535951
research-article2014
JADXXX10.1177/1087054714535951Journal of Attention DisordersFleming et al.
From Theory to Practice
Pilot Randomized Controlled Trial of Dialectical Behavior Therapy Group Skills Training for ADHD Among College Students
Journal of Attention Disorders 2015, Vol. 19(3) 260–271 © 2014 SAGE Publications Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1087054714535951 jad.sagepub.com
Andrew P. Fleming1, Robert J. McMahon2,3, Lyndsey R. Moran1, A. Paige Peterson1, and Anthony Dreessen1
Abstract Objective: ADHD affects between 2% and 8% of college students and is associated with broad functional impairment. No prior randomized controlled trials with this population have been published. The present study is a pilot randomized controlled trial evaluating dialectical behavior therapy (DBT) group skills training adapted for college students with ADHD. Method: Thirty-three undergraduates with ADHD between ages 18 and 24 were randomized to receive either DBT group skills training or skills handouts during an 8-week intervention phase. ADHD symptoms, executive functioning (EF), and related outcomes were assessed at baseline, post-treatment, and 3-month follow-up. Results: Participants receiving DBT group skills training showed greater treatment response rates (59-65% vs. 19-25%) and clinical recovery rates (5359% vs. 6-13%) on ADHD symptoms and EF, and greater improvements in quality of life. Conclusion: DBT group skills training may be efficacious, acceptable, and feasible for treating ADHD among college students. A larger randomized trial is needed for further evaluation. (J. of Att. Dis. 2015; 19(3) 260-271) Keywords adult ADHD treatment, college students, dialectical behavior therapy, mindfulness, executive functioning ADHD persists into adulthood in up to 80% of individuals diagnosed as children (Barkley, Murphy, & Fischer, 2007). Between 2% and 8% of college students meet criteria for ADHD (DuPaul, Weyandt, O’Dell, & Varejao, 2009). Compared with their undergraduate peers without ADHD, students with ADHD tend to have lower grade point averages (GPAs; Heiligenstein, Guenther, Levy, Savino, & Fulwiler, 1999) and graduation rates (Wolf, 2001); higher rates of academic probation (Frazier, Youngstrom, Glutting, & Watkins, 2007), depressive symptoms (Rabiner, Anastopoulos, Costello, Hoyle, & Swartzwelder, 2008), tobacco use and dangerous alcohol use (Rooney, ChronisTuscano, & Yoon, 2012), and overall psychological distress (Richards, Rosen, & Ramirez, 1999); and poorer self-reported quality of life (e.g., Blase et al., 2009). Despite the broad impairment associated with ADHD in college, very little treatment research has been conducted with this population. Two uncontrolled studies have described educational coaching interventions (Allsopp, Minskoff, & Bolt, 2005; Zwart & Kallemeyn, 2001). One recent placebo-controlled crossover study showed initial efficacy of stimulant medication, yet also highlighted the need for psychosocial intervention to address residual
impairment among responders as well as non-responders to stimulants (DuPaul et al., 2012). There are no known randomized treatment trials for college students with ADHD. A comprehensive review of ADHD symptomatology among college students has described the urgent need for treatment development research with this population (Weyandt & DuPaul, 2008). Given that no randomized trials have been conducted with this population, a pilot randomized controlled trial is needed to further advance Stage I treatment development (Rounsaville, Carroll, & Onken, 2001). Intervention research for adults with ADHD provides useful guidance in developing a treatment for college students with ADHD. Cognitive-behavioral therapy (CBT) interventions for adults with ADHD have shown efficacy in 1
University of Washington, Seattle, USA Simon Fraser University, Burnaby, British Columbia, Canada 3 Child & Family Research Institute, Vancouver, British Columbia, Canada 2
Corresponding Author: Andrew P. Fleming, Department of Psychiatry and Behavioral Sciences, University of Washington, 325 Ninth Ave., Box 359960, Seattle, WA 98104, USA. Email: [email protected]
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Fleming et al. a small number of randomized trials (Knouse, CooperVince, Sprich, & Safren, 2008). Both individual- (Safren et al., 2005; Safren et al., 2010) and group-based (Solanto et al., 2010) CBT reduced ADHD symptoms and functional impairment in well-controlled studies. These interventions follow a similar treatment model of 8 to 16 weekly sessions (1-2 hr each) including standard CBT components such as psychoeducation, behavioral skills training, and cognitive restructuring. In addition, mindfulness training and practice have been shown in one short-term study (Tang et al., 2007) to improve attention and self-regulation among undergraduate students. One open trial of an 8-week mindfulness training intervention for adolescents and adults with ADHD showed pre-/post-treatment improvements in ADHD symptoms and attention performance (Zylowska et al., 2008). Dialectical behavior therapy (DBT; Linehan, 1993a) was initially demonstrated to be effective in treating chronic suicidal behavior and borderline personality disorder (BPD); however, it has also shown efficacy in treating a broader range of disorders characterized by dysregulated emotions and behavior, including substance abuse disorders and eating disorders (Dimeff & Koerner, 2007). BPD and ADHD share several common behavioral elements (e.g., impulsivity, emotion dysregulation; Philipsen, 2006), and initial pilot data suggest that DBT group skills training may be efficacious in treating adults with ADHD (Philipsen et al., 2007). DBT was designed to flexibly incorporate cognitivebehavioral strategies and mindfulness/acceptance strategies, and therefore provides a natural synthesis of two broader lines of treatment research for adults with ADHD. Thus, to address this gap in evidence-based treatment for ADHD, the present study was designed as a Stage I pilot trial to provide an initial evaluation of the efficacy, acceptability, and feasibility of DBT group skills training targeted to reduce symptoms and impairment associated with ADHD among college students.
Method Thirty-three undergraduate students who met revised criteria for ADHD in adulthood (see below) and were seeking treatment were recruited from three universities (one public, two private) in a large city in the Pacific Northwest. Participants were stratified by a median split on ADHD inattentive symptoms and randomly assigned to receive either DBT group skills training or self-guided skills training handouts. Participants were assessed before treatment, after treatment, and 3 months after treatment, corresponding to the beginning and end of the academic quarter in which treatment was received, and the end of the following academic quarter. The study was approved by the University of Washington Institutional Review Board. Participants were required to be currently enrolled undergraduate students between the ages of 18 and 24, and
to meet Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-V; American Psychiatric Association, 2013) criteria for ADHD in adulthood, including symptom onset by age 12 and functional impairment in multiple domains. Because study enrollment was conducted prior to finalization of changes in DSM-V symptom thresholds for ADHD in adults, at least four (rather than five) symptom criteria were required in one domain, as recommended by Barkley (2011); two participants did not meet full DSM-V criteria (see Results). Exclusion criteria were as follows: current substance abuse/dependence, active suicidality, major depressive episode, and history of psychotic disorder, bipolar disorder, or pervasive developmental disorder. Individuals receiving psychotropic medication for ADHD must have maintained a stable medication and dose for 1 month prior to enrollment. Baseline variables by treatment condition are shown in Table 1. Figure 1 summarizes the flow of participants through the study. Participants were randomly assigned to treatment condition and were assessed at pre-treatment, post-treatment, and 3-month follow-up by an interviewer who was blind to participant condition.
Measures ADHD symptoms—Barkley Adult ADHD Rating Scale–IV (BAARS-IV). This 18-item questionnaire assesses the DSM-V criteria for ADHD, with clinical response and recovery cutoffs derived from population-based norms. The BAARS-IV (Barkley, 2011) shows adequate internal consistency and test–retest reliability, and strong construct validity and discriminant validity. Self-report of current symptoms was used as a primary outcome measure; self- and parent-report of childhood symptoms were used in eligibility screening. Executive functioning (EF)—Brown ADD Rating Scales (BADDS). This 40-item self-report questionnaire (Brown, 1996) yields T scores for five empirically derived clusters of EF (i.e., organization and prioritization, focused and sustained attention, regulation of alertness and sustained effort, affect modulation, and working memory), as well as a composite (total) index. The measure has been shown to have good internal consistency, test–retest reliability, construct validity, and discriminant validity, and includes cutoff scores for treatment response and recovery. Quality of life—ADHD Quality of Life Questionnaire (AAQoL). This 29-item self-report questionnaire assesses functioning and quality of life in four domains often affected by ADHD symptoms in adults: life productivity, psychological health, relationships, and life outlook. Subscale and overall scores are calculated on a 0-100 scale. The AAQoL (Brod, Johnston, Able, & Swindle, 2006) shows good internal consistency and construct validity.
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Table 1. Demographic and Clinical Characteristics of Intent-to-Treat Sample (N = 33). Dialectical behavior therapy (n = 17) Characteristic Sex Female Male Race White Latino Asian Black Multi-racial/Other University Public Private ADHD presentation Inattentive (four symptoms only) Inattentive (standard DSM-V) Combined (standard DSM-V) Psychopharmacological medication Methylphenidate only Amphetamine only Methylphenidate and SSRIa Amphetamine and SSRIb SSRI onlyc None Age (years) KBIT-2 Verbal IQ WAIS-IV Digit Span WRAML-2 Finger Windows Barkley Adult ADHD Rating Scale–4th edition Inattentive subscale Hyperactive subscale Impulsive subscale Brown ADD Scales Barkley Functional Impairment Scaled Beck Anxiety Inventory Beck Depression Inventory–2nd edition Adult ADHD Quality of Life Questionnaire
Skills handouts (n = 16)
N
%
N
%
7 10
41.2 58.8
7 9
43.8 56.2
11 3 1 0 2
64.7 17.7 5.9 0.0 11.8
8 2 1 1 4
50.0 12.5 6.3 6.3 25.0
12 5
70.6 29.4
12 4
75.0 25.0
1 15 1
5.9 88.2 5.9
1 11 4
5.9 68.8 25.0
5 5 1 0 1 5
29.4 29.4 5.9 0.0 5.9 29.4
3 8 1 1 0 3
18.8 50.0 5.9 5.9 0.0 18.8
M
SD
M
SD
21.20 108.94 10.06 8.24
1.67 10.96 2.22 1.75
21.50 111.06 10.31 7.94
1.12 16.83 2.24 2.32
26.59 11.24 8.41 80.59 4.29 14.18 10.65
3.71 2.51 2.53 19.24 1.51 13.69 7.86
26.25 11.50 9.12 77.31 4.24 15.25 13.56
2.75 3.74 2.45 17.43 1.56 8.93 8.26
55.98
11.51
51.35
12.99
Note. DSM-V = Diagnostic and Statistical Manual of Mental Disorders (5th ed.; American Psychiatric Association); SSRI = selective serotonin reuptake inhibitor; KBIT-2 = Kaufman Brief Intelligence Test–2nd Edition; WAIS-IV = Wechsler Adult Intelligence Scale–IV; WRAML = Wide Range Assessment of Memory and Learning; ADD = attention-deficit disorder. a Citalopram (n = 1); sertraline (n = 1). b Fluoxetine (n = 1). c Sertraline (n = 1). d Average functional impairment score.
