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CBT/DBT skills training for adults with attention deficit hyperactivity disorder
(ADHD)

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Psychiatria Danubina, 2016; Vol. 28, Suppl. 1, pp 103-107 Conference paper
© Medicinska naklada - Zagreb, Croatia

CBT/DBT SKILLS TRAINING FOR ADULTS WITH ATTENTION

DEFICIT HYPERACTIVITY DISORDER (ADHD)
Pierre Cole1, Sebastien Weibel1, Rosetta Nicastro1, Roland Hasler1, Alexandre Dayer1,2,
Jean-Michel Aubry1,2, Paco Prada1 & Nader Perroud1,2
1
Service of psychiatric specialties, Department of Mental Health and Psychiatry,
University Hospitals of Geneva, Geneva, Switzerland
2
Department of Psychiatry, University of Geneva, Geneva, Switzerland

SUMMARY
Background: Attention deficit hyperactivity disorder (ADHD) is associated with marked impairments in familial, social, and
professional functioning. Although stimulant treatments can be effective in adult ADHD, some patients will respond poorly or not at
all to medication. Previous studies demonstrated that cognitive behavioural therapy- (CBT) and dialectical behavior therapy- (DBT)
oriented interventions are effective in reducing the burden of the disease, which is mainly marked by depression, interpersonal
difficulties, low self-esteem, and low quality of life. In order to determine the effectiveness of this intervention, we assessed the
benefits of a CBT/DBT programme to reduce residual symptoms and help patients improve their quality of life.
Subjects and methods: 49 ADHD-patients, poor responders to medication, were enrolled in a one-year programme where they
received individual therapy, associated with weekly sessions of group therapy with different modules: Mindfulness, Emotion
Regulation, Interpersonal Effectiveness and Distress Tolerance, Impulsivity/Hyperactivity and Attention. Each subject was assessed
at baseline, at months 3 and 6, and at the end of the treatment for ADHD severity (ASRS v1.1), depression severity (BDI-II),
hopelessness (BHS), mindfulness skills (KIMS), anger expression and control (STAXI), impulsivity (BIS-11), quality of life
(WHOQOL-BREF), and social functioning (QFS). The 49 ADHD patients were compared with 13 ADHD subjects on a waiting list.
Linear mixed models were used to measure response to treatment.
Results: Overall, the psychotherapeutic treatment was associated with significant improvements in almost all dimensions. The
most significant changes were observed for BDI-II (b=-0.30; p<0.0001), ASRS total score (b=-0.16; p<0.0001), and KIMS AwA
(b=0.21; p<0.0001), with moderate to large effect sizes. Compared with the waiting list controls, ADHD patients showed a better,
albeit non-significant, pattern of response.
Conclusions: Individual and structured psycho-educational DBT/CBT groups support existing data suggesting that a structured
psychotherapeutic approach is useful for patients who respond partially or not at all to drug therapy.
Key words: attention deficit hyperactivity disorder (ADHD) - dialectical behavior therapy (DBT) - cognitive behavioural therapy
(CBT) – mindfulness - skills training group

* * * * *

INTRODUCTION national guidelines recommend psychotherapies for

adult ADHD sufferers, whenever possible and in addi-
Attention deficit hyperactivity disorder (ADHD) is tion to the psychopharmacological treatment (National
characterized by difficulties in sustaining attention, and Collaborating Centre for Mental Health 2009). For this
by impulsiveness and hyperactivity, leading to poor purpose, several psychotherapeutic treatments for adult
outcomes and impairments in professional, familial, and ADHD have been developed. The ones that have given
social functioning (Bush et al. 2010). ADHD is asso- rise to the greatest interest are individual or group cog-
ciated with reduced life expectancy and significant nitive behavioural therapy- (CBT) oriented programmes,
morbidity (Dalsgaard et al. 2015). which have been shown to be efficient in reducing
Despite being effective in reducing ADHD symp- ADHD symptoms, with medium to high effect sizes
toms in adults, many patients will still respond poorly (Stevenson 2003, Safren et al. 2010). More recently,
or not at all to medication. In addition, some of them mindfulness-based programmes and dialectical beha-
refuse to take psycho-pharmaceutical agents and other vior therapy- (DBT) based programmes have been
approaches are required (Wigal et al. 2009). Even for developed for adults suffering from ADHD, with
ADHD patients whose symptoms are in remission, effect sizes comparable to the ones found for CBT
having to cope with problems that have accumulated programmes (Philippsen et al. 2007, Hirvikoski et al.
over the years and affect parts of their social, family, 2011, Mitchell et al. 2013, Edel et al. 2014, Shoenberg
and professional lives can be problematic. Therefore, et al. 2014, Hepark et al. 2014, Bueno et al. 2015,
helping ADHD patients cope with dysfunctional beha- Jansen et al. 2015, Fleming et al. 2015). Initially
viours and teaching them new skills and strategies to designed for borderline personality disorder, DBT
manage their lives is as important as psychopharma- include an individual therapy and a skills training
cological interventions. In this perspective, most inter- group that features four modules aimed at balancing

