ADHD in adulthood has been associated with a range. Evaluation of Group Cognitive Behavioral Therapy for Adults With ADHD

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1 Journal of Attention Disorders OnlineFirst, published on February 29, 2008 as doi: / Evaluation of Group Cognitive Behavioral Therapy for Adults With ADHD Journal of Attention Disorders Volume XX Number X Month XXXX xx-xx 2008 Sage Publications / hosted at Jessica Bramham University College Dublin Susan Young Alison Bickerdike King s College London Deborah Spain South London and Maudsley NHS Foundation Trust Denise McCartan King s College London Kiriakos Xenitidis South London and Maudsley NHS Foundation Trust Objective: A brief cognitive behavioral therapy (CBT) group intervention was designed to treat comorbid anxiety, depression, and low self-esteem and self-efficacy in adults with ADHD. It was hypothesised that participants would gain knowledge about ADHD, experience a reduction in comorbid symptoms, and benefit from the supportive aspect of group treatment. Method: Participants in the study formed a CBT treatment group that attended six workshops and a waiting list control group. The intervention was evaluated with measures assessing knowledge about ADHD, psychological symptoms, and support received. The groups were compared using repeated measures ANOVAs. Results: The CBT group had significantly greater improvement on measures of knowledge about ADHD, self-efficacy, and self-esteem than the control group. Participants evaluations of the sessions suggested that sharing personal experiences with other adults with ADHD was an important aspect of the intervention. Conclusion: Brief CBT group treatments may be an acceptable and cost-effective intervention for adults with ADHD. (J. of Att. Dis. XXXX; XX(X) xx-xx) Keywords: adult ADHD; cognitive behavioral therapy; group treatment ADHD in adulthood has been associated with a range of social and emotional sequelae including comorbid disorders such as anxiety, depression, personality disorder, and substance abuse; academic underachievement, occupational problems, social interaction, and relationship difficulties; low self-esteem; and poor selfidentity (Biederman et al., 1993; Brassett-Grundy & Butler, 2004; Nadeau, 1995; Ratey, Greenberg, Bemporad, & Lindem, 1992; Weiss & Hechtman, 1993; Wender, 2000; Young, 2000; Young, Toone, & Tyson, 2003). This may especially be the case for individuals whose problems remain undiagnosed until adulthood (Young, Bramham, Gray, & Rose, 2008). As a result, many adults with ADHD will have developed an interpersonal style that is interpreted by others as negative and have experienced a lifetime of adverse interactions. They report a long-standing awareness that they are different in some way and internalize their difficulties, which in turn has a negative effect on self-esteem (Young & Bramham, 2007). Treatment for adults with ADHD typically follows a pharmacological route that addresses the core symptoms of inattention, hyperactivity, and impulsivity (Wilens, Spencer, & Biederman, 2002). However, in controlled studies of pharmacotherapy, 20% to 50% of adults are considered nonresponders due to insufficient symptom reduction or an inability to tolerate medication (Wender, Authors Note: Address correspondence to Jessica Bramham, UCD School of Psychology, University College Dublin, Newman Building, Belfield, Dublin 4, Ireland; jessica.bramham@ucd.ie. Copyright 2008 by SAGE Publications. 1

2 2 Journal of Attention Disorders 1998). Moreover, adults who are considered responders typically show a reduction in only 50% or less of the core symptoms of ADHD (Wilens et al., 2002). Thus, psychopharmacology is not entirely successful in treating ADHD symptoms in adulthood and adults may have greater need than children to access alternative treatments to help them learn strategies and skills for coping with functional impairments (Safren, Sprich, Chulvick, & Otto, 2004). ADHD adults recognize these problems as underachievement, organizational difficulties, poor problem solving, relationship difficulties, low mood, and poor self-esteem. They report a desire for psychological treatment to improve their quality of life and level of achievement (Young & Bramham, 2007). Adults with ADHD also request further information about the disorder to make sense of their past, indicating a role for psychoeducational interventions (Young et al., 2008). There is emerging evidence that psychological treatment may be beneficial for adults with ADHD (Safren, 2006), and it has already been demonstrated to improve symptoms in childhood (MTA