Strength-based Treatment Approach for Adults With ADHD
Condition: Attention Deficit Hyperactivity Disorder
MeSH terms: Hyperkinesis; Attention Deficit Disorder with Hyperactivity
Study type: Interventional

Summary: 
      The aim of the research is to develop a treatment program with positive self-awareness and
      self-determination outcomes for adults with Attention Deficit Hyperactivity Disorder (ADHD).
      Current treatments are based in a characterisation of ADHD oriented on deficits impairing
      everyday functioning, with primary goals of symptom control and reduction. However, treatment
      approaches are not standardised and only evidence short-term effectiveness. This project
      proposes an alternative approach to understanding ADHD behaviours, supported by Self
      Determination Theory (SDT). Research shows SDT based treatment approaches can support
      engagement of intrinsic motivation and longterm integration of behavioural change. ADHD
      research shows individuals are impaired in some contexts but not in others and can manage
      well, indicating potential for ADHD neurodiverse "strengths" which could be developed and
      supported. Recent psychology research recommends cultivating positive psychological factors
      and emotions to improve mental health and wellbeing. Adults aged 18+ with a confirmed ADHD
      diagnosis will be invited to participate in two projects: Intensive online interviews of 1
      hour will be conducted to identify, explore, and construct a theory about the factors, or
      "natural strengths" in lived experience of ADHD that help individuals to overcome everyday
      impairments. These factors will be incorporated into a pilot feasibility study of an SDT
      based 12-week treatment programme focusing on understanding the lived experience of ADHD and
      building on these strengths. The treatment will be designed for individual participants and
      delivered online. This study will have two sets of participants: one group will go directly
      to treatment, the other will go on a 12-week waiting list to create a comparison group. The
      second group will then be offered the 12-week treatment. Measures of experience of the
      participants will be looking for the feasibility, acceptability and efficacy of this
      treatment, as well as indicators of symptom improvement, and changes in self-awareness and
      self-regulation skills.
    

Detailed description: 
      ADHD symptoms negatively affect daily functioning both at work and at home, and have
      long-term impact in academic, occupational, social and emotional areas of functioning.
      Effective, long-term treatment outcomes benefit both the individual with ADHD and society as
      undiagnosed and untreated adults with ADHD may become an economic burden due to increased
      health care costs and decreased productivity at work. Russell Barkley postulated the first
      unifying theory of ADHD which places a core deficit of behavioural inhibition at the source
      of ADHD behaviours. Barkley's model is built upon observation of perceived chronic
      difficulties in behaviour, measured as "excessive or inappropriate for their age or
      development level.". Since the publication of this model, several theoretical models were
      proposed which attribute alternative cognitive sources for the development of ADHD symptoms,
      but Barkley's model forms the foundation for primary treatment recommendations. A recent
      review of the theories of ADHD recommended that more testable hypotheses need to be produced.
      While a variety of different interventions are available and the benefit of other forms of
      support is acknowledged (e.g. psychotherapy or coaching), the National Institute for Health
      and Care Excellence (NICE) only recommends interventions that match a similar protocol to
      medications: Randomised Controlled Trials (RCTs), which are primarily based in Cognitive
      Behavioural Therapy (CBT). It is therefore hypothesised that much of current research for the
      characterisation of ADHD is based on a cognitive behavioural paradigm that is deficit-focused
      with primary treatment outcomes of symptom reduction and control of maladaptive behaviours.
      Research in psychology suggests that a deficit-focus may not be the best approach to
      improving mental health, and it may be necessary to develop positive psychological factors
      and emotions that cultivate health and wellbeing. In ADHD, research suggests that this
      includes cognitive dynamism, creativity, and resilience, among others. There is a paucity of
      research in this area.

      This project proposes an alternative approach to understanding and working with ADHD
      behaviours, supported by Self Determination Theory (SDT). SDT is an empirical, organismic
      dialectical approach to human motivation and personality, originating in Positive Psychology.
      SDT guided research focuses on conditions that enhance intrinsic motivation, self-regulation,
      and wellbeing. The positive approach to active energisation and intention of behaviour in SDT
      is closely aligned to evidence of positive engagement in ADHD (e.g. via interest), therefore
      viewing ADHD behaviours from an SDT perspective allows for a different understanding of the
      action and intention of behaviour. An SDT based approach combined with psychotherapeutic
      principles for integration of a positive concept of self provides tools which are potentially
      effective for long term treatment.

