Eur Arch Psychiatry Clin Neurosci (2002) 252 : 177–184 DOI 10.

1007/s00406-002-0379-0

ORIGINAL PAPER

Bernd Hesslinger · Ludger Tebartz van Elst · Elisabeth Nyberg · Petra Dykierek ·
Harald Richter · Michael Berner · Dieter Ebert

Psychotherapy of attention deficit hyperactivity disorder in adults

A pilot study using a structured skills training program

Received: 19 April 2002 / Accepted: 18 July 2002

■ Abstract In clinical practice many adult patients

with attention deficit hyperactivity disorder (ADHD) Introduction
ask for an additional psychotherapeutic intervention
besides the medical therapy. In this paper we present a Many symptoms of attention deficit hyperactivity disor-
structured skill training program particularly tailored der (ADHD) in children persist into adulthood with a
for adult patients with ADHD. The program is based on severity that requires medical treatment [8, 17, 33].
the principles of cognitive-behavioral treatment for Dopaminergic hypoactivity is generally seen as a crucial
borderline personality disorder developed by M. Line- pathogenetic mechanism [14, 17]. Furthermore, there is
han. It was modified to suit the special needs of adult pa- evidence of subtle prefrontal neuropathology in adult
tients with ADHD. In this exploratory pilot study we patients with ADHD [19].
tested this program in a group setting. The following el- The most important symptoms in adult patients are
ements were presented: neurobiology of ADHD, mind- attention deficit, emotional instability, disorganized be-
fulness, chaos and control, behavior analysis, emotion havior and disinhibition. As patients age, hyperactivity
regulation, depression, medication in ADHD, impulse becomes less prominent and disorganization becomes
control, stress management, dependency,ADHD in rela- more prominent [4, 8, 17]. In monotonous situations or
tionship and self respect. when poorly motivated, patients typically complain
In an open study design patients were assessed clin- about difficulties in focusing attention and in selecting
ically using psychometric scales (Attention Deficit Hy- relevant stimuli. Thus they are regarded as dreamy, dis-
peractivity Disorder Checklist according to DSM-IV, 16 tractible, oblivious, and unreliable. Lack of persistence
items of the SCL-90-R, Beck-Depression Inventory, vi- often results in accusations of unreliability and selfish-
sual analogue scale) prior to and following group ther- ness. Patients often perform poor at college and work in
apy. This treatment resulted in positive outcomes in that spite of sometimes outstanding capabilities. This often
patients improved on all psychometric scales. results in frequent job loss, unemployment, social de-
cline and low self-esteem. Furthermore, these patients
■ Key words attention deficit hyperactivity disorder in are prone to interpersonal conflicts due to difficulties in
adults (ADHD) · psychotherapy · cognitive-behavioral impulse control, emotional instability and limited
treatment (CBT) · dialectic behavioral therapy (DBT) · recognition of social cues.
skills training While sometimes these symptoms and their sequels
motivate patients to seek professional help, more often
than this, patients are referred to psychiatrists or psy-
chotherapists because of comorbid psychiatric syn-
dromes like depression, anxiety, sleep disturbances or
substance abuse [7, 17]. Many controlled studies have fo-
Dr. Bernd Hesslinger () · L. Tebartz van Elst · E. Nyberg · cused on medical treatment of adult ADHD [17]. Posi-
P. Dykierek · H. Richter · M. Berner · D. Ebert
Albert-Ludwigs-University tive effects of group psychotherapy and coaching are re-
Department of Psychiatry and Psychotherapy ported [18]. Furthermore, manuals for the improvement
(Dir. Prof. Dr. M. Berger) of self management [32] are used and self-help groups
Hauptstr. 5 are established. However, in contrast to childhood
EAPCN 379

