Journal of Psychopathology and Behavioral Assessment (2020) 42:500–518

https://doi.org/10.1007/s10862-020-09794-8

Psychological Treatments in Adult ADHD: A Systematic Review

Tim Fullen 1 & Sarah L Jones 1,2 & Lisa Marie Emerson 3 & Marios Adamou 4

Published online: 18 March 2020

# Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder, characterized by symptoms of
inattention, hyperactivity and or impulsivity. First line treatment is medication; however, medication alone may not provide
sufficient functional improvement for some patients, or be universally tolerated. A recent surge in research to treat ADHD using
non-pharmacological interventions demands a comprehensive, systematic review of the literature. The aim of this review was to
examine the evidence base for psychological treatments for ADHD management in adulthood. A systematic search of PsycINFO,
MEDLINE, CINAHL, AMED, PubMed, and EMBASE was undertaken until January 2019 for peer-reviewed articles exploring
psychological interventions for adults (18 years with no upper limit) diagnosed with ADHD. A total of 53 papers were identified
for inclusion. Collectively, 92% of studies (employing various non-pharmacological interventions) found a variant of significant
positive effect on either primary or secondary outcomes associated with ADHD. The strongest empirical support derived from
Cognitive Behavioral Therapy interventions. In addition, findings indicated support for the effectiveness of Mindfulness,
Dialectical Behavior Therapy and Neurofeedback. Other types of interventions also demonstrated effectiveness; however,
support was limited due to lack of available research and methodological rigor. Psychological interventions should be considered
a valid and useful addition to clinical practice. Implications and areas for future research are discussed.

Keywords Adult ADHD . Non-pharmacological . Hyperactivity . Inattention . Psychological intervention . Clinical psychology

Introduction
Attention-deficit/hyperactivity disorder (ADHD) is one of the
most common neuropsychiatric conditions with a pooled
worldwide prevalence estimated at approximately 5% in
school-aged children, with persistence of impairing symptoms
in adulthood in up to 65% of cases. The pooled estimated
prevalence of ADHD in adults is approximately 2.5%
(Thapar and Cooper 2016). ADHD is characterized by a per-
sistent and impairing pattern of inattention and/or hyperactiv-
ity/impulsivity that causes significant impairment to daily liv-
ing (American Psychiatric Association (APA) 2013). Along
* Sarah L Jones
sarah.jones1@swyt.nhs.uk
1
South West Yorkshire Partnership NHS Foundation Trust,
Wakefield, UK
2
Manygates Clinic, Belle Isle Health Park, Portobello Road,
Wakefield WF1 5PN, UK
3
Griffith University, Mount Gravatt, Australia
4
University of Hudderfield, Huddersfield, UK
with these three main behavioral symptoms, ADHD also com-
monly presents with deficits in executive functions, emotion
regulation, and motivation alongside other secondary symp-
toms (Asherson et al. 2016). Many adults with ADHD who
are accustomed to their lifelong symptoms have a limited
awareness of how ADHD adversely affects their life. Some
report higher symptoms but lower impairments or vice versa,
which often affects diagnostic accuracy and requires individ-
ually focused diagnosing and holistic treatment plans.
Secondary problems associated with ADHD that must be con-
sidered in treatment strategies may include difficulties with
timekeeping which can subsequently effect maintaining em-
ployment, alongside issues with addiction or anger. Social and
relationship difficulties are often reported, also sleep-onset
insomnia, amongst others (please see Asherson et al. 2016;
Fields et al. 2017; Kolar et al. 2008; Weiss et al. 1999 for
further discussion).
Further to this, best evidence suggests ADHD is a hetero-
geneous condition, known to be highly co-morbid with a
range of other conditions (Jarrett and Ollendick 2008;
Jensen et al. 2001; Jensen et al. 1997; Nigg 2006). For in-
stance, as many as 81% of people diagnosed with ADHD will
also meet criteria for a substance abuse, anxiety, depressive
J Psychopathol Behav Assess (2020) 42:500–518
disorder or other mental health concern (McGough et al.
2005). This high comorbidity is one of the reasons why the
diagnosis of adult ADHD can be difficult and on occasion
missed in clinical practice (Jacob et al. 2007).
In terms of treatment options, pharmacological intervention
is the primary line of treatment for adult ADHD (NICE 2018).
Medication is safe and effective, with 70% of patients
reporting improvement compared to 7% of controls (Fields
et al. 2017; Spencer et al. 2001). As a consequence, this is
perhaps the reason that the majority of research has tended to
focus on the efficacy of the different classifications of medi-
cations available rather than non-pharmacological interven-
tions (Fredriksen et al. 2013; Mészáros et al. 2009;
Ravishankar et al. 2016; Wilens et al. 2001). Subsequently,
for clinicians wanting to employ psychological interventions,
such as Cognitive Behavioral Therapy (CBT) for example,
they have a more limited evidence base when compared with
interventions available for mood and anxiety disorders for
instance (Sprich et al. 2012). This is an interesting concern
for the field of adult ADHD, as in a review of practice guide-
lines, Gibbins and Weiss (2007) found considerable agree-
ment amongst Western practice guidelines that a shared care
approach, which includes medication and some form of
psychoeducation, along with follow-up procedures, is widely
recommended. The problem, they suggest, is that these best
practice guidelines are based on clinical consensus rather than
evidence. Nevertheless, the most recent UK guidelines from
the National Institute for Health and Care Excellence ( 2018)
advise psychological interventions are recommended for
symptom reduction in adult ADHD. They suggest considering
non-pharmacological treatment for adults with ADHD diag-
nosis when patients (i) do not wish to take medication (ii) have
difficulty adhering to it, or (iii) when medication is not effec-
tive. These guidelines are reflective of the growing conversa-
tion surrounding promoting the importance a more multidis-
ciplinary approach to the management of adult ADHD
([REMOVED]; De Crescenzo et al. 2017), rather than focus-
ing on medication. The recent NICE (2018) guidelines are a
welcome addition to the conversation, however, notably the
NICE Guidelines only report studies which met a narrow
search protocol, by including only Randomized Controlled
Trials (RCTs), matching the protocol used for medicines,
which precluded the identification of all available published
literature.
The current review aims to consider the wider evidence
base, a full consideration of the literature investigating psy-
chological interventions for adult ADHD, in order to develop
a narrative that considers the potential usefulness of fully in-
corporating psychological treatments in ADHD management.
Recent years have witnessed an upsurge of studies exploring
the efficacy of non-pharmacological treatments of adult
ADHD. Several reviews exist which have attempted to repre-
sent the current status of the knowledge for non-
501
pharmacological treatments. One of the earliest reviews un-
dertaken by Jadad et al. (1999) reviewed the evidence for
pharmacological versus non-pharmacological interventions,
concluding that pharmacology is consistently more effective
than non-pharmacological management. Whilst useful, this
review is now out-of-date. Davidson (2008) offered a review
in which all methods of assessment and treatment for adult
ADHD were considered. However, it could be argued that the
lack of a systematic method resulted in a superficial review.