Anxiety and depressive symptoms—Beck Anxiety Inventory (BAI) and Beck Depression Inventory-2nd edition (BDI2). These 21-item self-report measures (BAI; Beck, Epstein, Brown, & Steer, 1988; BDI-2; Beck, Steer, &
Brown, 1996) are widely used in clinical research and have strong reliability and validity. Both yield summed total scores that may be categorized by level of impairment.
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Fleming et al.
73 Assessed for eligibility
38 Excluded 28 Did not meet inclusion criteria 11 Age ≥ 25 years 6 History of PDD or Bipolar Disorder 4 Did not meet criteria for ADHD 3 Current major depressive episode 2 Recent ADHD medication change 2 Not currently enrolled undergraduate student 10 Declined to participate
35 Randomized
19 Randomized to group skills training 17 Received intervention 2 Could not participate due to scheduling constraints
16 Randomized to skills handouts 16 Received intervention
Post-treatment Assessment 16 Completed assessment 1 Was not retained for assessment
Post-treatment Assessment 16 Completed assessment
3-month Follow-up Assessment 16 Completed assessment 1 Was not retained for assessment
3-month Follow-up Assessment 16 Completed assessment
17 Included in analysis
16 Included in analysis
Figure 1. Flow of participants from randomization through analysis. Note. PDD = pervasive developmental disorder.
Academic performance. GPA from the academic quarter immediately prior to each assessment point was collected via official transcript. The following secondary outcome measures were also administered at each assessment: Mindfulness—Five Facet Mindfulness Questionnaire (FFMQ). This 39-item self-report questionnaire (Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006) assesses five clusters of behaviors representing a general tendency to be mindful in daily life. The five factors show adequate-togood internal consistency and strong construct validity. Neuropsychological performance—Conners’ Continuous Performance Test–2nd edition (CPT-2). This standardized computeradministered test presents single letters on a screen at varying rates for a total of 15 min. Participants are instructed to press a button in response to every letter except the target letter (“X”). The CPT-2 (Conners, 2000) provides total scores, T scores, and percentile ranks for omission errors,
commission errors, reaction time variability, as well as other measures. As in several previous studies (e.g., Murphy, Barkley, & Bush, 2001; Nigg, Willcutt, Doyle, & Sonuga-Barke, 2005), omission errors, commission errors, and reaction time standard error were used to assess response sustained attention, inhibition, and response variability, respectively. Participants also provided quantitative and qualitative reports of treatment acceptability.
Interventions The experimental intervention was delivered according to the DBT group skills training format (Linehan, 1993b). Given the behavioral targets most relevant to ADHD in adults (Barkley et al., 2007), and the unique developmental and environmental context of ADHD in college (Fleming & McMahon, 2012), the DBT skills taught in this intervention were adjusted from standard DBT (see Figure 2 for intervention content by session). The intervention included a
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Session 1
Group orientation and goal-setting Psychoeducation; Mindfulness
Session 2
Daily planner use Chunking tasks and prioritization
Session 3
Structuring environment Using social support
Session 4
Managing sleep, eating, and exercise
Session 5
Generalizing and troubleshooting skills use
Session 6
Emotion regulation (e.g., opposite action)
Session 7
Generalizing and troubleshooting skills use
Session 8
Review of skills Plan for high-demand period
Session 9a
Review of skills Plan for maintaining skills use
Figure 2. Dialectical behavior therapy intervention content by session. a
Booster session delivered in Week 1 of the following academic quarter.
15-min individual pre-group meeting focused on motivation enhancement, eight weekly 90-min group sessions focused on skills acquisition and strengthening, and seven weekly 10- to 15-min individual coaching phone calls focused on skills generalization. A 90-min booster group session was held during the first week of the follow-up quarter to promote maintenance of skills use. Treatment sessions were conducted at an on-campus outpatient psychology clinic. The intervention was delivered by a group leader (A.P.F.) and co-leader (L.R.M.) who were both advanced graduate students in child clinical psychology. Both therapists had received intensive training in DBT and were current members of a DBT consultation team led by Dr. Marsha Linehan. Intervention was supervised by a licensed psychologist with experience in assessment and treatment of college students with ADHD. Participants in the skills handouts (SH) comparison treatment condition received 34 pages of SH, drawn from a manual for treatment of adults with ADHD (Tuckman, 2007) and designed to reflect publicly available self-help materials for ADHD. Topics included the following: (a) psychoeducation about ADHD and EF, (b) organization, (c) planning, (d) time management, (e) structuring environment, and (f) stress management.
Data Analysis The two treatment groups were compared on baseline variables using independent samples t tests for continuous data and chi-square tests for categorical data. Linear regressions were conducted to explore potential baseline predictors of
change. Univariate repeated-measures analysis of variance (RM ANOVA; Winer, 1971) with Greenhouse–Geisser correction (Greenhouse & Geisser, 1959) was used to compare overall relative change in outcome variables between the two treatment conditions. Response and recovery analyses were conducted using chi-square tests. Response was defined using the Reliable Change Index (RCI; Jacobson & Truax, 1991). Recovery was defined as both reliable change (i.e., response) and reduction of symptoms below the 93rd percentile (BAARS-IV) or 96th percentile (BADDS), as prescribed by each measure. Data were analyzed using SPSS Version 19 (SPSS Inc, 2010).
Results The intent-to-treat sample included 17 and 16 participants DBT group skills training and self-guided SH, respectively. One participant dropped out of DBT after four sessions and did not complete the post-treatment or follow-up assessments; all other participants completed treatment and the three study assessments. Missing data from this participant were imputed conservatively using the last observation carried forward (LOCF) method (Fayers, Curran, & Machin, 1998). Two participants receiving DBT and one receiving SH had substantial ADHD medication changes during the study (>25% change in dose or change in medication type). One participant in each treatment condition met four (rather than five) ADHD inattentive symptom criteria. All analyses were conducted with and without medication changes, and with and without participants who did not meet full DSM-V criteria. The pattern of results did not differ; thus, results from the full intent-to-treat sample are reported. No differences were found between the treatment groups on any variable at baseline (all ps > .10). Baseline demographic and primary clinical variables are displayed in Table 1. Primary outcome data and results from the RM ANOVAs are summarized in Table 2, along with withinand between-groups mean change scores and effect sizes of mean change scores. Treatment response and recovery rates by condition are displayed in Table 3.
ADHD Inattentive Symptoms In intent-to-treat analyses (N = 33), participants who received DBT showed an overall trend toward lower ADHD inattentive symptoms, F(2, 62) = 3.13, p = .056, partial η2 = .092, when compared with those receiving SH. Based on planned contrasts, DBT did not significantly outperform SH at post-treatment, F(1, 31) = 2.29, p = .14, d = 0.55, but showed significantly greater improvement at follow-up, F(1, 31) = 5.82, p = .02, d = 0.81. On BAARS-IV inattentive scores, 11 of 17 (65%) DBT participants showed positive response at post-treatment, compared with 6 of 16 (38%) SH participants, χ2(1) = 2.44, p = .12. Among those responding to treatment, 10 (59%) showed recovery after
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DBT SH DBT SH DBT SH DBT SH DBT SH DBT SH
Group
26.59 (3.71) 26.25 (2.74) 80.59 (19.24) 77.31 (17.43) 54.56 (12.58) 51.35 (12.99) 14.18 (13.69) 15.25 (8.93) 10.65 (7.86) 13.56 (8.26) 3.04 (0.65) 3.19 (0.47)
M (SD) 18.94 (4.94) 20.94 (5.08) 60.29 (23.17) 75.56 (18.46) 67.09 (11.24) 52.80 (12.60) 9.82 (9.25) 15.75 (11.07) 7.47 (5.94) 11.19 (10.27) 3.02 (0.47) 3.10 (0.58)
M (SD) 7.65 5.31 20.29 1.75 12.53 1.45 4.35 −0.50 3.18 2.38 −0.02 −0.09
Within group
0.07
0.80
4.85
11.07
18.54
2.33
vs. control
Mean differencesa
1.75 1.30 0.95 0.10 1.05 0.11 0.37 −0.05 0.46 0.25 −0.04 −0.17
Within group
*
**
*** *** ***
Significanced
0.04
0.10
0.44
0.90
0.94
0.55
vs. control
Effect sizesa,b
Pre- vs. post-treatment
*
**
Significancee 18.06 (4.92) 21.06 (4.12) 59.06 (24.86) 71.75 (15.85) 61.71 (15.26) 55.50 (15.19) 10.06 (10.63) 14.87 (8.72) 10.76 (9.12) 10.75 (9.14) 2.97 (0.63) 3.19 (0.44)
M (SD)
Follow-up
8.53 5.19 21.53 5.56 7.15 4.15 4.12 0.38 −0.12 2.81 −0.07 0.00
Within group
−0.07
−2.93
3.74
3.00
15.97
3.34
vs. control
Mean differencesa
1.96 1.48 0.97 0.33 0.51 0.29 0.34 0.04 −0.01 0.32 −0.10 0.00
Within group
*
*
*** *** ***
Significanced
−0.07
−0.34
0.35
0.21
0.81
0.84
vs. control
Effect sizesa,c
Pre-treatment vs. follow-up
**
*
Significancee
0.240
1.375
1.588
3.469
5.457
3.130
F
.008
.042
.049
.101
.150
.092
η2
.056 .007 .038 .213 .260 .765
p
Between-groups RM ANOVA
Note. BAARS inatt. = Barkley Adult ADHD Rating Scale–4th edition, inattentive symptoms; DBT = dialectical behavioral therapy; SH = self-guided skills handouts; BADDS = Brown ADD Rating Scales; AAQoL = Adult ADHD Quality of Life Questionnaire; BAI = Beck Anxiety Inventory; BDI-2 = Beck Depression Inventory–2nd edition; GPA = grade point average (college); RM ANOVA = repeated-measures analysis of variance. aMean differences and effect sizes calculated such that positive values represent improvement in all variables. b Effect sizes calculated with pooled standard deviation from pre-treatment and post-treatment. c Effect sizes calculated with pooled standard deviation from pre-treatment and follow-up. d Significance value for T2 versus T1 or T3 versus T1 planned contrasts in within-groups RM ANOVA. e Significance value for DBT versus SH planned contrast in between-groups RM ANOVA. *p < .05. **p < .01. ***p < .001.
