Adolescents with ADHD - Follow-up of a Group CBT Intervention: Satisfaction, Feasibility, and Long-Term Efficacy
Doctoral thesis
Permanent lenke
https://hdl.handle.net/11250/3063609Utgivelsesdato
2023Metadata
Vis full innførselSamlinger
- Institutt for psykisk helse [1333]
Sammendrag
Norsk sammendrag
Ungdom med ADHD - Oppfølgingsstudie av en gruppebehandling basert på kognitiv atferdsterapi
ADHD (Attention Deficit/Hyperactivity Disorder) kjennetegnes av utfordringer med oppmerksomhet, uro og impulskontroll av et slikt omfang at det gir problemer med å fungere på flere områder i livet. Ungdom med ADHD har en høy risiko for å utvikle andre psykiske vansker og opplever ofte utfordringer i forhold til både skole, fritid, venner og familie. Anbefalt behandling for ADHD er opplæring/kunnskap, tilrettelegging, og medisiner. Dette er for mange ikke tilstrekkelig for å oppnå normalisering av symptom eller funksjon. Kognitiv atferdsterapi (KAT) er en anbefalt tilleggsbehandling, men vi har enda manglende kunnskap om KAT for ungdom med ADHD.
Deltagerne i denne studien var ungdom i alderen 14 til 18 år som alle hadde fått diagnose ADHD i BUP og fremdeles opplevde funksjonsnedsettende symptomer etter standard behandling inkludert minst 2 måneder med stabil medisinering. Deltagerne ble tilfeldig fordelt mellom en kontrollgruppe og en behandlingsgruppe som fikk KAT som gruppebehandling gjennom 12 ukentlige timer. KAT-programmet besto av 6 timer om kjernesymptomer ADHD, 4 timer om samtidige vansker, og 2 timer med fokus på forberedelse til fremtiden.
Vi samlet inn data ved hjelp av spørreskjema og klinisk vurdering ved inntak i studien og rett etter behandlingsperioden, og ved telefonintervju ett år etter inntak. Vi fant at KATprogrammet var veldig godt likt og velegnet for gjennomføring i klinikken. Det var også godt oppmøte til gruppetimene og få som sluttet underveis. Vi fant imidlertid ikke at programmet ga bedring i ADHD-symptomer eller funksjon ved oppfølging etter ett år sammenlignet med kontrollgruppen. Mange av deltagerne i studien hadde også slutten med medisinene sine og hadde lite eller ingen oppfølging til tross for at de fortsatt hadde betydelig grad av symptomer. Våre resultater viser at disse ungdommene med ADHD som fortsatt har symptomer etter behandling er en sammensatt gruppe der mange har tilleggsvansker. Mange har også betydelige utfordringer med eksekutive funksjoner, som viser seg blant annet i evnen til å få oversikt og organisere oppgaver, komme i gang, holde orden, og regulere oppmerksomhet, følelser og atferd.
Det er behov for å forbedre programmet gitt i denne studien. Mulighet for individuell tilpasning og moduler spesielt rettet mot eksekutive funksjonsvansker vil kunne gi bedre effekt. Fremtidige studier bør også utforske om kombinasjon av individuelle timer og gruppetimer er hensiktsmessig. Mer vekt på gjennomføring av hjemmeoppgaver og involvering av foreldre og/eller lærere vil sannsynligvis være fornuftig. Når vi fortsetter arbeidet med å gi bedre oppfølging for ungdom med ADHD bør vi også ta hensyn til utfordringer med selv-innsikt, motivasjon, og motstand mot behandling som vi ofte møter hos denne gruppen. English summary
Adolescents with attention deficit/hyperactivity disorder (ADHD) have a high risk of adverse outcomes and a negative life trajectory into adulthood. First line treatment, including medication, has well-documented effects on core symptoms but is often not enough to normalise function. Resistance to treatment and discontinuation of medication are also common issues in this population. Cognitive behavioural treatment (CBT) is a recommended treatment option for adolescents with ADHD. However, evidence regarding CBT for this population is limited.
