Published on in Vol 9 (2025)

This is a member publication of Bibsam Consortium

Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/66388, first published .
Web-Based Stress Management for Working Adults With Attention-Deficit/Hyperactivity Disorder (ADHD): Single-Arm, Open Pilot Trial

Web-Based Stress Management for Working Adults With Attention-Deficit/Hyperactivity Disorder (ADHD): Single-Arm, Open Pilot Trial

Web-Based Stress Management for Working Adults With Attention-Deficit/Hyperactivity Disorder (ADHD): Single-Arm, Open Pilot Trial

1Department of Psychology, Stockholm University, Albanovägen 12, Stockholm, Sweden

2Department of Psychiatry and Psychotherapy, University Hospital Bonn, Bonn, Germany

3Department of Health, Education and Technology, Luleå University of Technology, Luleå, Sweden

4Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Stockholm, Sweden

5School of Psychology, Korea University, Seoul, Republic of Korea

6Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden

7Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden

Corresponding Author:

Martin Oscarsson, MSc


Background: National and international guidelines advocate for a multimodal approach to treating adult attention-deficit/hyperactivity disorder (ADHD), combining pharmacotherapy with psychological interventions. While recent reviews support cognitive behavioral therapy (CBT) as a viable treatment for ADHD in adults, evidence remains limited. Another challenge is the availability of psychological interventions, with stimulants remaining the primary treatment choice for adults with ADHD. One promising approach to increasing access to psychological interventions is the dissemination of internet-delivered CBT.

Objective: This study evaluated the feasibility, acceptability, and effects of a guided web-based stress management program specifically designed for working adults with ADHD. The intervention aimed to enhance quality of life by addressing stress, exhaustion, anxiety, and depression, commonly experienced by this population.

Methods: Thirty-six participants took part in a single-arm open trial, with assessments before, during, and after the intervention. The intervention consisted of 12 modules based on CBT principles, focusing on executive functioning, stress management, and emotion regulation, with clinician support on demand. Primary and secondary outcomes included quality of life (Adult ADHD Quality of Life Scale [AAQoL]), perceived stress (Perceived Stress Scale [PSS-10]), exhaustion (Karolinska Exhaustion Disorder Scale [KEDS]), anxiety (Generalized Anxiety Disorder 7-item Scale [GAD-7]), depression (Patient Health Questionnaire [PHQ-9]), and ADHD symptoms (the World Health Organization Adult ADHD Self-Report Scale [ASRS]).

Results: Results indicated a statistically and clinically significant improvement in quality of life (Cohen d=0.84), and a reduction in ADHD symptoms (d=0.98), as well as statistically significant reductions in perceived stress (d=0.83), exhaustion (d=1.12), anxiety (d=1.70), and depression (d=1.25). Improvements were sustained at a 12-week follow-up. A clinically significant improvement in quality of life was observed in 36% (13/36) of participants. Participants reported high satisfaction with the program and the guidance. Adherence was high, with an overall assessment response rate of 84%, a mean of 78% of modules opened, and no explicit dropouts. Twelve of the 36 participants reported negative effects. Qualitative content analysis of participants’ written feedback revealed positive experiences and suggestions for improvement.

Conclusions: This study suggests promise for web-delivered interventions tailored to the needs of adults with ADHD, pending further research and development in controlled studies.