Knouse & Safren (2011) reviewed CBT based interventions
for adult ADHD; however, this review was also limited as it
did not have remit to consider different forms of psycho-social
treatments. More recently Vidal-Estrada et al. (2012) conduct-
ed a review in which they included all forms and modalities of
talking therapies. This review is the most inclusive to date and
included RCTs, controlled, and non-controlled research.
Nevertheless, it excluded potentially rich sources of data such
as studies which focused on secondary symptoms of ADHD
and data provided by adults below the age of 19. In addition,
Estrada et al. (2012) did not utilize a comprehensive and in-
clusive methodology. Young et al. (2016) conducted a system-
atic review and meta-analysis on the efficacy of CBT for
adults with ADHD, concluding moderate to large effect sizes
supporting the efficacy of CBT. Whilst Young’s et al. (2016)
review is a welcome addition to the literature; it is limited in its
approach to the question of the efficacy of psychological in-
terventions for ADHD for two main reasons. Firstly, it in-
cludes only RCTs, and secondly it is specific only to CBT.
Lopez et al. (2018) conducted a Cochrane systematic review
of CBT interventions for adult ADHD; they concluded ‘low
quality’ evidence from RCTs that suggests CBT treatments
may be of benefit for ADHD in the short term only. Again,
whilst welcome, this review was strict within its scope. Lee
et al. (2017) conducted a systematic review looking at
mindfulness-based interventions for different age groups.
They concluded mindfulness-based interventions were effi-
cient in improving attention; however, this was only based
on five studies, and focused on primary ADHD symptoms
only. De Crescenzo et al. (2017) conducted the most recent
review of treatments for adult ADHD, finding that evidence
for the effectiveness of non-pharmacological interventions is
only at a preliminary stage; that when compared with pharma-
cological treatments, much more empirical evidence is re-
quired before support for the efficacy of psychological inter-
ventions is yielded. The accelerated rise in research exploring
psychological interventions for the management of ADHD in
adulthood is welcome and requires an up to date comprehen-
sive review.
Here, we report the findings from a systematic review of
the research for psychological interventions for treatment of
ADHD in adulthood. A broad definition of psychological
treatment is employed to include a range of therapeutic
models (e.g. CBT, 3rd wave approaches), cognitive and
502
behavioral interventions, including those delivered by a
trained therapist, self-help and technology-assisted.
Method
Inclusion Criteria
Quantitative reports of psychological interventions for adults
with ADHD where outcome measures have been obtained
were included. Criteria stipulated that studies appear in peer-
reviewed journals in English language. Case studies are ex-
cluded. Due to the relative infancy of research on psycholog-
ical treatment for adult ADHD, studies of controlled and non-
controlled design are included here. No time limits were ap-
plied to the search parameters.
ADHD is a multidimensional construct represented by
core/primary symptoms yet commonly accompanied by sec-
ondary problems affecting the individual’s mental state, life-
style or social functioning (Rucklidge et al. 2007; Bachmann
et al. 2018). Therefore, this review considers all outcomes
relating to primary symptoms of ADHD, as well as psycho-
social outcomes that capture secondary impacts of ADHD.
Studies may or may not include follow-up of various lengths.
For the purposes of the review, adulthood is defined from
18 years old with no upper limit. Participants must have met
diagnostic criteria for ADHD confirmed either by clinical as-
sessment, or as reported using a cut off on at least one recog-
nized diagnostic tool. Participants could also report any co-
morbidity commonly associated with ADHD (e.g. bi-polar);
however, any diagnosis that might take precedent (e.g.
moderate-severe intellectual disability) was excluded here.
Data Extraction
Where reported, the following data were extracted from each
article: author, year, country, participant demographics (num-
ber of participants, attrition, gender, and age), design of study,
conditions, interventions, and main findings (including signif-
icance value, and effect size).
Search Strategies
The following terms were used for medical condition (OR)
across databases: attention deficit OR ADD OR adhd OR
addh OR adhs OR AD/HD OR HKD OR hyperkin* OR hy-
per-kin* OR hyperactiv* OR hyper-activ*. An exhaustive list
of search terms was employed for intervention including;
structured psychological treatment programs delivered as
self-help, individual or group therapy, technology-assisted in-
terventions, and digital technology interventions (see appen-
dix 1 for full list).
J Psychopathol Behav Assess (2020) 42:500–518
In order to identify relevant primary studies, databases ger-
mane to the research area (PsycINFO, MEDLINE, CINAHL,
AMED, PubMed, and EMBASE) were searched. Final
searches were conducted in January 2019. In addition, hand
searches of published systematic reviews, and of key journal
publications were undertaken. Finally, following the application
of the inclusion criteria, citation searches concluded the search.
Study Quality Assessment
The study quality was assessed using a standardized quality-
rating tool. The Downs and Black (Downs and Black 1998)
method provides a framework for assessing the quality of ran-
domized and non-randomized trials. The quality rating check-
list considers the following areas: (i) reporting (ii) external va-
lidity, (iii) bias, (iv) confounding variables, and (v) power. Four
of the five subscales demonstrated high internal consistency
and the quality index correlates highly with existing standard-
ized appraisal tools for assessing randomized studies (r = .90).
Papers rated as poor quality were included in data extrac-
tion as our primary search objective was of including all avail-
able research. Poor quality papers were notably limited in the
quality of reporting and internal validity due to lack of con-
trolling for confounding variables. Out of a maximum score of
27, classified as excellent were 23–27, good 19–22, fair 14–
18, and poor <14. Quality was assessed independently by two
authors; any uncertainty of rating was discussed with other
authors in order to achieve a consensus and agree a score.
Whilst quality rating was useful in giving an overall evalua-
tion of the literature, it was not a used as an exclusion criterion.
More than 20,000 results were identified through database
searching, along with 59 papers through other methods such
as hand searching. Of these, when duplicates were removed
>15,000 results remained. Results were screened, determining
396 results as inappropriate. This left 94 articles to assess for
eligibility using PICOS methodology, 41 of which were ex-
cluded for reasons cited in Fig. 1. Finally, 53 studies were
included in this systematic review.
Results
In terms of quality rating, 13.2% of papers included in the
review were rated excellent, 39.6% good, 35.8% fair, and
11.3% were rated poor. The median quality score was 20, with
a range of 11 to 26.
In terms of the psychological approach reported in the stud-
ies included here; the most common was CBT (including both
group and individual sessions) with 23 studies (Anastopoulos
et al. 2018; Bramham et al. 2009; Cherkasova et al. 2016;
Cole et al. 2016; Corbisero et al. 2018; Dittner et al. 2018;
Emilsson et al. 2011; Hiltunen et al. 2014; Hirvikoski et al.
2015; LaCount et al. 2015; Nasri et al. 2017; Pettersson et al.
J Psychopathol Behav Assess (2020) 42:500–518 503