BDI-2 total GPA
BAARS inatt. BADDS total AAQoL total BAI total
Outcome measure
Pre-treatment
Posttreatment
Table 2. Results of Primary Outcome Measures: Means, Standard Deviations, Confidence Intervals and Mean Change Effect Sizes (Cohen’s d) by Treatment Group.
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Table 3. Treatment Response and Recovery Rates by Treatment Group. Post-treatment a
Response Outcome measure BAARS-IV inattentive BAARS-IV total score BADDS total score
Group
N
%
DBT SH DBT SH DBT SH
11 6 10 4 11 3
64.7 37.5 58.8 25.0 64.7 18.8
3-month follow-up b
Responsea
Recovery
Significance.c
* **
N
%
10 5 10 2 9 1
58.8 31.3 58.8 12.5 52.9 6.3
Significancec
** **
N
%
11 4 9 3 10 4
64.7 25.0 52.9 18.8 58.8 25.0
Recoveryb
Significancec * * *
N
%
Significancec
9 4 8 1 8 2
52.9 25.0 47.1 6.3 47.1 12.5
** *
Note. BAARS-IV = Barkley Adult ADHD Rating Scale–4th edition; DBT = dialectical behavior therapy group skills training; SH = self-guided skills handouts; BADDS = Brown ADD Rating Scales. a Response indicated by symptom reduction greater than Reliable Change Index (RCI): BAARS-IV inattentive and total: 95% confidence of symptom reduction BADDS total: 90% confidence of symptom reduction b Recovery indicated by reliable change and reduction of symptoms to within normal range: BAARS-IV inattentive and total: below 93rd percentile (1.5 SD) BADDS total: below clinical cutoff score of 60 (97th percentile, 1.7 SD) c Significance value for DBT versus SH chi-square test. *p < .05. **p < .01. ***p < .001.
DBT, while 5 (31%) showed recovery after SH, χ2(1) = 2.53, p = .11. At follow-up, 11 (65%) DBT participants showed positive response, compared with 4 (25%) SH participants, χ2(1) = 5.24, p = .02. Of these, 9 (53%) showed recovery after DBT, while 4 (25%) showed recovery after SH, χ2(1) = 2.70, p = .10.
EF Participants who received DBT showed greater EF improvement compared with those receiving SH, F(2, 62) = 5.46, p = .007, partial η2 = .150. Based on planned contrasts, DBT outperformed SH both at post-treatment, F(1, 31) = 9.85, p = .004, d = 0.94, and at follow-up, F(1, 31) = 7.61, p = .01, d = 0.81. On BADDS total scores, 11 of 17 (65%) participants receiving DBT showed positive response at post-treatment, compared with 3 of 16 (19%) receiving SH, χ2(1) = 7.13, p = .008; among those responding to treatment, 9 (53%) showed recovery after DBT, while 1 (6%) showed recovery after SH, χ2(1) = 8.51, p = .004. At follow-up, 10 (59%) DBT participants showed positive response at posttreatment, compared with 4 (25.0%) SH participants, χ2(1) = 3.86, p = .049; of these, 8 (47%) showed recovery after DBT, while 2 (13%) showed recovery after SH, χ2(1) = 3.66, p = .03.
Quality of Life Participants who received DBT experienced greater quality of life improvement, F(2, 62) = 3.47, p = .038, partial η2 = .101, than those receiving SH. Based on planned contrasts,
DBT significantly outperformed SH at post-treatment, F(1, 31) = 6.69, p = .015, d = 0.90, but not at follow-up, F(1, 31) = .423, p = .52, d = 0.21.
Comorbid Symptoms and GPA Participants who received DBT did not show significant change in anxiety symptoms, F(2, 62) = 1.59, p = .21, partial η2 = .049; depressive symptoms, F(2, 62) = 1.38, p = .26, partial η2 = .042; or GPA, F(2, 56) = .24, p = .77, partial η2 = .008, when compared with those receiving SH. Secondary outcome analyses are presented in Table 4.
Mindfulness Participants who received DBT showed a greater improvement in overall mindfulness on the FFMQ, F(2, 62) = 4.15, p = .031, partial η2 = .118, versus those receiving SH. Based on planned contrasts, DBT outperformed SH both at posttreatment, F(1, 31) = 4.28, p = .047, d = 0.72, and at followup, F(1, 31) = 5.70, p = .023, d = 0.75.
Inattention, Impulsivity, and Response Variability Participants who received DBT showed a trend toward greater improvement in CPT-2 omission errors, F(2, 60) = 3.09, p = .066, partial η2 = .093, versus those receiving SH. Based on planned contrasts, DBT outperformed SH both at follow-up, F(1, 30) = 4.50, p = .042, d = 0.81 and showed a trend toward greater improvement at post-treatment, F(1, 30) = 3.50, p = .071, d = 0.74. DBT did not
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DBT SH DBT SH DBT SH
DBT SH
Group
48.64 (8.56) 45.90 (4.47) 51.17 (9.95) 51.97 (10.03) 49.02 (12.96) 47.65 (13.53)
116.00 (16.65) 115.75 (13.36)
M (SD)
46.26 (6.95) 52.04 (19.95) 46.07 (9.15) 51.35 (11.80) 46.91 (13.51) 47.75 (14.06)
129.82 (14.29) 118.81 (15.51)
M (SD)
2.37 −6.14 5.11 0.61 2.12 −0.10
13.82 3.06
Within group
Mean differences
2.22
4.50
8.52
10.76
vs. control
0.30 −0.42 0.53 0.06 0.16 −0.01
0.89 0.21
Within group
a,b
**
Significanced
0.16
0.44
0.74
0.72
vs. control
Effect sizes
Pre- vs. post-treatment a
*
Significancee
46.31 (7.34) 50.99 (13.96) 46.75 (10.38) 52.48 (11.64) 45.91 (11.90) 50.46 (13.06)
129.12 (14.81) 117.56 (15.00)
M (SD)
Follow-up
2.33 −5.09 4.43 −0.51 3.11 −2.81
13.12 1.81
Within group
5.93
4.94
7.42
11.31
vs. control
Mean differencesa
0.29 −0.49 0.44 −0.05 0.25 −0.21
0.83 0.13
Within group
***
Significanced
0.46
0.47
0.81
0.75
vs. control
Effect sizesa,c
Pre-treatment vs. follow-up
*
*
Significancee
1.455
1.432
3.088
4.149
F
.046
.046
.093
.118
η2
.066 .247 .243
.031
p
Between-groups RM ANOVA
Note. FFMQ = Five Facet Mindfulness Questionnaire; DBT = Dialectical behavior therapy group skills training; SH = self-guided skills handouts; CPT-2 = Conners’ Continuous Performance Test–2nd edition; RM ANOVA = repeated-measures analysis of variance. a Mean differences and effect sizes calculated such that positive values represent improvement on all variables. b Effect sizes calculated with pooled standard deviation from pre-treatment and post-treatment. c Effect sizes calculated with pooled standard deviation from pre-treatment and follow-up. d Significance value for T2 versus T1 or T3 versus T1 planned contrasts in within-groups RM ANOVA. e Significance value for DBT versus SH planned contrast in between-groups RM ANOVA. *p < .05. **p < .01. ***p < .001.
Reaction time SE
Commission errors
CPT-2 Omission errors
FFMQ Total
Outcome measure
Pre-treatment
Posttreatment
Table 4. Results of Secondary Outcome Measures: Means, Standard Deviations, Confidence Intervals, and Mean Change Effect Sizes (Cohen’s d) by Treatment Group.
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significantly outperform SH on CPT-2 commission errors, F(2, 60) = 1.43, p = .25, partial η2 = .046, or response time standard error, F(2, 60) = 1.46, p = .24, partial η2 = .046.
Baseline Predictors Among all baseline variables, only participant age predicted greater improvement in EF at post-treatment after controlling for baseline EF and the effect of treatment condition, F(1, 29) = 5.197, p = .030, β = −.33; however, when age was entered as a covariate in RM ANOVAs, no Time × Age or Time × Age × Condition interactions were significant (all ps > .10), and the pattern of results was unchanged.
