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Integrative Couples Group Treatment for Emerging

Adults With ADHD Symptoms
Brian T. Wymbs, Ohio University
Brooke S.G. Molina, University of Pittsburgh

Preliminary evidence suggests that adaptations of cognitive-behavioral therapy (CBT) are promising interventions for adult ADHD,
but few studies have specifically targeted emerging adults. Moreover, given that inaccurate self-appraisals are common among
individuals with ADHD, there is reason to suspect that many emerging adults with elevated ADHD symptoms may respond better to
interventions that include input from significant others. The present study tested the feasibility and acceptability of a novel program
integrating components of CBT for adult ADHD with couples therapy to treat emerging adults with clinically elevated ADHD symptoms
in the context of their romantic relationships. Fifteen couples including at least 1 emerging (18- to 35-year-old) adult with clinically
elevated ADHD symptoms participated in an open trial of this 6-session, small-group integrated intervention. Primary analyses
indicated that participant adherence to the integrated protocol was good and satisfaction ratings of the program content and delivery
were high. Exploratory comparisons of effect sizes indicated that individuals with elevated ADHD symptoms reported fewer symptoms of
inattention and hyperactivity/impulsivity following treatment, while participants with and without elevated ADHD symptoms
indicated lower relationship impairment. Partner ratings corroborated some, but not all, areas of improvement. Though more rigorous
investigations are sorely needed, preliminary findings highlight the potential utility of the integrative treatment for emerging adults with
clinically elevated ADHD symptoms.

A TTENTION-DEFICIT/HYPERACTIVITYdisorder (ADHD), a
syndrome characterized by chronic difficulties with
paying attention and managing hyperactivity/impulsivity,
is common in childhood (5.2% of international popula-
tion; Polanczyk, de Lima, Horta, Biederman, & Rohde,
2007) and in adulthood (4.4% of U.S. population; Kessler
et al., 2006). Functional deficits among children and
adolescents with ADHD are multiple (e.g., academic
underperformance, interpersonal difficulties) and well
established (Barkley, 2006). In contrast, researchers
have only recently begun to highlight the considerable
impairment associated with ADHD in adulthood, with the
bulk of the evidence collected from emerging adults
(aged 18 to 35). These studies indicate that emerging
adults with ADHD report more antisocial behavior,
substance abuse, educational and occupational difficul-
ties, hazardous driving, financial mismanagement, and
discordant interpersonal relationships than those without
ADHD (Barkley, Murphy, & Fischer, 2008). Acknowledg-
ing the prevalence and impairments of adult ADHD, and
Keywords: ADHD; CBT; couples therapy; group treatment; emerging
adults
1077-7229/14/© 2014 Association for Behavioral and Cognitive
Therapies. Published by Elsevier Ltd. All rights reserved.
its staggering cost (e.g., $20 billion lost annually by U.S.
labor force; Kessler, Adler, Ames, Barkley et al., 2005),
effective interventions for ADHD in adulthood are sorely
needed.
Treatment for Adult ADHD
Although efficacious pharmacological and psychoso-
cial treatments have been developed for children with
ADHD (Biederman & Spencer, 2008; Pelham & Fabiano,
2008), researchers are only beginning to develop and test
interventions for adults with ADHD. Most adult ADHD
treatment outcome studies have been medication trials
(Peterson, McDonagh, & Fu, 2008), with psychostimulants
being the most studied and seemingly effective option for
ADHD in adulthood. However, at least two concerns are
worth noting regarding stimulant medication treatment of
adult ADHD. First, relatively few adults with ADHD take
psychiatric medication (e.g., 14.5% to 25%; Barkley et al.,
2008; Kessler et al., 2006). Second, though evidence
indicates that stimulants may improve driving perfor-
mance of adults with ADHD (Barkley & Cox, 2007),
evidence is scarce regarding whether it reduces other
functional deficits associated with ADHD in adulthood
(Peterson et al., 2008). In light of the limited uptake and
uncertain efficacy of pharmacotherapy for adult ADHD,
research on psychosocial treatments is indicated.