Fig. 1 PRISMA flow diagram

(Moher et al. 2009) Records identified through Additional records identified
database searching through other sources
(n = >20,000) (n = 59)

Records after duplicates removed

(n = >15,000)

Records screened Records excluded

(n = 490) (n = 396)

Full-text articles Full-text articles

assessed for eligibility excluded, with reasons
(n = 94) (n = 41)
Age criterion = 4
Comorbidity criterion = 2
Intervention criterion = 18
Studies included in the Outcome criterion = 5
systematic review Population criterion = 6
Study design = 6
(n = 53)

2017; Ramsay and Rostain 2011; Rostain and Ramsay 2006;
Safren et al. 2005a, 2005b, 2010; Salakari et al. 2010; Stern
et al. 2014; Vidal et al. 2013; Virta et al. 2008; Weiss et al.
2012; Young et al. 2015, 2017) followed by Mindfulness ap-
proaches with 9 studies (Bachmann et al. 2018; Bueno et al.
2015; Edel et al. 2017; Gu et al. 2018; Hepark et al. 2015;
Hoxhaj et al. 2018; Janssen et al. 2018; Mitchell et al. 2017;
Schoenberg et al. 2014) and Dialectical Behavioral Therapy
(DBT) with 8 studies (Cole et al. 2016; Edel et al. 2017;
Fleming et al. 2015; Hesslinger et al. 2002; Hirvikoski et al.
2011; Morgensterns et al. 2016; Nasri et al. 2017; Philipsen
et al. 2007). Neurofeedback (NFB) with 5 studies (Cowley
et al. 2016; Mayer et al. 2016; Mayer et al. 2012;
Schönenberg et al. 2017; Zilverstand et al. 2017),
Psychoeducation approaches with 3 studies (Hoxhaj et al.
2018; Salomone et al. 2015; Vidal et al. 2013),
Hypnotherapy with 2 (Hiltunen et al. 2014; Virta et al.
2015), Metacognitive therapy with 2 (Solanto et al. 2010;
Solanto, Solanto et al. 2008), CogMed training with 2
(Dentz et al. 2017; Mawjee et al. 2015), Cognitive remedia-
tion therapy with 1 (Stevenson et al. 2002), Goal management
training with 1 (In de Braek et al. 2017), Psychotherapy with 1
(Philipsen et al. 2007), Self-directed psychosocial intervention
with 1 (Stevenson et al. 2003) and, Stress management train-
ing with 1 study (Langer et al. 2013).1
1
Studies may be listed in more than once, if the study explored more than one
intervention.
Discussion
The development of an evidence-based narrative surrounding
the value of psychological interventions for adult ADHD is
imperative for comprehensive ADHD management.
Psychological treatments that are effective and reliable will
enable clinicians to carefully manage adult ADHD within a
flexible, informed approach. Continuing to build this narrative
will allow knowledge of a range of treatment options that can
work alongside psychostimulants, or instead of them. Such a
narrative can offer patients a holistic approach to their condi-
tion and potentially fit in with their treatment preference and
any expectations they might have of their care.
With psychological treatments being the mainstay of inter-
ventions in mental health, collecting, synthesizing and pre-
senting the evidence base relating to ADHD is necessary, as
not only will this help clinicians identify the modalities which
they can apply in practice, it will also allow researchers to
identify where further research is required. Currently, psycho-
logical interventions as applied to adulthood ADHD can only
fairly be characterized as nascent, as the total of the studies
which met inclusion criteria, here, was quite small (n = 53).
Yet promisingly, half of the studies included here were rated
good or excellent using the Downs and Black (1998) quality
rating system, suggesting these findings can surely influence
the narrative pertaining to the evidence base for use of psy-
chological treatments.
This review suggests that whilst a variety of different psy-
chological interventions have shown significant improvement
504
of ADHD symptoms (please refer to Table 1), it was CBT,
Mindfulness, DBT and (cautiously) Neurofeedback, that have
the most empirical support, establishing themselves as poten-
tially effective interventions for primary and/or secondary out-
come measures of ADHD in adulthood.
Cognitive Behavioral Therapy
It is useful to be reminded that CBT is a generic term
encompassing a range of approaches (Grazebrook and
Garland 2005). A unifying theme of this approach is a focus
upon cognitive restructuring and changing maladaptive be-
havioral strategies underpinning and maintaining psychologi-
cal distress. CBT can also be distinguished by its structured
approach which includes agenda setting, reviewing progress,
content and setting of tasks between sessions. This structure
was primarily devised with the intention of treating affective
disorders however it has been adapted to treat a range of other
conditions including the primary and secondary symptoms of
ADHD using a modular approach (Young and Bramham
2012). In terms of the CBT studies included in this review,
more than half of the papers reported that CBT was adminis-
tered in a group format; with most CBT studies reporting
effectiveness of intervention. An important consideration is
that whilst there was much heterogeneity in the studies in
terms of content, approaches included various modules rele-
vant to living with a diagnosis of ADHD, involving objectives
such as goal attainment, interpersonal skills, coping strategies,
problem solving, cognitive restructuring, distraction avoid-
ance and motivation. A focus on executive functioning such
as organization, time management and planning was also a
theme. Frequently, manuals by Safren (Safren et al. 2005b),
or the R&R2ADHD program (Young and Ross 2007) were
employed or adapted to meet specific objectives of the indi-
vidual studies. Regardless of the approach, most studies under
review found CBT to be an effective intervention on vari-
ous primary (inattention, hyperactivity/impulsivity) and
secondary (psychosocial) outcome measures. Most studies
had control groups (or other interventions as control
groups) with a relatively high sample number adding to
the quality of their findings. Collectively CBT studies with
varying design quality demonstrated a high rate of positive
effect and taking heed from the highest quality rated stud-
ies in this review, a confident picture surrounding the use-
fulness of CBT approaches in adult ADHD emerges. This
narrative is in line with previous works which suggested
that CBT is an effective intervention for the management
of ADHD (Jensen et al. 2016; Knouse et al. 2017; Lopez
et al. 2018). Whilst this is a positive step forward, our
findings however suggest that although there is evidence
to support the efficacy of CBT, a unified approach to its
delivery has not been settled.
J Psychopathol Behav Assess (2020) 42:500–518
Mindfulness
Mindfulness is underpinned by the core principles of accep-
tance, present moment awareness and self-compassion devel-
oped through a process of meditation. The emphasis of a
mindfulness approach is on the experiential process. The ori-
gins of mindfulness stem from Buddhist practices, however in
recent years it has been secularized and used in a variety of
forms in mental health services (Mind 2018). In terms of
mindfulness interventions, all the studies included in this re-
view were in group setting using a variation of the Mindful
Awareness Practices (MAP) approach (Kabat-Zinn 1990;
Segal, Segal et al. 2002; Zylowska 2012). Each study reported
positive effects on primary symptoms of ADHD, with the
exception of one (Mitchell et al. 2017) who reported positive
effects for ADHD symptoms but not on secondary measures
of executive function. Eight out of nine studies had a control
group (or other interventions as control), however a design
weakness here was that only three out of nine studies included
follow-up analysis, so we cannot confidently determine if the
positive effect lasted beyond the period of intervention. The
positive effect of mindfulness reported here, supports previous
reviews which have found mindfulness-based approaches to
be an effective intervention for ADHD (Aadil et al. 2017;
Cairncross and Miller 2016).
Dialectical Behavioral Therapy
The five DBT studies under review employed group interven-
tions as opposed to individual courses, and all studies reported
a significant positive effect of DBT on core symptoms of
ADHD. This cognitive behavioral psychotherapy model was
devised for use in group settings with a view to helping those
suffering with emotional dysregulation and relationship diffi-
culties. DBT shares characteristics with CBT in that it encour-
ages awareness and change of maladaptive thought and be-
havioral processes but also employs the use of mindfulness
and acceptance principles. The DBT approach was originally
designed to be run in weekly groups of 2–3 h with individual
support in between sessions. Of the studies under review here,
adaptations and additions to manuals by Linehan (1993) and
Hesslinger (Hesslinger et al. 2004) were frequent. Whilst, this
intervention group included two RCTs, samples were relative-
ly small and whilst we found support for DBT’s positive in-
fluence, this is not based on best evidence. Improving sample
size to provide better statistical power in these studies would
be a welcome addition to the narrative here. Another concern
is the non-specific confounding effects of group interaction
and controlling for this in future studies would be an important
step. Nevertheless, DBT positions itself as a potentially useful
psychotherapeutic approach, albeit requiring additional
research.
Table 1 Characteristics of the studies included in the review

First author, Participant details Intervention (type, mode of delivery, Design Main findings (effect size if reported) Quality rating
year, country no. of sessions, duration)
n Attrition Female Mean
% % age

Anastopoulos, 106 16,9 59.1 20.2 CBT (Group program + individual Open clinical trial, pre and post Pre and post: significant reductions in IN symptoms (d = −.78), HI 20 (good)
2018, US sessions [ACCESS]), 8 phases, assessment. symptoms (d = −.83), behavior regulation (d = .64),
tapered over 4 years) metacognition (d = .66), and declines in anxiety (d = .42) and
depression (d = .34) symptoms.
Improvements in IN (d = .83), HI (d = .43), behavioral regulation
(d = .64), metacognition (d = .58), anxiety (d = .58) and
depression (d = .35) remained stable 5 to 7 months after active
treatment concluded.
Bachmann, 74 54.09 55 40.13 Mindfulness v Psychoeducation (as Randomized controlled trials. Pre Pre and post: significant reduction in ADHD symptoms* 20 (good)
J Psychopathol Behav Assess (2020) 42:500–518