Acceptability Participants in the DBT condition attended 88% of scheduled sessions; 6% of participants dropped out of treatment. Participants gave higher total acceptability scores to DBT than SH (9.00 vs. 5.47), t(30) = 5.59, p < .001, with a very large effect size (d = 2.00). One-sample t tests comparing with a test value of 5.0 (neutral) suggest that the 90-min session length was appropriate (M = 5.06, SD = 1.39), t(15) = .18, p = .86, and that the nine-session treatment length may have been too brief (M = 4.19, SD = 1.60), t(15) = −2.03, p = .06. Participants receiving SH gave an approximately neutral rating for the helpfulness of the handouts (M = 5.50, SD = 2.97). Participants who received DBT group skills training provided the following ratings of the usefulness of each treatment component, in order from highest to lowest rating (rated on a 0-10 Likert-type scale): mindfulness (mindfulness practice, non-judgmentalness, etc.; M = 9.25, SD = 1.13), structuring the environment (study context, using support, etc.; M = 8.69, SD = 1.99), planning (chunking, prioritizing, listing tasks, etc.; M = 8.69, SD = 1.85), organization (planner, notepad, etc.; M = 8.13, SD = 2.42), emotion regulation (functions of emotions, opposite action; M = 7.75, SD = 3.40), managing daily life rhythms (sleep, eating, exercise, etc.; M = 7.56, SD = 2.87), pros and cons (making decisions in advance; M = 7.31, SD = 2.12), information about ADHD (causes, common experiences, etc.; M = 6.69, SD = 2.27).
Discussion To our knowledge, this is the first randomized controlled trial of any intervention for ADHD among college students. This study evaluated the efficacy, acceptability, and feasibility of DBT group skills training (Linehan, 1993a), incorporating cognitive-behavioral skills previously tested for adults with ADHD (Safren et al., 2010; Solanto et al., 2010). Participants were randomly assigned to receive either weekly DBT group skills training or self-guided skills
training handouts. Participants were assessed before and after an 8-week treatment phase and 3 months following the end of treatment. When compared with SH, DBT group skills training appears to be efficacious in improving several key markers of ADHD impairment. Based on intent-to-treat analyses, individuals receiving DBT group skills training showed a greater improvement in EF and quality of life, with trends toward greater improvement in inattentive and total symptoms of ADHD. Pre-treatment versus post-treatment mean change effect sizes comparing DBT group skills training with SH on these four measures ranged from moderate to large (d = 0.47-0.94). On all of these measures with the exception of quality of life, DBT group skills training continued to outperform SH 3 months after treatment, with pretreatment versus follow-up effect sizes ranging from moderate to large (d = 0.71-0.84). Although a large withingroup effect size was observed on functional impairment at both post-treatment and follow-up, DBT group skills training did not significantly outperform SH on this measure. Similarly, DBT group skills training did not outperform SH in improving anxiety, depressive symptoms, or GPA. Compared with SH, DBT group skills training produced a greater proportion of participants with clinically meaningful response to treatment (59%-65% vs. 19%-25%), and with recovery into the normal range (53%-59% vs. 6%-13%), on total ADHD and EF symptoms. Overall response rates of clinical response to DBT group skills training and SH are comparable with those observed with intervention and control conditions in previous randomized trials of individual- (Safren et al., 2010) and group-based (Solanto et al., 2010) CBT skills training interventions for adults with ADHD (53%-67% vs. 23%-33% and 53% vs. 28%, respectively). Although evidence of treatment efficacy on primary outcomes is based on self-report measures, participants receiving DBT also showed a trend toward greater improvement in CPT-2 omission errors, a neuropsychological measure of inattention. Effect sizes were moderate-to-large at posttreatment and follow-up (d = 0.74 and d = 0.81, respectively). Results also suggest that group skills training outperformed SH in improving self-reported overall mindfulness, with relative improvement maintained 3 months after treatment; effect sizes at post-treatment and follow-up were moderate-to-large (d = 0.72 and d = 0.75, respectively). Participants gave higher acceptability ratings to DBT than to SH (d = 2.00). Dropout from group skills treatment was very low (6%) and treatment attendance was high (88% of scheduled sessions attended). In this sample, mindfulness (M = 9.25), structuring the environment (M = 8.69), and planning (M = 8.69) received the highest participant ratings of utility. It is important to note that this study was not designed to detect differences in
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Fleming et al. participants’ ratings of the usefulness of each skill, and conclusions cannot be drawn from these numerical differences. However, these ratings suggest that further research is warranted to evaluate the independent and additive contributions of mindfulness and cognitive-behavioral skills for this population. Despite lower efficacy and acceptability relative to group skills training, the SH intervention may have potential utility as well. Treatment response rates of approximately 25% on ADHD and executive function symptoms are comparable with those of relaxation training or supportive psychotherapy control conditions reported in previous studies of CBT for adults with ADHD (Safren et al., 2010; Solanto et al., 2010). Given the very low cost of this intervention, skills training handouts may be worthy of further study as an alternative treatment for use when more efficacious interventions are not feasible.
adults and the initial evidence of its efficacy among college students, it will be important for future studies to evaluate the relative efficacy and acceptability of psychopharmacological and psychosocial interventions, both independently and in conjunction, for the treatment of ADHD among college students. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by the University of Washington—Robert C. Bolles Doctoral Research Fellowship.
References
Limitations The small sample size of this pilot randomized trial does not provide the statistical power needed to detect small-tomoderate effect sizes or to assess mediators and moderators of treatment response. This study cannot rule out therapist effects or non-specific factors of group psychotherapy, although the latter concern is mitigated by the fact that response rates with SH approximate those of supportive group psychotherapy or similar control conditions in previous trials for adults with ADHD.
Conclusion and Future Directions The present study represents the first known randomized controlled trial of any intervention for ADHD among college students. Overall, results suggest that DBT group skills training may be a useful intervention for college students with ADHD, improving participants’ ADHD symptoms, EF, and quality of life to a greater degree than skills training via self-guided handouts. Mean change effect sizes ranged from moderate to large immediately after treatment (d = 0.47-0.94) and 3 months after treatment (d = 0.71-0.84). The intervention may also improve mindfulness and sustained attention. Participant acceptability of the treatment is high, and the group-based approach requires fewer resources and thus may offer greater feasibility than interventions delivered individually. In the future, randomized trials with greater statistical power are needed to fully assess primary efficacy, control for non-specific factors of group psychotherapy, and evaluate mediators and moderators of treatment effect. Efficiency of treatment may be improved by a component analysis of mindfulness training and cognitive-behavioral skills training. Finally, given the strong empirical support for stimulant medication treatment of ADHD among children and
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DuPaul, G. J., Weyandt, L. L., O’Dell, S. M., & Varejao, M. (2009). College students with ADHD: Current status and future directions. Journal of Attention Disorders, 13, 234-250. DuPaul, G. J., Weyandt, L. L., Rossi, J. S., Vilardo, B. A., O’Dell, S. M., Carson, K. M., . . .Swentosky, A. (2012). Double-blind, placebo-controlled, crossover study of the efficacy and safety of lisdexamfetamine dimesylate in college students with ADHD. Journal of Attention Disorders, 16, 202-220. Fayers, P. M., Curran, D., & Machin, D. (1998). Incomplete quality of life data in randomized trials: Missing items. Statistics in Medicine, 17, 679-696. Fleming, A. P., & McMahon, R. J. (2012). Developmental context and treatment principles for ADHD among college students. Clinical Child and Family Psychology Review, 15, 303-329. Frazier, T. W., Youngstrom, E. A., Glutting, J. J., & Watkins, M. W. (2007). ADHD and achievement: Meta-analysis of the child, adolescent, and adult literatures and a concomitant study with college students. Journal of Learning Disabilities, 40, 49-65. Greenhouse, S. W., & Geisser, S. (1959). On methods in the analysis of profile data. Psychometrika, 24, 95-112. Heiligenstein, E., Guenther, G., Levy, A., Savino, F., & Fulwiler, J. (1999). Psychological and academic functioning in college students with attention deficit hyperactivity disorder. Journal of American College Health, 47, 181-185. Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 12-19. Knouse, L. E., Cooper-Vince, C., Sprich, S., & Safren, S. A. (2008). Recent developments in the psychosocial treatment of adult ADHD. Expert Review of Neurotherapeutics, 8, 15371548. Linehan, M. M. (1993a). Cognitive-behavioral treatment of borderline personality disorder. New York, NY: Guilford. Linehan, M. M. (1993b). Skills training manual for treating borderline personality disorder. New York, NY: Guilford. Murphy, K. R., Barkley, R. A., & Bush, T. (2001). Executive functioning and olfactory identification in young adults with attention deficit-hyperactivity disorder. Neuropsychology, 15, 211-220. Nigg, J. T., Willcutt, E. G., Doyle, A. E., & Sonuga-Barke, E. J. (2005). Causal heterogeneity in attention-deficit/hyperactivity disorder: Do we need neuropsychologically impaired subtypes? Biological Psychiatry, 57, 1224-1230. Philipsen, A. (2006). Differential diagnosis and comorbidity of attention-deficit/hyperactivity disorder (ADHD) and borderline personality disorder (BPD) in adults. European Archives of Psychiatry and Clinical Neuroscience, 256, 42-46. Philipsen, A., Richter, H., Peters, J., Alm, B., Sobanski, E., Colla, M., . . .Hesslinger, B. (2007). Structured group psychotherapy in adults with attention deficit hyperactivity disorder: Results of an open multicentre study. The Journal of Nervous and Mental Disease, 195, 1013-1019. Rabiner, D. L., Anastopoulos, A. D., Costello, J., Hoyle, R. H., & Swartzwelder, H. S. (2008). Adjustment to college in students with ADHD. Journal of Attention Disorders, 11, 689-699. Richards, T. L., Rosen, L. A., & Ramirez, C. A. (1999). Psychological functioning differences among college students
with confirmed ADHD, ADHD by self-report only, and without ADHD. Journal of College Student Development, 40, 299-304. Rooney, M., Chronis-Tuscano, A., & Yoon, Y. (2012). Substance use in college students with ADHD. Journal of Attention Disorders, 16, 221-234. Rounsaville, B. J., Carroll, K. M., & Onken, L. S. (2001). A stage model of behavioral therapies research: Getting started and moving on from stage I. Clinical Psychology: Science and Practice, 8, 133-142. Safren, S. A., Otto, M. W., Sprich, S., Winett, C. L., Wilens, T. E., & Biederman, J. (2005). Cognitive-behavioral therapy for ADHD in medication-treated adults with continued symptoms. Behaviour Research and Therapy, 43, 831-842. Safren, S. A., Sprich, S., Mimiaga, M. J., Surman, C., Knouse, L., Groves, M., & Otto, M. W. (2010). Cognitive behavioral therapy vs relaxation with educational support for medication-treated adults with ADHD and persistent symptoms: A randomized controlled trial. Journal of the American Medical Association, 304, 875-880. Solanto, M. V., Marks, D. J., Wasserstein, J., Mitchell, K., Abikoff, H., Alvir, J. M., & Kofman, M. D. (2010). Efficacy of metacognitive therapy for adult ADHD. The American Journal of Psychiatry, 167, 958-968. SPSS Inc. (2010). SPSS base 19.0 for Windows user’s guide. Chicago, IL: Author. Tang, Y. Y., Ma, Y., Wang, J., Fan, Y., Feng, S., Lu, Q., . . .Posner, M. I. (2007). Short-term meditation training improves attention and self-regulation. Proceedings of the National Academy of Sciences of the United States of America, 104, 17152-17156. Tuckman, A. (2007). Integrative treatment for adult ADHD. Oakland, CA: New Harbinger. Weyandt, L. L., & DuPaul, G. J. (2008). ADHD in college students: Developmental findings. Developmental Disabilities Research Reviews, 14, 311-319. Winer, B. J. (1971). Statistical principles in experimental design. New York, NY: McGraw-Hill. Wolf, L. E. (2001). College students with ADHD and other hidden disabilities: Outcomes and interventions. Annals of the New York Academy of Sciences, 931, 385-395. Zwart, L. M., & Kallemeyn, L. M. (2001). Peer-based coaching for college students with ADHD and learning disabilities. Journal of Postsecondary Education and Disability, 15, 1-15. Zylowska, L., Ackerman, D. L., Yang, M. H., Futrell, J. L., Horton, N. L., Hale, T. S., . . .Smalley, S. L. (2008). Mindfulness meditation training in adults and adolescents with ADHD: A feasibility study. Journal of Attention Disorders, 11, 737-746.