Please cite this article as: Wymbs & Molina, Integrative Couples Group Treatment for Emerging Adults With ADHD Symptoms, Cognitive and
Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.06.008
2 Wymbs & Molina
Regrettably, few researchers have examined the efficacy
of psychotherapy for ADHD in adulthood. Reviews of this
small body of work suggest that adaptations of cognitive--
behavioral therapy (CBT) have the most empirical support
(Knouse & Safren, 2010; Weiss et al., 2008). CBT for adult
ADHD reviews skills to improve organization and behav-
ioral self-control as well as strategies to manage stress and
harmful cognitions perpetuating task avoidance (Ramsay,
2010). Participants in open trials (e.g., Rostain & Ramsay,
2006; Solanto, Marks, Mitchell, Wasserstein, & Kofman,
2008; Virta et al., 2008) and randomized-controlled trials
report lower overall ADHD symptoms after CBT (e.g.,
Safren et al., 2010; Solanto et al., 2010; Stevenson,
Whitmont, Bornholt, Livesey, & Stevenson, 2002; Weiss et
al., 2012). Nonetheless, these findings are limited in several
respects. First, study samples were largely comprised of
adults at later stages of development (e.g., mean age N 35 for
the controlled trials). Second, though two studies have
shown that CBT may improve clinician- and self-ratings of
overall functioning (Rostain & Ramsay, 2006; Weiss et al.,
2012), there is generally limited evidence indicating that
CBT reduces functional difficulties associated with ADHD
in adulthood. Third, despite demonstrating a lack of insight
into their deficits (Knouse, Bagwell, Barkley, & Murphy,
2005) and a tendency to underreport their symptoms
relative to secondary informants (e.g., Zucker et al., 2002),
CBT trials have yet to collect data from other informants
(e.g., romantic partners, friends) in order to corroborate
changes reported by adults with ADHD. Given these
limitations, there remains a need to further develop and
evaluate novel interventions for ADHD in adulthood,
especially among emerging adults.
Case for Treating Emerging Adults With ADHD in
Context of Romantic Relationships
A growing evidence base highlights the struggles of
emerging adulthood (Arnett, 2004). Arnett suggests that the
primary developmental milestone for emerging adults is
self-sufficiency. Emerging adults are expected to learn how
to manage a broadening array of responsibilities (e.g.,
spending within means, excelling at school/work) with
progressively less support and structure provided by their
parents. Not surprisingly, becoming self-sufficient is an
arduous task for emerging adults with ADHD. They
commonly report having more difficulties with managing
finances, achieving education beyond high school, and
maintaining employment than their peers without ADHD
(e.g., Barkley et al., 2008). In light of the notable impairment
they experience adjusting to life on their own, effective
interventions are warranted for young adults with ADHD.
There is reason to speculate that CBT may be in-
effective for many emerging adults with ADHD. In brief,
CBT requires the ability to accurately self-monitor and
Please cite this article as: Wymbs & Molina, Integrative Couples Group Treatment for Emerging Adults With ADHD Symptoms, Cognitive and
Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.06.008
self-regulate without prompting from others. Some programs
include significant others for individual or optional
sessions (e.g., Safren et al., 2010; Virta et al., 2008), but
their role in treatment is minimal. In light of their
difficulties with being self-sufficient (Barkley et al., 2008)
and recognizing when their behavior is impaired (e.g.,
Knouse et al., 2005), emerging adults with ADHD may not
be prepared to make behavioral changes on their own.
Integrating CBT with support from significant others
would seem to improve chances of a positive treatment
response.
Treating emerging adults with ADHD in the context of
their romantic relationships is an intriguing new direction
for several reasons. First, adults with elevated ADHD
symptoms are just as likely to be in romantic relationships
as those without ADHD symptoms (Barkley, Fischer,
Smallish, & Fletcher, 2006) and their partners often voice
concerns about how ADHD behavior disrupts their
relationship functioning (Robin & Payson, 2002). The
demand for services addressing the strain that adults with
elevated ADHD symptoms place on romantic relationships
is evidenced by the wide array of popular psychology books
on this topic (e.g., Hallowell & Hallowell, 2010; Orlov, 2010;
Pera, 2008). Second, if romantic partners are willing and
able to voice their concerns in the moment to adults with
elevated ADHD symptoms, they could play an important
role in helping them recognize when their behavior causes
difficulties for their relationship (and possibly other
domains of functioning). If partners of adults with elevated
ADHD symptoms highlight behaviors to change during or
in between therapy sessions, this may increase the
likelihood of their loved ones responding positively to
treatment. Third, couples therapy is an evidence-based
treatment for many mental health problems, including two
often reported by adults with elevated ADHD symptoms
(e.g., depression, substance abuse; Baucom, Whisman, &
Paprocki, 2012). Baucom and colleagues (2012) noted that
individual therapy is often ineffective when the couple is
distressed or when partners contribute to the problem.
Given studies reporting high levels of relationship dissatis-
faction in couples affected by adult ADHD (e.g., Eakin et
al., 2004) and anecdotal evidence indicating that partners
of adults with elevated ADHD symptoms enable their
difficulties by compensating for them (e.g., taking on extra
responsibilities; Eakin et al.), it seems that a couples therapy
approach to treating adults with elevated ADHD symptoms
is needed. Taken together, treating emerging adults with
ADHD in the context of their romantic relationships has