2018, controls) (8 weeks, 2.5 h per week) and post. (CAARS) for both conditions post treatment. Decrease in
Germany self-rated memory problems post treatment for mindfulness
condition*. See paper for neurobiological results.
Beuno, 2015, 60 – 50 29.6 Mindfulness v control Non-randomized controlled trial, Treatment v control: NS difference between groups on affective 17 (fair)
Brazil (Group program [MAP], 2.5 h sessions pre and post assessment. ratings, QOL and attentional measures.
+ homework, 8 weeks) Pre and post change: ASRS inattention***, HI***; BDI*
(g = −.07); STAI-T* (g = .08); PANAS on (negative affect**
(g = −0.7); positive affect*** ( = 1.3); sadness* ( = −0.6);
joviality* ( = 0.7); self-assurance*** ( = 0.9);
attentiveness* ( = 1.0); fatigue* ( = −0.8); serenity* ( =
0.8); shyness*** ( = −1.0); fear*** ( = −0.5).
Bramham, 61 32.8 34.4 33 Group CBT v controls (6 sessions Non-randomized controlled trial, Treatment versus control: Treatment group showed significantly 15 (fair)
2009, UK & (across 3 one day workshops held pre and post assessment. greater improvement on knowledge about ADHD*.
Ireland monthly for 3 months). Pre and post change: for HADS anxiety and depression variables,
main effect of time but not group for anxiety** and
depression**. Self-esteem improved for both groups**, but
significantly greater for the treatment group*. Self-efficacy
improved for those who had received CBT**.
Cherkasova, 88 27.3 29.5 34.63 Group CBT + M v CBT (1.5 h group Un-blinded randomized controlled CBT + M group showed greater improvements compared to the 20 (good)
2016, sessions plus individual coaching trial. Pre, post, 3 and 6 month CBT group on self-reported ADHD symptoms** (d = .99),
Canada sessions, 12 weeks). follow up. observer-rated ADHD symptoms* (d = .64) organizational
skills** (d = 1.02) and self-esteem** (d = .67). Group
differences were ns after follow-up.
Groups did not differ in effects of global functional impairment
(SDS, BDI, BAI, SCL – 90, GSI, AXI).
Cole, 2016, 62 14.3 46.8 37.8 Psychotherapy (CBT/DBT) v controls Non-randomized controlled. Psychotherapy group showed significant improvements in all the 13 (Poor)
Switzerland (Individual and group sessions, Baseline, 3 months, 6 months dimensions*, most significant changes where demonstrated for
weekly, 12 month period) and post. BDI-II*** (d = .85), ASRS*** (d = .63) and KIMS AwA***
(d = .61).
Ns differences between groups.
Corbisiero, 50 4 44.2 32.05 CBT + M v M + SCM (12, 120 min Randomized controlled trial. Pre, Ns differences between treatment and controls. 22 (good)
2018, sessions over 10–12 weeks) post and follow-up assessment.
Switzerland
Cowley, 2016, 54 3.7 53.7 36.1 Randomized controlled trial. Pre Ns between treatment and controls on TOVA performance. 24 (excellent)
Finland and post assessment.
505
Table 1 (continued)
506

First author, Participant details Intervention (type, mode of delivery, Design Main findings (effect size if reported) Quality rating
year, country no. of sessions, duration)
n Attrition Female Mean
% % age

Neurofeedback v controls (~40 h long Treatment group demonstrated higher reduction of inattention*
sessions 2 to 5 times per week over and HI* compared to controls.
2–4 months)
Dentz, 2017, 55 20 49.1 41.7 CogMed training v controls (Mean Randomized controlled. Pre × 2, Time main effect was significant on verbal WM (DS)** for both 25 (excellent)
France session time of 42 min, 5 times per post assessment and 6 months groups. Main effect of group x time was reported for treatment
week, for 5 weeks) follow up. group only** (d = .06). Improvements continued to follow
up** (d = .63). Ns effect of group.
Letter sequencing task also demonstrated improved scored for
both groups**. Main effect of group x time for treatment
group** (d = .83) for visuospatial WM, plus at follow-up**
(d = .71). Ns effects for WM and EF in daily life or ADHD
symptoms.
Dittner, 2018, 60 23.3 25 35.9 CBT v controls (15 sessions over Proof of concept randomized Treatment group improved relative to controls on the CSS at post 26 (excellent)
UK 30 weeks. Plus follow up session at controlled trial. Pre, post treatment*** and both follow-ups**. Treatment group also
42 weeks) (30 weeks) and 42 weeks. showed significantly different scores on the WSAS compared
to controls at post treatment** and at 30 week follow-up**.
See paper for secondary outcomes.
Edel, 2017, 91 – 39.6 35.3 Mindfulness v DBT skills group (2 h Open study. Non-controlled, Treatment comparison: Ns differences by group. 18 (fair)
Germany sessions for 13 weeks) non-random assignment to one Pre and post change: WRI total score*, mindfulness* and
of two treatments, pre and post. self-efficacy* for both groups.
Emilsson, 54 26 63 33.8 CBT + M v M as controls (15 session Randomized controlled trial. Pre, ITT analysis. Ns differences between groups at end of treatment 22 (good)
2011, integrated manualized group and post and 3 month follow up on CGI, BAI, BDI, RATE-S. CBT + M had lower scores
Iceland individual program) compared to controls on inattention scale* (d = .94),
hyperactivity* (d = .32), BCS** (d = .76) antisocial scale*
(d = .84). At 3 month follow up: CBT + M group lower scores
on inattention* (d = 1.14); hyperactivity** (d = 0.58); BCS***
(d = 1.08); BAI* (d = 0.83); BDI* (d = 1.32); RATE-S
(d = 1.08); RATE-E* (d = 1.12); social functioning scale*
(d = 1.24); antisocial scale* (d = 0.89).
Fleming, 33 6 42.5 21.4 DBT skills group v skills hand-out Randomized controlled trial. Pre, Treatment comparison: DBT group showed greater treatment 20 (good)
2015, US (90 min sessions, 8 weekly post assessment and 3 month response; BAARS*** (ES = .55); BAADS*** (ES = .94);
sessions) follow up. AAQOL** (ES = .90).
3 month follow up: DBT group showed greater treatment
response; BAARS* (ES = .09); BAADS** (ES = .15);
AAQOL** (ES = 0.10).
Gu, 2018, 54 3.70 44.4 20.3 MBCT v controls (1 h weekly sessions Randomized controlled trial. Pre, MBCT showed an overall trend toward lower ADHD inattentive 20 (good)
China (+ homework)for 6 weeks) post assessment and 3 months. Symptoms** and greater improvement than controls on HI. At
follow-up, 71% of treatment group showed recovery compared
to 31% of controls*. Main effects of time on BDI (anxiety)*.
Main effect of group on MAAS at post treatment** (d = 1.06)
and follow-up** (d = 1.03). Treatment group also
demonstrated better performance on neuropsychological
tasks* (see paper for detail).
103 17 54.4 35.9 MBCT v controls (12 week program) 22 (good)
J Psychopathol Behav Assess (2020) 42:500–518
Table 1 (continued)

First author, Participant details Intervention (type, mode of delivery, Design Main findings (effect size if reported) Quality rating
year, country no. of sessions, duration)
n Attrition Female Mean
% % age

Hepark, 2015, Preliminary randomized controlled Treatment v control: treatment had less ADHD symptoms on
Netherlands trial CAARS-INV** (d = .39) and CAARS-S** (d = .78).
Improved on BRIEF-ASR** (d = .43–.93) and KIMS*
(d = 0.54). Depression/anxiety/patient function showed ns.
Moderation analysis showed improvement was independent of
medication.
Hesslinger, 18 38.9 27.8 32.3 DBT skills group (13, 2 h sessions over Non-randomizes assignment to one Treatment group showed improvement on BDI (p = 0.05, 18 (fair)
2002, 3 months) of two conditions, pre post ES = 99); ADHD-CL** (ES = 2.22); SCL-16* (ES = 1.35);
Germany assessment. VAS** (ES = 2.09); selective* and split attention*.
J Psychopathol Behav Assess (2020) 42:500–518