Author Biographies Andrew P. Fleming, PhD, is a senior fellow in psychiatry and behavioral sciences at the University of Washington. He completed doctoral study in the Child Clinical Psychology program at the University of Washington, where he received extensive training in assessment and treatment of ADHD, and in dialectical behavior therapy (DBT). He served as principal investigator on this research trial and primary author of this manuscript. Robert J. McMahon, PhD, is professor of psychology and Leading Edge Endowment Fund of British Columbia Leadership
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Fleming et al. Chair at Simon Fraser University, and a scientist at the Child & Family Research Institute. He is also professor emeritus at the University of Washington. He provided oversight for this trial and assisted in the writing of this manuscript.
A. Paige Peterson, BS, is a doctoral student in child clinical psychology at the University of Washington. She assisted in the collection of these research data and in the writing of this manuscript.
Lyndsey R. Moran, MS, is a doctoral student in child clinical psychology at the University of Washington. She assisted in the delivery of the DBT intervention and in the writing of this manuscript.
Anthony Dreessen, BS, is post-baccalaureate research assistant at the University of Washington. He assisted in the collection of these research data and in the writing of this manuscript.
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research-article2014
JADXXX10.1177/1087054714535951Journal of Attention DisordersFleming et al.
From Theory to Practice
Pilot Randomized Controlled Trial of Dialectical Behavior Therapy Group Skills Training for ADHD Among College Students
Journal of Attention Disorders 2015, Vol. 19(3) 260–271 © 2014 SAGE Publications Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1087054714535951 jad.sagepub.com
Andrew P. Fleming1, Robert J. McMahon2,3, Lyndsey R. Moran1, A. Paige Peterson1, and Anthony Dreessen1
Abstract Objective: ADHD affects between 2% and 8% of college students and is associated with broad functional impairment. No prior randomized controlled trials with this population have been published. The present study is a pilot randomized controlled trial evaluating dialectical behavior therapy (DBT) group skills training adapted for college students with ADHD. Method: Thirty-three undergraduates with ADHD between ages 18 and 24 were randomized to receive either DBT group skills training or skills handouts during an 8-week intervention phase. ADHD symptoms, executive functioning (EF), and related outcomes were assessed at baseline, post-treatment, and 3-month follow-up. Results: Participants receiving DBT group skills training showed greater treatment response rates (59-65% vs. 19-25%) and clinical recovery rates (5359% vs. 6-13%) on ADHD symptoms and EF, and greater improvements in quality of life. Conclusion: DBT group skills training may be efficacious, acceptable, and feasible for treating ADHD among college students. A larger randomized trial is needed for further evaluation. (J. of Att. Dis. 2015; 19(3) 260-271) Keywords adult ADHD treatment, college students, dialectical behavior therapy, mindfulness, executive functioning ADHD persists into adulthood in up to 80% of individuals diagnosed as children (Barkley, Murphy, & Fischer, 2007). Between 2% and 8% of college students meet criteria for ADHD (DuPaul, Weyandt, O’Dell, & Varejao, 2009). Compared with their undergraduate peers without ADHD, students with ADHD tend to have lower grade point averages (GPAs; Heiligenstein, Guenther, Levy, Savino, & Fulwiler, 1999) and graduation rates (Wolf, 2001); higher rates of academic probation (Frazier, Youngstrom, Glutting, & Watkins, 2007), depressive symptoms (Rabiner, Anastopoulos, Costello, Hoyle, & Swartzwelder, 2008), tobacco use and dangerous alcohol use (Rooney, ChronisTuscano, & Yoon, 2012), and overall psychological distress (Richards, Rosen, & Ramirez, 1999); and poorer self-reported quality of life (e.g., Blase et al., 2009). Despite the broad impairment associated with ADHD in college, very little treatment research has been conducted with this population. Two uncontrolled studies have described educational coaching interventions (Allsopp, Minskoff, & Bolt, 2005; Zwart & Kallemeyn, 2001). One recent placebo-controlled crossover study showed initial efficacy of stimulant medication, yet also highlighted the need for psychosocial intervention to address residual
impairment among responders as well as non-responders to stimulants (DuPaul et al., 2012). There are no known randomized treatment trials for college students with ADHD. A comprehensive review of ADHD symptomatology among college students has described the urgent need for treatment development research with this population (Weyandt & DuPaul, 2008). Given that no randomized trials have been conducted with this population, a pilot randomized controlled trial is needed to further advance Stage I treatment development (Rounsaville, Carroll, & Onken, 2001). Intervention research for adults with ADHD provides useful guidance in developing a treatment for college students with ADHD. Cognitive-behavioral therapy (CBT) interventions for adults with ADHD have shown efficacy in 1
University of Washington, Seattle, USA Simon Fraser University, Burnaby, British Columbia, Canada 3 Child & Family Research Institute, Vancouver, British Columbia, Canada 2
Corresponding Author: Andrew P. Fleming, Department of Psychiatry and Behavioral Sciences, University of Washington, 325 Ninth Ave., Box 359960, Seattle, WA 98104, USA. Email: [email protected]
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Fleming et al. a small number of randomized trials (Knouse, CooperVince, Sprich, & Safren, 2008). Both individual- (Safren et al., 2005; Safren et al., 2010) and group-based (Solanto et al., 2010) CBT reduced ADHD symptoms and functional impairment in well-controlled studies. These interventions follow a similar treatment model of 8 to 16 weekly sessions (1-2 hr each) including standard CBT components such as psychoeducation, behavioral skills training, and cognitive restructuring. In addition, mindfulness training and practice have been shown in one short-term study (Tang et al., 2007) to improve attention and self-regulation among undergraduate students. One open trial of an 8-week mindfulness training intervention for adolescents and adults with ADHD showed pre-/post-treatment improvements in ADHD symptoms and attention performance (Zylowska et al., 2008). Dialectical behavior therapy (DBT; Linehan, 1993a) was initially demonstrated to be effective in treating chronic suicidal behavior and borderline personality disorder (BPD); however, it has also shown efficacy in treating a broader range of disorders characterized by dysregulated emotions and behavior, including substance abuse disorders and eating disorders (Dimeff & Koerner, 2007). BPD and ADHD share several common behavioral elements (e.g., impulsivity, emotion dysregulation; Philipsen, 2006), and initial pilot data suggest that DBT group skills training may be efficacious in treating adults with ADHD (Philipsen et al., 2007). DBT was designed to flexibly incorporate cognitivebehavioral strategies and mindfulness/acceptance strategies, and therefore provides a natural synthesis of two broader lines of treatment research for adults with ADHD. Thus, to address this gap in evidence-based treatment for ADHD, the present study was designed as a Stage I pilot trial to provide an initial evaluation of the efficacy, acceptability, and feasibility of DBT group skills training targeted to reduce symptoms and impairment associated with ADHD among college students.
Method Thirty-three undergraduate students who met revised criteria for ADHD in adulthood (see below) and were seeking treatment were recruited from three universities (one public, two private) in a large city in the Pacific Northwest. Participants were stratified by a median split on ADHD inattentive symptoms and randomly assigned to receive either DBT group skills training or self-guided skills training handouts. Participants were assessed before treatment, after treatment, and 3 months after treatment, corresponding to the beginning and end of the academic quarter in which treatment was received, and the end of the following academic quarter. The study was approved by the University of Washington Institutional Review Board. Participants were required to be currently enrolled undergraduate students between the ages of 18 and 24, and
to meet Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-V; American Psychiatric Association, 2013) criteria for ADHD in adulthood, including symptom onset by age 12 and functional impairment in multiple domains. Because study enrollment was conducted prior to finalization of changes in DSM-V symptom thresholds for ADHD in adults, at least four (rather than five) symptom criteria were required in one domain, as recommended by Barkley (2011); two participants did not meet full DSM-V criteria (see Results). Exclusion criteria were as follows: current substance abuse/dependence, active suicidality, major depressive episode, and history of psychotic disorder, bipolar disorder, or pervasive developmental disorder. Individuals receiving psychotropic medication for ADHD must have maintained a stable medication and dose for 1 month prior to enrollment. Baseline variables by treatment condition are shown in Table 1. Figure 1 summarizes the flow of participants through the study. Participants were randomly assigned to treatment condition and were assessed at pre-treatment, post-treatment, and 3-month follow-up by an interviewer who was blind to participant condition.