potential to be an effective intervention.
Study Aims
This study describes the results of an open trial
assessing the feasibility and acceptability of a novel,
 Novel Treatment for Emerging Adults with ADHD
small-group intervention for emerging adults with ADHD
integrating CBT for ADHD with evidence-based couples
therapy techniques. The integrated intervention was
designed for couples including emerging adults with
elevated ADHD symptoms. Fifteen couples with at least
one 18- to 35-year-old adult reporting clinically elevated
levels of inattention, hyperactivity/impulsivity, or both
participated in the trial. Given that the primary utility of
piloting novel interventions is to examine their feasibility
and acceptability (Leon, Davis, & Kraemer, 2011),
feasibility and acceptability of the integrated intervention
are the primary outcome measures examined in this
study. Feasibility was assessed by examining rates of
participant screening, recruitment and retention. Treat-
ment adherence and acceptability was examined through
collecting participant satisfaction ratings on program
content and format as well as by monitoring the degree to
which participants followed program expectations (e.g.,
arriving on time for sessions, completed homework
assignments). Though it is improper to overinterpret effect
sizes of outcome comparisons conducted as part of pilot
studies (Leon et al., 2011), we will also present preliminary
outcome results of emerging adults who received the
integrated intervention for the sake of discussion. To this
end, we explored whether individuals with elevated ADHD
symptoms reported pre- to posttreatment changes in in-
attention, hyperactivity/impulsivity, and romantic relation-
ship impairment. Change in partner-reported symptoms
and relationship impairment, as well as gender-specific
effects, were also explored.
Method
Participants
Recruitment
Participants were recruited via posting flyers on bus
stops and Craigslist.com in an urban area of western
Pennsylvania. This simple, relatively inexpensive proce-
dure netted 140 phone or email inquiries in about 1 year.
Following a brief study description, 72 callers agreed to
complete eligibility screening. Reasons for disinterest
included scheduling concerns, discomfort with group
meetings, and lack of monetary compensation. Among
those screened, 35 did not meet eligibility requirements
(i.e., 18 to 35 years of age; in a romantic relationship for at
least 6 months; no children; and, if medicated for ADHD,
agreeing to refrain from changing dose/type of medica-
tion). Among couples meeting screening criteria, 27
consented to participate and 15 presented for treatment.
The chief reason for dropout after meeting inclusion
criteria was the inability to interest partners in participa-
tion. Couples who dropped out after consenting reported
changing availability, relationships dissolving, and loss of
interest. Couples were not required to endorse relation-
ship dissatisfaction or conflict to gain entry into this study.
Please cite this article as: Wymbs & Molina, Integrative Couples Group Treatment for Emerging Adults With ADHD Symptoms, Cognitive and
Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.06.008
3
Data collected from the 15 couples with at least 1 adult
meeting study criteria for elevated ADHD symptoms and
attended the CBT group program are presented in this
study.
Diagnostic Procedures
Current symptoms of inattention, hyperactivity, and
impulsivity were measured using the World Health
Organization Adult ADHD Self-Report Scale (ASRS;
Kessler, Adler, Ames, Demler et al., 2005). The ASRS
includes 18 questions assessing each of the inattention
and hyperactivity/impulsivity symptoms listed as criteria
for ADHD in the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV; American Psychiatric Association
[APA], 1994). However, because DSM-IV criteria describe
ADHD symptoms as they present in childhood (e.g.,
“Often fails to give close attention to details or makes
careless mistakes in schoolwork, work, or other activi-
ties”), the ASRS reworded symptoms to improve face
validity of ADHD in adulthood (e.g., “How often do you
make careless mistakes when you have to work on a boring
or difficult project?”). Respondents were asked to indicate
how often they exhibit symptoms (0 = never, 1 = rarely,
2 = sometimes, 3 = often, and 4 = very often), with items
endorsed as occurring “often” or “very often” being
considered clinically significant. Responding “sometimes”
was also considered clinically significant for seven of the
ASRS items given the low base rates of these symptoms
(Kessler, Adler, Ames, Demler, et al., 2005). The ASRS has
been validated for use with emerging adults at risk for
ADHD and has demonstrated good test-retest reliability
(ICC = .84; Adler et al., 2006). A partner-report version of
the ASRS was generated for the present study. The
partner-report ASRS was created by changing “you” in
each item to “he/she” (e.g., “How often does he/she make
careless mistakes when he/she has to work on a boring or
difficult project?”).
To judge whether participants met study criteria for
clinically elevated ADHD symptoms, we used the “or"
rule. Specifically, participants who self-reported, or if their
partners reported, four or more clinically significant
symptoms of inattention, hyperactivity/ impulsivity, or
both on the ASRS met criteria for elevated ADHD
symptoms. This symptom threshold was chosen because
evidence suggests it is an appropriate cutoff for diagnos-
ing ADHD in adulthood (Barkley et al., 2008). Relatedly,
given clinical recommendations for assessing adult ADHD
(see McGough & Barkley, 2004), both self- and informant
(in this case, partner) ratings of inattention and
hyperactivity/impulsivity were collected and given equal
weight towards identifying participants with or without
clinically elevated ADHD symptoms. All participating
couples included at least one adult with clinically elevated
ADHD symptoms.
4 Wymbs & Molina