Trial Registration: OSF Registries osf.io/u2cdj; https://osf.io/u2cdj

JMIR Form Res 2025;9:e66388

doi:10.2196/66388

Keywords



Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder, affecting between 3% and 7% of adults worldwide [Song P, Zha M, Yang Q, et al. The prevalence of adult attention-deficit hyperactivity disorder: a global systematic review and meta-analysis. J Glob Health. Feb 11, 2021;11:04009. [CrossRef] [Medline]1]. Core symptoms are inattention, hyperactivity, and impulsivity. However, theoretical models propose a general deficiency in executive functions as a basis for the symptoms [Willcutt EG. Theories of ADHD. In: Barkley RA, editor. Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. Guilford Press; 2015:391-404. ISBN: 978-1-4625-1772-52]. While the clinical presentation is well-defined in children, symptoms may have a more subtle and heterogeneous expression in adults. Despite growing evidence on the assessment and treatment of adult ADHD, many patients are underdiagnosed and undertreated, due to lack of recognition, misunderstandings, and poor access to specialized care [Kooij JJS, Bijlenga D, Salerno L, et al. Updated European Consensus Statement on diagnosis and treatment of adult ADHD. Eur Psychiatry. Feb 2019;56:14-34. [CrossRef] [Medline]3,Kooij SJJ, Bejerot S, Blackwell A, et al. European consensus statement on diagnosis and treatment of adult ADHD: the European Network Adult ADHD. BMC Psychiatry. Sep 3, 2010;10(1):67. [CrossRef] [Medline]4]. Adults with ADHD have a general increased risk of experiencing mental health problems. A majority of adults with ADHD meet the criteria for at least 1 comorbid psychiatric disorder, most commonly mood, anxiety, or substance use disorders [Kessler RC, Adler L, Barkley R, et al. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry. Apr 2006;163(4):716-723. [CrossRef] [Medline]5-Wilens TE, Biederman J, Faraone SV, Martelon M, Westerberg D, Spencer TJ. Presenting ADHD symptoms, subtypes, and comorbid disorders in clinically referred adults with ADHD. J Clin Psychiatry. Nov 2009;70(11):1557-1562. [CrossRef] [Medline]7].

Adult ADHD has also been linked to stress and fatigue, and adults with ADHD generally score higher than those with no ADHD on measures of these constructs [Combs MA, Canu WH, Broman-Fulks JJ, Rocheleau CA, Nieman DC. Perceived Stress and ADHD symptoms in adults. J Atten Disord. May 2015;19(5):425-434. [CrossRef] [Medline]8,Rogers DC, Dittner AJ, Rimes KA, Chalder T. Fatigue in an adult attention deficit hyperactivity disorder population: a trans-diagnostic approach. Br J Clin Psychol. Mar 2017;56(1):33-52. [CrossRef] [Medline]9]. ADHD is also highly likely to be an underlying factor in cases of burnout [Brattberg G. PTSD and ADHD: underlying factors in many cases of burnout. Stress Health. Dec 2006;22(5):305-313. [CrossRef]10]. In addition, adults with ADHD are more likely to experience stressful life events, such as divorce, loss of a job, and financial loss [Friedrichs B, Igl W, Larsson H, Larsson JO. Coexisting psychiatric problems and stressful life events in adults with symptoms of ADHD--a large Swedish population-based study of twins. J Atten Disord. Jan 2012;16(1):13-22. [CrossRef] [Medline]11]. The inattentive nature of ADHD may lead to excessive proofreading, procrastination, and perfectionism, while impulsivity and lack of reflection may result in the acceptance of more tasks and responsibilities. This, combined with hyperactivity and difficulties relaxing, may lead to stress and exhaustion [Andreassen CS, Griffiths MD, Sinha R, Hetland J, Pallesen S. The relationships between workaholism and symptoms of psychiatric disorders: a large-scale cross-sectional study. PLOS ONE. 2016;11(5):e0152978. [CrossRef] [Medline]12].

The impact of ADHD extends beyond individual well-being. Compared with their intellectual potential, many adults with ADHD underperform academically and professionally [Biederman J, Petty CR, Fried R, et al. Educational and occupational underattainment in adults with attention-deficit/hyperactivity disorder. J Clin Psychiatry. Aug 2008;69(8):1217-1222. [CrossRef] [Medline]13]. In most modern work environments, symptoms of inattention, hyperactivity, and impulsivity pose significant challenges [Adamou M, Arif M, Asherson P, et al. Occupational issues of adults with ADHD. BMC Psychiatry. Feb 17, 2013;13(1):59. [CrossRef] [Medline]14]. In addition to impaired work performance and lower perceived effectiveness, adults with ADHD report significantly greater problems with attendance, teamwork, and social interaction at the workplace compared to controls [Fuermaier ABM, Tucha L, Butzbach M, Weisbrod M, Aschenbrenner S, Tucha O. ADHD at the workplace: ADHD symptoms, diagnostic status, and work-related functioning. J Neural Transm. Jul 2021;128(7):1021-1031. [CrossRef]15]. The accumulation of performance impairment and interpersonal challenges, along with symptoms of psychiatric comorbidities, may significantly diminish the quality of life of adults with ADHD [Asherson P, Akehurst R, Kooij JJS, et al. Under diagnosis of adult ADHD: cultural influences and societal burden. J Atten Disord. Jul 2012;16(5 Suppl):20S-38S. [CrossRef] [Medline]16,Pawaskar M, Fridman M, Grebla R, Madhoo M. Comparison of quality of life, productivity, functioning and self-esteem in adults diagnosed with ADHD and with symptomatic ADHD. J Atten Disord. Jan 2020;24(1):136-144. [CrossRef] [Medline]17]. Additional negative outcomes include productivity losses and costs associated with sickness absence [Kleinman NL, Durkin M, Melkonian A, Markosyan K. Incremental employee health benefit costs, absence days, and turnover among employees with ADHD and among employees with children with ADHD. J Occup Environ Med. Nov 2009;51(11):1247-1255. [CrossRef] [Medline]18]. Several studies, such as the one by de Graaf et al [de Graaf R, Kessler RC, Fayyad J, et al. The prevalence and effects of adult attention-deficit/hyperactivity disorder (ADHD) on the performance of workers: results from the WHO World Mental Health Survey Initiative. Occup Environ Med. Dec 2008;65(12):835-842. [CrossRef] [Medline]19], have indicated that adults with ADHD have more sickness absence days than controls, with some reporting rates twice [Kessler RC, Lane M, Stang PE, Van Brunt DL. The prevalence and workplace costs of adult attention deficit hyperactivity disorder in a large manufacturing firm. Psychol Med. Jan 2009;39(1):137-147. [CrossRef] [Medline]20] or several times as high [Daley D, Jacobsen RH, Lange AM, Sørensen A, Walldorf J. The economic burden of adult attention deficit hyperactivity disorder: a sibling comparison cost analysis. Eur Psychiatry. Sep 2019;61:41-48. [CrossRef] [Medline]21].

