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.