Current Sample complaints about ADHD symptoms in childhood. While only

Fifteen couples met inclusion criteria for elevated 1 of 12 women with clinically elevated ADHD symptoms was
ADHD symptoms and attended the treatment groups. ever diagnosed and treated for ADHD as a child (she was
Table 1 presents demographic data for the sample. treated with stimulant medication), 6 of the 13 men meeting
Couples were comprised of primarily young (mean age symptom cutoffs for adult ADHD were diagnosed and
of 25 years old) Caucasian adults who completed at least treated with ADHD in childhood. Three received stimulant
some years of college. Most couples were unmarried, but medication and counseling as children, 2 received stimu-
all were in committed long-term relationships. Of the 25 lants-only as children, and 1 received counseling-only as a
adults meeting study criteria for elevated ADHD symp- child. Only 2 of 12 females and 4 of 13 males with clinically
toms, most were identified by self and partner reports elevated ADHD symptoms reported receiving treatment for
(60%). Cases with clinically elevated ADHD symptoms ADHD at the time of enrollment. Both females and 2 males
were also identified by self-report only (20%) or by reported receiving stimulant medication while the remain-
partner-report only (20%). Most men and women with ing 2 males reported receiving stimulants and counseling.
elevated ADHD symptoms were identified as either
inattentive-only or inattentive and hyperactive/impulsive
in symptomatology. Surprisingly, for most (67%) of the Integrative Treatment Group for Adults With Elevated
couples, both partners had four or more clinically ADHD Symptoms
significant symptoms of inattention, hyperactivity/impul- The novel intervention under investigation in this study
sivity, or both. was designed to treat adult ADHD in the context of
Many participants with clinically elevated ADHD symp- romantic relationships. The program sought to (a) foster
toms in adulthood also reported similar difficulties as ADHD self-management skills and (b) improve interper-
children. Specifically, 6 of 12 women and 8 of 13 men sonal communication and problem-solving skills in order to
recalled peer relationship difficulties and/or parent/teacher encourage significant others to prompt/reinforce atten-
tiveness and behavioral self-control. To achieve these
goals, core components of CBT for adult ADHD (Safren,
Perlman, Sprich, & Otto, 2004) were combined with key
Table 1
Sample Demographics for 15 Participating Couples ingredients of an evidence-based relationship distress pre-
vention program (Markman, Stanley, Blumberg, Jenkins, &
Females Males Whiteley, 2004; see also Markman, Renick, Floyd, Stanley, &
Individual Variables M (SD) or % M (SD) or % Clements, 1993) to form an integrated protocol.
Average Age 24.73 (5.15) 25.07 (4.91) The integrative group program included six 1.5-hour
% Caucasian 73.33 66.67 weekly sessions. Sessions (except Week 1) began with a
% High School Graduate or GED 13.33 20.00 review of homework assigned during the previous week’s
% Partial College 40.00 33.33 session. Afterwards, the group leader (BTW) facilitated a
% 2-yr/4-yr Degree 20.00 26.67 discussion of ADHD self-management and relationship-
% Graduate/Professional Training 26.67 20.00 building skills (see Table 2 for curricula). Proper use of
% Inattentive-Only 33.33 46.67 these skills was reinforced further by demonstrations from
% Hyperactive/Impulsive-Only 20.00 6.67 the group facilitator, within-couple practice during
% Inattentive + Hyperactive/ 26.67 33.33
sessions, and homework assignments prompting at-home
Impulsive
practice. Adults not at risk for ADHD participated in all
Couple Variables M (SD) or % aspects of the integrative treatment, even ADHD self-
management skills, as it was thought that they may benefit
% Not Married, Not Living Together 46.67
from learning the same skills as their partners. Those
% Not Married, Living Together 26.67
without elevated ADHD symptoms were also prompted to
% Married 26.67
Length of Relationship (years) 2.17 (1.34)
contribute examples of times when their partners with
If living together, how long? 1.08 (.62) elevated ADHD symptoms demonstrated impairment and
(years) could benefit from employing the skills taught. Impor-
If married, how long? (years) 0.75 (.21) tantly, partners were not expected or asked to act as
% Only Male with Elevated 20.00 therapists for homework assignments. Rather, in-between
ADHD Symptoms session activities were organized around repetition of
% Only Female with Elevated 13.33 ADHD self-management and relationship-building skills
ADHD Symptoms discussed and practiced during sessions.
% Male + Female with Elevated 66.67 Notably, every session also included discussions of (a)
ADHD Symptoms
accepting differences in partner behavior as strengths of the

Please cite this article as: Wymbs & Molina, Integrative Couples Group Treatment for Emerging Adults With ADHD Symptoms, Cognitive and
Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.06.008
 Novel Treatment for Emerging Adults with ADHD 5

Table 2
Session Content for Integrative Group Program

Session ADHD Self-Management Content Relationship-Building Content

1 Psychoeducation on Adult ADHD Importance of Supportive Relationships
How ADHD Helps + Harms Relationships Ways to Defuse Big Arguments
Homework: Tracking How Often ADHD Sparks Relationship Conflict

2 Impact of Inattention on Daily Functioning Communication Obstacles

Reducing Distractibility Speaker-Listener Technique
Homework: Attention Training and Discuss How to Improve Attentiveness in Relationship

3 Impact of Anger/Stress on Daily Functioning Hidden Issues in Relationship

Deep Breathing + Progressive Muscle Relaxation Preventing Arguments
Homework: Practice Anger/Stress Management and Discuss
Rules for Problem-Solving

4 Setting up Daily Calendar/Notebook Common Reasons for Disagreements

Prioritizing Tasks Steps to Resolve Problems
Homework: Practice Using Organization Tools and Hold
Problem-Solving Discussion

5 CBT Model of ADHD Managing Relationship Expectations

Impulsive/Avoidant Thought Errors Impact of Family and Prior Relationships
Homework: ADHD Thought Monitoring and Discuss Influence
of Avoidance on Relationship

6 Challenging Impulsive/Avoidant Thinking Seeking/Granting Forgiveness

Planning Ahead for Adult ADHD Preserving Commitment

relationship and (b) tolerance of minor, inappropriate
behaviors that cannot be changed by partners. Given the
realistic possibility that certain ADHD behaviors may never
“normalize”—even with significant improvement in self--
management skills—we felt it was important to clarify that
some behavioral issues may never disappear completely. The
need for all couples, not just those including adults with
ADHD, to accept/tolerate certain “annoying” behaviors of
their partners for the sake of preserving their relationship is
highlighted. Additional related topics of discussion included
ways “to pick battles” and best practices for ignoring and/or
coping with minor, inappropriate behavior.
As stated earlier, this is a small group treatment.
Couples included in the present study were spread across
three groups. The relationship distress prevention pro-
gram adapted in this study (Markman et al., 2004) was
selected in part due to its small-group delivery. CBT for
adult ADHD has also been taught successfully in small
groups (e.g., Bramham et al., 2009; Solanto et al., 2008,
2010; Virta et al., 2008). Solanto and colleagues stated that
group-based treatment of adult ADHD is not only
cost-effective, but also enhances treatment efficacy via
group members providing support, motivation, and
constructive criticism/feedback to each other. Extending
their rationale, we believed that the power of group
processes would be accelerated in the integrative group
program due to the added dynamic layer (individuals
within couples within a group). As such, not only might
adults with and without ADHD benefit from the
contributions/support made by other members of the
group, but they also might benefit from the opportunity
to support and practice with each other during and
between sessions.
Primary Dependent Variables
Treatment Adherence
During the intervention, participant adherence to the
integrative group treatment protocol was monitored each
week by the clinician (BTW). The clinician recorded
whether or not couples attended sessions, arrived on time
for sessions, and completed homework assignments.
Treatment Satisfaction
Acceptability of the intervention was measured after the
last treatment session. Participants with and without elevated
ADHD symptoms rated how satisfied (1 = Not at all satisfied to
5 = Very much satisfied) they were with the group leader,