National and international guidelines, such as those by Kooij et al [Kooij JJS, Bijlenga D, Salerno L, et al. Updated European Consensus Statement on diagnosis and treatment of adult ADHD. Eur Psychiatry. Feb 2019;56:14-34. [CrossRef] [Medline]3] and the National Institute for Health and Care Excellence [NICE. Attention deficit hyperactivity disorder: diagnosis and management. 2018. URL: https://www.nice.org.uk/guidance/cg72 [Accessed 2025-04-21] 22], advise a multimodal approach for the treatment of adult ADHD, combing pharmacotherapy with psychological interventions. Psychological interventions for adult ADHD include psychoeducation and cognitive behavioral therapy (CBT). While recent reviews, such as those by Fullen et al [Fullen T, Jones SL, Emerson LM, Adamou M. Psychological treatments in adult ADHD: a systematic review. J Psychopathol Behav Assess. Sep 2020;42(3):500-518. [CrossRef]23] and Nimmo-Smith et al [Nimmo-Smith V, Merwood A, Hank D, et al. Non-pharmacological interventions for adult ADHD: a systematic review. Psychol Med. Mar 2020;50(4):529-541. [CrossRef] [Medline]24], lend support to CBT as a viable treatment of ADHD in adults, evidence is limited due to a lack of available research and significant methodological issues with the included studies. Another limitation of CBT and other psychological interventions for adult ADHD is that of availability, with stimulants, in practice, remaining the treatment of choice for adults with ADHD [Kooij JJS, Bijlenga D, Salerno L, et al. Updated European Consensus Statement on diagnosis and treatment of adult ADHD. Eur Psychiatry. Feb 2019;56:14-34. [CrossRef] [Medline]3].

While pharmacological treatment may be effective in reducing core symptoms of ADHD, functional impairment often remains. When discussing CBT for adults with ADHD and potential mechanisms of change, Ramsay [Ramsay JR. CBT for adult ADHD: adaptations and hypothesized mechanisms of change. J Cogn Psychother. Feb 2010;24(1):37-45. [CrossRef]25] considered Barkley’s theory of executive functioning and self-regulation [Barkley RA. Behavioral inhibition, sustained attention, and executive functions: constructing a unifying theory of ADHD. Psychol Bull. Jan 1997;121(1):65-94. [CrossRef] [Medline]26,Barkley RA. Etiologies of ADHD. In: Barkley R, editor. Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. Guilford Press; 2015:356-390. ISBN: 978-1-4625-1772-527]. Executive functions, such as behavioral inhibition, verbal and nonverbal working memory, and emotional self-regulation, are necessary for a person when organizing and executing goal-directed actions. Impaired executive functioning in adult ADHD interferes not only with the actual management of everyday tasks and activities, but also with the ability to modify dysfunctional behaviors associated with the disorder. In short, most adults with ADHD know what needs to change in terms of their behavior but fall short in implementing and maintaining changes. Consequently, Ramsay [Ramsay JR. CBT for adult ADHD: adaptations and hypothesized mechanisms of change. J Cogn Psychother. Feb 2010;24(1):37-45. [CrossRef]25] characterized ADHD as an implementation disorder.