79104 Freiburg, Germany

Tel.: +49-7 61/27 06-5 01 ADHD, where behavioral and cognitive–behavioral
Fax: +49-7 61/27 06-6 19 therapy was evaluated [1–3, 28], to our knowledge there
E-Mail: [email protected] are no controlled studies published in the literature,
178

looking at the benefit of psychotherapy in adult patients ■ Test phase

with ADHD [6]. In a first test phase, group therapy was offered to patients with adult
Even though medical treatment is often effective and ADHD without applying any exclusion criteria and without any psy-
the benefit of psychotherapy has not yet been proven, chometric evaluation. In this probationary group therapy, patient sat-
most clinicians working with adult ADHD patients isfaction proved to be high and dropout rate was low (1 of 7 patients).
Based on this experience and on the suggestions of the patients, the
would agree that there is a need for the development of final manual of the therapy was specified. Then, another session of
a psychotherapy tailored to suit the special needs of group psychotherapy based on these modified principles was offered
these patients. to patients seeking help for ADHD at the outpatient clinic of the De-
In the literature some authors point at a comorbidity partment of Psychiatry and Psychotherapy.
between ADHD and borderline personality disorder [7,
12, 20, 24, 25]. In the past we also have seen patients who, ■ Patient selection
fulfilling both the diagnostic criteria for ADHD and bor-
derline personality disorder, responded well to cogni- Diagnosis of ADHD was established by experienced senior psychia-
tive-behavioral treatment or – in another terminology – trists employing a structured clinical interview following the DSM-IV
criteria modified for adult patients [4]. The diagnosis and onset of
Dialectical Behavioral Therapy (DBT) developed by M. ADHD symptoms in childhood was confirmed psychometrically us-
Linehan [21, 22]. ing the Wender-Utah-Rating Scale (WURS) [29]. Furthermore, the
From a phenomenological point of view there are persistence of relevant symptoms into adulthood was established us-
some similarities between ADHD and borderline per- ing a self-rating ADHD Check List (ADHD-CL) for adults following
the individual 18 DSM-IV criteria symptoms (0 = not present, 2 = se-
sonality disorder: deficits in affect regulation, impulse vere, minimum score = 0, maximum score = 36).
control, substance abuse, low self esteem and disturbed For patients to be eligible for this study, they had to clearly fulfill
interpersonal relationship are common in both condi- DSM-IV criteria for ADHD. In addition a minimum score of 35 in the
tions. In ADHD attention deficit is most pronounced in 25 items of the Wender-Utah-Rating Scale best correlating with
situations which lack external stimulation. In contrast, ADHD (WURS–25) and a score > 17 in the ADHD-CL was required.
A history of substance abuse in the past 6 months, a lifetime his-
patients with borderline personality disorder often ex- tory of bipolar disorder, schizophrenia, mental handicap or border-
perience dissociative symptoms when they feel emo- line personality disorder served as exclusion criteria. In particular,
tionally stressed. From a neurophysiological point of patients with chronic suicidal or self injurious behavior were not in-
view dissociation in borderline personality disorder cluded.
The need for inpatient treatment during the psychotherapeutic
might be regarded as a special form of attention deficit course or the failure to attend more than 2 sessions without excuse
[discussion in 12]. served as dropout criteria.
Mechanisms of affect regulation, however, differ
quite dramatically in the two conditions. Patients with
■ Patients
ADHD, the majority being male, often try to regulate
their labile emotional balance by excessive sports, sexual The treatment program was offered to eleven patients consecutively
behavior, or sometimes impulsive aggressive behavior seen at our outpatient clinic who fulfilled the above mentioned crite-
(“fight or flight”). Patients with borderline personality ria. Of these eleven patients eight agreed to participate (5 males, 3 fe-
disorder (generally female, often with posttraumatic males, age range: 19–44 years, mean age: 31.9 years (SD 9.0)). Two of
the remaining three patients could not comply with the times of the
stress symptoms), on the other hand, tend to slide into therapy sessions and one patient did not respond at all. Six of the eight
“freezing behavior” or “dissociative states” when being patients included fulfilled DSM-IV criteria for the combined subtype
stressed emotionally. The self injurious cutting or burn- of ADHD, 1 patient for predominantly inattentive subtype and 1 pa-
ing behavior is then used to put an end to these states of tient for predominantly hyperactive-impulsive subtype. In all pa-
tients the onset of clinically relevant ADHD symptomatology was as-
tension. sessed to be before the age of 7 years. The WURS–25 scores ranged
Given these considerations and our positive experi- between 44 and 77 points with a mean group score of 58.0 points (SD
ence with DBT in patients with both ADHD and border- 12.1; cutoff > 35) (see Table 2). Comorbid disorders were recurrent de-
line personality disorder, we decided to offer elements of pressive disorder (3 patients), social phobia (2 patients) and insom-
nia (2 patients). Two patients were unemployed at the time of the
DBT skills training [22] to a group of patients with study, 3 were employees, 2 students, and one patient was self em-
ADHD alone.For our purpose the treatment manual was ployed. This demographic distribution regarding age, sex, education,
modified according to the specific needs of ADHD pa- and employment status appeared to be fairly representative for the
tients. It was our goal to work through relevant sections general sample of patients seen at our outpatient clinic. However, due
in a group therapy setting and to establish, if this proce- to the small sample size it may not be representative for ADHD as a
whole since it is a heterogeneous disorder with a wide range of symp-
dure is of any use to the adult ADHD patients. As crite- toms, severity and comorbidities.
ria of improvement, self rating psychometric scales were
used to measure changes in symptomatology of ADHD,
depressive symptoms and overall personal health status. ■ Psychotherapeutic setting