The overall aim of this thesis was to improve treatment and care for adolescents with ADHD by evaluating satisfaction, feasibility, and long-term efficacy of a group CBT intervention. We further aimed to improve our knowledge of the challenges for this group of patients in a manner that could improve future interventions.
The studies in this thesis are part of a randomised controlled trial (RCT) comparing a group CBT intervention as addition to standard clinical treatment, including medication, to no additional treatment. Participants were adolescents diagnosed with ADHD who still experienced impairing symptoms after standard treatment, including at least 2 months on stable medication. Participants were randomised to either a group CBT intervention or a control group. The intervention was delivered in 12 weekly sessions focused on core symptoms of ADHD (6 sessions), associated difficulties (4 sessions), and preparation for the future (2 sessions).
In Study I, we found that the programme was feasible and very well-liked by the targeted population, with high attendance rates and few dropouts. In Study II, we found, contrary to our hypothesis, that the treatment programme delivered in this trial failed to prove efficacy on core symptoms and functional impairment at one-year follow-up when compared to control conditions. We also found that despite reporting overall symptom levels above or just below the clinical threshold, many of the adolescents in both the intervention and control group stopped taking their medication and had little or no contact with health care providers at follow-up. In Study III, we found that participants in this trial had considerable executive functional deficits as measured by the Behavior Rating Inventory of Executive Function (BRIEF) at the time of inclusion. Correlation and agreement between parents’, teachers’, and self-reported scores on BRIEF varied, and whereas teachers generally reported the highest problem scores on all scales and indexes, adolescents generally self-reported the lowest problem scores.
In conclusion, the population of adolescents with ADHD still impaired after standard treatment, including medication, represents a heterogeneous group in which comorbidities and executive functional deficits are frequently present. The group CBT intervention delivered in the RCT failed to show a treatment effect on symptom level when added to standard care. The program was, however, feasible and well-liked, with few dropouts and high rates of attendance. Future improvements might include more individual tailoring and targeting of specific problem domains and/or comorbid conditions and difficulties. As the group aspect of treatment seems to be highly appreciated by these adolescents, future studies should explore whether a combination of group and individual modules could be helpful. Furthermore, including more practice on skills and involving parents and/or teachers to some extent might improve outcomes. An emphasis on adherence and competence in the delivery of treatment is also warranted. In future follow-up studies, a broader range of outcome measures related to functional outcomes should be included, preferably evaluated by multiple informants. Lastly, as we continue to strive towards improving treatment and care for these adolescents, the challenge remains that self-awareness, motivation, and treatment resistance are issues we need to address to facilitate change.
Består av
Paper 1: Andersen, Ann Christin; Sund, Anne Mari; Thomsen, Per Hove; Lydersen, Stian; Young, Susan; Nøvik, Torunn Stene. Cognitive behavioural group therapy for adolescents with ADHD: a study of satisfaction and feasibility. Nordic Journal of Psychiatry 2021 ;Volum 76.(4) s. 280-286. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/)Paper 2: Andersen, Ann Christin; Sund, Anne Mari; Thomsen, Per Hove; Lydersen, Stian; Young, Susan; Nøvik, Torunn Stene. One year follow-up of Participants in a Randomized Controlled Trial of a CBT-based Group Therapy Program for Adolescents Diagnosed with ADHD (2022). This paper is under review for publication and is therefore not included.
Paper 3: Andersen, Ann Christin; Sund, Anne Mari; Thomsen, Per Hove; Lydersen, Stian; Haugan, Anne-Lise Juul; Nøvik, Torunn Stene. Executive function measured by BRIEF in adolescents diagnosed and treated for ADHD: problem profiles and agreement between informants. Child Neuropsychology: A Journal of Normal and Abnormal Development in Childhood and Adolescence 2023. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by/4.0/)