One way to increase access to psychological interventions is the dissemination of internet-delivered cognitive behavioral therapy (iCBT) [Andersson G, Carlbring P. Internet interventions in clinical psychology. In: Comprehensive Clinical Psychology. Elsevier; 2022:194-205. [CrossRef] ISBN: 978-0-12-822232-428]. iCBT with minimal clinician support has been shown to yield similar effects to face-to-face therapy for several psychiatric and somatic disorders, although repeated direct comparisons remain limited to a few specific conditions [Hedman-Lagerlöf E, Carlbring P, Svärdman F, Riper H, Cuijpers P, Andersson G. Therapist-supported Internet-based cognitive behaviour therapy yields similar effects as face-to-face therapy for psychiatric and somatic disorders: an updated systematic review and meta-analysis. World Psychiatry. Jun 2023;22(2):305-314. [CrossRef] [Medline]29]. In a recent review and meta-analysis by Svärdman et al [Svärdman F, Sjöwall D, Lindsäter E. Internet-delivered cognitive behavioral interventions to reduce elevated stress: a systematic review and meta-analysis. Internet Interv. Sep 2022;29:100553. [CrossRef] [Medline]30], iCBT was shown effective in reducing self-reported stress, as well as anxiety and depressive symptoms, among adults experiencing stress and stress-related disorders. iCBT has also been evaluated for adults with ADHD. In a recent randomized controlled trial (RCT) by Nasri et al [Nasri B, Cassel M, Enhärje J, et al. Internet delivered cognitive behavioral therapy for adults with ADHD —a randomized controlled trial. Internet Interv. Sep 2023;33:100636. [CrossRef] [Medline]31], guided iCBT was found to yield significantly greater improvement on the main ADHD outcome measure than a treatment-as-usual control. In another recent RCT, Kenter et al [Kenter RMF, Gjestad R, Lundervold AJ, Nordgreen T. A self-guided internet-delivered intervention for adults with ADHD: Results from A randomized controlled trial. Internet Interv. Apr 2023;32:100614. [CrossRef] [Medline]32] found that an unguided web intervention (MyADHD) based on CBT, dialectical behavior therapy and goal management training, was superior to a psychoeducation-only control in a sample of adults with ADHD. Earlier RCTs on adult ADHD include 1 by Pettersson et al [Pettersson R, Söderström S, Edlund-Söderström K, Nilsson KW. Internet-based cognitive behavioral therapy for adults with ADHD in outpatient psychiatric care. J Atten Disord. Apr 2017;21(6):508-521. [CrossRef] [Medline]33], showing that unguided iCBT was superior to a waiting list control, and 1 by Moëll et al [Moëll B, Kollberg L, Nasri B, Lindefors N, Kaldo V. Living SMART—a randomized controlled trial of a guided online course teaching adults with ADHD or sub-clinical ADHD to use smartphones to structure their everyday life. Internet Interv. Mar 2015;2(1):24-31. [CrossRef]34], showing that a CBT-inspired guided web-based course was superior to a waiting list control.

In a recent qualitative study on stress- and work-related psychological problems among adults with ADHD [Oscarsson M, Nelson M, Rozental A, Ginsberg Y, Carlbring P, Jönsson F. Stress and work-related mental illness among working adults with ADHD: a qualitative study. BMC Psychiatry. Nov 30, 2022;22(1):751. [CrossRef] [Medline]35], participants reported few and unsatisfactory experiences of health care support beyond pharmacological treatment of the ADHD symptoms. Several participants specifically mentioned a desire for interventions designed for patients with a relatively high level of functioning, with an emphasis on executive functions. While psychoeducational interventions for adult ADHD may include information and exercises related to workplace functioning, such as in the study by Hirvikoski et al [Hirvikoski T, Lindström T, Carlsson J, Waaler E, Jokinen J, Bölte S. Psychoeducational groups for adults with ADHD and their significant others (PEGASUS): a pragmatic multicenter and randomized controlled trial. Eur Psychiatry. Jul 2017;44:141-152. [CrossRef] [Medline]36], it is not a primary focus in most common ADHD interventions. In fact, a recent review by Lauder et al [Lauder K, McDowall A, Tenenbaum HR. A systematic review of interventions to support adults with ADHD at work—implications from the paucity of context-specific research for theory and practice. Front Psychol. 2022;13:893469. [CrossRef] [Medline]37] failed to identify any ADHD interventions specifically designed with the workplace context and workplace functioning as a central component.