Hiltunen, 17 – 64.7 35.6 CBT v hypnotherapy (10 weekly Randomized controlled trial. Pre, Treatment comparison: Both treatments brought significant 21 (good)
2014, individual sessions) post, 3 and 6 month follow up. improvements on ADHD scale*. Greater improvements in
Finland hypnotherapy; SCL-90* (ES = .21), BDI-II* (ES = .18) and
SCL-16 (trend).
Post, to 3 and 12 months follow up: SCL-90 Time x Group
interaction*. Greater maintained gains in hypnotherapy;
anxiety* (ES = .28) and depression* (ES = .18).
Hirvikoski, 51 20 59.2 38.9 DBT skills group v discussion group as Randomized controlled trial. Pre, Treatment comparison: significant reduction on the ADHD 22 (good)
2011, controls (14, 2 h sessions) post, 3 and 12 month follow up. symptom scale* (d = .57) in the DBT group only. Participants
Sweden in both groups reported increased well-being*** (d = .53).
Follow up: participants in skills training more able to cope with
their deficits after treatment* (d = .67). After completion of
treatment, the skills training group scored higher on education*
(d = .78) and mindfulness* (d = .67).
Hirvikoski, 108 21.3 37.6 37.6 CBT psychoeducation group program Single treatment condition, pre and Pre, post and follow up: improvements on ADHD 20 15 (fair)
2015, (8, 2.5 h sessions) post and 6 month follow up. questions*** (ƞ2 = .20), BDI** (ƞ2 = .09), BAI* (ƞ2 = .06) and
Sweden perceived stress scale* (ƞ2 = .06).
Hoxhaj, 2018, 81 – 49 39.5 Mindfulness v psychoeducation Randomized controlled trial. Pre, Both groups showed improvement on the inattention scale*** 22 (good)
Germany (8 weeks. 2.5 h sessions [+ 8 weeks, 8 months. and all subscales*. Ns differences between groups on all core
homework]) symptoms.
In de Braek, 27 – 37 36.7 Goal management training with Controlled (cohort study). Random Treatment group improved on CIBIS/C cognition* relative to 18 (fair)
2017, psychoeducation v psychoeducation assignment. Pre, post, follow-up controls. Ns effects of group on CIBIS/C general. Time effects
Netherlands only as controls (12 [1 individual, 11 at 12 and 24 weeks. of SCL-90**, CFQ*** and zoo planning time*, ns effects of
group], 2 h sessions for 12 weeks) group. Ns differences at follow-up.
Janssen, 2018, 120 – 53 39.35 MBCT + TAU v TAU (8 weeks, 2.5 h Single-blind, randomized ITT analysis: both MBCT + TAU groups showed a reduction of 24 (good)
The sessions [+ homework]) controlled trial. Pre, post, 3, clinician-rated ADHD symptoms at post-treatment (d = .41).
Netherlands 6 month follow-up. This effect was maintained at 6-month follow-up. More MBCT
+ TAU (27%) than TAU participants (4%) showed a ⩽30%
reduction of ADHD symptoms. MBCT + TAU patients
compared with TAU patients also reported significant
improvements in ADHD symptoms, mindfulness skills,
self-compassion and positive mental health at post-treatment,
which were maintained until 6-month follow-up. MBCT +
TAU reported no improvement in executive functioning at
post-treatment.
507
Table 1 (continued)
508

First author, Participant details Intervention (type, mode of delivery, Design Main findings (effect size if reported) Quality rating
year, country no. of sessions, duration)
n Attrition Female Mean
% % age

LaCount, 17 29.4 64.7 25.4 Combined individual and group CBT Non-controlled single treatment Pre and post: significantly lower scores post-treatment for 17 (fair)
2015, US (12 sessions, weekly) group, pre and post. inattention* (d = .93), but not hyperactivity (ns). Significant
improvements in school* (d = .51) and work* (d = .63)
functioning scales, but not life-skills/self-concept scales (ns).
Langer, 2013, 18 5.55 61.1 34.4 Stress management training group (1 Single treatment group, pre and Pre and post: Excessive demands at work**, chronic worry 15 (fair)
Germany per week for 4 weeks, 3 h each) post. mean***, chronic stress**
Mawjee, 2015, 97 28 58 23.9 CogMed WM training (computerized) Randomized controlled study. Pre, Pre and post: WAIS-IV: DS forwards standard** and shortened* 21 (good)
Germany (Three conditions: (i) 45 min post, 3 month follow-up. length, DS backwards standard** and shortened** better at T2
session (ii) 15 min session (iii) compared to controls. Ns difference between treatment groups.
WLC. 25 sessions, 5 days per week DS sequencing score: Standard length treatment* group did
for 5/6 weeks) better than shortened length and controls. Ns differences
between shortened length treatment and controls.
CANTAB spatial span forwards: standard*** and
shortened** length did significantly better than controls.
Ns differences between training groups. CANTAB spatial
span backwards: At T2 standard* and shortened* length did
better than controls. Ns differences between training groups.
WRAML forward: standard length did significantly better
than the shortened group* and controls***. Ns differences
between shortened treatment and controls. WRAML
backward: standard** length did significantly better than
controls. Ns differences between shortened and standard and
shortened and controls.
Improvements maintained at 3 months*
BOLD = Significant at Bonferroni correction
Mayer, 2016, 24 20.8 37.5 33.3 Neurofeedback (30 sessions. Non-controlled. Pre and post Pre and post: Improvements on all measures: ADHD symptoms*, 14 (fair)
Germany ~25 weeks, including a 3 week assessment. depression* and anxiety* and Go NoGo performance*).
break)
Mayer, 2012, 18 – 38.9 27.6 Neurofeedback (1–3 times per week Comparison of treatment and Treatment comparison: Difference between controls the ADHD 11 (poor)
Germany for 1 h, over 15 weeks) control, pre and post. group (d = −.84) in contingent negative variation*.
Pre and post: Neurofeedback brought increase of the CNV mean
amplitude from T1 to T2 (d = −.62). ADHD symptoms*
(d = −.73), inattention* (d = −.56) and impulsivity* (d = −.60).
Mitchell, 22 9.1 55.6 38.4 Mindfulness v controls (8 week Pilot. Controlled. Stratified and Relative to controls, treatment group improved on ADHD: 16 (fair)
2017, US program, weekly group therapy randomized. Pre and post. (self-report) inattention** (d = 1.66), HI** (d = 1.76),
(2.5Hours + homework). (clinician) inattention*** (d = 3.14), HI** (d = 1.35),
functioning (self-report)** (d = 1.66), (clinician)** (d = 1.52).
EF: DFES (total) (self-report)** (d = 1.45)*(clinician)***
(d = 2.67). BREIF-A (total)** (d = 1.55). Emotion
dysregulation: DERS (total)** (d = 1.63). Distress tolerance
scale*: (d = 1.27). Ns improvement for direct measures of
executive functioning.
See paper for subscale analysis
98 20 68.4 37.4 16 (fair)
J Psychopathol Behav Assess (2020) 42:500–518
Table 1 (continued)

First author, Participant details Intervention (type, mode of delivery, Design Main findings (effect size if reported) Quality rating
year, country no. of sessions, duration)
n Attrition Female Mean
% % age

Morgenstern, DBT skills group (14 weekly 2 h Single treatment group, pre, post, Pre and post: Barkley current ADHD symptom scale***
2016, sessions) 3 month follow up. (ES = 0.20); functional impairment*** (ES = 0.19); aggression
Sweden and irritability*** (ES = 0.16); BDI*** (ES = 0.14); PSS*
(ES = 0.08); KSQ** (ES = 0.10); SSD** (ES = 0.15);
MAAS** (ES = 0.12); AAQoL* (ES = 0.97).
Post to 3 month follow up: Barkley current ADHD symptom
scale*** (ES = 0.22); functional impairment*** (ES = 0.15);
aggression and irritability mean [trend] (ES = 0.06); BDI**
(d = 0.08); KSQ** (ES = 0.12); SDS** (ES = 0.11); MAAS**
J Psychopathol Behav Assess (2020) 42:500–518

(ES = 0.14); AAQ* (ES = 0.15); AAQoL** (ES = 0.17).