Cooperative Group, 1999). Wilens et al. (1999) reported that an open trial of cognitive behavioral therapy (CBT) was effective in improving the core symptoms and associated problems of ADHD in 69% of the sample. However, there was no control group or medication-only group, so it is difficult to determine whether these changes were specifically associated with the CBT intervention. This limitation was addressed by Safren et al. (2005), who conducted a randomized controlled trial comparing CBT plus continued psychopharmacology with continued psychopharmacology alone. At the outcome assessment, those who were randomized to CBT had lower independently evaluated ADHD symptoms and global severity as well as self-reported ADHD symptoms. Those in the CBT group also had lower independent and self-reported anxiety, lower independently rated depression, and a trend to have lower self-reported depression. This study sought to extend Safren et al. s (2005) finding of CBT affecting difficulties associated with ADHD in adulthood. However, given that adults with ADHD often feel isolated from their peers, it was hypothesised that a group format would provide additional benefits through enabling adults with ADHD to meet others with similar difficulties. The group format also enables the development of a supportive network whereby skills can be rehearsed without judgment. A fixed-length closed group seemed to be most suitable for adults with ADHD who may also have difficulty committing themselves to a process that they perceive as lengthy, as it will not satisfy their need for immediate gratification (Young, 2000). Two group treatment studies have also been shown to be effective for adults with ADHD (Hesslinger et al., 2002), even following a relatively brief intervention (Stevenson, Whitmont, Bornholt, Livesey, & Stevenson, 2002). However, neither study used a control group to evaluate the efficacy of the intervention against medication alone. The purpose of this study was to examine the client acceptability and effectiveness of a brief CBT intervention for adults with ADHD. Participants attending group workshops for adults with ADHD were compared with a medication-alone control group. There were three aims for the intervention and it was hypothesised that there would be improvement in these areas for those receiving CBT in comparison with controls: (a) psychoeducation about ADHD; (b) development of psychological strategies to face future challenges with greater confidence and expectations of achievement, that is, to improve selfesteem and self-efficacy; and (c) support through allowing individuals to meet others with the disorder. Study Design Method Sixty-one Caucasian clients (40 males, 21 females) diagnosed with ADHD in adulthood (based on DSM-IV criteria) attended six consecutive ADHD workshop series held at the Adult ADHD Service at the Maudsley Hospital, London (CBT/medication group). The mean age was years (SD = 9.63). Fifty-nine of this group were prescribed medication [N = 30: slow release methylphenidate (18-54 mg); N = 21: immediate release methylphenidate (5-30 mg); N = 5: atomoxetine (40-80 mg); N = 2: venlafaxine (300 mg); N = 1: rispiridone (4 mg)], and two participants elected to attend the group workshops before trying medication. The majority of the group had not received any previous psychological intervention; four had received counseling in the past, two had worked with an ADHD coach, and one had received individual CBT from a clinical psychologist. One third of participants dropped out during the course of treatment (N = 20) and did not complete the final set of measures. There were no significant differences between their pre-treatment ratings compared with those who completed the workshop series. The CBT/medication group was compared with a medication-only group made up of ADHD clients within the same service and who were on the waiting list to attend the CBT group workshops. Their mean age was years (SD = 8.31). All were taking stimulant medication and were not receiving any other psychological intervention. Questionnaires were posted to 110 clients