The limited offering and inadequate provision of psychological interventions for working adults with ADHD are particularly conspicuous when considering the high prevalence of ADHD and the potential of resource-efficient iCBT. Inspired by existing psychological interventions for ADHD, stress, and common psychiatric comorbidities, and informed by interviews with working adults with ADHD, we developed a guided web-based stress management program specifically for the adult population with ADHD. The program was based on CBT principles, aiming to enhance quality of life by addressing stress, exhaustion, anxiety, and depression. In this pilot study, we evaluate the feasibility, acceptability, and effects of this novel intervention.


Design

This was a single-arm open trial with repeated measures before, during, and after the intervention. The primary aim was to evaluate the feasibility, acceptability, and effects of a guided web-based stress management program for working adults with ADHD.

Preregistration

The research question, desired sample size, included variables, and planned main analysis were preregistered on Open Science Framework [Oscarsson M. Internet-based stress management for working adults with ADHD: preregistration. Open Science Framework. Feb 2, 2023. URL: https://osf.io/u2cdj [Accessed 2025-05-22] 38]. Preregistration was completed during the recruitment phase before any participants had started the intervention.

Participants

Information about the study was shared on social media by a large Swedish ADHD patient interest group (Riksförbundet Attention), who posted about the study on their Facebook page, and by the research team, who posted in relevant Facebook groups and on LinkedIn. The study was conducted entirely on the web, without involvement of any physical or clinical sites. All recruitment, screening, informed consent, and data collection took place via the secure web intervention platform iTerapi [Vlaescu G, Alasjö A, Miloff A, Carlbring P, Andersson G. Features and functionality of the Iterapi platform for internet-based psychological treatment. Internet Interv. Nov 2016;6:107-114. [CrossRef]39]. Accompanying the recruitment information was a link to a site on the iTerapi platform, where those interested were invited to read more about the study. The site provided details including participation criteria and a button to create an account and submit a notice of interest in participation. Provision of informed consent was required to submit a notice of interest.

Upon the creation of an account, prospective participants were sent a link to validate their email address and to complete a web-based screening questionnaire. The screening questionnaire included questions regarding sociodemographics and ADHD diagnosis, as well as self-report measures of quality of life, perceived stress, symptoms of exhaustion, anxiety, depression, and symptoms of ADHD. The questionnaire also included questions regarding possible concurrent psychological or pharmacological treatment of ADHD or mental health problems.

To be eligible for the study, participants needed to be aged 20‐64 years (Swedish definition of working age), fluent in Swedish, have a diagnosis of ADHD, and work half-time or more. They also needed to score >19 on the Perceived Stress Scale (PSS-10; 75th percentile [Rozental A, Forsström D, Johansson M. A psychometric evaluation of the Swedish translation of the Perceived Stress Scale: a Rasch analysis. BMC Psychiatry. Sep 22, 2023;23(1):690. [CrossRef] [Medline]40]), or >18 on the Karolinska Exhaustion Disorder Scale (KEDS; at risk for exhaustion disorder [Lindsäter E, van de Leur JC, Rück C, Hedman-Lagerlöf E, Bianchi R. Psychometric and structural properties of the Karolinska Exhaustion Disorder Scale: a 1,072-patient study. BMC Psychiatry. Sep 2, 2023;23(1):642. [CrossRef] [Medline]41]), or >4 on the Generalized Anxiety Disorder 7-item Scale (GAD-7; mild anxiety [Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. May 22, 2006;166(10):1092-1097. [CrossRef] [Medline]42]), or >9 on the Patient Health Questionnaire (PHQ-9; moderate depression [Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. Sep 2001;16(9):606-613. [CrossRef] [Medline]43]). Participants were excluded in cases of severe depression (PHQ-9>19), suicidality (PHQ-9 item 9>1), concurrent psychological treatment, start of psychological treatment scheduled for the next 3 months, psychotropic medication dosage not stable for at least 1 month, or change in psychotropic medication scheduled for the next 3 months.

In total, 47 individuals created an account on the treatment platform. One did not complete the screening questionnaire, while 4 met the exclusion criteria (1 on sick leave, 1 with a recent change in psychotropic medication, 1 with a scheduled change in psychotropic medication, and 1 with a score above 19 on the PHQ-9). The remaining 42 were invited to participate in the study, and 36 accepted the invitation. Table 1 shows the characteristics of the final sample.