The group was chaired by two psychotherapists being trained in DBT.

Participants agreed to a setting with 13 sessions on a weekly base over
Methods a period of 3 months each session lasting 2 hours. There was no
charge for the participants. Written material and daily exercises were
Approval for the study was obtained from the local ethics committee. distributed to the participants before and after each session. Partici-
All patients gave written informed consent at the onset of therapy. pants had the opportunity to ask for additional individual sessions
 179
and were allowed to contact therapists by phone in case of severe cri- ■ Control group
sis.
A group of 7 patients (5 males, 2 females, age range 18–53 years, mean
age: 32.7 years (SD 13.1),WURS–25: 58.6 (SD 15.1)) fulfilling the same
■ Psychometric scales criteria was assessed with the same methodology and served as a con-
trol group. They were put on a waiting list for our treatment and sent
The following self rating psychometric scales were used to measure to clinical management in a regular outpatient setting with the rec-
changes in terms of clinical improvement: the ADHD Checklist ommendation of medical treatment according to the guidelines of
(ADHD-CL) (see above), the Beck-Depression Inventory (BDI) [5] ADHD. Furthermore, behavioral therapy was recommended. The
and an adapted version of the Symptom Check List (SCL-90-R) [13] agreement was to repeat the psychometric scales after 3 months and
containing 16 items (of the total 90 items) to our clinical impression to include these patients in the next treatment session about half a
relevant for ADHD (SCL-16). The SCL-16 included the following year later. Unfortunately, after 3 months 4 of these 7 patients were lost
items: item 2 (nervousness), 9 (memory deficits), 10 (carelessness), 11 to follow-up due to reasons perhaps closely related to the symptoma-
(excitability), 24 (emotional outburst), 26 (self reproach), 28 (difficul- tology of ADHD. Two of the remaining three had begun a new med-
ties to start), 41 (inferiority complex), 44 (sleep disturbances), 55 ication with methylphenidate in the meantime, the other had started
(concentration deficits), 57 (feeling of tension), 69 (embarrassment), reboxetine. Although this control group is compromised by the high
71 (exertion), 78 (restlessness), 79 (worthlessness), 90 (thinking drop out rate and medication effects, following respective recom-
something is wrong with comprehension). The possible scores ranged mendation, we calculated a group comparison of the treatment effects
between zero and four for each item (score 0 = not present, 4 = very se- by carrying forward the last observation.
vere; minimum score = 0, maximum total score = 68). Finally, a visual
analogue scale (VAS) ranging from 0 (worst) to 10 (best) was used [ac-
cording to 23] to measure the overall personal health status before ■ Statistical analysis
and after the therapy.
In order to analyze structural equality of the treatment and control
group, we compared age, and baseline psychometric scores using two-
■ Neuropsychological tests sample t-tests. Possible sex differences were analyzed using the chi-
square procedure.
Neuropsychological testing was performed in the treatment group at To test for treatment effects within the two groups, the psycho-
baseline and following treatment. In an attempt to cover the core neu- metric data before and after therapy were analyzed statistically using
ropsychological deficits of ADHD the following tests were selected: the non parametric paired-Wilcoxon test. Effect sizes for treatment
effects were calculated by subtracting the mean psychometric scores
1. verbal and letter fluency test [9, 26];
prior to and after therapy and dividing these differences by the stan-
2. the Stroop Test [27] indicating mental speed and inhibitory exec-
dard deviation of the differences.
utive functions;
A p-value of 0.05 was chosen as the criterion of significance for all
3. the Digit Symbol Subtest of the revised version of the Wechsler In-
comparisons.All data were analyzed using SPSS for Windows (version
telligence Test battery [30] testing split attention;
9.01).
4. the KLT [15], an established test of continuous attention;
5. the d2-Test [10] measuring selective attention; and
6. mental control, digit span and visual memory span of the revised
■ Contents of the therapy
Wechsler-Memory Scale indicating short-term memory, working
memory and general attentional capacities [31].
The following therapy elements were integrated as described (for
With lack of persistence being one of the deficits of ADHD we kept overview see Table 1)
the neuropsychological test battery brief and abstained from doing a
full intelligence battery in order to improve the compliance of the pa-
Clarification
tients.
Patients with ADHD often do not recognize their problems as a symp-
tom of a “disorder”. Frequently being misdiagnosed, they feel misun-
■ Evaluation derstood in therapies together with other patients and stop attending.
A correct diagnosis alone often results in substantial relief since it al-
At the end of the course of the treatment, evaluation forms were dis- lows the patients to understand their problems and symptoms as part
tributed and patients were asked to rate given statements by checking of a recognized disorder.
one of five options (true, rather true, don’t know, rather not true, not In order to prepare the patients in advance and to avoid prema-
true) and by doing so rating the psychotherapy. Evaluation was
anonymous and did not affect further management in any way. Pa-
tients were asked to comment on their opinion regarding the speci- Table 1 Overview: Contents of the Therapy
ficity and the effects of the therapy, and to make their suggestions for
improving the treatment. Session Contents
Number

