Cognitive behavioural group therapy as addition to psychoeducation and pharmacological treatment for adolescents with ADHD symptoms and related impairments: a randomised controlled trial.

BACKGROUND: Cognitive behavioural therapy (CBT) is recommended for attention-deficit/hyperactivity-disorder (ADHD) in adolescents. However, all CBTs are not created equal, and the guidelines do not specify which CBT interventions are the most effective for this patient group. This study examines the efficacy of a group CBT without parent involvement as follow-up treatment compared to no additional CBT in adolescents with persistent and impairing ADHD symptoms after a short psychoeducational intervention and medical treatment. METHODS: The authors conducted a two-arm parallel randomized controlled trial in two child and adolescent mental health outpatient clinics in Norway. One hundred patients aged 14-18 years with a diagnosis of ADHD (66%) or subthreshold ADHD (34%) were randomized to either a 12-week group CBT program (N = 50) or a non-CBT control condition (N = 50). Assessments were made at admission to the clinic, two weeks before and two weeks after treatment. The primary outcomes were parent-, teacher- and self-ratings of ADHD symptoms (ADHD Rating Scale-IV), and the secondary outcomes were ratings of ADHD symptom severity, executive function, functional impairment, and emotional problems. Evaluators blinded to group allocation rated ADHD symptom severity with the Clinical Global Impression Scale for Severity (CGI-S) at baseline and post-treatment. RESULTS: Analyses using mixed-effects models showed no difference between the treatment arms from baseline to post treatment in primary and secondary outcomes. CONCLUSIONS: Contrary to our hypothesis, we found no incremental treatment effect on the part of a group CBT as follow-up to psychoeducation and pharmacological treatment on ADHD symptoms and accompanying impairments. Limitations with the CBT was the large number and low dosage of treatment components, causing restricted time for practice. Unlike evidence-based, individualized targeted CBTs with parent involvement, a group CBT directed solely at the adolescents with no parent involvement does not appear effective for treating ADHD. TRIAL REGISTRATION: NCT02937142 , 18/10/2016.

Psychometric properties of the Weiss Functional Impairment Rating Scale parent and self-reports in a Norwegian clinical sample of adolescents treated for ADHD.

OBJECTIVE: To analyze the psychometric properties of the Norwegian version of the Weiss Functional Impairment Rating Scale parent and self-reports (WFIRS-P and WFIRS-S) in adolescents with ADHD. METHODS: 102 clinically referred patients, of which 86% were enrolled in an ongoing RCT program (Clinical trials NCT02937142), were diagnosed with ADHD according to the Diagnostic and Statistical Manual of Mental Disorders version IV (DSM-IV). The conceptual framework of the WFIRS-P and the WFIRS-S was evaluated using confirmatory factor analysis (CFA), reliability was estimated using Cronbach's alpha, convergent and divergent validity was assessed using correlations with the Children's Global Assessment Scale (C-GAS) and the ADHD Rating Scale-IV (ADHD-RS-IV). RESULTS: CFA supported the original factor structure of the questionnaires, both a first-order and a second-order model revealed acceptable model fit. Internal consistency was satisfactory across domains. The parent-adolescent agreement was moderate. The correlations between the C-GAS and the total scores of the WFIRS-P and WFIRS-S were low to moderate (r = -0.29 to -0.38). The ADHD-RS-IV correlated moderately (r = 0.49) with WFIRS-P, the correlation with WFIRS-S was weak (r = 0.28) supporting divergent validity. In multiple regression analyses, the ADHD-RS total score was the strongest predictor of the total score in both the WFIRS questionnaires, with internalizing disorder showing an additional small contribution. Age, gender and full-scale IQ gave no additional contribution in explaining the variance. CONCLUSIONS: The findings support the use of the Norwegian version of the WFIRS-S and the WFIRS-P in the evaluation of functional impairment in adolescents with ADHD.

[Formula: see text] Executive function measured by BRIEF in adolescents diagnosed and treated for ADHD: problem profiles and agreement between informants.