Nasri, 2017, 18 16.67 44 39.7 Combined cognitive and dialectical Uncontrolled pilot study. Pre, post Pre, post and follow up 1 and 6 months: 14 (fair)
Sweden behavior therapy (14 week and follow up at 1 and 6 months. Primary outcomes: ASRS improved** (d = 1.29) and remained
program, 3 h weekly session) stable after 6 months. Secondary outcomes: Improvements on
ADHD-RS* (d = 1.46), MADRS-S* (d = .45), PSS-4*
(d = .72), SDS* (d = .76), DERS* (d = .87).
Pettersson, 45 – 64.4 37.4 Internet based cognitive behavioral Randomized controlled trial. Pre, ITT analysis: significant reduction in ADHD symptoms for the 20 (good)
2017, therapy v controls (solo treatment - post, 6 month follow up. iCBT-S group in comparison with controls at post-treatment;
Sweden 10 computer modules minimum of between-group effect size (d = 1.07). The result was
10 days apart. Group - computer maintained at 6-month follow-up. Ns effects on secondary
modules 10 weekly 3 h sessions) outcomes.
Philipsen, 419 – 47.5 35 Psychotherapy v controls (12 weekly Randomized controlled trial. Pre, Pre to 12 weeks: Symptoms decreased more in patients assigned 16 (fair)
2015, sessions of group psychotherapy or 12, 24, 52 weeks, 2.5 years to methylphenidate group ES = −0.81 compared to placebo on
Germany individual counselling. Followed by the ADHD Index score ES = −0.50**. Ns difference between
10 monthly sessions over 52 weeks) groups beyond methylphenidate and placebo. Follow up: No
significant differences between groups at follow up, results
stable.
Philipsen, 72 8.3 40.3 35.8 DBT group (13, 2 h weekly sessions) Single treatment condition, pre, Pre to follow up: Significant differences before and after 16 (fair)
2007, post, 3 months. treatment*** (ES = 0.67); ADHD-CL*** (ES = 0.41);
Germany SCL-90-R*** (ES = 0.21); BDI*** (ES = 0.31); VAS***
(ES = 0.47).
Ramsey, 2011, 5 – 20 36.6 CBT (16 individual sessions across Single condition, pre and post. Pre and post: BADDS-Total* (ES = .83); BADDS-Activation* 12 (poor)
US 6 months, 50 min each) (ES = .54)
Rostain, 2006, 43 – 25.6 30.8 CBT (16 individual sessions across Single condition, pre and post. Pre and post: BADDS Total*** (ES = 0.9); BADDS 15 (fair)
US 6 months, 50 min each) Activation*** (ES = 0.82); BADDS Attention** (ES = 1.06);
BADDS Effort*** (ES = 0.72); BADDS Affect***
(ES = 0.47); BADDS Memory*** (ES = 0.70); CGI-A***
(ES = 1.29); CGI*** (ES = 1.08).
Safren, 2010, 86 7.2 44.2 43.3 CBT v relaxation with education (12 Randomized controlled trial. Pre, Treatment comparison: CBT better ADHD rating scale** 22 (good)
US weekly sessions of 50 min) post, 6 and 12 month. (d = 0.60) and Clinical Global Impression scale scores*
(d = 0.53) compared to relaxation.
Follow up: Ns difference when examining the post-treatment,
6-month and 12-month follow-up assessment CBT group
maintained gains.
31 – 50 45.5 18 (fair)
509
Table 1 (continued)
510

First author, Participant details Intervention (type, mode of delivery, Design Main findings (effect size if reported) Quality rating
year, country no. of sessions, duration)
n Attrition Female Mean
% % age

Safren, 2005, CBT (+M) v controls (+M) (15 weekly Randomized controlled trial. Pre Primary outcome: CBT lower independent-evaluator-rated scores
US sessions) and post assessment. on the ADHD rating scale** (ES = 1.2) and overall
CGI-severity** (ES = 1.4) at post-treatment, Secondary: CBT
lower on Hamilton Depression Scale** (ES = .65); Hamilton
Anxiety Scale* (ES = .55), and self-ratings on the BAI*
(ES = .43).
Salakari, 2010, 29 13.8 52 31 CBT (group, 11 weekly sessions) Single condition, pre, post, 3 and Main effect of time at post treatment, BAADS*,(ES = .13), 19 (good)
Finland 6 month. SCL-16 symptom elevation 3 months after the treatment*
(ES = .21), elevation ns at 6 months. Fewer symptoms at
3 months*(ES = .17) and 6 months* (ES = .23), SCL-16 at
each time point, main effect of time* (ES = .16), treatment
group fewer symptoms at 6 months** (ES = .37).
Salomone, 51 27.5 29.4 32.2 Self-alert psycho-education and Randomized controlled trial. Pre, CAARS: Significant time group interaction for Impulsivity and 23 (excellent)
2015, biofeedback (2 training session 1 h post, 3 months assessment. Emotional Liability* (ES = 0.12), time group effect for
Ireland 20 min, 20 min of biofeedback and problems with Self Concept** (ES = 0.16), significantly lower
10 min of computerized exercises, scores in the SAT group compared to controls* and at 3 month
5 days out of 15, for 5 weeks) follow up*. Time group interaction was found for ADHD
Index** (ES = 0.22); lower scores in SAT group –training **
and 3-month follow up**. Psychological functioning: time
group interaction for the GSES* (ES = 0.16). Higher
self-efficacy scores compared to controls after training**, and
3 month follow up**. Time group effect for BDI* (ES = 0.13),
lower depression in SAT than controls at post-training*** and
3-month follow up**.
Schonenberg, 113 4.2 42.4 43.4 Neurofeedback (three conditions: 30 Triple blind randomized controlled All treatment groups improved significantly on CAARS between 25 (excellent)
2017, sessions of NFB over 15 weeks / 15 trial. Pre, during treatment pre-treatment and 6 months regardless of condition***.
Germany sessions of sham NFB over 8 weeks, post treatment after
15 weeks / metacognitive therapy 16 weeks and 6 months.
group received 12 sessions over
12 weeks)
Schoenberg, 50 12 46 36.7 Mindfulness based cognitive therapy v Randomized controlled trial. Pre Behavioral variables: Main effect of condition for task***. 17 (fair)
2014, controls (12 weekly, 3 h sessions) post. Pre-post, false alarms means**; correct* and reaction time* for
Netherlands Single condition, pre and post. No-Go.
Clinical effects: CAARS-SV, main effects of group*. Reduced
inattention***, HI*** and global ADHD index***.
Mindfulness: main effect of domain* and time-group***
interaction, reflected mindfulness skills for all domains in the
MBCT group pre-to-post; ‘observe’*, ‘act-with-awareness’
*** and ‘act-without-judgement’*. Ns changes in the WL
group.
Solanto, 2010, 88 26.5 29 41.5 Meta-cognitive therapy group therapy Randomized controlled trial. Pre Treatment comparison: MCT group; AISRS-IN*** 20 (good)
US v supportive group as controls and post. AISRS-TMOP***; Conners-Observer-IN* compared to
(12 week program) controls.
J Psychopathol Behav Assess (2020) 42:500–518
Table 1 (continued)

First author, Participant details Intervention (type, mode of delivery, Design Main findings (effect size if reported) Quality rating
year, country no. of sessions, duration)
n Attrition Female Mean
% % age

Pre and post: Improvement on AISRS-IN*, AISRS-TMOP*,

Conners-Observer-IN*, Brown-Total*, BRIEF-A*, Metacog*
and ON-TOP*.
Solanto, 2008, 38 21 57.9 41.8 Meta-cognitive therapy groups (2 h Single treatment condition, pre and Improvements on: CAARS-S:L DSM-IV subscales; Inattentive** 12 (poor)
US sessions for 8 or 12 weekly) post assessment. (ES = .588), BADDS Total score*** (ES = .669),
Activation*** (ES = .595), Attention*** (ES = .558),
Effort*** (ES = .591), Affect*** (ES = .449), Memory***
(ES = .527), ON-TOP *** (ES = .615).
Stern, 2014, 60 35 56.7 37.2 CBT (computerized) (12 weeks, 4–5 Randomized controlled trial. Pre Treatment comparison: Ns time group interaction indicating both 21 (good)
J Psychopathol Behav Assess (2020) 42:500–518