■ Medication 1 Clarification
2 Neurobiology/Mindfulness I
Following a naturalistic design medical treatment was left to the de- 3 Mindfulness II
cision of the patients. 4 Chaos and Control
Methylphenidate: One patient who was on methylphenidate 5 Dysfunctional Behavior/Behavior Analysis I
stopped this medication during the therapy course while another pa- 6 Behavior Analysis II
tient not taking any drugs at baseline started on methylphenidate. In 7 Emotion Regulation
total, three patients started and ended the psychotherapy on a med- 8 Depression/Medication in ADHD
ication with methylphenidate (20–50 mg/d). 9 Impulse Control
Antidepressants: One patient was on antidepressant medication 10 Stress Management
(desipramine) when the group started but stopped it during the treat- 11 Dependency
ment phase. 12 ADHD in Relationship/Self Respect
13 Retrospect and Outlook
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ture termination of the therapy, they received written information Impulse control
about their diagnosis of ADHD and the precise goals and sequence of
Impulsivity and loss of impulse control are further core symptoms of
the course of group therapy. The ability to control ADHD rather than
ADHD. The exercises focusing on impulse control started with be-
to be controlled by ADHD was defined as the overall objective of the
havior analyses of situations where loss of impulse control generally
course.
occurs frequently. The most common symptom reported in our co-
In the first session, following a general introduction, patients were
hort was difficulty in controlling anger. Short- and long-term conse-
educated regarding the symptoms and signs of ADHD. The diagnosis
quences of impulsive behavior were discussed and goal-directed be-
was reestablished for every patient by comparing the general de-
havior was trained again following Linehan [22].
scription of ADHD with the individual biography. A general agree-
ment was settled regarding the modalities of the therapy. Finally, the
expectations and aims of the participants as well as possible reserva- Stress
tions were discussed.
As mentioned above disorganized behavior is another core symptom
of ADHD. Affected patients often feel that this behavior is a result of
Neurobiology/mindfulness emotional stress and experience this deficit as stressful in itself. Prob-
Attention deficit is one of the primary deficits in ADHD. Many other lems with planning and organizing sequential behavior often result in
symptoms derive from it. In the second section patients were edu- a situation in which patients with ADHD do several different things
cated about the scientific knowledge regarding psychological and at the same time, feel pressurized, and end up finishing none of their
neurobiological aspects of attention and concentration. projects.
Subsequently, the concept of mindfulness was discussed and pa- The session focusing on this problem started with education by
tients were familiarized with training of mindfulness as described by informing the patients about the stress-performance relation. Subse-
Linehan [22]. Mindfulness skills in Linehan’s diction [21] “are central quently, stress management techniques were trained, which were
to DBT”. They are seen as psychological and behavioral versions of adapted according to personal resources. Exercises to improve per-
meditation skills in DBT “drawn most heavily from the practice of sonal stress tolerance were practiced following the DBT manual.
Zen” [21]. In DBT there are three “what” skills (observing, describing,
participating) and three “how” skills (taking a nonjudgmental stance, Dependency
focusing on one thing at a time, being effective) [22]. Situations in
which the patients succeeded or failed to behave in a mindful way Substance abuse is one of the most common comorbid diagnoses in
were analyzed. In all following sessions patients were asked to train ADHD. Most patients suffering from ADHD have a history of drug
these mindfulness skills and to repeat them on a daily basis as home- abuse. To deal with this problem, patients were educated about symp-
