter design, involving 7 outpatient clinics, increased the external validity and generalizability of the results. It shows the intervention can be effectively delivered across different settings and provider teams.
4. The study included a naturalistic clinical sample of adults with ADHD, with few exclusion criteria. This suggests the findings may generalize well to typical patient populations seen in real-world practice.
5. The DBT-bGT was manual-based and adherence to the manual was monitored, ensuring consistency of the intervention delivery. Therapists also received training and ongoing supervision to maintain treatment fidelity.
6. A range of outcome measures were used, assessing not only core ADHD symptoms but also important secondary outcomes like executive functioning, emotion regulation, depressive symptoms, and quality of life. This provides a more comprehensive picture of treatment impact.
7. All participants were followed up 6 months after completing DBT-bGT, providing data on longer-term outcomes and maintenance of treatment gains. This is important given the chronic nature of ADHD.
8. Intent-to-treat analyses were used, including all randomized participants. This is a conservative approach that preserves randomization and reduces bias from selective attrition.
9. Validated and widely used assessment instruments were employed, enhancing the comparability and interpretability of the results.

Limitations

While the study had notable strengths, some limitations should be considered when interpreting the results:

1. The TAU control condition was not standardized, so there may have been heterogeneity in the treatment received by this group. It’s unclear if DBT-bGT was being compared to an active, evidence-based treatment or to minimal/no intervention. A more structured comparison group, such as a supportive therapy group, could help isolate the specific effects of DBT.
2. There was no control for non-specific group factors like peer support, which may have contributed to the treatment effects in the DBT-bGT group. An individual DBT condition could tease apart the impacts of DBT content vs. group process.
3. All outcomes were based on self-report measures, which are prone to subjective biases. The inclusion of clinician-rated measures or objective performance tasks could provide converging evidence for the treatment effects.
4. The sample was predominantly White and from a single country (Norway), limiting the generalizability to more diverse populations and healthcare systems.
5. Participants were not blinded to their treatment assignment, as is typical in psychotherapy studies. This raises the possibility of expectancy effects influencing self-reported outcomes.
6. Medication use was not tightly controlled during the study. While most participants were on stable doses, some did have medication changes, which could have impacted their symptom trajectories.
7. Longer follow-up periods beyond 6 months would be desirable to assess the durability of treatment gains, given the lifespan nature of ADHD.
8. The study did not examine potential mediators or moderators of treatment response, which could inform efforts to optimize and individualize the intervention.

These limitations suggest caution in broadly generalizing the results and point to avenues for further research to replicate and extend the findings.

Implications

The results support DBT-based group treatment as an effective adjunctive intervention for adults with ADHD, particularly for those with residual symptoms after medication treatment.

The group format offers a cost-effective way to deliver skills training and support to multiple patients. However, additional treatment may be necessary for co-occurring anxiety.

To implement DBT group treatment in real-world settings, clinician training and structural supports will be needed. Future research should explore patient and provider experiences, predictors of treatment response, and cost-effectiveness to guide implementation and optimization efforts.

Overall, this study highlights the potential of DBT as a skills-based approach to help adults better cope with ADHD symptoms and improve functioning.

With its focus on building mindfulness, emotional regulation, and interpersonal effectiveness, DBT may be uniquely suited to address the multifaceted challenges of adult ADHD.

References

Primary reference

Halmøy, A., Ring, A. E., Gjestad, R., Møller, M., Ubostad, B., Lien, T., Munkhaugen, E. K., & Fredriksen, M. (2022). Dialectical behavioral therapy-based group treatment versus treatment as usual for adults with attention-deficit hyperactivity disorder: a multicenter randomized controlled trial. Bmc Psychiatry, 22(1), 738. https://doi.org/10.1186/s12888-022-04356-6

Other references

Bramham, J., Young, S., Bickerdike, A., Spain, D., McCartan, D., & Xenitidis, K. (2009). Evaluation of group cognitive behavioral therapy for adults with ADHD. Journal of Attention Disorders, 12(5), 434-441. https://doi.org/10.1177/1087054708314596

Fleming, A. P., McMahon, R. J., Moran, L. R., Peterson, A. P., & Dreessen, A. (2015). Pilot randomized controlled trial of dialectical behavior therapy group skills training for ADHD among college students. Journal of Attention Disorders, 19(3), 260-271. https://doi.org/10.1177/1087054714535951

Halleland, H. B., Sørensen, L., Posserud, M. B., Haavik, J., & Lundervold, A. J. (2019). Occupational status is compromised in adults with ADHD and psychometrically defined executive function deficits. Journal of Attention Disorders, 23(1), 76-86. https://doi.org/10.1177/1087054714564622

Newark, P. E., & Stieglitz, R. D. (2010). Therapy-relevant factors in adult ADHD from a cognitive behavioural perspective. ADHD Attention Deficit and Hyperactivity Disorders, 2(2), 59-72. https://doi.org/10.1007/s12402-010-0023-1

Philipsen, A., Richter, H., Peters, J., Alm, B., Sobanski, E., Colla, M., Münzebrock, M., Scheel, C., Jacob, C., Perlov, E., Tebartz van Elst, L., & Hesslinger, B. (2007). Structured group psychotherapy in adults with attention deficit hyperactivity disorder. The Journal of Nervous and Mental Disease, 195(12), 1013-1019.

Skirrow, C., & Asherson, P. (2013). Emotional lability, comorbidity and impairment in adults with attention-deficit hyperactivity disorder. Journal of Affective Disorders, 147(1-3), 80-86. https://doi.org/10.1016/j.jad.2012.10.011

Keep Learning

Here are some reflective questions related to this study that could prompt further discussion:

1. Given the positive results of this study, what barriers might exist to implementing DBT-based group treatment for adult ADHD in real-world clinical settings? How could these be addressed?
2. The study found improvements in emotional regulation at 6-month follow-up but not immediately post-treatment. What are some possible explanations for this delayed effect? What implications does this have for the ideal “dose” or duration of DBT treatment for ADHD?
3. How might the group therapy format in particular contribute to the treatment effects found in this study? What unique benefits (and challenges) might a group approach offer for adults with ADHD compared to individual therapy?
4. This study included adults with ADHD who were mostly stabilized on medication already. For what kinds of adult ADHD patients would you be most likely to recommend adjunctive DBT-based group treatment? What factors would influence your clinical decision making?
5. The design of this study prioritized external validity by using a naturalistic TAU control condition. What are the pros and cons of this approach compared to a more tightly controlled comparison group? How do we balance internal and external validity in intervention research?
6. Based on the results of this study, what would you identify as the top research priorities for further developing and optimizing DBT-based treatment for adult ADHD? What specific questions remain unanswered?