3 Bramham et al. / Cognitive Behavioral Therapy 3 at the same times as data collection for the pre- and posttreatment ratings of the CBT/medication group. Thirtyseven Caucasian clients (21 males, 16 females; 34%) returned both sets of questionnaires. All participants were diagnosed with ADHD by a consultant psychiatrist on the basis of a full psychiatric interview, rating scales of childhood and current behavior completed by an informant and the participant, a neuropsychological assessment, and consideration of school reports where possible. Participants were offered the group CBT intervention as part of the clinical service. They were asked to complete measures for research purposes and gave consent for this information to be used in evaluation of the treatment. No one declined to participate, even though they were reassured that nonparticipation would not affect the service they received in any way. It took approximately 10 to 15 minutes to complete the questionnaires. They were completed by the CBT/medication group at the beginning and end of each day of workshops. The control group completed the questionnaires at home and returned them by mail. Description of the CBT Workshop Series The workshop series included three 1-day workshops held monthly (i.e., 1 day per month over 3 months). The groups were attended on average by 10 clients (range = 8-15). The sessions content included material from the Young-Bramham Programme modules on inattention and memory, impulsivity, frustration and anger, anxiety, depression, social relationships, time management, problem solving, and preparing for the future (Young & Bramham, 2007). Session 1 (what it means to have ADHD) and Session 6 (the future with ADHD) mainly provided psychoeducation about the disorder. Psychoeducation is important so that individuals develop an understanding of the core and associated symptoms of ADHD and their presentation. It is particularly important in allowing the person with ADHD to understand his or her behavior, therefore repairing self-esteem. Understanding that the disorder has a neurodevelopmental basis will allow clients to begin to battle against the previous labels of lazy or stupid. The aim was to promote insight into the diagnosis of ADHD, the meaning of the diagnosis, and the effect it has on the individual (Weiss & Hechtman, 1993). Session 2 (anger and frustration) was devised to address the low frustration tolerance that can often lead to explosive outbursts in adults with ADHD. Participants were guided to learn to identify the internal cues for anger, use coping self statements to inhibit open expression of anger, and generate a plan for responding and having a contingency plan if one becomes too angry to deal with the situation (Nadeau, 1995). Session 3 (emotions and ADHD) was provided in view of the high incidence of mood disorders in the ADHD population. Adults with ADHD will have experienced a history of failure in many aspects of their lives. The cumulative effect of this is often low self-esteem and a belief that the situation can never be changed (Murphy, 1998). The main emphasis of the CBT model is to encourage patients to help themselves and to emphasize selfefficacy in the future. The session focused on discovering the connections between mood, thoughts, and behavior and allowing participants to reexamine this cycle to improve mood. Session 4 (relationship skills) concerned problems with inattention, impulse control, all-or-nothing thinking, and disorganization, all of which can affect ADHD individuals ability to perform socially. Therefore, the group setting was used to offer an opportunity to learn more about social and interpersonal skills (DuPaul, Ervin, Hook, & McGoey, 1998). The sharing of both problems and coping strategies was used to generate a larger number of potential interventions, and the group provided a safe environment in which to practice verbal and nonverbal communication skills techniques. In Session 5 (time management and problem solving), practical approaches to time management and problem solving were provided, given the evidence that people with ADHD need a structured and methodological approach. Exercises were used to demonstrate specific techniques for planning and problem solving. Interest and motivation were maintained by applying and alternating a variety of techniques, including individual and small group exercises, role-plays, modeling, group discussions, and didactic teaching using a PowerPoint slide show. There were frequent breaks during the workshops and detailed handouts were provided that contained exercises to complete within the workshop or later at home to reinforce the techniques presented. Measures Acceptability and feasibility of the intervention were measured by attendance at the workshops and completion of evaluation forms at the end of each session. The sessions were evaluated using six versions of the Evaluation Questionnaire, where the first question related to the specific session topic and seven subsequent questions were more general (see Table 1). Participants rated the following items on a scale from 0 (not at all) to 4 (a great deal).