Please cite this article as: Wymbs & Molina, Integrative Couples Group Treatment for Emerging Adults With ADHD Symptoms, Cognitive and
Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.06.008
6 Wymbs & Molina
session content, contributions from group members, and the
overall group quality. They were given room to include
narrative comments within each section.
Preliminary Outcome Variables
ADHD Symptoms
Immediately before and after the integrated group
treatment, couples completed a battery of questionnaires
assessing ADHD symptoms and relationship impairment.
To assess change in ADHD symptoms among those
meeting with elevated ADHD symptoms, inattention and
hyperactivity/impulsivity item scores (0–3) for self- and
partner-ASRS ratings were summed and divided by 9 to
compute mean symptom levels before and after treatment.
Relationship Quality
Participants with and without elevated ADHD symptoms
reported how positive and negative they felt about their
relationship on the Positive and Negative Relationship
Quality scale (Fincham & Linfield, 1997). Respondents
were asked to rate how positive (1 = Not at all positive to 10 =
Completely positive) and how negative (1 = Not at all negative
to 10 = Completely negative) they felt about (a) qualities of
their partner, (b) feelings towards their partner, (c)
feelings about their relationship. Responses were summed
to create positive and negative relationship quality scales.
Fincham and Linfield (1997) reported good internal
consistency for both positive (α’s range from .87–.90)
and negative scales (α’s range from .89–.91). We also
assessed relationship quality from perspectives of partici-
pants with and without elevated ADHD symptoms using the
Relationship Impact Checklist (RIC; Robin & Payson,
2002). The RIC asks respondents to endorse whether (or
not) they or their partner exhibit 34 behaviors known to
spark romantic relationship discord (e.g., doesn’t respond
when spoken to, pays bills late, doesn’t remember being
told things, takes out frustrations on me). Robin and Payson
found that internal consistency for the number of issues
reported by partners with and without ADHD were
acceptable (α’s ranged from .79–.85). The total number
of problematic relationship behaviors endorsed by self- and
partner report were analyzed separately.
Analytical Design
Given the small sample size and concern for under-
powered comparisons, significance tests were not con-
ducted. Instead, we computed Cohen’s d (Cohen, 1988)
to assess the magnitude of change in ADHD symptoms
and relationship functioning from pre- to posttreatment
assessments. We acknowledge that Leon and colleagues
(2011) cautioned against computing and interpreting
effect sizes derived from pilot testing. However, to allow
the reader a better opportunity to judge the potential
utility of this program, the decision was made to provide
Please cite this article as: Wymbs & Molina, Integrative Couples Group Treatment for Emerging Adults With ADHD Symptoms, Cognitive and
Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.06.008
effect sizes for pre-post comparisons made in this study. As
recommended for repeated measures data (Dunlop,
Cortina, Vaslow, & Burke, 1996), means and standard
deviations at both time points were used to calculate effect
sizes (i.e., Mpre 1n Mpost / SDpooled). According to Cohen’s
metric, d = .20 indicates a small effect, d = .50 indicates a
medium effect, and d = .80 indicates a large effect. Effects
sizes were computed by collapsing across male and female
reports and, to explore for possible sex-specific effects,
separately by participant gender.
Results
Treatment Adherence and Satisfaction
Eleven out of 15 (73%) couples attended every session
as a couple. Two couples missed one session and 2 couples
missed two sessions. Absences usually involved one
member of the couple missing the session—only once
did both members of a couple miss a session. Seven out of
15 (47%) couples were on time or early for every session.
Every couple but one was on time or early for at least half
of the sessions. (The couple that was repeatedly late had a
scheduling conflict, forcing them to arrive 15 minutes late
every session.) Only 4 (27%) of the couples completed
every homework assignment, but 13 out of 15 (87%)
completed at least half of the assignments between
sessions. Participants were quite satisfied with the weekly
group instruction (M = 4.34, SD = .61), content (M = 4.45,
SD = .57), contributions from fellow group members
(M = 4.21, SD = .77), and the program overall (M = 4.52,
SD = .51). Participant comments also indicated their strong
approval of the group content (e.g., “The techniques for
identifying/resolving conflicts were much appreciated!”),
contributions from group members (e.g., “People were very
open with personal things and it was nice to get a new
perspective and know these things happen to other
people”), and their overall progress (e.g., “We have been
fighting less and when we do, we can recognize where we
are going wrong”).
ADHD Symptoms and Relationships Quality
Collapsing reports from females and males with elevated
ADHD symptoms, there were small treatment effects for
self-reports of inattention symptoms and medium effects
for impulsivity-hyperactivity symptoms (Table 3). Effect
sizes were in the same direction (improvement with
treatment) for partner reports of both domains, but effect
sizes were smaller. Ratings from females with elevated
ADHD symptoms indicated a large treatment effect for
inattentiveness; this effect was corroborated somewhat by
partner ratings (small effect). Ratings from males with
elevated ADHD symptoms (and their partners) indicated
no effect of treatment on their level of inattention. Both
females and males with elevated ADHD symptoms reported
medium treatment effects on hyperactivity/impulsivity at
 Novel Treatment for Emerging Adults with ADHD 7