      One of the challenges to designing effective treatment is the variability of impairment
      experienced by individuals with ADHD. Impairments are viewed as "clusters" of chronic
      difficulty for everyone with an ADHD diagnosis, however individual profiles can differ
      significantly. This implies there are situations or contexts where individuals with ADHD can
      function successfully. Two phases of this project have been developed to support this
      hypothesis. The aim of Phase 2 is to generate a theory, grounded in data, that explains a)
      why and how individuals with ADHD experience variable impairment; b) the impact of variable
      impairment for those with ADHD; and c) processes and strategies used by those with ADHD to
      resolve their main concerns regarding the impact and consequences of the variable impairment
      of ADHD. The purpose is to identify universal selective strengths that support individuals
      with ADHD to manage the variability of their impairment. In support of these alternative
      theories and approaches, Phase 3 of this project aims to examine the participant
      acceptability, feasibility, and efficacy of a novel strength - based programme of therapeutic
      self-development, psychoeducation and skills training for adults with a diagnosis of ADHD.
      This programme will use a multi-modal psychotherapeutic approach and educational methodology
      to assist participants in understanding ADHD and develop self-management skills.

      While ADHD is primarily viewed as a neurobiological disorder with no cure, the possibility
      that ADHD may confer advantages to the individual is widely debated. Research on phenomena
      concerning the experience of ADHD has theoretical implications, and grounded theory is
      presented as a research methodology that is ideal for an area where not much research or
      theorising has been done before. There are currently several methodological approaches to
      grounded theory, and for this project it was deemed most appropriate to use a Constructivist
      approach. This approach introduces a pragmatic epistemological perspective on the researcher
      by recognising the subjectivity and researcher involvement in construction and interpretation
      of data in theory construction. This was thought to be an important element to monitor during
      the research process due to the researcher's own personal experience of ADHD.

      In keeping with the focus on selecting cases which may provide new insights for developing
      theory, this project will aim to approach three different groups for participation: NHS
      patients from the Adult ADHD Clinic at the Southwest Yorkshire Partnership NHS Foundation
      Trust; university students at the University of Huddersfield and the University of Cambridge;
      and ADHD Support Groups for adults with ADHD. Analysis of individual case studies was
      considered, however as current perspectives of positive psychological factors in ADHD are
      identified as "individual strengths", it was thought a case comparison on interviews might
      identify the phenomenon in a more universal way.

      The Phase 2 grounded theory research aims to reach saturation following analysis of 5-10
      participant interviews. However, due to the nature of grounded theory, this can only be
      finalised as part of the process. It is possible more participants will

      Unlike other qualitative methods, grounded theory approaches recommend that the inquiry
      shapes the data collection. This process of finding and generating data that is "rich", or
      detailed, focused, and full, provides solid material for substantive analysis. Therefore,
      this project will identify some areas to begin initial data collection, while remaining open
      to emerging potential data examples. These areas are intensive interviews, videos, and memos
      or field notes by the researcher.

      Study Design - Pilot Study This is a wait list control study design with pre-, within, and
      post-treatment measures. A rolling entry of participants will be conducted, where once
      individuals have been screened their entry into the study will begin. A maximum of 30 adults
      aged 18+ with a confirmed diagnosis of ADHD will be allocated using block randomisation to
      the SDT theory-based model or wait list over a 12-week period. Following the 12-week wait,
      the wait list group will also be enrolled in the SDT theory-based model. This ensures all
      participants receive the opportunity to experience the treatment.

      Participants will be recruited from NHS patients at the Adult ADHD Clinic at the Southwest
      Yorkshire Partnership NHS Foundation Trust only.Phase 3 is a pilot feasibility study, and the
      aim is to recruit 15 participants per arm for the two arm pilot study.