Israel times per week for 20 min) and post assessment. groups benefitted. Only significant difference between groups
on Sustained attention* (d = 0.38).
Pre and post treatment group significant findings: Total ASRS**
(d = 1.07), BRIEF-A** (d = 0.65), BRIEF-A MI** (d = .97),
COPM** (d = .77).
Stevenson, 35 – 37.1 39.9 Self-directed psychosocial intervention Randomized controlled trial. Pre, No significance values reported. Clinical significance assumed in 16 (fair)
2003, (Three therapist led sessions, post and 2 months. event of 33% drop in symptoms. Improvements in treatment
Australia self-help book, and access to support group from pre to 2 month follow up on ADHD symptoms
workers) mean 111.9 to 67; organizational skills mean 84.1 to 66.1; trait
anger mean 23.1 to 18.8.
Stevenson, 43 – 32.6 35.9 Cognitive remediation therapy (8, 2 h, Randomized controlled trial. Pre, Significant treatment effects for treatment compared to control, 13 (poor)
2002, weekly sessions) post, 2 and 12 months. pre and post, all ADHD symptoms*, org skills*, state anger*,
Australia trait anger*. One year follow up: treatment improvements on
ADHD symptoms* (d = 1.4), organizational skills* (d = 1.2),
anger* (d = 0.5).
Vidal, 2013, 32 18.8 46.9 39.5 Psychoeducation v CBT (2 h, 12 Randomized controlled trial. Pre Treatment comparison: Ns effect of group. Both groups showed 21 (good)
Spain weekly sessions over 3 months) and post assessment. reductions on all outcomes. Pre and post: ADHD-RS**
(d = .12); CAARS inattention* (d = .15); hyperactivity**
(d = .19); impulsivity* (d = .32); self-esteem* (d = .12); CGI-S
self-report** (d = .32); clinician** (d = .34); QLESQ*
(d = .33); STAI-S** (d = .35) and BDI* (d = .10).
Virta, 2015, 58 – 74.1 28.5 Hypnosis and hypnotic suggestions Controlled trial. Pre and post Significant test condition × group interaction in mean reaction 13 (poor)
Finland (30 min session followed by a hypnosis, after suggestions, and times on CPT*. ADHD group were slower in reaction times*
continuous performance test) after study.
Virta, 2008, 29 – 48.3 31 Cognitive–Behaviorally Oriented Single condition. Assessment Three months before treatment to post: Reduction in BADDS 16 (fair)
Finland Group Rehabilitation (1.5–2 h, 11 3 months before treatment, pre activation**, affect mean*, total mean*, SCL-16*.
sessions weekly) and post.
Weiss, 2012, 48 30.5 20 35.6 CBT with M v CBT without M (9 Randomized controlled trial. Pre, Both groups showed improvements in outcome measures. Within 23 (excellent)
US & weekly individual sessions, booster 15 and 20 weeks. participant effects of time: ADHD RS-Inv*** (ES = 1.1) at
Canada sessions week 15 and 20) 15 weeks and maintained at 20 weeks. SDS*** (ES = 0.5) at
15 weeks, (ES = .44) at 20 weeks.
Young, 2017, 95 60 65.3 35.2 CBT + M v Treatment as usual Randomized controlled trial. Pre, CBT + M showed greater improvement on all scales (combined 22 (good)
Iceland (TAU) + M (15, 90 min sessions, post, 3 month follow-up. scores from BL to FU) RATE-S (total)*** (d = .54) RATE-S
twice weekly for 8 weeks) symptoms*** (d = .55), RATE-S emotional control**
(d = 0.32), RATE-S antisocial scale** (d = 0.50), RATE-S
511
Table 1 (continued)
512

First author, Participant details Intervention (type, mode of delivery, Design Main findings (effect size if reported) Quality rating
year, country no. of sessions, duration)
n Attrition Female Mean
% % age

social functioning (d = .41). Overall effect of time (post v

3 month follow up) (adjusted for baseline, group, age,
emotional control scale) showing a steady improvement. CGI
also correlated with RATE-S scores at BL, PT and FU** except
antisocial scale at PT and social functioning at FU.
Young, 2015, 95 47.9 65.3 35 CBT + M v TAU + M (15, 90 min Randomized controlled trial. Pre, Ns differences between group except that TAU+M had lower 25 (excellent)
UK sessions) post, and 3 month follow up. BCS HI**. Overall effect of time: BAI* (d = 0.58), BDI*
(d = 0.52) and QOL* (d = 0.56).
Zilverstand, 13 – 53.5 36.9 fMRI neurofeedback training (4 Randomized. Single blind study. Both groups had significant activation levels between 2nd and 3rd 22 (good)
2017, weekly training sessions, 60 min) Pre and post treatment training session with levels remaining high until end of
Netherlands assessment. training*. Better ability to inhibit response* and higher
accuracy on WM tasks*, predicted improvement over sessions
in NFB group only*.
Pre and post: both groups demonstrated improvement on MSIT*.
NFB group only showed improvements on SA-DOTS* and
2-back WM*.