Table 3
Mean Levels of Inattention and Hyperactivity/Impulsivity Before and After Treatment

Self-Report Report by Partner

Pre-Treatment Post-Treatment Pre-Treatment Post-Treatment
M (SD) M (SD) d [CI 95%] M (SD) M (SD) d [CI 95 %]
Inattention Combined 2.20 (.61) 1.97 (.62) .38 [.22, .55] 2.19 (.62) 2.08 (.62) .18 [.01, .35]
Female 2.28 (.57) 1.83 (.64) .76 [.59, .92] 1.92 (.72) 1.70 (.63) .33 [.15, .52]
Male 2.14 (.67) 2.10 (.60) .06 [− .11, .24] 2.44 (.40) 2.44 (.35) .00 [− .10, .10]
Hyperactivity/Impulsivity Combined 1.93 (.72) 1.56 (.80) .50 [.29, .70] 1.83 (.76) 1.60 (.72) .32 [.12, .52]
Female 1.98 (.75) 1.58 (.91) .49 [.26, .72] 1.79 (.85) 1.71 (.76) .10 [− .12, .32]
Male 1.89 (.72) 1.54 (.72) .50 [.30, .69] 1.87 (.70) 1.50 (.70) .54 [.35, .73]
Note. "Self-report” data provided by 12 females and 13 males with clinically elevated ADHD symptoms. “Report by partner” data provided by
romantic partners regarding the adults with elevated ADHD symptoms. d = Cohen’s d (.2 = small effect, .5 = medium effect, .8 = large effect;
Cohen, 1988). CI 95% = 95% confidence intervals; Combined = data collapsed across respondent gender. Data presented are average
response scores for items assessing inattentiveness and hyperactivity/impulsivity. Item response scale: 0 = never, 1 = rarely, 2 = sometimes,
3 = often, and 4 = very often (Kessler, Adler, Ames, Demler, et al., 2005).

posttreatment. Partner ratings corroborated improvement
by males, but not females.
Participants indicated no effect of treatment on
positive relationship quality (Table 4). However, they
did report less relationship negativity at posttreatment
(medium effect). The magnitude of this effect differed by
participant gender. Female ratings indicated a small-sized
treatment effect on negativity while ratings from males
indicated a medium-sized treatment effect on negativity.
Participants self-reported no effect of treatment on
behaviors associated with relationship difficulties
(Table 5). However, their partners’ ratings indicated a
small effect. Ratings from females with elevated ADHD
symptoms indicated a small effect of treatment on the
number of conflict-inducing behaviors they exhibited.
Again, partner ratings corroborated this assessment.
Males with elevated ADHD symptoms indicated no
change in the number of conflict-inducing behaviors
they exhibited. However, ratings from their partners
indicated they exhibited fewer harmful behaviors at
posttreatment (small effect).
Discussion
Empirical support for adaptations of CBT as an
intervention for adult ADHD is growing. However, little
evidence indicates that CBT is effective for emerging
adults with ADHD. Moreover, data suggest that emerging
adults with ADHD may not be developmentally prepared
to make behavioral changes on their own as expected
by CBT. We conducted a pilot study to examine the
feasibility and acceptability of a novel treatment for
ADHD in emerging adulthood that integrated CBT with
evidence-based couples therapy techniques. We were able

Table 4
Positive and Negative Relationship Quality Before and After Treatment

Pre-Treatment Post-Treatment
M (SD) M (SD) d [CI 95%]
Positive Relationship Quality a Combined 26.13 (4.11) 26.03 (3.57) .03 [− .48, .53]
Female 26.13 (4.41) 25.47 (4.31) .15 [− .57, .86]
Male 26.13 (3.94) 26.60 (2.67) -.14 [− .85, .58]
Negative Relationship Quality b Combined 13.47 (5.90) 10.57 (6.31) .47 [− .04, .98]
Female 13.13 (5.50) 11.73 (5.27) .26 [− .47, .97]
Male 13.80 (6.45) 9.40 (7.19) .64 [− .11, 1.36]
Note. Data provided by 12 females and 13 males with clinically elevated ADHD symptoms. d = Cohen’s d (.2 = small effect, .5 = medium effect,
.8 = large effect; Cohen, 1988); CI 95% = 95% confidence intervals.
a
Sum of 3 items comprising the positivity subscale of the Positive and Negative Relationship Quality Scale. Normative Median for Females = 28;
Normative Median for Males = 27 (Fincham & Linfield, 1997).
b
Sum of 3 items comprising the negativity subscale of the Positive and Negative Relationship Quality Scale. Normative Median for
Females = 10; Normative Median for Males = 11 (Fincham & Linfield, 1997).