4 4 Journal of Attention Disorders Table 1 Evaluation Questionnaire Items # Item 1 Do you feel that you have learned more about ADHD (frustration and anger, emotions and ADHD, social relationships, time management and problem solving, and preparing for the future)? 2 How useful was the information covered? 3 Was the content relevant to your experiences? 4 How well did you understand the techniques and strategies suggested for dealing with your symptoms and problems? 5 How confident do you feel about using the techniques? 6 How likely are you to use these techniques? 7 How helpful was it to share your personal experiences in a group? 8 Did you benefit from hearing about others experiences and coping strategies? Psychoeducation was assessed by a 20-item True/False Knowledge Quiz (see the appendix), which was especially devised for the study. Psychological symptoms were assessed using measures of anxiety, depression, self-esteem, and self-efficacy as follows: Anxiety and depression subscale scores of the Hospital Anxiety and Depression Scale (HADS; Zigmond & Snaith, 1983). This is a widely used 14-item self-report questionnaire that divides into two subscales that measure anxiety and depression respectively. Two reviews of the HADS support it for the purposes of clinical screening for both severity and case detection of anxiety disorders and depression (Bjelland, Dahl, Haug, & Neckelmann, 2002; Herrmann, 1997). It has been reported to be reliable in relevant patient groups including those with a psychiatric history, in primary care, and in the general population (Bjelland et al., 2002; Snaith & Zigmond, 1994). Total self-esteem score from Culture Free Self-Esteem Inventory (Battle, 1981). This is a self-report inventory in true/false format that assesses self-esteem and has been standardized on a large sample in the United States. Its average internal consistency coefficients range from.81 to.93. It correlates strongly with other measures of self-esteem and self-concept, and cross-cultural studies have been reported to demonstrate its cultural fairness (Battle, 1981). Total score from General Self-Efficacy Scale (Schwarzer & Jerusalem, 1995). This measure was devised to assess a general sense of perceived self-efficacy to predict coping with daily hassles as well as adaptation after experiencing all kinds of stressful life events. This scale has been Topic Table 2 Total Evaluation Scores for Sessions validated in 14 cultures in both adult and adolescent populations (Scholz, Gutiérrez-Doña, Sud, & Schwarzer, 2002). Responses are made on a 4-point scale and there is no cutoff score, but the total score can be used to evaluate change in perception of self-efficacy (Jerusalem & Schwarzer, 1992). Supportive function of the groups was evaluated using the mean score across workshops for items from the Evaluation Questionnaire that related to the experience of sharing and hearing others experiences as part of a group (items 7 and 8). Statistical Analyses To determine change over time by participants who completed the workshop series, for each outcome variable, a repeated measures ANOVA was used with group (CBT/medication vs. medication alone) as a betweensubjects factor and time as a within-subjects factor (baseline vs. outcome). Results Acceptability and Feasibility Forty-one participants attended all three workshops, 6 people attended two workshops (5 people attended days 1 and 2; 1 person attended days 1 and 3), and 14 people attended one workshop. There were no significant differences between the evaluation scores for the six sessions, indicating that all aspects of the workshops were equally valued (see Table 2), with clients generally rating that they had learned a lot from them. Furthermore, several clients requested future workshops on the topics of medication, substance misuse, sleep problems, and the positive aspects of ADHD. Psychoeducation Mean Evaluation Score (SD) 1. What does it mean to have ADHD (N = 61) (3.92) 2. Coping with feelings of frustration and anger (N = 61) (5.57) 3. Coping with feelings of anxiety and depression (N = 47) (4.11) 4. Interpersonal relationships (N = 47) (3.77) 5. Time management and problem solving (N = 42) (4.91) 6. The future with ADHD (N = 42) (6.05) There was a main effect of time, F(1, 75) = 17.80, p <.001, and a main effect of group, F(1, 75) = 6.971, p =.010.