Measures ADHD symptoms—Barkley Adult ADHD Rating Scale–IV (BAARS-IV). This 18-item questionnaire assesses the DSM-V criteria for ADHD, with clinical response and recovery cutoffs derived from population-based norms. The BAARS-IV (Barkley, 2011) shows adequate internal consistency and test–retest reliability, and strong construct validity and discriminant validity. Self-report of current symptoms was used as a primary outcome measure; self- and parent-report of childhood symptoms were used in eligibility screening. Executive functioning (EF)—Brown ADD Rating Scales (BADDS). This 40-item self-report questionnaire (Brown, 1996) yields T scores for five empirically derived clusters of EF (i.e., organization and prioritization, focused and sustained attention, regulation of alertness and sustained effort, affect modulation, and working memory), as well as a composite (total) index. The measure has been shown to have good internal consistency, test–retest reliability, construct validity, and discriminant validity, and includes cutoff scores for treatment response and recovery. Quality of life—ADHD Quality of Life Questionnaire (AAQoL). This 29-item self-report questionnaire assesses functioning and quality of life in four domains often affected by ADHD symptoms in adults: life productivity, psychological health, relationships, and life outlook. Subscale and overall scores are calculated on a 0-100 scale. The AAQoL (Brod, Johnston, Able, & Swindle, 2006) shows good internal consistency and construct validity.
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Table 1. Demographic and Clinical Characteristics of Intent-to-Treat Sample (N = 33). Dialectical behavior therapy (n = 17) Characteristic Sex Female Male Race White Latino Asian Black Multi-racial/Other University Public Private ADHD presentation Inattentive (four symptoms only) Inattentive (standard DSM-V) Combined (standard DSM-V) Psychopharmacological medication Methylphenidate only Amphetamine only Methylphenidate and SSRIa Amphetamine and SSRIb SSRI onlyc None Age (years) KBIT-2 Verbal IQ WAIS-IV Digit Span WRAML-2 Finger Windows Barkley Adult ADHD Rating Scale–4th edition Inattentive subscale Hyperactive subscale Impulsive subscale Brown ADD Scales Barkley Functional Impairment Scaled Beck Anxiety Inventory Beck Depression Inventory–2nd edition Adult ADHD Quality of Life Questionnaire
Skills handouts (n = 16)
N
%
N
%
7 10
41.2 58.8
7 9
43.8 56.2
11 3 1 0 2
64.7 17.7 5.9 0.0 11.8
8 2 1 1 4
50.0 12.5 6.3 6.3 25.0
12 5
70.6 29.4
12 4
75.0 25.0
1 15 1
5.9 88.2 5.9
1 11 4
5.9 68.8 25.0
5 5 1 0 1 5
29.4 29.4 5.9 0.0 5.9 29.4
3 8 1 1 0 3
18.8 50.0 5.9 5.9 0.0 18.8
M
SD
M
SD
21.20 108.94 10.06 8.24
1.67 10.96 2.22 1.75
21.50 111.06 10.31 7.94
1.12 16.83 2.24 2.32
26.59 11.24 8.41 80.59 4.29 14.18 10.65
3.71 2.51 2.53 19.24 1.51 13.69 7.86
26.25 11.50 9.12 77.31 4.24 15.25 13.56
2.75 3.74 2.45 17.43 1.56 8.93 8.26
55.98
11.51
51.35
12.99
Note. DSM-V = Diagnostic and Statistical Manual of Mental Disorders (5th ed.; American Psychiatric Association); SSRI = selective serotonin reuptake inhibitor; KBIT-2 = Kaufman Brief Intelligence Test–2nd Edition; WAIS-IV = Wechsler Adult Intelligence Scale–IV; WRAML = Wide Range Assessment of Memory and Learning; ADD = attention-deficit disorder. a Citalopram (n = 1); sertraline (n = 1). b Fluoxetine (n = 1). c Sertraline (n = 1). d Average functional impairment score.
Anxiety and depressive symptoms—Beck Anxiety Inventory (BAI) and Beck Depression Inventory-2nd edition (BDI2). These 21-item self-report measures (BAI; Beck, Epstein, Brown, & Steer, 1988; BDI-2; Beck, Steer, &
Brown, 1996) are widely used in clinical research and have strong reliability and validity. Both yield summed total scores that may be categorized by level of impairment.
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Fleming et al.
73 Assessed for eligibility
38 Excluded 28 Did not meet inclusion criteria 11 Age ≥ 25 years 6 History of PDD or Bipolar Disorder 4 Did not meet criteria for ADHD 3 Current major depressive episode 2 Recent ADHD medication change 2 Not currently enrolled undergraduate student 10 Declined to participate
35 Randomized
19 Randomized to group skills training 17 Received intervention 2 Could not participate due to scheduling constraints
16 Randomized to skills handouts 16 Received intervention
Post-treatment Assessment 16 Completed assessment 1 Was not retained for assessment
Post-treatment Assessment 16 Completed assessment
3-month Follow-up Assessment 16 Completed assessment 1 Was not retained for assessment
3-month Follow-up Assessment 16 Completed assessment
17 Included in analysis
16 Included in analysis
Figure 1. Flow of participants from randomization through analysis. Note. PDD = pervasive developmental disorder.
Academic performance. GPA from the academic quarter immediately prior to each assessment point was collected via official transcript. The following secondary outcome measures were also administered at each assessment: Mindfulness—Five Facet Mindfulness Questionnaire (FFMQ). This 39-item self-report questionnaire (Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006) assesses five clusters of behaviors representing a general tendency to be mindful in daily life. The five factors show adequate-togood internal consistency and strong construct validity. Neuropsychological performance—Conners’ Continuous Performance Test–2nd edition (CPT-2). This standardized computeradministered test presents single letters on a screen at varying rates for a total of 15 min. Participants are instructed to press a button in response to every letter except the target letter (“X”). The CPT-2 (Conners, 2000) provides total scores, T scores, and percentile ranks for omission errors,
commission errors, reaction time variability, as well as other measures. As in several previous studies (e.g., Murphy, Barkley, & Bush, 2001; Nigg, Willcutt, Doyle, & Sonuga-Barke, 2005), omission errors, commission errors, and reaction time standard error were used to assess response sustained attention, inhibition, and response variability, respectively. Participants also provided quantitative and qualitative reports of treatment acceptability.
Interventions The experimental intervention was delivered according to the DBT group skills training format (Linehan, 1993b). Given the behavioral targets most relevant to ADHD in adults (Barkley et al., 2007), and the unique developmental and environmental context of ADHD in college (Fleming & McMahon, 2012), the DBT skills taught in this intervention were adjusted from standard DBT (see Figure 2 for intervention content by session). The intervention included a
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Session 1
Group orientation and goal-setting Psychoeducation; Mindfulness
Session 2
Daily planner use Chunking tasks and prioritization
Session 3
Structuring environment Using social support
Session 4
Managing sleep, eating, and exercise
Session 5
Generalizing and troubleshooting skills use
Session 6
Emotion regulation (e.g., opposite action)
Session 7
Generalizing and troubleshooting skills use
Session 8
Review of skills Plan for high-demand period
Session 9a
Review of skills Plan for maintaining skills use
Figure 2. Dialectical behavior therapy intervention content by session. a
Booster session delivered in Week 1 of the following academic quarter.
15-min individual pre-group meeting focused on motivation enhancement, eight weekly 90-min group sessions focused on skills acquisition and strengthening, and seven weekly 10- to 15-min individual coaching phone calls focused on skills generalization. A 90-min booster group session was held during the first week of the follow-up quarter to promote maintenance of skills use. Treatment sessions were conducted at an on-campus outpatient psychology clinic. The intervention was delivered by a group leader (A.P.F.) and co-leader (L.R.M.) who were both advanced graduate students in child clinical psychology. Both therapists had received intensive training in DBT and were current members of a DBT consultation team led by Dr. Marsha Linehan. Intervention was supervised by a licensed psychologist with experience in assessment and treatment of college students with ADHD. Participants in the skills handouts (SH) comparison treatment condition received 34 pages of SH, drawn from a manual for treatment of adults with ADHD (Tuckman, 2007) and designed to reflect publicly available self-help materials for ADHD. Topics included the following: (a) psychoeducation about ADHD and EF, (b) organization, (c) planning, (d) time management, (e) structuring environment, and (f) stress management.
Data Analysis The two treatment groups were compared on baseline variables using independent samples t tests for continuous data and chi-square tests for categorical data. Linear regressions were conducted to explore potential baseline predictors of
change. Univariate repeated-measures analysis of variance (RM ANOVA; Winer, 1971) with Greenhouse–Geisser correction (Greenhouse & Geisser, 1959) was used to compare overall relative change in outcome variables between the two treatment conditions. Response and recovery analyses were conducted using chi-square tests. Response was defined using the Reliable Change Index (RCI; Jacobson & Truax, 1991). Recovery was defined as both reliable change (i.e., response) and reduction of symptoms below the 93rd percentile (BAARS-IV) or 96th percentile (BADDS), as prescribed by each measure. Data were analyzed using SPSS Version 19 (SPSS Inc, 2010).
Results The intent-to-treat sample included 17 and 16 participants DBT group skills training and self-guided SH, respectively. One participant dropped out of DBT after four sessions and did not complete the post-treatment or follow-up assessments; all other participants completed treatment and the three study assessments. Missing data from this participant were imputed conservatively using the last observation carried forward (LOCF) method (Fayers, Curran, & Machin, 1998). Two participants receiving DBT and one receiving SH had substantial ADHD medication changes during the study (>25% change in dose or change in medication type). One participant in each treatment condition met four (rather than five) ADHD inattentive symptom criteria. All analyses were conducted with and without medication changes, and with and without participants who did not meet full DSM-V criteria. The pattern of results did not differ; thus, results from the full intent-to-treat sample are reported. No differences were found between the treatment groups on any variable at baseline (all ps > .10). Baseline demographic and primary clinical variables are displayed in Table 1. Primary outcome data and results from the RM ANOVAs are summarized in Table 2, along with withinand between-groups mean change scores and effect sizes of mean change scores. Treatment response and recovery rates by condition are displayed in Table 3.