Please cite this article as: Wymbs & Molina, Integrative Couples Group Treatment for Emerging Adults With ADHD Symptoms, Cognitive and
Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.06.008
8 Wymbs & Molina

Table 5
Frequency of Conflict-Inducing Behaviors Before and After Treatment

Self-Report Report by Partner

Pre-Treatment Post-Treatment Pre-Treatment Post-Treatment
M (SD) M (SD) d [CI 95%] M (SD) M (SD) d [CI 95%]
Combined 15.07 (6.09) 14.17 (5.77) .15 [− .36, .66] 15.31 (6.33) 12.90 (5.05) .42 [− .10, .91]
Female 14.07 (5.78) 12.67 (4.65) .27 [− .46, .98] 17.40 (5.99) 14.40 (4.76) .55 [− .19, 1.27]
Male 16.07 (6.42) 15.67 (6.51) .06 [− .66, .78] 13.07 (6.09) 11.29 (5.00) .32 [− .44, 1.06]
Note. n = 30 (15 males, 15 females), including 12 females and 13 males with clinically elevated ADHD symptoms. “Report by partner” data
provided by romantic partners regarding the adults with elevated ADHD symptoms. d = Cohen’s d (.2 = small effect, .5 = medium effect, .8 =
large effect; Cohen, 1988); CI 95% = 95% confidence intervals. Combined = data collapsed across respondent gender. Data presented are the
sum totals of the number of items endorsed (out of 34) on the Relationship Impact Checklist, which lists behaviors commonly associated with
relationship discord (Robin & Payson, 2002).

to recruit 15 couples to participate in three treatment
groups in 1 year using simple and inexpensive methods.
Attendance and retention were excellent, and high
satisfaction ratings suggested that participants liked the
integrated intervention content and the group format. A
preliminary exploration of outcome data indicated that
emerging adults with elevated ADHD symptoms reported
lower levels of inattention and hyperactivity/impulsivity,
while participants with and without elevated ADHD
symptoms reported a reduction in relationship negativity.
Partner ratings corroborated some, but not all, areas of
improvement. In sum, results from this open trial
highlight the feasibility, acceptability, and potential utility
of the integrative group program for emerging adults with
clinically elevated ADHD symptoms.
To have 15 couples attend the integrated group
intervention without any dropouts underscores the feasi-
bility and acceptability of this program. Moreover, it was
equally impressive that an inexpensive recruitment strategy
(i.e., posting flyers on bus stops and Craigslist.com)
advertising a couples group for individuals with ADHD
resulted in over 140 callers with interest in the program.
That said, the fact that only slightly more than 10% of
individuals who called with interest in the integrated
intervention ended up completing it underscores the
need to consider how we can improve recruitment and
treatment delivery. For example, a number of callers were
unable to meet the weeknights the group was scheduled to
occur. Given that many young couples do not have much
shared time in early evening hours due to school or work
obligations, offering the program during lunch hours, on
weekends, or online with video chat technology are
intriguing alternatives. A common reason for folks being
excluded from this trial was having children. As emerging
adults with ADHD tend to get pregnant at younger ages
than emerging adults without ADHD (Flory, Molina,
Pelham, Gnagy, & Smith, 2006), we are planning to adapt
the integrated intervention to address concerns faced by
young parents. Finally, in light of a number of interested
callers having a difficult time convincing their partner to
join the group, future recruitment efforts will include
attempts made to contact their partners directly in order to
have a conversation with them about potential barriers and
treatment expectations with hopes that will improve rates of
partner engagement.
Participant attendance and treatment satisfaction
ratings support the palatability of the integrative group
program for emerging adults with elevated ADHD
symptoms. For a population characterized by its forget-
fulness and inconsistent motivation, especially at this
age, it was striking that no couples dropped out of
treatment, that both members of most (73%) couples
attended every session, and that all but one couple
arrived on time or early for at least half of the sessions.
Though our homework compliance results were less
impressive, rates of homework completion were similar
to those reported by clinical trials for other psychopa-
thologies (e.g., substance use; Carroll, Nich, & Ball,
2005). Treatment adherence and acceptability data are
limited in studies of psychosocial treatment for adult
ADHD. Virta and colleagues (2008) indicated very few
treatment dropouts (1 out of 30) and good attendance
(participants attended 86% of sessions) for their CBT
program. Solanto et al. (2008) reported eight dropouts
(79% sample retained), with 50% of treatment com-
pleters attending every session, 40% missing one or 2
sessions, and the remainder missing three or more.
However, neither study reported the level of engage-
ment (e.g., timeliness, homework completion) or par-
ticipant satisfaction with their programs. Three
randomized clinical trials (Safren et al., 2010; Solanto
et al., 2010; Weiss et al., 2012) also reported low attrition,
but no study indicated the level of participant atten-
dance, engagement, or treatment satisfaction. Given the
dearth of adherence and acceptability data reported by
prior studies of CBT for adult ADHD, it is difficult to
assess the relative significance of our findings. Still, our
results underscore the ability of the integrative group
program to engage emerging adults with clinically
elevated ADHD symptoms and their partners.