5 Bramham et al. / Cognitive Behavioral Therapy 5 Table 3 Knowledge and Psychological Symptoms at Baseline and Outcome for CBT/Medication and Medication-Alone Groups CBT + Medication (N = 41) Medication Alone (N = 37) Measure [M (SD)] Baseline Outcome Baseline Outcome Knowledge quiz (1.87) (1.67) (1.72) (1.66) HADS anxiety (3.96) (5.35) (5.35) (3.22) HADS depression 8.02 (4.25) 6.27 (3.78) 7.25 (4.28) 6.31 (3.08) Self-efficacy (7.83) (6.41) (5.60) (5.62) Self-esteem (6.82) (6.61) (8.09) (6.16) Note: CBT = cognitive behavioral therapy; HADS = Hospital Anxiety and Depression Scale. A significant interaction between time and group, F(1, 75) = , p =.001, indicated that the CBT/medication group s knowledge had improved more greatly at outcome on the quiz (see Table 3). Psychological Symptoms For the HADS anxiety and depression variables, there was a main effect of time [Anxiety: F(1, 75) = 8.265, p =.005; Depression: F(1, 75) = 7.274] but no main effect of group nor any interaction between group time. This indicates that at outcome, anxiety and depression symptoms improved significantly from baseline for both groups regardless of whether the participants had received CBT. For the self-efficacy variable, there was a main effect of neither group nor time, but there was a significant interaction between group time, F(1, 75) = , p <.001. This shows that improved outcome on this measure depended on whether the participants had received CBT. The total self-esteem score showed main effects of both group, F(1, 75) = 4.461, p =.038, and time, F(1, 75) = , p <.001, and an interaction between group time, F(1, 75) = 6.345, p =.014, indicating that selfesteem improved for both the CBT group and the medication-alone group over time, but this improvement was significantly greater for the CBT group. Supportive Function To evaluate whether any particular aspects of the intervention were more useful to participants, the total score for each question included in the Evaluation Questionnaire was examined separately, with particular focus on items 7 and 8 (see Table 4). The scores suggest that, across the workshops, hearing the personal experiences of others was valued most by the participants. However, repeated measures analyses of variance (ANOVAs) did not indicate that this was significantly greater than any other aspect, F(7, 2) = 4.267, p =.203. Discussion This study examined the feasibility, client acceptability, and effectiveness of a brief cognitive behavioral group intervention for adults with ADHD. This treatment was provided to clients attending a series of three group workshops held 1 day per month for 3 months. This study contributes to the evidence base for psychological intervention in adult ADHD. It is clear from both the improvement on standardized measures of relevant psychological symptoms and the feedback from those who took part in the groups that CBT group intervention for adults with ADHD is a worthwhile endeavor. Moreover, it was shown that this could be achieved in a brief cost-effective group intervention, which in turn may reduce multiple presentations to psychiatric services and their associated cost implications (Dalsgaard, Mortensen, Frydenberg, & Thomsen, 2002; Young et al., 2003). The groups were shown to be feasible and acceptable to ADHD adult clients in this format. Although one third did not complete all 3 days, this is consistent with rates reported by a forensic outpatient service (Fox & Schaapveld, 2006) but higher than that reported from studies including both inpatients and outpatients (Gould, Mueser, Bolton, Mays, & Goff, 2001). These workshops were held at a national adult ADHD service, which receives referrals and provides treatment across the United Kingdom, and thus many participants did not live locally and were required to travel a considerable distance. For those who attended all three workshops, these appear to have been well received and the topics equally valued. Outcome measures were selected to evaluate the three primary objectives of treatment. All these objectives were successfully met as shown by significant improvement in knowledge, self-esteem, and self-efficacy in the combined CBT/medication group compared with participants in the waiting list medication-alone group. Both groups showed improvement in symptoms of anxiety and depression.

