Introduction
Attention deficit hyperactivity disorder (ADHD) is a prevalent neurodevelopmental disability that significantly impacts cognition, parent-child relationships, academic performance, and psychosocial functioning (Jasmin & Priti, 2013). The formation of ADHD is influenced by various factors, with genetic and environmental factors being the primary causative agents. ADHD is known to have a high heritability rate and may be triggered by additional factors such as family adversity, low socioeconomic status, or head injuries (Thapar et al., 2012). Adolescents with ADHD commonly exhibit symptoms like poor concentration, high levels of activity, and impulsiveness (Harpin, 2005). If left untreated, these impairments often persist into adulthood, posing significant challenges in daily life skills and future employment prospects. Furthermore, research conducted by Nøvik et al. (2020) reveals that individuals with ADHD face a higher risk of developing comorbidities compared to the general population. These comorbidities include anxiety, depression, bipolar disorder, and personality disorders, among others. Additionally, studies by Ghosh et al. (2017) indicate a strong comorbidity between ADHD and oppositional defiant disorder (ODD), characterized by frequent and persistent angry or irritable moods that overlap with symptoms of ADHD.
Social adjustment refers to an individual’s capacity to engage in appropriate social behavior and adapt to various social situations (Romera et al., 2016). It reflects one’s ability to navigate the expectations and constraints of society, including establishing satisfying interpersonal relationships with peers and family members and fostering a harmonious work environment (American Psychological Association, 2022). Harpin (2005) highlights that children and adolescents with ADHD often struggle to meet these demands, leading to difficulties in successfully adapting to their social surroundings. In line with the findings of Aduen et al. (2018), research indicates that children with ADHD commonly experience impaired social functioning and face challenges in social adjustment, including higher rates of peer rejection and reduced participation in social activities with friends.
In addition, Deault (2010) found that impaired social function might also trigger family dysfunction, causing more stress at home, higher possibilities of parental psychopathology and toxic parent-child relationships. These adverse psychosocial influences on family members especially set forth high levels of parenting stress. As a result of regaining an important role after giving birth to a baby, most parents experience various levels of parental stress. As Biodic et al. (2019) presented, parents of adolescents with ADHD tend to show higher levels of anxiety in all domains since parenting stress is related to dysfunctional parent-child interactions. It is very challenging for parents to educate their children with ADHD, which entails a lot of effort and stress. At the same time, children with ADHD are prone to be more impulsive in behaviors and more emotional in sentiment, which hinders a good relationship with parents in return.
Since the pattern of lacking social adjustment among children with ADHD leads to maladaptive social life and an increase of parenting stress, it draws great attention for an immediate need and target to apply intervention. Appropriate interventions are crucial to solve these issues as soon as possible to avoid long-term and unreversed side effects of the disability, such as long-term drawback on problematic interpersonal relationship, academic failure and even to delinquent behavior and substance abuse (Aduen et al., 2018). Aduen et al. (2018) also found that pharmacological treatment and social skills interventions both are beneficial to alleviate the symptoms of ADHD and can help with dysfunctional social interactions. According to Polanczyk et al. (2014), 66% of children with ADHD took medication for the disorders have improved attention, perseverance, and work productivity. Pharmacotherapy has long been considered to be a prevalent and effective treatment for ADHD, but applying medication to patients with ADHD exclusively is not sufficient to reduce ADHD symptoms and its co-morbidities as suggested. Therefore, this study aims to investigate whether coordinating CBGT with non-pharmacological intervention will decrease parenting stress and improve social adaptation abilities of children with ADHD. The non-pharmacological interventions include cognitive behavioral therapy, attention skills treatment and behavioral therapy (Aduen et al., 2018), which offers an inspiration of our experiment on testing the effectiveness of CBGT on enhancing social adjustment functioning and decreasing parenting stress.
Cognitive-Behavioral Therapy (CBT)11CBT: cognitive-behavioral therapy is a psychological intervention that is known for mental disorders for a wide range of people, and it offers remarkable improvement in adaptive functioning along with ADHD symptoms (Nøvik et al., 2020). Based on the definition of CBT, Cognitive-Behavioral Group Therapy (CBGT) involves clients expressing their thoughts and feelings in a group setting and having opportunities to discuss and cooperate interpersonally (Moloud et al., 2022). Traditionally, CBGT involves a group of people guided by one or more therapists to enhance their social functioning through group collaboration and behavioral experiments (Thimm & Antonsen, 2014). At the same time, other members of the group act as co-therapists and benefit from the cohesive nature of the group as well (Ezhumalai et al., 2018). In addition to the traditional CBGT, our study applied a modified CBGT that incorporated pain tolerance social skills to the behavioral section for teens and targeted coaching for parents. Parents coach focused on using Dialectical behavioral therapy-based (DBT) parental coping strategies, which is an effective way to address any factors that impede parents’ motivation to acquire new skills for adolescent emotional and behavioral problems (Swales & Dunkley, 2020) The DBT parent coaching provides guidance for parents to understand the formation and maintenance of the biological and social patterns of adolescent behavioral problems with ADHD and how to deal with them effectively. We believe that the group is able to create an environment in which children can see the impact of their actions on others and receive feedback from others on their actions. Any distorted thinking patterns or difficulties in school and family life can clearly be identified at this point.
Researchers have found that school-based cognitive behavioral therapy was effective in treating anxiety disorders, depression disorders, ADHD, and obsessive-compulsive disorders (Parker et al., 2016). The possibility that CBT helps to improve cognitive functioning and ADHD symptoms is the reason why we believed that modified CBGT was beneficial to both socially adaptive functioning adolescents with ADHD and impulsivity aggression comorbidity as well as their parents’ stress. But Nøvik et al. (2020) stated that there were only three published studies on CBT with ADHD adolescents, and the information and effects of group therapy on ADHD were hard to retrieve. For this reason, we examined the effectiveness of a modified Cognitive Behavioral Group Therapy (CBGT) in treating children with ADHD and parenting stress to provide more information for future research. CBT helps improve cognitive function and may assist in the improvement of ADHD symptoms and function. The DBT-based parent coaching component simultaneously aims to enhance parents’ comprehension of ADHD adolescents, foster greater recognition, and develop more effective communication skills. These improvements contribute to the creation of a more inclusive microenvironment that supports ADHD adolescents in distress. Consequently, we strongly believe that the modified CGBT therapy holds significant benefits for both ADHD-impulsive aggression comorbid adolescents dealing with social adjustment dysfunction and their parents, reducing parental stress levels. Additionally, we expand the research direction and perspective of pre-adolescents with ADHD and their associated comorbidities. As a result, our study indicates that through the CBGT intervention for both children and parents, the core symptoms of ADHD of these children have been alleviated as well as their ability to interact well with their families and peers. In addition to that, the positive outcomes of these programs have a subsequent effect on the parents’ stress levels.