ADHD Inattentive Symptoms In intent-to-treat analyses (N = 33), participants who received DBT showed an overall trend toward lower ADHD inattentive symptoms, F(2, 62) = 3.13, p = .056, partial η2 = .092, when compared with those receiving SH. Based on planned contrasts, DBT did not significantly outperform SH at post-treatment, F(1, 31) = 2.29, p = .14, d = 0.55, but showed significantly greater improvement at follow-up, F(1, 31) = 5.82, p = .02, d = 0.81. On BAARS-IV inattentive scores, 11 of 17 (65%) DBT participants showed positive response at post-treatment, compared with 6 of 16 (38%) SH participants, χ2(1) = 2.44, p = .12. Among those responding to treatment, 10 (59%) showed recovery after
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DBT SH DBT SH DBT SH DBT SH DBT SH DBT SH
Group
26.59 (3.71) 26.25 (2.74) 80.59 (19.24) 77.31 (17.43) 54.56 (12.58) 51.35 (12.99) 14.18 (13.69) 15.25 (8.93) 10.65 (7.86) 13.56 (8.26) 3.04 (0.65) 3.19 (0.47)
M (SD) 18.94 (4.94) 20.94 (5.08) 60.29 (23.17) 75.56 (18.46) 67.09 (11.24) 52.80 (12.60) 9.82 (9.25) 15.75 (11.07) 7.47 (5.94) 11.19 (10.27) 3.02 (0.47) 3.10 (0.58)
M (SD) 7.65 5.31 20.29 1.75 12.53 1.45 4.35 −0.50 3.18 2.38 −0.02 −0.09
Within group
0.07
0.80
4.85
11.07
18.54
2.33
vs. control
Mean differencesa
1.75 1.30 0.95 0.10 1.05 0.11 0.37 −0.05 0.46 0.25 −0.04 −0.17
Within group
*
**
*** *** ***
Significanced
0.04
0.10
0.44
0.90
0.94
0.55
vs. control
Effect sizesa,b
Pre- vs. post-treatment
*
**
Significancee 18.06 (4.92) 21.06 (4.12) 59.06 (24.86) 71.75 (15.85) 61.71 (15.26) 55.50 (15.19) 10.06 (10.63) 14.87 (8.72) 10.76 (9.12) 10.75 (9.14) 2.97 (0.63) 3.19 (0.44)
M (SD)
Follow-up
8.53 5.19 21.53 5.56 7.15 4.15 4.12 0.38 −0.12 2.81 −0.07 0.00
Within group
−0.07
−2.93
3.74
3.00
15.97
3.34
vs. control
Mean differencesa
1.96 1.48 0.97 0.33 0.51 0.29 0.34 0.04 −0.01 0.32 −0.10 0.00
Within group
*
*
*** *** ***
Significanced
−0.07
−0.34
0.35
0.21
0.81
0.84
vs. control
Effect sizesa,c
Pre-treatment vs. follow-up
**
*
Significancee
0.240
1.375
1.588
3.469
5.457
3.130
F
.008
.042
.049
.101
.150
.092
η2
.056 .007 .038 .213 .260 .765
p
Between-groups RM ANOVA
Note. BAARS inatt. = Barkley Adult ADHD Rating Scale–4th edition, inattentive symptoms; DBT = dialectical behavioral therapy; SH = self-guided skills handouts; BADDS = Brown ADD Rating Scales; AAQoL = Adult ADHD Quality of Life Questionnaire; BAI = Beck Anxiety Inventory; BDI-2 = Beck Depression Inventory–2nd edition; GPA = grade point average (college); RM ANOVA = repeated-measures analysis of variance. aMean differences and effect sizes calculated such that positive values represent improvement in all variables. b Effect sizes calculated with pooled standard deviation from pre-treatment and post-treatment. c Effect sizes calculated with pooled standard deviation from pre-treatment and follow-up. d Significance value for T2 versus T1 or T3 versus T1 planned contrasts in within-groups RM ANOVA. e Significance value for DBT versus SH planned contrast in between-groups RM ANOVA. *p < .05. **p < .01. ***p < .001.
BDI-2 total GPA
BAARS inatt. BADDS total AAQoL total BAI total
Outcome measure
Pre-treatment
Posttreatment
Table 2. Results of Primary Outcome Measures: Means, Standard Deviations, Confidence Intervals and Mean Change Effect Sizes (Cohen’s d) by Treatment Group.
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Table 3. Treatment Response and Recovery Rates by Treatment Group. Post-treatment a
Response Outcome measure BAARS-IV inattentive BAARS-IV total score BADDS total score
Group
N
%
DBT SH DBT SH DBT SH
11 6 10 4 11 3
64.7 37.5 58.8 25.0 64.7 18.8
3-month follow-up b
Responsea
Recovery
Significance.c
* **
N
%
10 5 10 2 9 1
58.8 31.3 58.8 12.5 52.9 6.3
Significancec
** **
N
%
11 4 9 3 10 4
64.7 25.0 52.9 18.8 58.8 25.0
Recoveryb
Significancec * * *
N
%
Significancec
9 4 8 1 8 2
52.9 25.0 47.1 6.3 47.1 12.5
** *
Note. BAARS-IV = Barkley Adult ADHD Rating Scale–4th edition; DBT = dialectical behavior therapy group skills training; SH = self-guided skills handouts; BADDS = Brown ADD Rating Scales. a Response indicated by symptom reduction greater than Reliable Change Index (RCI): BAARS-IV inattentive and total: 95% confidence of symptom reduction BADDS total: 90% confidence of symptom reduction b Recovery indicated by reliable change and reduction of symptoms to within normal range: BAARS-IV inattentive and total: below 93rd percentile (1.5 SD) BADDS total: below clinical cutoff score of 60 (97th percentile, 1.7 SD) c Significance value for DBT versus SH chi-square test. *p < .05. **p < .01. ***p < .001.
DBT, while 5 (31%) showed recovery after SH, χ2(1) = 2.53, p = .11. At follow-up, 11 (65%) DBT participants showed positive response, compared with 4 (25%) SH participants, χ2(1) = 5.24, p = .02. Of these, 9 (53%) showed recovery after DBT, while 4 (25%) showed recovery after SH, χ2(1) = 2.70, p = .10.
EF Participants who received DBT showed greater EF improvement compared with those receiving SH, F(2, 62) = 5.46, p = .007, partial η2 = .150. Based on planned contrasts, DBT outperformed SH both at post-treatment, F(1, 31) = 9.85, p = .004, d = 0.94, and at follow-up, F(1, 31) = 7.61, p = .01, d = 0.81. On BADDS total scores, 11 of 17 (65%) participants receiving DBT showed positive response at post-treatment, compared with 3 of 16 (19%) receiving SH, χ2(1) = 7.13, p = .008; among those responding to treatment, 9 (53%) showed recovery after DBT, while 1 (6%) showed recovery after SH, χ2(1) = 8.51, p = .004. At follow-up, 10 (59%) DBT participants showed positive response at posttreatment, compared with 4 (25.0%) SH participants, χ2(1) = 3.86, p = .049; of these, 8 (47%) showed recovery after DBT, while 2 (13%) showed recovery after SH, χ2(1) = 3.66, p = .03.
Quality of Life Participants who received DBT experienced greater quality of life improvement, F(2, 62) = 3.47, p = .038, partial η2 = .101, than those receiving SH. Based on planned contrasts,
DBT significantly outperformed SH at post-treatment, F(1, 31) = 6.69, p = .015, d = 0.90, but not at follow-up, F(1, 31) = .423, p = .52, d = 0.21.
Comorbid Symptoms and GPA Participants who received DBT did not show significant change in anxiety symptoms, F(2, 62) = 1.59, p = .21, partial η2 = .049; depressive symptoms, F(2, 62) = 1.38, p = .26, partial η2 = .042; or GPA, F(2, 56) = .24, p = .77, partial η2 = .008, when compared with those receiving SH. Secondary outcome analyses are presented in Table 4.
Mindfulness Participants who received DBT showed a greater improvement in overall mindfulness on the FFMQ, F(2, 62) = 4.15, p = .031, partial η2 = .118, versus those receiving SH. Based on planned contrasts, DBT outperformed SH both at posttreatment, F(1, 31) = 4.28, p = .047, d = 0.72, and at followup, F(1, 31) = 5.70, p = .023, d = 0.75.
Inattention, Impulsivity, and Response Variability Participants who received DBT showed a trend toward greater improvement in CPT-2 omission errors, F(2, 60) = 3.09, p = .066, partial η2 = .093, versus those receiving SH. Based on planned contrasts, DBT outperformed SH both at follow-up, F(1, 30) = 4.50, p = .042, d = 0.81 and showed a trend toward greater improvement at post-treatment, F(1, 30) = 3.50, p = .071, d = 0.74. DBT did not
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DBT SH DBT SH DBT SH
DBT SH
Group
48.64 (8.56) 45.90 (4.47) 51.17 (9.95) 51.97 (10.03) 49.02 (12.96) 47.65 (13.53)
116.00 (16.65) 115.75 (13.36)
M (SD)
46.26 (6.95) 52.04 (19.95) 46.07 (9.15) 51.35 (11.80) 46.91 (13.51) 47.75 (14.06)
129.82 (14.29) 118.81 (15.51)
M (SD)
2.37 −6.14 5.11 0.61 2.12 −0.10
13.82 3.06
Within group
Mean differences
2.22
4.50
8.52
10.76
vs. control
0.30 −0.42 0.53 0.06 0.16 −0.01
0.89 0.21
Within group
a,b
**
Significanced
0.16
0.44
0.74
0.72
vs. control
Effect sizes
Pre- vs. post-treatment a
*
Significancee
46.31 (7.34) 50.99 (13.96) 46.75 (10.38) 52.48 (11.64) 45.91 (11.90) 50.46 (13.06)
129.12 (14.81) 117.56 (15.00)
M (SD)
Follow-up
2.33 −5.09 4.43 −0.51 3.11 −2.81
13.12 1.81
Within group
5.93
4.94
7.42
11.31
vs. control
Mean differencesa
0.29 −0.49 0.44 −0.05 0.25 −0.21
0.83 0.13
Within group
***
Significanced
0.46
0.47
0.81
0.75
vs. control
Effect sizesa,c
Pre-treatment vs. follow-up
*
*
Significancee
1.455
1.432
3.088
4.149
F
.046
.046
.093
.118
η2
.066 .247 .243
.031
p
Between-groups RM ANOVA
Note. FFMQ = Five Facet Mindfulness Questionnaire; DBT = Dialectical behavior therapy group skills training; SH = self-guided skills handouts; CPT-2 = Conners’ Continuous Performance Test–2nd edition; RM ANOVA = repeated-measures analysis of variance. a Mean differences and effect sizes calculated such that positive values represent improvement on all variables. b Effect sizes calculated with pooled standard deviation from pre-treatment and post-treatment. c Effect sizes calculated with pooled standard deviation from pre-treatment and follow-up. d Significance value for T2 versus T1 or T3 versus T1 planned contrasts in within-groups RM ANOVA. e Significance value for DBT versus SH planned contrast in between-groups RM ANOVA. *p < .05. **p < .01. ***p < .001.