work. toms and signs of dependency, effects and side effects of psychotropic
substances in ADHD, and the nature and consequences of high risk
and dependent behaviors often seen in ADHD (sexuality, high risk
Chaos and control sport, internet, etc.).We then practiced behavior analyses focusing on
Disorganized behavior is one of the core diagnostic criteria of ADHD dependent behavior and tried to develop alternative behavioral
often resulting in difficulties at school, work and in interpersonal re- strategies.
lationships. In the therapeutic context chaos was defined as follows:
“Chaos is, if ADHD takes control of me”. Control was defined as an ADHD in relationships/self-respect
antipodal concept: “Control is, when I seize control of ADHD”. Fol-
lowing Hallowell and Ratey [18] a list of concrete advice (how to plan The symptoms associated with ADHD render affected patients vul-
a day, how to organize help, etc.) were presented to the patients. Mech- nerable to negative experiences during childhood, at school, univer-
anisms how to precisely realize these suggestions in everyday life were sity and work. In particular the attention deficit is the reason why
discussed. many patients do not achieve positions in private or professional life
which correspond to their abilities and intelligence. Furthermore, the
interpersonal relationships are affected at home and at work com-
Dysfunctional behavior/behavior analysis monly resulting in criticism and rejection. This often leads to dra-
In this section different behavior patterns were analyzed. Dysfunc- matically reduced self esteem. The effects and consequences of ADHD
tional behavior was defined as the kind of behavior patients want to including possible advantages of the disorder for the individual biog-
change. The core concepts of behavior analysis (detailed and precise raphy were discussed and patients had the opportunity to share their
description of the behavior, preceding events, predisposing constella- experiences.
tions, consequences, development of alternative strategies, preven-
tion, apology, compensation) were introduced and taught to provide Session with partners and family members
the patients with strategies for independent behavior analysis. Time
and again accurate examples of behavior analyses were practiced in Many families, partnerships and marriages are affected by the symp-
the following group sessions. toms of ADHD of a family member or partner. Hallowell and Ratey
[18] vividly describe the problems that often result from ADHD
Emotions within interpersonal relationships. To address this problem, educa-
tional literature about ADHD as well as the content and the objectives
Emotional instability and brief recurrent depressive or dysphoric of the psychotherapy was handed out to partners and family mem-
states or feelings of emptiness are all common in ADHD. In the sec- bers. Arrangements were made to meet with partners or families of
tion “emotions”, the patients were first informed about modern the- every participant separately. In these sessions patients and partners
ories of emotion (primary emotions, signal and communicatory had the opportunity to present and discuss their specific problems.
aspects of emotions, relationship cognition–emotion and emo-
tion–behavior). Following this, exercises of emotional analysis (emo-
tional record, emotional diary) and emotional regulation skills Retrospect and outlook
according to Linehan were demonstrated to the group [22]. In the last session the experiences in the therapy were summarized
and the next steps were planned (transformation to a self-help
Depression/medication in ADHD group).
Patients were taught about the diagnosis and therapy of depressive
disorders, since depression is very common in ADHD. Then, the prin-
ciples of medical treatment of depression and ADHD were explained
and every patient had the opportunity to report and discuss his per-
sonal experiences with his medication.
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age and gender. Furthermore, both groups were well