6 6 Journal of Attention Disorders Evaluation Questionnaire Item Table 4 Total Scores for Each Item Mean Item Score (SD) 1. Knowledge gained 3.15 (1.06) 2. Usefulness 3.30 (0.68) 3. Relevance 3.18 (0.95) 4. Understanding of techniques and strategies 3.00 (0.93) 5. Confidence in using techniques and strategies 2.48 (1.12) 6. Likelihood of using techniques and strategies 2.55 (1.09) 7. Helpfulness of sharing personal experience 3.15 (1.06) 8. Benefit of hearing others experiences 3.44 (0.91) Change in self-esteem could be related to the increased experience of success and control that took place over the course of the workshops. In addition, in line with the change in increased knowledge and understanding of ADHD, this may reflect a change in attribution of etiology for their difficulties. Adults with ADHD, who have not been correctly diagnosed in childhood, may have experienced years of failure and rejection, which may have become internalized (Young et al., 2008). It is possible that a greater understanding of the neuropsychiatric mechanisms of the disorder allows these individuals to reattribute the blame for their difficulties externally and, therefore, lessen its effect on self-esteem. The finding of change over time for both groups, but additional improvements in the CBT/medication group, emphasizes the importance of a multimodal approach to intervention. Stimulant medication has been demonstrated to be effective in this population. This helps reduce problems associated with primary symptoms but may also have a secondary effect on mood-related problems. CBT seems to be important in helping people with ADHD understand their disorder, cope with their difficulties, and repair self-esteem. There were clear benefits with regard to the group experience. In their evaluation feedback, participants reported that they had appreciated this aspect of the therapy as they felt that they had finally met people who have had similar life experiences and who understood them. This is consistent with the frequent reports of adults with ADHD of feelings of isolation and of feeling misunderstood by others. The high degree of satisfaction related to getting to know the other group members suggests that a closed group format is valuable. This study contributes to a small but growing evidence base for CBT for adults with ADHD. Nevertheless, it is not without its limitations. Pharmacotherapy was not carefully matched between the CBT/medication and medication-alone groups and it is possible that some individuals changed medication during the intervention period. Further research should specifically monitor medication changes or preferably include a CBT-only group not prescribed medication. Second, outcome assessments were self-reported and it would have been useful to include information or ratings from family or friends. Other studies of CBT for ADHD (e.g., Safren et al., 2005) also employed clinician ratings of change. This method would have been advantageous, although it is practically more difficult in a group setting. Third, the measures were administered by group facilitators, which may have led to socially desirable responding. Further research would therefore benefit from the involvement of an independent investigator who is able to evaluate treatment outcomes and eliminate potential biases. Fourth, the study only examined posttreatment outcome and did not include a follow-up period to investigate maintenance of gains. It is possible that treatment gains on measures reflected an immediate increase in perception of self-efficacy and self-esteem after spending a day with individuals who had similar difficulties. However, this inflation in scores may be short-lived; therefore, a follow-up assessment seems warranted in further studies. The final and most challenging limitation is that the study did not employ a randomized control design. It is therefore difficult to conclude with confidence that the group CBT intervention alone was the cause of change. Further investigations should include a support group as a control condition to determine the additive value of the CBT component of the group workshops beyond their supportive benefit. Despite these limitations, the results suggest that brief group CBT treatments may be a useful and cost-effective means for adults with ADHD to impart psychological strategies, repair self-esteem, and develop confidence for future endeavors.