Reaction time SE
Commission errors
CPT-2 Omission errors
FFMQ Total
Outcome measure
Pre-treatment
Posttreatment
Table 4. Results of Secondary Outcome Measures: Means, Standard Deviations, Confidence Intervals, and Mean Change Effect Sizes (Cohen’s d) by Treatment Group.
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significantly outperform SH on CPT-2 commission errors, F(2, 60) = 1.43, p = .25, partial η2 = .046, or response time standard error, F(2, 60) = 1.46, p = .24, partial η2 = .046.
Baseline Predictors Among all baseline variables, only participant age predicted greater improvement in EF at post-treatment after controlling for baseline EF and the effect of treatment condition, F(1, 29) = 5.197, p = .030, β = −.33; however, when age was entered as a covariate in RM ANOVAs, no Time × Age or Time × Age × Condition interactions were significant (all ps > .10), and the pattern of results was unchanged.
Acceptability Participants in the DBT condition attended 88% of scheduled sessions; 6% of participants dropped out of treatment. Participants gave higher total acceptability scores to DBT than SH (9.00 vs. 5.47), t(30) = 5.59, p < .001, with a very large effect size (d = 2.00). One-sample t tests comparing with a test value of 5.0 (neutral) suggest that the 90-min session length was appropriate (M = 5.06, SD = 1.39), t(15) = .18, p = .86, and that the nine-session treatment length may have been too brief (M = 4.19, SD = 1.60), t(15) = −2.03, p = .06. Participants receiving SH gave an approximately neutral rating for the helpfulness of the handouts (M = 5.50, SD = 2.97). Participants who received DBT group skills training provided the following ratings of the usefulness of each treatment component, in order from highest to lowest rating (rated on a 0-10 Likert-type scale): mindfulness (mindfulness practice, non-judgmentalness, etc.; M = 9.25, SD = 1.13), structuring the environment (study context, using support, etc.; M = 8.69, SD = 1.99), planning (chunking, prioritizing, listing tasks, etc.; M = 8.69, SD = 1.85), organization (planner, notepad, etc.; M = 8.13, SD = 2.42), emotion regulation (functions of emotions, opposite action; M = 7.75, SD = 3.40), managing daily life rhythms (sleep, eating, exercise, etc.; M = 7.56, SD = 2.87), pros and cons (making decisions in advance; M = 7.31, SD = 2.12), information about ADHD (causes, common experiences, etc.; M = 6.69, SD = 2.27).
Discussion To our knowledge, this is the first randomized controlled trial of any intervention for ADHD among college students. This study evaluated the efficacy, acceptability, and feasibility of DBT group skills training (Linehan, 1993a), incorporating cognitive-behavioral skills previously tested for adults with ADHD (Safren et al., 2010; Solanto et al., 2010). Participants were randomly assigned to receive either weekly DBT group skills training or self-guided skills
training handouts. Participants were assessed before and after an 8-week treatment phase and 3 months following the end of treatment. When compared with SH, DBT group skills training appears to be efficacious in improving several key markers of ADHD impairment. Based on intent-to-treat analyses, individuals receiving DBT group skills training showed a greater improvement in EF and quality of life, with trends toward greater improvement in inattentive and total symptoms of ADHD. Pre-treatment versus post-treatment mean change effect sizes comparing DBT group skills training with SH on these four measures ranged from moderate to large (d = 0.47-0.94). On all of these measures with the exception of quality of life, DBT group skills training continued to outperform SH 3 months after treatment, with pretreatment versus follow-up effect sizes ranging from moderate to large (d = 0.71-0.84). Although a large withingroup effect size was observed on functional impairment at both post-treatment and follow-up, DBT group skills training did not significantly outperform SH on this measure. Similarly, DBT group skills training did not outperform SH in improving anxiety, depressive symptoms, or GPA. Compared with SH, DBT group skills training produced a greater proportion of participants with clinically meaningful response to treatment (59%-65% vs. 19%-25%), and with recovery into the normal range (53%-59% vs. 6%-13%), on total ADHD and EF symptoms. Overall response rates of clinical response to DBT group skills training and SH are comparable with those observed with intervention and control conditions in previous randomized trials of individual- (Safren et al., 2010) and group-based (Solanto et al., 2010) CBT skills training interventions for adults with ADHD (53%-67% vs. 23%-33% and 53% vs. 28%, respectively). Although evidence of treatment efficacy on primary outcomes is based on self-report measures, participants receiving DBT also showed a trend toward greater improvement in CPT-2 omission errors, a neuropsychological measure of inattention. Effect sizes were moderate-to-large at posttreatment and follow-up (d = 0.74 and d = 0.81, respectively). Results also suggest that group skills training outperformed SH in improving self-reported overall mindfulness, with relative improvement maintained 3 months after treatment; effect sizes at post-treatment and follow-up were moderate-to-large (d = 0.72 and d = 0.75, respectively). Participants gave higher acceptability ratings to DBT than to SH (d = 2.00). Dropout from group skills treatment was very low (6%) and treatment attendance was high (88% of scheduled sessions attended). In this sample, mindfulness (M = 9.25), structuring the environment (M = 8.69), and planning (M = 8.69) received the highest participant ratings of utility. It is important to note that this study was not designed to detect differences in
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Fleming et al. participants’ ratings of the usefulness of each skill, and conclusions cannot be drawn from these numerical differences. However, these ratings suggest that further research is warranted to evaluate the independent and additive contributions of mindfulness and cognitive-behavioral skills for this population. Despite lower efficacy and acceptability relative to group skills training, the SH intervention may have potential utility as well. Treatment response rates of approximately 25% on ADHD and executive function symptoms are comparable with those of relaxation training or supportive psychotherapy control conditions reported in previous studies of CBT for adults with ADHD (Safren et al., 2010; Solanto et al., 2010). Given the very low cost of this intervention, skills training handouts may be worthy of further study as an alternative treatment for use when more efficacious interventions are not feasible.
adults and the initial evidence of its efficacy among college students, it will be important for future studies to evaluate the relative efficacy and acceptability of psychopharmacological and psychosocial interventions, both independently and in conjunction, for the treatment of ADHD among college students. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by the University of Washington—Robert C. Bolles Doctoral Research Fellowship.
References
Limitations The small sample size of this pilot randomized trial does not provide the statistical power needed to detect small-tomoderate effect sizes or to assess mediators and moderators of treatment response. This study cannot rule out therapist effects or non-specific factors of group psychotherapy, although the latter concern is mitigated by the fact that response rates with SH approximate those of supportive group psychotherapy or similar control conditions in previous trials for adults with ADHD.
Conclusion and Future Directions The present study represents the first known randomized controlled trial of any intervention for ADHD among college students. Overall, results suggest that DBT group skills training may be a useful intervention for college students with ADHD, improving participants’ ADHD symptoms, EF, and quality of life to a greater degree than skills training via self-guided handouts. Mean change effect sizes ranged from moderate to large immediately after treatment (d = 0.47-0.94) and 3 months after treatment (d = 0.71-0.84). The intervention may also improve mindfulness and sustained attention. Participant acceptability of the treatment is high, and the group-based approach requires fewer resources and thus may offer greater feasibility than interventions delivered individually. In the future, randomized trials with greater statistical power are needed to fully assess primary efficacy, control for non-specific factors of group psychotherapy, and evaluate mediators and moderators of treatment effect. Efficiency of treatment may be improved by a component analysis of mindfulness training and cognitive-behavioral skills training. Finally, given the strong empirical support for stimulant medication treatment of ADHD among children and
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Author Biographies Andrew P. Fleming, PhD, is a senior fellow in psychiatry and behavioral sciences at the University of Washington. He completed doctoral study in the Child Clinical Psychology program at the University of Washington, where he received extensive training in assessment and treatment of ADHD, and in dialectical behavior therapy (DBT). He served as principal investigator on this research trial and primary author of this manuscript. Robert J. McMahon, PhD, is professor of psychology and Leading Edge Endowment Fund of British Columbia Leadership
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Fleming et al. Chair at Simon Fraser University, and a scientist at the Child & Family Research Institute. He is also professor emeritus at the University of Washington. He provided oversight for this trial and assisted in the writing of this manuscript.
A. Paige Peterson, BS, is a doctoral student in child clinical psychology at the University of Washington. She assisted in the collection of these research data and in the writing of this manuscript.
Lyndsey R. Moran, MS, is a doctoral student in child clinical psychology at the University of Washington. She assisted in the delivery of the DBT intervention and in the writing of this manuscript.
Anthony Dreessen, BS, is post-baccalaureate research assistant at the University of Washington. He assisted in the collection of these research data and in the writing of this manuscript.
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