AAQOL , ADHD quality of life questionnaire; ADHD, attention deficit hyperactivity disorder; ADHD-RS, ADHD rating scale; AXI, angry expression; ASRS, ADHD severity; index; BAADS, Brown ADD
rating scales; BAARS, Barkley adult ADHD rating scale–IV; BAI, Beck anxiety inventory; BDI, Beck depression inventory; BHS, hopelessness; BL, baseline; BREIF-ASR, behavior rating inventory of
executive function- adult self-report version; C, controls; CAARS-INV, Conners’ adult ADHD rating scale investigator rating version; CAARS-S, Conners’ adult ADHD rating scale self-report version;
CBT , cognitive behavior therapy; CBT+ M, cognitive behavioral therapy with medication, CGI, clinical global impression; CIBIC, clinician’s interview-based impression of change; CIBIS/C, clinician’s
interview-based impression of severity/change; QLESQ CSS, adult Barkley current symptom scale; DERS, difficulties in emotion regulation scale; DS, digit span; FU, follow-up; fMRI, functional magnetic
resonance imaging; GSI, symptom checklist 90 of the global severity index; HADS, hospital anxiety and depression scale; HI, hyperactivity-impulsivity; ITT, intention to treat analysis; KIMS, mindfulness
skills; MAAS, mindful attention and awareness scale; MADRS-S, Montgomery-Asberg depression rating scale (self-report version); MSIT, multi source interference task; NFB, neurofeedback; NS, non/no
significant/significance; PANAS, positive and negative affect schedule; PSS-4, perceived stress scale-4 item version; PT, post treatment; QoL, Quality of life enjoyment and satisfaction questionnaire; RATE-
S, see https://www.psychology-services.uk.com/resources.htm#resource-9; RCT, randomized controlled trial; SA-DOTS, sustained attention dots task; SCL – 90, symptom checklist - 90; SCM, standardized
clinical management; SDS, Sheehan disability scale; STAXI, anger expression and control; T, treatment; TOVA, test of variables of attention; VAS, visual analogue scale; WM, working memory; WSAS, work
and social adjustment scale; WAIS-IV digit span, Wechsler adult intelligence scale 4th edition digit span; WRAML, wide range assessment of memory and learning; WRI, adult ADHD Wender-Reimherr
interview; WM, working memory; 2-back WM, 2-back working memory task
*p < 0.05 **p < 0.01 ***p < 0.001 d = Cohen’s effect size, g = Hedge’s effect size
J Psychopathol Behav Assess (2020) 42:500–518
J Psychopathol Behav Assess (2020) 42:500–518
Neurofeedback
Whilst this review finds support for the effectiveness of NFB
interventions, we remain tentative in our inferences as to its
usefulness. NFB remains a controversial approach, with some
suggesting it is (as yet) too experimental to be considered a
valid intervention for Adult ADHD (Arns et al. 2009). All
NFB studies reported positive effect however Zilverstand
et al. (2017) reported discordant results, finding positive ef-
fects on cognitive functioning, but not clinical outcomes.
Moreover, Schönenberg et al. (2017) in one of the highest
quality rated studies included in this review, found sham feed-
back produced the same improvement as true feedback. With
this in mind, we suggest that before any inferences are made
on the usefulness of NFB, more research is required to estab-
lish long term effectiveness of approach on core symptoms of
ADHD and generalizability beyond task. This is somewhat in
line with a review by Moriyama et al. (2012) which found
positive results for the effectiveness of NFB for ADHD, but
the level of support decreased when higher quality studies
were considered separately. Whilst support is evident, we pro-
pose that we are unable to suggest NFB is a beneficial inter-
vention in the same manner as CBT or mindfulness and that
more robust research is required in this area.
Due to the small number of studies and varying design
quality, we can only cautiously suggest interventions such as
psychoeducation, meta-cognitive therapy, self-alert training,
group therapy, hypnosis, etc., (see Table 1) as demonstrating
usefulness in reducing primary or secondary symptoms of
adult ADHD. We suggest that these interventions need further
consideration (e.g., randomization, blinded design) before ef-
ficacy can be justly considered. However, what is interesting
here is the observation that for those studies that have com-
pared two interventions (e.g., intervention as control), findings
show improvement in ADHD symptoms, whether primary or
secondary, from baseline to post treatment, yet differences
between conditions are less frequent (e.g., Bachmann et al.
2018; Bueno et al. 2015; Edel et al. 2017; Hiltunen et al.
2014; Hoxhaj et al. 2018; Vidal et al. 2013). Therefore, it
seems there may be other variables which account for the
change beyond the approach of the intervention. Future re-
search should consider this.
Strengths and Limitations
This review employed board nonetheless stringent inclusion
criteria, alongside a consideration of a wide variety of study
designs. At the time of writing, we believe this to be the most
comprehensive review of the literature on psychological inter-
ventions for adult ADHD. However, whilst this review is con-
fident in its inferences, it must be acknowledged that there are
potential limitations in its conclusions that should be acknowl-
edged. Firstly, this review included only peer-reviewed
513
studies. This could potentially restrict the research available
to review. Secondly, many the studies included in the review
employed relatively small sample sizes, and furthermore, a
number were flawed with methodological weaknesses; it is
proposed here that this may limit the inferences we are able
to establish. Moreover, we did not include meta-analyses; this
was inappropriate due to the variation in study designs under
review. Another issue to consider is the ‘file drawer’ phenom-
ena (Rosenthal 1979); a term coined to reference the notion
that researchers are often less likely to publish research that
has not demonstrated a significant effect, therefore resulting in
a publication bias (Kühberger et al. 2014). It is possible that
this review would be limited in its conclusions due to this
phenomenon; however, the level (or relevance) of this poten-
tial issue is unknown here. Another point of contention relates
to the idea of clinical versus statistical importance.
Ranganathan et al. (2015) suggest that the term ‘clinical im-
portance’ and ‘statistically significant’ are often used inter-
changeably, yet they are, in fact, entirely different concepts.
In this sense, it should be acknowledged that the conclusions
here are based on statistical significance, and relevance to
clinical application is assumed.
Here, we have grouped interventions based on what we
deemed was their main approach, however we must acknowl-
edge the heterogeneous nature of the studies included in the
review, and that the overlap within interventions reported here
is large; therefore, making categorizing interventions for the
purpose of evaluation a somewhat difficult task. Lee et al.
(2017) also addresses this issue when suggesting that
mindfulness-based approaches (for example) are often very
different and studies require a clearer protocol to enable strin-
gent evaluation of their usefulness. Further research that looks
in-depth at the efficacy of standardized approaches is
warranted.
Concluding Remarks
This review summarizes the psychological approaches that
have been used in treatment of adult ADHD. It highlights that
the quality of studies is on average good, although their num-
ber and scope could be considered limited. Also, there is het-
erogeneity in the design, and most were conducted in group
settings. Nevertheless, here, we find support for the use of
psychological interventions in the treatment of ADHD in adult
populations. Collectively, 92% of studies (employing various
non-pharmacological interventions) found a variant of signif-
icant positive effect on either primary or secondary outcomes
associated with ADHD. Psychological interventions should
be considered a valid and useful addition to clinical practice.
This review calls for a continuation into the effectiveness of
various psychological interventions with robust methodolog-
ical approaches. If the evidence base for psychological inter-
ventions continues to grow, there is a potential to improve
514
approaches to treatment and subsequently and most impor-
tantly, patient experience of adult ADHD.
Future Directions
This systematic review highlights important implications for
future research in the area of psychological interventions in
Adult ADHD in both individual and group settings. Having
reviewed a wide variety of interventions we found that the
majority demonstrated an improvement in primary ADHD
outcomes. At the same time, the need for a more research
has also come to light; the results from other interventions
under review here are interesting and encouraging.
Also, an important consideration for future research is that
many of the papers implemented approaches that take differ-
ent elements from various manuals and psychoeducation pro-
grams. These are subsequently adapted for individual research
objectives, but it may be useful for research purposes in the
future, to ensure fidelity to the intervention model tested.
A further, key recommendation is that there are more stud-
ies focusing on long-term outcomes rather than including pre
and post measures and short-term follow-ups only. This would
also help with evaluating the economic impact of these inter-
ventions compared to medication.
Compliance with Ethical Standards
Conflict of Interest Tim Fullen, Sarah L Jones, Lisa Marie Emerson and
Marios Adamou declare that they have no conflict of interest.
This research did not receive any specific grant from funding agencies
in the public, commercial, or not-for-profit sectors.
Statement of Human Rights The nature of this review is retrospective.
Informed consent was not necessary, in line with our institution. This
article does not contain any studies with human participants performed
by any of the authors.
Statement on the Welfare of Animals This article does not contain any
studies with animals performed by any of the authors.
Appendix 1
(Boolean search, truncation or wildcards were adapted to each
database)
(attention deficit OR ADD OR adhd OR addh OR adhs OR
AD/HD OR HKD OR hyperkin* OR hyper-kin* OR
hyperactiv* OR hyper-activ* OR inattent* OR impuls*)
1. AND (psycho* AND (treatment$ OR therapy OR training
OR approach OR program* OR technique OR intervention).
2. AND “psycho* treatment$” OR “psycho* therapy” OR
“psycho* training” OR “psycho* approach” OR “psycho*
program*” OR “psycho* technique” OR “psycho*
intervention”.
3. AND (psychoeducation OR psycho-education).
J Psychopathol Behav Assess (2020) 42:500–518
4. AND “social skills”.
5. AND “behavio*r modification”.
6. AND (“cognitive behavio*r*” OR cognitive-behavio*r*).
7. AND (cognitive (treatment$ OR therapy OR training OR
approach OR program* OR technique OR intervention)).
8. AND “cognitive restructuring”.
9. AND (attention training OR ATT).
10. AND “working memory training”.
11. AND “cognitive remediation”.
12. AND “executive function training”.
13. AND (neurofeedback OR neuro-feedback).
14. AND (behavio*r training OR behavio*r therapy OR be-
havio*r treatment OR behavio*r intervention).
15. AND (MBCT OR MBSR OR mindfulness OR meditat*
OR relaxation).
16. AND (“acceptance and commitment therapy” OR ACT).
17. AND ((“compassion focused” OR compassion-focused)
therapy OR CFT).
18. AND ((“compassionate mind” OR compassionate-mind)
training CMT).
19. AND (metacognitive OR meta-cognitive).
20. AND counsel*ing.
21. AND (((“dialectical behavio*r”) AND (treatment$ OR
therapy OR training OR approach OR program* OR tech-
nique OR intervention)) OR DBT).
22. AND (family AND (treatment$ OR therapy OR training
OR approach OR program* OR technique OR intervention).
23. AND (systemic AND (treatment$ OR therapy OR training
OR approach OR program* OR technique OR intervention).
24. AND (self management OR self-management OR self-
help OR self help).
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