Results matched regarding the different psychometric scores at
baseline which were as follows for the control group
■ Psychometric scales (means): WURS-25: 58.6 (SD 15.1); BDI: 16.3 (SD 11.7);
ADHD-CL: 24.7 (SD 5.2); SCL-16: 34.4 (SD 18.9); VAS:
■ Treatment group. After 13 sessions there was a signif- 3.87 (SD 1.0).With the last observation being carried out
icant improvement on all psychometric instruments in the 4 drop-out cases, the follow-up figures for the con-
used (Table 2; Fig. 1). The BDI score improved from a trol group were BDI: 14.7 (SD 13.2; ES = 0.20); ADHD-
mean score of 16.8 before (range 10–22) to 9.3 points CL: 20.9 (SD 6.2; ES = 0.79); SCL-16: 27.3 (SD 15.8;
(range 2–21) after therapy (Z = –1.96; p = 0.05; effect size ES = 0.64); VAS: 5.0 (SD 2.8; ES = 0.42).
(ES) = 0.99). The ADHD-CL decreased from 24.4 (range
20–28) to 15.3 (range 10–20) points (Z = –2.52; p = 0.01;
ES = 2.22). The SCL-16 improved from mean 36.4 points ■ Neuropsychological tests
(range 19–51) to 20.0 [14–26] points (Z = –2.21; p = 0.02;
Table 3 summarizes our neuropsychological findings.At
ES = 1.35). Finally, the personal health status rated on the
baseline our patients scored well within the normal
visual analogue scale VAS improved a mean 4.13 points
range of the respective tests [9, 10, 15, 26, 27, 30, 31]. At
from 2.5 [1.1–4.7] to 6.63 [2.7–8.8](Z = –2.521; p = 0.01;
follow-up, the treatment phase patients showed signifi-
ES = 2.09).
cant improvement in terms of selective (d2) and split at-
tention (DSS, Stroop). The number of omissions and
■ Control group. There were no significant differences
mistakes did not change significantly, whereas the psy-
between the treatment and control group with respect to
chomotor speed increased in the d2 test. Two patients
were unable to manage the calculation tasks of the KLT
Fig. 1 Change in psychometric scores in the treatment group after psychotherapy
at the beginning of the treatment. Despite the small re-
(grey = pre, white = post) sulting n, there was still a tendency towards improve-
ment in this task following treatment. No significant dif-
ferences were found in the domains of primary and
working memory (digit span, visual memory span), flu-
ency and executive functions.