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 Pierre Cole, Sebastien Weibel, Rosetta Nicastro, Roland Hasler, Alexandre Dayer, Jean-Michel Aubry, Paco Prada & Nader Perroud:
CBT/DBT SKILLS TRAINING FOR ADULTS WITH ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)
Psychiatria Danubina, 2016; Vol. 28, Suppl. 1, pp 103-107

change-oriented skills (interpersonal effectiveness and weekly individual psychotherapy sessions and group
emotion regulation) and acceptance-based skills sessions (Perroud et al. 2015). To the four traditional
(mindfulness and distress tolerance). Since difficulties DBT modules (Mindfulness, Emotion Regulation, Inter-
in emotional regulation, impulsivity and interpersonal personal Effectiveness, and Distress Tolerance), we
relationships are shared by ADHD and borderline per- added two modules inspired from CBT interventions
sonality disorder, adapted DBT skills training groups (Impulsivity/Hyperactivity and Attention). The treatment
with additional CBT modules have been developed for was given over a 12-month period. Homework assign-
adult ADHD (Perroud et al. 2015, Philipsen et al. ments are given to the participants. The first hour of the
2015). The fact that mindfulness and emotion regu- group session is dedicated to reviewing the homework
lation are given more weight in DBT than in other given at the end of the previous session. Participants are
traditional CBT programmes is believed to better help encouraged to participate and share their difficulties or
patients cope with dimensions such as emotion strategies with the group. The second hour of the group
dysregulation, which is believed to be as important as session is dedicated to psycho-education and mindful-
attention deficit and/or hyperactive/impulsive symp- ness training. Weekly individual sessions aim at helping
toms in ADHD. Previous studies (Philipsen et al. 2007, patients generalize acquired skills outside the sessions
Hirvikoski et al. 2011, Edel et al. 2014, Philipsen et al. and reviewing tasks that were given in group sessions.
2014, Fleming et al. 2015) have indeed shown that Whether in individual therapy or in group skills
besides reducing core ADHD symptoms, such as training, the search for balance between acceptance and
attention deficit and impulsivity, CBT- and DBT- change is always the preferred objective of our thera-
oriented interventions and mindfulness-based pro- peutic strategies. The therapists are nurses, psycholo-
grammes are also effective in reducing the burden of gists or psychiatrists, all trained in DBT and CBT. All
the disease, which includes depression, anxiety, inter- of them attended weekly team meetings to discuss the
personal difficulties, low self-esteem, and low quality evolution of patients and difficulties encountered during
of life and functioning. The most effective treatments group and individual sessions. Furthermore, these
are those given to medicated patients in highly struc- weekly consultation meetings help ensure adherence to
tured and manual-based programmes comprising skills treatment by the therapists. Each subject was assessed at
training that teaches patients to use specific skills to baseline, at months 3 and 6, and at the end of treatment
alleviate ADHD difficulties affecting organization, for ADHD severity (ASRS v1.1), depression severity
planning, motivation, and emotion, and to help them (BDI-II), hopelessness (BHS), mindfulness skills
use these skills outside sessions. Based on these obser- (KIMS), and anger expression and control (STAXI).
vations, the aim of our study was to assess the The control group included 13 ADHD patients (38.9
effectiveness of an adapted DBT/CBT skills training age, DS =13.47, 6 women; 46.1%) registered on a
group for adult ADHD sufferers who are poor or par- waiting list. Patients on the waiting list had a monthly
tial responders to medication (Perroud et al. 2015). medical follow-up to assess the evolution of symptoms
and their response to treatment. No specific psycho-
SUBJECTS AND METHODS therapeutic interventions were provided and only some
elements of ADHD-oriented psycho-education were
For the purpose of this study, we recruited patients given to the patients. Waiting list controls were assessed
suffering from ADHD who are being treated in our at baseline and at the one-year follow-up. The study was
specialized centre for the treatment of adult ADHD. The approved by the Ethical Committee of the University
diagnosis was established according to DSM-V criteria Hospitals of Geneva and complies with the Helsinki
by trained psychiatrists and based on a semi-structured Declaration.
interview (DIVA 2.0). It also included a detailed
investigation of childhood ADHD and its persistence Statistical Analyses
into adulthood (Kooij et al. 2008). 49 ADHD patients Linear mixed models with fixed treatment time
(36.6 age, DS =10.02, 23 women; 46.9%), following a effect and random individual effect, fitted with maxi-
pharmacological treatment or not, were enrolled in the mum likelihood, as described previously (Uher et al.
psychotherapeutic programme of our study. Patients 2009), were used to measure response to treatment
were referred to psychotherapeutic interventions if they among ADHD patients following psychotherapeutic
were found to be poor responders to medication (resi- group sessions and individual skills training. These
dual symptoms despite appropriate dosage of medica- models, refitted with additional fixed effects of gender,
tion) or if they failed to respond altogether (non-res- age and baseline levels of each of the scales used to
ponse despite high dosage of medication (>100mg of assess response to treatment, were then used to compare
equivalent of methylphenidate) or if the patient suffered ADHD patients undergoing the psychotherapeutic
from side-effects preventing him/her from taking the intervention with ADHD patients on the waiting list,
medication). As described previously, patients followed and to analyse predictors of response.