Table 1. Demographic and clinical characteristics of participants (n=36) in a single-arm pilot trial of a web-based stress-management intervention for working adults with attention-deficit/hyperactivity disorder in Sweden.
CharacteristicsParticipants (n=36)
Age (years), mean (SD)44.4 (8.29)
Gender, n (%)
Women28 (78)
Men7 (19)
 Other or did not want to assign1 (3)
Education level, n (%)
Elementary school0 (0)
High school4 (11)
University ≤3 years7 (19)
University >3 years25 (69)
Employment rate (percentage of full-time), mean (SD)92.9 (11.7)
Psychotropic medication, n (%)
Yes31 (86)
No5 (14)

Measures

The main outcome measure was quality of life, measured with the Adult ADHD Quality of Life Scale (AAQoL [Brod M, Johnston J, Able S, Swindle R. Validation of the Adult Attention-Deficit/Hyperactivity Disorder Quality-of-Life Scale (AAQoL): a disease-specific quality-of-life measure. Qual Life Res. Feb 2006;15(1):117-129. [CrossRef] [Medline]44]). Secondary outcome measures were perceived stress, measured with the PSS-10; symptoms of exhaustion, measured with the KEDS; anxiety, measured with the GAD-7; depression, measured with the PHQ-9; and symptoms of ADHD, measured with the World Health Organization Adult ADHD Self-Report Scale (ASRS) Symptoms Checklist [Kessler RC, Adler L, Ames M, et al. The World Health Organization Adult ADHD Self-Report Scale (ASRS): a short screening scale for use in the general population. Psychol Med. Feb 2005;35(2):245-256. [CrossRef] [Medline]45]. The frequency and time points of measurement are shown in Table 2. Week 12 is postintervention and week 24 is follow-up. Subscale results are reported for the PSS-10 and the ASRS. The ASRS was modified to reflect the last 4 weeks, and formatted without the shaded boxes, as is common in ADHD intervention research. The Negative Effects Questionnaire (NEQ-20 [Rozental A, Kottorp A, Forsström D, et al. The Negative Effects Questionnaire: psychometric properties of an instrument for assessing negative effects in psychological treatments. Behav Cogn Psychother. Sep 2019;47(5):559-572. [CrossRef] [Medline]46]) was used to explore negative effects and adverse events.

Table 2. Overview of outcome measures and assessment time points during a 12-week guided web-based stress-management intervention and 12-week follow-up for working adults with attention-deficit/hyperactivity disorder in Sweden.
MeasureBaselineWeek 2Week 4Week 6Week 8Week 10Week 12Week 24
AAQoLaN/AbN/AN/A
ASRScN/AN/AN/A
PSS-10dN/AN/AN/A
KEDSe
PHQ-9f
GAD-7g
NEQ-20hN/AN/AN/AN/AN/AN/AN/A

aAAQoL: Adult Attention-Deficit/Hyperactivity Disorder Quality of Life.

bN/A: not applicable.

cASRS: Adult ADHD Self-Report Scale.

dPSS-10: Perceived Stress Scale.

eKEDS: Karolinska Exhaustion Disorder Scale.

fPHQ-9: Patient Health Questionnaire.

gGAD-7: Generalized Anxiety Disorder 7-item Scale.

hNEQ-20: Negative Effects Questionnaire.

At week 12, participants were also invited to answer open-ended questions about their experiences of the intervention and rate their treatment satisfaction from 1 to 4 on 7 items.

Intervention

The intervention, called “Working with ADHD,” was developed to increase the quality of life for working adults with ADHD by addressing and managing stress, exhaustion, anxiety, and depression. The program is based on CBT principles, incorporating psychoeducation, basic behavior analysis, goal setting, and simple behavioral experiments. The development process began with a comprehensive review of existing psychological interventions targeting ADHD, stress, and common psychiatric comorbidities.

As part of a previous qualitative study [Oscarsson M, Nelson M, Rozental A, Ginsberg Y, Carlbring P, Jönsson F. Stress and work-related mental illness among working adults with ADHD: a qualitative study. BMC Psychiatry. Nov 30, 2022;22(1):751. [CrossRef] [Medline]35], 20 working adults with ADHD were asked about their interest in and attitudes toward a hypothetical web-based psychological intervention developed specifically for working adults with ADHD. In addition to being generally positive toward the concept, the participants underscored 3 things that would increase the likelihood of its success: treatment content presented in short, accessible modules with clear rationale; the option to choose modules based on needs and urgency; and the inclusion of clinician support.