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 Novel Treatment for Emerging Adults with ADHD
Though caution should be taken when interpreting
treatment effects observed in pilot studies (Leon et al.,
2011), effects of the integrative group program on ADHD
symptoms and relationship impairment are worth discuss-
ing briefly. The participants with elevated ADHD symptoms
reported lower levels of inattention and hyperactivity/
impulsivity after the integrative group program. The
positive effects of treatment on self-reported ADHD
symptoms, particularly hyperactivity/impulsivity, are com-
parable to effects reported in prior open trials of CBT for
adult ADHD (e.g., Solanto et al., 2008; Virta et al., 2008).
The effect size similarity is especially noteworthy when
considering that the integrative group program was much
briefer (6 sessions x 90 min/session = 540 min) than
therapies tested in the other open trials (800–1440 min).
However, longer CBT programs for adult ADHD tested in
randomized clinical trials (e.g., Safren et al., 2010; Solanto
et al., 2010) found larger effects on self-reported ADHD
symptoms than those found in this study. Further refine-
ment of the integrative group intervention (e.g., including
more content for inattentiveness) may be necessary to
improve its impact on ADHD symptoms.
After treatment, participants reported less relation-
ship negativity, and partners reported that their
significant others exhibited fewer conflict-inducing
behaviors. While preliminary, this is one of a small
group of studies to find positive effects of treatment in a
core domain of functional impairment for individuals
with elevated ADHD symptoms (for others, see Barkley
& Cox, 2007; Rostain & Ramsay, 2006; Weiss et al.,
2012). Acknowledging the deleterious impact of ADHD
symptoms on adult romantic relationships (e.g., Bieder-
man et al., 2006; Canu, Tabor, Michael, Bazzini, &
Elmore, 2014; Kessler et al., 2006; Wymbs et al., 2012),
finding effects of the integrative group program on
romantic relationships is encouraging. Improvement in
relationship functioning may be valuable because it could
facilitate romantic partners continuing to compensate for
the difficulties of adults with elevated ADHD symptoms
(Eakin et al., 2004). Of course, finding a change in
relationship functioning was not surprising given that
treatment included evidence-based, relationship-building
skills (Baucom et al., 2012). Future studies are needed to
investigate whether the integrative intervention facilitates
improvement in other areas of functioning impaired in
emerging adults with ADHD (e.g., managing finances,
substance use).
Interestingly, we found that partners corroborated
many, but not all, areas of improvement reported by the
participants with elevated ADHD symptoms. For example,
partners agreed that males with elevated ADHD symptoms
exhibited fewer symptoms of hyperactivity/impulsivity after
treatment. Conversely, partners of females with elevated
ADHD symptoms did not corroborate their self-reported
Please cite this article as: Wymbs & Molina, Integrative Couples Group Treatment for Emerging Adults With ADHD Symptoms, Cognitive and
Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.06.008
9
improvement in hyperactivity/impulsivity. Although many
studies of CBT for adult ADHD have included clinician
assessments of functioning, only two studies have relied on
assessments from significant others. Virta et al. (2008) found
that significant others failed to notice improvement in
ADHD symptoms that adults with ADHD reported. In
contrast, Solanto and colleagues (2010) found that
significant others corroborated posttreatment gains
reported by adults with ADHD. Given the somewhat
unreliable self-perceptions of adults with ADHD (e.g.,
Knouse et al., 2005; Zucker et al., 2002), gathering evidence
from significant others is important to judge observable
effects of treatment.
Though preliminary data for the integrative group
program are encouraging, several factors limit generaliz-
ability of these findings. First and foremost, the lack of a
control group is an important limitation of this study.
There is reason to believe that recruitment feasibility and
participant satisfaction ratings may have differed without
a control condition or random assignment to condition
(Leon et al., 2011). It also makes it impossible to conclude
that preliminary symptom change findings were direct
result of treatment (rather than from the passage of
time). Future studies will need to compare feasibility,
acceptability, and outcome data of participants in the
integrative protocol group versus those in a waitlist group
or an active treatment control group (e.g., self-help,
stimulant medication). Second, the small sample size
limited the analysis to examination of effect sizes, and the
limited sample size resulted in wide-ranging confidence
intervals for many of these effects. As such, readers should
take caution before overinterpreting these results, partic-
ularly those of gender-specific comparisons. Larger trials
of this program will allow for more confidence to be
placed in effect sizes as well as for traditional significance
tests to be conducted. Third, no follow-up data were
collected. In order to justify the efficacy of the integrative
group treatment, investigators will need to show long-
term maintenance of gains beyond assessments conduct-
ed immediately after treatment. Fourth, participants with
elevated ADHD symptoms were not required to have
ADHD diagnoses or receive treatment for ADHD as
children, though many did. As such, like many treatment
outcome studies to this point (e.g., Solanto et al., 2008;
Virta et al., 2008), the generalizability of results discussed
herein may only extend to the population sampled. Fifth,
couples with children were excluded. Additional sessions
that include parent management training may be needed
for couples with children. Future studies may also benefit
from incorporating enhanced recruitment procedures to
engage more couples affected by ADHD as well as from
more objective measures of behavior change (e.g., reports
from boss, observational coding) to rule out potential
biases.
10 Wymbs & Molina
Our pilot study explored the feasibility, acceptability,
and preliminary efficacy of the integrative group program
for ADHD in emerging adulthood. Although results were
not consistent across all measures, we generally found
positive effects of the program. Coupled with high rates of
participation and satisfaction, these preliminary results
were encouraging and suggest that treating emerging
adults with elevated ADHD symptoms in the context of
romantic relationships is a possible new direction for
future research on treatments for this population.
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Please cite this article as: Wymbs & Molina, Integrative Couples Group Treatment for Emerging Adults With ADHD Symptoms, Cognitive and
Behavioral Practice (2014), http://dx.doi.org/10.1016/j.cbpra.2014.06.008