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 Pierre Cole, Sebastien Weibel, Rosetta Nicastro, Roland Hasler, Alexandre Dayer, Jean-Michel Aubry, Paco Prada & Nader Perroud:
CBT/DBT SKILLS TRAINING FOR ADULTS WITH ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)
Psychiatria Danubina, 2016; Vol. 28, Suppl. 1, pp 103-107

Table 1. Comparing ADHD treated versus waiting list control

ADHD treated ADHD waiting list controls
Mean SD Mean SD b p
Age 36.61 10.02 38.92 13.47 -0.21 0.495
Years of education 15.27 3.08 17.00 2.92 -0.56 0.084
N % N %
2 p
Gender (female) 23 46.94 6 46.15 0.01 0.960
Attentional 11 22.45 8 61.54
ADHD type Hyp./Impul. 2 4.08 0 0.00 7.56 0.023
Combined 36 73.47 5 38.46
Currently working (YES) 27 55.10 11 84.62 3.77 0.052
Married or living in couple (YES) 23 46.94 6 46.15 0.01 0.960
Pharmacological treatment for ADHD 30 61.22 10 76.92 1.11 0.293
Other pharmacological treatment
12 24.49 4 30.77 9.18 0.002
(benzo.; antid.; antipsych.; mood stab.)
Current psychiatric comorbidity
23 46.94 8 61.54 0.87 0.349
(MDD; BD; Anx. Dis.; Subst. Use Dis.; BPD)

Evolution of scores for ASRS attentional, ASRS total score, KIMS Des., KIMS Obs., and STAXI anger in for controls
(ADHD in waiting list) and treated ADHD subjects. Bars=Standard Deviation
Figure 1. Evolution ADHD treated versus waiting list control

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 Pierre Cole, Sebastien Weibel, Rosetta Nicastro, Roland Hasler, Alexandre Dayer, Jean-Michel Aubry, Paco Prada & Nader Perroud:
CBT/DBT SKILLS TRAINING FOR ADULTS WITH ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)
Psychiatria Danubina, 2016; Vol. 28, Suppl. 1, pp 103-107