      Acceptability, feasibility, and efficacy of the intervention will be measured by attendance
      and completion of evaluation forms at the end of each session. A follow up interview a week
      post-treatment will provide an opportunity for feedback and evaluation by post-treatment
      measures. Due to Covid-19 restrictions for research that requires in-person contact,
      consideration for the safety of participants and institution and NHS staff was incorporated
      into this study design. All interviews, screening, and treatment sessions will be conducted
      online, on an NHS approved video platform.

      To test for treatment effects within the two groups, the psychometric data before and after
      therapy will be analysed statistically using a paired samples t-test, or dependant t-test. To
      test for treatment effects within the two groups, the psychometric data before and after
      therapy will be analysed statistically using the non-parametric paired-Wilcoxon test. Cohen's
      D will be calculated as a measure of effect size. To reduce bias, an intention to treat
      analysis will be used but it is recognised that challenges may occur due to missing data;
      based on withdrawal, loss to follow up, or non-response of assessment questionnaires and the
      degree of this this will be considered at the time of analysis. Therefore, the study will be
      reviewed using the revised Cochrane risk-of-bias tool for randomised trials (RoB 2). All
      analysis will be conducted with SPSS version 26.

      The ethical process for this project is being reviewed by the University of Huddersfield
      School of Human and Health Sciences - School Research Ethics and Integrity Committee (SREIC)
      and will be reviewed by a relevant NHS ethics committee. Governance approvals will be
      obtained from university and NHS Trust sites. All sessions with Participants will be held in
      adherence with the Ethical Framework for Good Practice set by the UK Council for
      Psychotherapy (UKCP).

      A British Association for Counselling and Psychotherapy (BACP) accredited psychotherapy
      supervisor will be engaged for two hours per month or one hour for every six patient sessions
      for the duration of the project to measure progress and review case work with participants if
      needed.

      Participants will receive an invitation to an initial interview to discuss participation in
      the study. An information sheet detailing the purpose, activities, outcomes, and results of
      Phase 2 will be provided, including the researcher contact details (name, phone number, email
      address). Participants will be encouraged to read the information sheet again and ask
      questions on the assessment day prior to signing the consent form. The voluntary nature of
      participation and the ability to withdraw an individual's consent at any time will be
      emphasised during the study.

      For the Phase 2 intensive interviews, all participants will be entered into a draw for a £50
      Amazon voucher. This was suggested by the lived experience group as contribution to research
      for ADHD was not considered enough of a benefit alone.

      For participants in the Phase 3 pilot study, they will receive 11 weekly sessions of
      individually focused therapeutic coaching support which is not currently accessible within
      the service. It is possible that a waitlist control design study might be an incentive for
      participants to join, as all participants in the study will eventually receive the
      intervention. However, we considered it unethical to offer a place in the study without the
      option to receive the intervention. Participants will be given a minimum of 24 hours and up
      to three days to consider participation in the study, and the researcher will be available to
      answer any questions they have.

      A critical element of this research project is the exploration and representation of the
      lived experience of adults with ADHD, and the applicability, efficacy, and accessibility of
      the results. Therefore, this project has involved a patient participation group in pre-study
      preparation before recruitment. A small group of 5-6 adults with ADHD who expressed strong
      interest in the research have reviewed and refined recruitment materials for Phase 2 and
      Phase 3, including the recruitment flyers, patient information sheets, consent forms and
      interview guide.
    

Intervention name(s): ADDapt Ability Framework
Intervention type(s): Behavioral
Intervention description(s): 12 week individual therapeutic coaching intervention
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: This is a wait list control study design with pre-, within, and post-treatment measures. A rolling entry of participants will be conducted, where once individuals have been screened their entry into the study will begin. A maximum of 30 adults aged 18+ with a confirmed diagnosis of ADHD will be allocated using block randomisation to the SDT theory-based model or wait list over a 12-week period. Following the 12-week wait, the wait list group will also be enrolled in the SDT theory-based model. This ensures all participants receive the opportunity to experience the treatment.
Masking: None (Open Label)
Primary purpose: Treatment