Executive functional deficits (EFDs) play an important role in functional impairment in adolescents with attention deficit/hyperactivity disorder (ADHD). More knowledge of executive function (EF) profiles and informant discrepancies will guide clinicians and provide tailored treatment advice. The objectives of this study were to use teacher, parent, and self-reported EF ratings to describe (a) problem profiles and (b) the correlation and agreement between informants. This study included 100 adolescents aged 14-18 years with ADHD still experiencing clinically impairing symptoms despite standard treatment including medication. EFs were measured using the Behavior Rating Inventory of Executive Function (BRIEF). Agreement between informants was quantified using Pearson correlation and informant discrepancies were analyzed using paired samples t-test. Overall, the results indicated considerable EFDs in the study population. Correlation and agreement varied between the informants. Agreement was highest between adolescents and their parents, especially for female participants, and lowest between male participants and their teachers. Teachers reported the highest level of EFDs, whereas adolescents generally self-reported EFDs at a lower level than both parents and teachers. Identifying and tailoring treatment for EFDs might improve future prognosis for adolescents with ADHD, however, self-awareness of these difficulties is a challenge that needs to be considered when planning interventions.

Executive functions mediate the association between ADHD symptoms and anxiety in a clinical adolescent population.

Objective: Attention-deficit/hyperactivity disorder (ADHD) is associated with a high prevalence of anxiety disorders in children and adolescents. The reasons for this association are poorly understood. Preliminary findings with young adults have suggested that executive functions and functional impairment may mediate the relationship between symptoms of ADHD and mixed anxiety and depressive symptoms. The objective of this study was to explore whether ADHD symptoms, executive functions and functional impairment predict anxiety in a clinical adolescent population. In addition, we investigated the possible mediating role of executive functions and functional impairment in this relationship. Method: One hundred adolescents with ADHD and their parents completed the ADHD Rating Scale IV (ADHD RS-IV), the Behavior Rating Inventory of Executive Function (BRIEF), and the Weiss Functional Impairment Rating Scale (WFIRS) in relation to an RCT study. The adolescents also completed the Screen for Child Anxiety-Related Emotional Disorders (SCARED). Analyses were conducted using regression and a serial multiple mediator model. Results: In the regression analyses, parent-rated ADHD symptoms were unable to predict anxiety, but ADHD inattention symptoms predicted anxiety in the self-ratings. Executive dysfunction and functional impairment predicted anxiety in both the parent- and self-reports. In the mediation analyses ADHD symptoms alone did not predict anxiety, but executive dysfunction mediated this relationship as expected. Functional impairment mediated this relationship indirectly through executive functions. The results were similar in the parent- and self- reports. Conclusion: The results pinpoint executive dysfunction as an important treatment target for alleviating anxiety in adolescents with impairing ADHD symptoms.

Cognitive-behavioural group therapy for adolescents with ADHD: study protocol for a randomised controlled trial.

INTRODUCTION: Persistence of attention deficit hyperactivity disorder (ADHD) into adolescence is a significant burden to patients. Clinical guidelines recommend non-pharmacological therapies, but the evidence to support this recommendation is sparse. This study aims to evaluate the effect of a 12-week group cognitive-behavioural therapy (CBT) programme for adolescents with ADHD aged 14-18 years, who still have impairing symptoms after treatment with medication. We will study the effect of the treatment on ADHD symptoms and examine moderators and mediators of the effect of the treatment on ADHD. METHODS AND ANALYSIS: We conduct a randomised controlled trial of CBT group therapy in adolescents with ADHD recruited from child psychiatric outpatient units in Mid-Norway. 99 adolescents who met inclusion criteria and consented to participation have been randomised to a 12-week group intervention or to a control group receiving treatment as usual. Assessments are made at admission to the clinic, preintervention, postintervention and at a 9-month follow-up, obtaining adolescent, parent and teacher reports. Clinicians blinded to group allocation rate all participants as to their functioning preintervention and at the two postintervention assessment points. The primary outcome is change in symptom scores on the ADHD Rating Scale-IV. ETHICS AND DISSEMINATION: The Regional Committee for Medical and Health Research Ethics in South East Norway approved the study protocol (2015/2115). We will disseminate the findings in peer-reviewed publications and conference presentations, to user organisations and at courses attended by families and professionals. Two PhD students will publish and defend dissertations relating to the study. Planned publications include primary and secondary outcomes and patient satisfaction with the treatment. Furthermore, we plan to publish a manual of CBT group therapy in adolescent ADHD to benefit treatment of patients in Norway and elsewhere. TRIAL REGISTRATION NUMBER: NCT02937142.