■ Evaluation forms
The treatment was generally regarded as helpful and, in
particular, as very specific for the deficits that patients
experienced. Patients felt better educated and felt they
were better able to cope with ADHD. All patients stated
that the setting as a group was most helpful. Psychoedu-
cation, the therapists, and the exercises were mentioned
[grey pre psychotherapy, white post psychotherapy, numbers = mean, BDI Beck as further helpful factors in a descending order. The rat-
Depression Inventory, ADHD-CL Attention Deficit Hyperactivity Disorder Checklist ing of the different therapy modules mentioned above
according to DSM-IV (see text), SCL-16 16 items of the SCL-90-R (see text), VAS vi-
sual analogue scale to measure the overall personal health status (0 = worst, was very heterogeneous; however, none of the modules
10 = best), above: significance, non parametric Wilcoxon-Test] was assessed as unhelpful.

Table 2 Psychometric assessment of patients in the

treatment group before and after psychotherapy Patient Sex Age WURS-25 BDI ADHD-CL SCL-16 VAS
(pre/post) Number in years Pre/post Pre/post Pre/post Pre/post

1 F 37 61 21/2 27/20 45/23 4.3/8.8

2 F 33 46 10/13 22/10 19/19 2.0/6.3
3 F 23 64 22/9 25/17 48/17 1.3/7.3
4 M 42 55 19/9 23/12 51/20 1.2/5.9
5 M 44 47 20/21 20/19 26/26 2.0/2.7
6 M 32 44 10/8 23/13 25/14 4.7/6.8
7 M 19 77 17/9 28/19 40/23 1.1/7.9
8 M 25 70 15/3 27/12 37/18 3.4/7.3
Mean 31.9 58.0 16.8/9.3 24.4/15.3 36.4/20.0 2.5/6.6
[SD] [9.0] [12.1] [4.7]/[5.9] [2.8]/[3.9] [11.8]/[3.9] [1.4]/[1.8]

WURS Wender-Utah-Rating Scale (see text). Pre/post psychotherapy: BDI Beck Depression Inventory; ADHD-CL
Attention Deficit Hyperactivity Disorder Checklist according to DSM-IV (see text); SCL-16 16 items of the SCL-90-
R (see text); VAS visual analogue scale to measure the overall personal health status (0 = worst, 10 = best); SD
standard deviation
182

Table 3 Results of neuropsychological testing in the

treatment group (baseline and follow up) Test Item Baseline Follow-up p Sign.
N=8 N=8
Mean value SD Mean value SD

fluency 29.00 1.97 29.88 1.44 0.496

d2 total amount 405.00 54.57 461.75 42.49 0.025 *
d2 number of mistakes
and omissions 39.75 25.60 33.50 30.30 0.496
variance 16.00 9.65 12.63 2.77 0.310
DSS 51.42 12.28 58.71 15.19 0.018 *
KLT 110.00 54.79 128.00 46.70 0.075
Stroop FWL 34.50 4.50 30.87 4.22 0.018 *
FSB 50.25 8.43 45.63 5.04 0.017 *
Interference (time) 81.62 18.65 69.87 9.21 0.093
WMS-R mental control 6.00 0.00 6.00 0.00 1.00
digit span 13.88 2.95 15.00 2.82 0.105
visual memory span 16.50 1.77 17.25 1.39 0.336