The intervention had 3 main areas of focus. The first was compensatory strategies for executive function deficiencies, with a foundation in Barkley’s theory of ADHD and Ramsay’s proposed mechanisms of change. This included information and exercises regarding organization, planning, and prioritization, inspired by the CBT manual for adult ADHD by Safren et al [Safren SA, Sprich S, Mimiaga MJ, et al. Cognitive behavioral therapy vs relaxation with educational support for medication-treated adults with ADHD and persistent symptoms: a randomized controlled trial. JAMA. Aug 25, 2010;304(8):875-880. [CrossRef] [Medline]47]. Also included were information and exercises from CBT for procrastination, inspired by interventions developed by Rozental et al [Rozental A, Forsell E, Svensson A, Andersson G, Carlbring P. Internet-based cognitive-behavior therapy for procrastination: a randomized controlled trial. J Consult Clin Psychol. Aug 2015;83(4):808-824. [CrossRef] [Medline]48].

The second area of focus was stress management and recovery. Here, the theoretical basis was the cognitive behavioral model of clinical burnout by Almén [Almén N. A cognitive behavioral model proposing that clinical burnout may maintain itself. Int J Environ Res Public Health. Mar 26, 2021;18(7):3446. [CrossRef] [Medline]49]. Information and exercises revolved around the balance between stress reactivity and stress recovery, with an emphasis on recovery-facilitating behaviors. This also included information and exercises regarding sleep, inspired by the ADHD-specific behavioral insomnia intervention by Jernelöv et al [Jernelöv S, Larsson Y, Llenas M, Nasri B, Kaldo V. Effects and clinical feasibility of a behavioral treatment for sleep problems in adult attention deficit hyperactivity disorder (ADHD): a pragmatic within-group pilot evaluation. BMC Psychiatry. Jul 24, 2019;19(1):226. [CrossRef] [Medline]50].

The third and final area of focus was emotion regulation. The role of emotional dysregulation in the clinical presentation of adult ADHD has been extensively discussed in the literature, illustrated, for example, by the study by Hirsch et al [Hirsch O, Chavanon M, Riechmann E, Christiansen H. Emotional dysregulation is a primary symptom in adult attention-deficit/hyperactivity disorder (ADHD). J Affect Disord. May 2018;232:41-47. [CrossRef] [Medline]51]. Emotional dysregulation, as a component of adult ADHD, has also been linked to occupational impairment [Barkley RA, Fischer M. The unique contribution of emotional impulsiveness to impairment in major life activities in hyperactive children as adults. J Am Acad Child Adolesc Psychiatry. May 2010;49(5):503-513. [CrossRef] [Medline]52]. It may take different forms, including a hypersensitivity to criticism and failure [Oscarsson M, Nelson M, Rozental A, Ginsberg Y, Carlbring P, Jönsson F. Stress and work-related mental illness among working adults with ADHD: a qualitative study. BMC Psychiatry. Nov 30, 2022;22(1):751. [CrossRef] [Medline]35], as well as impatience and irritability [Barkley RA, Fischer M. The unique contribution of emotional impulsiveness to impairment in major life activities in hyperactive children as adults. J Am Acad Child Adolesc Psychiatry. May 2010;49(5):503-513. [CrossRef] [Medline]52]. In this intervention, information and exercises revolved around assertiveness and self-esteem [Hagberg T, Manhem P, Oscarsson M, Michel F, Andersson G, Carlbring P. Efficacy of transdiagnostic cognitive-behavioral therapy for assertiveness: a randomized controlled trial. Internet Interv. Apr 2023;32:100629. [CrossRef] [Medline]53], as well as perfectionism [Rozental A, Shafran R, Wade T, et al. A randomized controlled trial of internet-based cognitive behavior therapy for perfectionism including an investigation of outcome predictors. Behav Res Ther. Aug 2017;95:79-86. [CrossRef] [Medline]54] and self-compassion [Diedrich A, Grant M, Hofmann SG, Hiller W, Berking M. Self-compassion as an emotion regulation strategy in major depressive disorder. Behav Res Ther. Jul 2014;58:43-51. [CrossRef] [Medline]55].