7 Bramham et al. / Cognitive Behavioral Therapy 7 Appendix Please circle the appropriate letter according to whether you think the following 20 statements are true or false. Please answer according to your knowledge of the disorder in general, rather than relating the questions to yourself. 1. ADHD is a disorder present from childhood. 2. ADHD is contagious. 3. People with ADHD find it difficult to follow rules. 4. ADHD symptoms can be treated with medication. 5. People with ADHD can never fulfill their potential. 6. People with ADHD are distractible. 7. People with ADHD have difficulties concentrating. 8. People grow out of ADHD but the rate varies from person to person. 9. People with ADHD are less intelligent than the normal population. 10. Whether you have ADHD depends on how you were brought up. 11. More females than males have ADHD. 12. People with ADHD prefer short-term rewards over long-term rewards. 13. People with ADHD have difficulties with self-restraint. 14. ADHD is a lifelong condition. 15. People with ADHD become bored more easily than other people. 16. People with ADHD are likely to have additional psychological problems. 17. People with ADHD rarely get tired. 18. ADHD is a problem of motivation. 19. People with ADHD find it difficult to organize themselves. 20. People with ADHD are slow to understand instructions. References Battle, J. (1981). Culture-Free Self Esteem Inventories for children and adults. Seattle, WA: Special Child Publications. Biederman, J., Faraone, S. V., Spencer, T., Wilens, T., Norman, D., Lapey, K. A., et al. (1993). Patterns of psychiatric comorbidity, cognition, and psychosocial functioning in adults with attention deficit hyperactivity disorder. American Journal of Psychiatry, 150, Bjelland, I., Dahl, A. A., Haug, T. T., & Neckelmann, D. (2002). The validity of the Hospital Anxiety and Depression Scale. An updated literature review. Journal of Psychosomatic Research, 52, Brassett-Grundy, A., & Butler, N. (2004). Prevalence and adult outcomes of attention-deficit hyperactivity disorder. London: Bedford Group for Lifecourse and Statistical Studies, Institute of Education, University of London. Dalsgaard, S., Mortensen, P. B., Frydenberg, M., & Thomsen, P. H. (2002). Conduct problems, gender and adult psychiatric outcome of children with attention-deficit hyperactivity disorder. British Journal of Psychiatry, 181, DuPaul, G. J., Ervin, R. A., Hook, C. L., & McGoey, K. E. (1998). Peer tutoring of children with attention deficit hyperactivity disorder: Effects on classroom behaviour and academic performance. Journal of Applied Behaviour Analysis, 31(4), Fox, S., & Schaapveld, P. (2006). A forensic psychology outclient anger management group. Forensic Update, 87, Gould, R. A., Mueser, K. T., Bolton, E., Mays, V., & Goff, D. (2001). Cognitive therapy for psychosis in schizophrenia: An effect size analysis. Schizophrenia Research, 48, Herrmann, C. (1997). International experiences with the Hospital Anxiety and Depression Scale a review of validation data and clinical results. Journal of Psychosomatic Research, 42, Hesslinger, B., Tebartz van Elst, L., Nyberg, E., Dykierek, P., Richter, H., Berner, M., & Ebert, D. (2002). Psychotherapy of attention deficit hyperactivity disorder in adults a pilot study using a structured skills training programme. European Archives of Psychiatry and Clinical Neuroscience, 252(4), Jerusalem, M., & Schwarzer, R. (1992). Self-efficacy as a resource factor in stress appraisal processes. In R. Schwarzer (Ed.), Selfefficacy: Thought control of action (pp ). Washington, DC: Hemisphere. MTA Cooperative Group. (1999). A 14 month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Archives of General Psychiatry, 56, Nadeau, K. G. (1995). A comprehensive guide to attention deficit disorder in adults. New York: Brunner/Mazel. Ratey, J. J., Greenberg, M. S., Bemporad, J. R., & Lindem, K. J. (1992). Unrecognised attention-deficit hyperactivity disorder in adults presenting for outclient psychotherapy. Journal of Child and Adolescent Psychopharmacology, 2, Safren, S. A. (2006). Cognitive-behavioral approaches to ADHD treatment in adulthood. Journal of Clinical Psychiatry, 67(Suppl. 