* results with a significance level of P < 0.05

When patients were asked to rate the overall therapy evidence of the efficacy and specificity presented is low
following the German school grading system between 1 (level IV) [11]. However, to our knowledge there are no
(= very good) and 6 (= very bad), it was rated with a controlled studies looking at the effects of psychother-
mean score of 1.4 (range: 1–3). There was no dropout. apy in adult patients with ADHD with a higher level of
Following completion of the course the participants de- evidence. Pre-post changes in psychometric scores (for
cided to continue as a self-help group. ADHD related domains: ADHD Checklist and SCL-16;
for depressive symptoms and overall health status: BDI
and VAS) in the treatment group are significant despite
Discussion the small sample size. Since there was no overall change
in concomitant medication with stimulants in the treat-
In this paper we introduce a structured skill-training ment group, this change cannot be attributed to a med-
program for adult patients with ADHD. The therapy is ication effect. Like in other pilot studies the results are
developed for a group setting. It is based on the princi- very preliminary in nature. However, they may be used
ples of dialectic behavioral therapy (DBT) for border- to formulate hypotheses and hopefully encourage fur-
line personality disorder, a cognitive-behavioral treat- ther larger and controlled studies.
ment according to M. Linehan, and modified to suit the The improvement in some of the neuropsychological
specific needs and deficits of adult patients with ADHD. tests does not necessarily translate into an improvement
The different modules follow the core symptoms of in therapeutic outcome in terms of symptomatology. At
ADHD and their psychosocial sequelae. baseline the mean patients scores of the tests were
What are the methodological problems of this study? within the normal range. Even though the test-retest re-
This is an exploratory pilot study and, therefore, like in liability for all tests used is good (coefficient of stability
psychopharmacological pilot studies, the number of ranged between 0.67 (DSS) and 0.96 (Stroop)) other ef-
cases is very small. The control group is clearly compro- fects might explain the post-treatment change. Im-
mised by the high dropout rate. Thus, we do not want to provements might be due to practice effects, to a de-
comment on the differences in outcome between the crease of depressive symptoms, or might be taken as an
treatment and control group. Following respective sug- indicator of good motivation following the treatment
gestions, we calculated effect sizes for the treatment as phase.
well as the control group by carrying forward the base- Given that lack of persistence is one of the symptoms
line observation of those four patients in the control of ADHD, it is remarkable that there were no dropouts
group who were lost to follow-up. Even though this pro- and no problems with unpunctuality or missings of ses-
cedure resulted in differences between the two groups in sions in our treatment group. Subjective evaluation of
favor of our treatment group, the data should be held participants indicates that they regarded the therapy as
with caution. Furthermore, in three patients of our con- specific and effective. The setting as a group therapy,
trol group, an adequate medical treatment of ADHD was psychoeducation and the continuous practice of exer-
introduced between baseline and follow-up assessment, cises were rated as the most helpful factors of the thera-
while in our treatment group there was no overall peutic process by the patients.
change in medication. Thus, according to the criteria of The therapists, on the other hand, felt that the dialec-
the evidence-based-medicine paradigm [16], the level of tic approach established by M. Linehan in her cognitive-
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behavioral treatment of borderline personality disorder chotherapy and this constellation might explain the lim-
was very helpful for the treatment of adult ADHD pa- itation of psychotherapy in childhood ADHD.
tients in that it seems to be important to keep the bal- Further research in larger samples is needed to eval-
ance between acceptance and validation of the ADHD- uate the clinical benefit of psychotherapy in patients
related symptoms, on the one hand, and to teach the with ADHD in adulthood. In addition, such studies
skills for change and self management, on the other should compare psychotherapy to medical and com-
hand. bined treatment and should also address maintaining
Finally, we want to stress the fact that there are many effects.
differences in the nature and therapy of borderline per-
sonality disorder and ADHD. In particular, the absence ■ Acknowledgment The authors wish to thank the anonymous ref-
erees for their encouragement and their helpful and clarifying sug-
of chronic suicidality, parasuicidal behavior, posttrau- gestions to improve the manuscript.
matic stress symptoms and difficulties in establishing a
therapeutic relationship in ADHD makes it “easier” to
work with these patients and change might be brought
about “faster” than in patients with borderline personal- References
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