RESULTS anger (b=0.41; p<0.0001); a higher baseline STAXI

anger in score (b=0.34; p=0.001); a higher baseline
Controls were more likely to be sufferers of ADHD STAXI anger out score (b=0.38; p=0.003); and a higher
attention type than participants undergoing the psycho- level of education (b=-0.23; p=0.05).
therapeutic treatment. They were also more likely to
receive other pharmacological treatments, such as DISCUSSION
benzodiazepine; antidepressants; antipsychotics and/or
mood stabilizers. At baseline, controls and treated The results of this study are consistent with the lite-
patients did not differ in any of the other clinical and rature on the subject and show a positive impact of struc-
demographic characteristics. 7 of the ADHD patients tured skills training on ADHD symptomatology, depres-
following the psychotherapeutic treatment dropped out sion, hopelessness, and anger expression, with roughly
during the one-year programme (14.29%). None of the medium to large effect sizes in a group of adult ADHD
clinical and demographic baseline characteristics were patients (Philipsen et al. 2007, Mitchell et al. 2013,
associated with dropping-out (Table 1). Bueno et al. 2015). The low rate of drop-out emphasizes
the patients’ interest for, and satisfaction with, this kind
Response to treatment of structured programme. This programme addresses the
growing expectation of patients that a structured pro-
Overall, the psychotherapeutic treatment was associa-
gramme will help improve ADHD symptoms and the
ted with significant improvements in all the dimensions,
associated disease. The effectiveness of this skills training
expect for KIMS Obs. (b=0.02; p=0.628) and STAXI
programme in a population of adult ADHD sufferers
angerout (b=-0.09; p=0.069). The most significant
might be explained by its focus on emotion regulation
changes over time were observed for BDI-II (b=-0.30;
and mindfulness skills, indirectly highlighted by the im-
p<0.0001), with a large effect size (Cohen’s d =-0.85),
provement on STAXI subscales, with better anger control
followed by ASRS total score (b=-0.16; p<0.0001) and
and expression among ADHD subjects after the one-year
KIMS AwA (b=0.21; p<0.0001), with intermediate effect
intervention and with improved mindfulness skills, as
sizes (Cohen’s d =-0.63 and 0.61 respectively). Other
shown by the evolution of the KIMS score. As in pre-
variables showing intermediate effect sizes were BHS
vious studies (Philipsen et al. 2007, Hirvikoski et al. 2011,
(b=-0.15; p=0.01; Cohen’s d=-0.52), ASRS attentional
Edel et al. 2014, Philipsen et al. 2014, Fleming et al.
(b=-0.16; p=0.0001; Cohen’s d=-0.59) and ASRS
2015), improving these parameters has a positive effect
hyp./imp. (b=-0.13; p=0.0002; Cohen’s d=-0.46). Overall
on the ADHD symptoms. Further supporting the relevan-
during the year spent on the waiting list, controls suffe-
ce of our psychotherapeutic intervention for adult ADHD
red a worsening of their attentional symptoms as measu-
is the fact that patients on a waiting list tend to worsen
red by the ASRS v1.1, with a large effect size (b=0.32;
their ADHD symptoms (increase of ASRS scores), both
p=0.031; Cohen’s d=1.58), of their hyperactive/impul-
on the attentional and hyperactive/impulsive dimensions.
sive symptoms, with a large effect size (b=0.32;
This suggests that monthly assessments of adult ADHD
p=0.042; Cohen’s d=1.17), and of their ASRS total
sufferers who respond poorly to pharmaceutical agents
score (b=0.36; p=0.03; Cohen’s d=1.52). They showed a
are insufficient (National Collaborating centre for mental
decrease in KIMS Obs (b=-0.18; p=0.015; Cohen’s
health 2009). This study has limitations, the main one
d=-0.58), but paradoxically reported a significant
being the small sample size, especially for the waiting-list
increase in KIMS AwA (b=0.27; p<0.0001; Cohen’s
controls; it might help explain the absence of significant
d=1.24). Finally their control of anger worsened, with
differences between the groups. We are therefore unable
an intermediate effect size (b=-0.15; p=0.014; Cohen’s
to exclude the idea that observed improvements in ADHD
d=-0.60). Comparing the two groups for evolution
patients undergoing the psychotherapeutic intervention
during follow-up, no significant differences emerged in
can be better explained by a phenomenon such as regres-
terms of response to treatment. Some small to moderate
sion to the mean. Nevertheless, our results are in line with
effect sizes, specifically for ASRS attentional, ASRS
previous studies in the field. Furthermore, the fact that
total score, KIMS Obs, KIMS Des and STAXI anger in
controls worsen on most of the assessed dimensions
should also be mentioned here (Figure 1).
during the year spent on the waiting list supports the idea
that our approach is a useful intervention for adult
Predictors of treatment response ADHD. In addition, patients were only monitored over a
Considering level of depression measured by the one-year period, and we cannot state whether our
BDI-II as the dependent variable indicative of treatment intervention is associated with a long-term improvement
response, good response to treatment was associated, of ADHD symptoms. Finally, this study was a non-
unsurprisingly, with a higher baseline level of dep- randomized study on a small sample of patients. The
ression (b=0.81; p<0.0001); a higher baseline severity design of the study probably leads to a recruitment bias
of ADHD (b=0.35; p=0.012); a higher level of among patients enrolled in the programme or placed on
hopelessness (b=0.59;p<0.0001); a poor baseline KIMS the waiting list. Further studies are clearly needed in this
AWJ (b=-0.39; p=0.002); a higher baseline level of state field in order to answer these questions.

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 Pierre Cole, Sebastien Weibel, Rosetta Nicastro, Roland Hasler, Alexandre Dayer, Jean-Michel Aubry, Paco Prada & Nader Perroud:
CBT/DBT SKILLS TRAINING FOR ADULTS WITH ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)
Psychiatria Danubina, 2016; Vol. 28, Suppl. 1, pp 103-107

CONCLUSIONS 10. Hirvikoski T, Waaler E & Alfredsson J: Reduced ADHD

symptoms in adults with ADHD after structured skills
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Correspondence:
Pierre Cole, MD
TRE Program, Service of Psychiatric Specialties,
Department of Mental Health and Psychiatry, University Hospital of Geneva
20bis rue de Lausanne, 1201, Geneva, Switzerland
E-mail: [email protected]

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