8), 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. Behavior Research and Therapy, 43, Safren, S. A., Sprich, S., Chulvick, S., & Otto, M. W. (2004). Psychosocial treatments for adults with attention-deficit/hyperactivity disorder. Psychiatric Clinics of North America, 27, Scholz, U., Gutiérrez-Doña, B., Sud, S., & Schwarzer, R. (2002). Is general self-efficacy a universal construct? Psychometric findings from 25 countries. European Journal of Psychological Assessment, 18(3), Schwarzer, R., & Jerusalem, M. (1995). Generalized Self-Efficacy Scale. In J. Weinman, S. Wright, & M. Johnston (Eds.), Measures in health psychology: A user s portfolio. Causal and control beliefs (pp ). Windsor, UK: NFER-Nelson. Snaith, R. P., & Zigmond, A. S. (1994). The Hospital Anxiety and Depression Scale manual. Windsor, UK: NFER-Nelson. Stevenson, C. S., Whitmont, S., Bornholt, L., Livesey, D., & Stevenson, R. J. (2002). A cognitive remediation programme for adults with attention deficit hyperactivity disorder. Australian and New Zealand Journal of Psychiatry, 36(5), Weiss, G., & Hechtman, L. T. (1993). Hyperactive children grown up. New York: Guilford. Wender, P. H. (1998). Attention-deficit hyperactivity disorder in adults. The Psychiatric Clinics of North America, 21(4), Wender, P. (2000). Attention deficit hyperactivity disorder in children and adults. New York: OUP. Wilens, T. E., McDermott, S. P., Biederman, J., Abrantes, A., Hehesy, A., & Spencer, T. J. (1999). 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8 8 Journal of Attention Disorders Wilens, T. E., Spencer, T. J., & Biederman, J. (2002). A review of the pharmacotherapy of adults with attention deficit/hyperactivity disorder. Journal of Attentional Disorders, 5(4), Young, S. (2000). ADHD children grown up: An empirical review. Counselling Psychology Quarterly, 13, Young, S., & Bramham, J. (2007). ADHD in adults: A psychological guide to practice. Chichester, UK: Wiley. Young, S., Bramham, J., Gray, K., & Rose, E. (2008). The experience of receiving a diagnosis and treatment of ADHD in adulthood: A qualitative study of clinically referred patients using Interpretative Phenomenological Analysis. Journal of Attention Disorders, 11(4), Young, S., Toone, B., & Tyson, C. (2003). Comorbidity and psychosocial profile of adults with attention deficit hyperactivity disorder. Personality and Individual Differences, 35, Zigmond, A. S., & Snaith, R. P. (1983). The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica, 67(6), Jessica Bramham is a lecturer in clinical neuropsychology at the School of Psychology, University College Dublin. She is a chartered clinical psychologist and clinical neuropsychologist. Her research interests include adulthood ADHD assessment and treatment, social cognition, and neuropsychiatry. Susan Young is a senior lecturer in forensic clinical psychology at the Institute of Psychiatry, King s College London, Institute of Psychiatry. She is a chartered clinical and forensic psychologist and a clinical neuropsychologist. Her research interests include neurodevelopmental disorders and forensic risk assessment. Alison Bickerdike is a trainee clinical psychologist at the Institute of Psychiatry, King s College London. She has been involved in evaluation of the group cognitive behavioural intervention at the Adult ADHD Service of the South London and Maudsley NHS Foundation Trust. Deborah Spain is a cognitive behavioral therapist at the Adult ADHD Service of the South London and Maudsley NHS Foundation Trust. She specializes in therapeutic intervention with adults with neurodevelopmental disorders. Denise McCartan is a trainee clinical psychologist at the Institute of Psychiatry, King s College London. Her research interests are the neuropsychology of ADHD in adults and children, and memory and language functioning in temporal lobe epilepsy. Kiriakos Xenitidis is a consultant psychiatrist at the Adult ADHD Service of the South London and Maudsley NHS Foundation Trust. He is also an honorary senior lecturer at the Section of Brain Maturation of the Institute of Psychiatry, King s College London. His research interests include the interface of ADHD with other neurodevelopmental disorders in adulthood and forensic aspects of ADHD, autism, and intellectual disabilities.