The intervention content was delivered in 12 modules over 12 weeks on the iTerapi platform. The platform is responsive and usable on computers, tablets, and smartphones. First, participants were granted access to a new module every Monday for 4 weeks. Then, participants were granted access to 6 new modules, to work on for 6 weeks, according to their preference and perceived needs. Finally, participants were granted access to 2 new modules, weeks 11 and 12, respectively. This is detailed in Table 3.

Table 3. Overview of the 12-module web-based stress management intervention (“Working with ADHD”) delivered over 12 weeks to working adults with attention-deficit/hyperactivity disorder in Sweden.
ModuleThemeContent
1ADHDa, stress, self-assessment, and goalsADHD, stress, and mental health; assessment of current situation; and goal formulation
2Communication and boundary settingPerformance-based self-esteem, assessment of and working with self-esteem, self-compassion, regulating strong emotions, and communicating boundaries
3SleepADHD and sleep, sleep assessment, sleep hygiene, and sleep restriction
4RecoveryThe recovery paradox, assessment, recovery every day, practicing self-awareness, and finding balance in everyday life
5Planning and prioritizationUse of calendar and to-do list, and prioritizing tasks
6Problem-solvingStepwise problem-solving, breaking tasks into smaller parts, and attention span
7PerfectionismPerfectionism, stress, and ADHD; assessment of perfectionist behaviors; practicing flexible thinking; and seeing the positive
8ProcrastinationProcrastination, stress, and ADHD; assessment; motivation; minimum effort; and managing distractions
9Disclosing the diagnosisJob seeking with ADHD and disclosing the diagnosis at the workplace
10Rights and responsibilities at the workplaceGeneral rights and responsibilities of employees; and the right to accommodation
11Repetition and reflectionSummary of previous modules, assessment of what has been helpful, and noting progress
12Beyond the programSetbacks and relapses; and identifying risk situations

aADHD: attention-deficit/hyperactivity disorder.

All modules were structured into brief sections, each alternating between information, assessment, and exercises. Most modules included 1500‐2000 words in total. Participants were instructed to complete all assessments and exercises in writing, using their preferred medium (eg, notes app or spiral notebook). At the conclusion of each module, participants were offered suggestions for implementing new strategies in their daily lives. In addition, select sections within each module included prompts for participants to reach out to the research group for support.

Support was available on demand through asynchronous messaging on the treatment platform. All support was provided by a licensed psychologist with 5 years of clinical experience working with adults with ADHD. The support primarily consisted of encouragement and affirmation [Berg I, Hovne V, Carlbring P, et al. “Good job!”: Therapists’ encouragement, affirmation, and personal address in internet-based cognitive behavior therapy for adolescents with depression. Internet Interv. Dec 2022;30:100592. [CrossRef] [Medline]56] and did not introduce new treatment content. Each participant also received 2 scheduled, prewritten messages per week: one on Mondays containing information about new modules or offering general encouragement to engage with the treatment content and another later in the week encouraging participants to reach out with questions or request feedback on the exercises. Messages from participants were answered at least once every weekday, that is, within 36 hours.

All participants received email notifications for new messages. If a participant had not logged in for a week, they were first contacted via email the following Monday and then twice by telephone later in the week. Participants were contacted via email and telephone in a similar manner if they did not respond to assessments. Study staff were immediately notified if a participant at any point scored PHQ-9 >19 (severe depression cutoff) or PHQ-9 item 9 >1 (suicidality cutoff), in which case the participant was contacted via telephone.

Analysis

Linear mixed models were fitted to estimate the fixed effects of time and the random effects of participant intercepts and participant slopes, using all available data from screening to postintervention. The models used unstructured covariance patterns and restricted maximum likelihood estimation for missing data. Paired-samples t tests (2-tailed) were used to compare full-scale follow-up scores with screening scores using last observation carried forward (LOCF) imputation. Effect sizes Cohen d were calculated on estimated random means for screening to postintervention, and raw means for screening to follow-up, using the mean differences and the pooled SDs.

The Jacobson and Truax [Jacobson NS, Truax P. Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. J Consult Clin Psychol. Feb 1991;59(1):12-19. [CrossRef] [Medline]57] method was used to analyze clinical significance, using cutoff A (ie, 2 SDs in the direction of a functioning distribution) and reliable change index (RCI) on screening and postintervention AAQoL and full-scale ASRS data with LOCF imputation. Deterioration was defined as exceeding the RCI in a negative direction, while unchanged corresponded to a change score not exceeding the RCI. Analysis of missing data was done using one-way ANOVA. Adherence, treatment satisfaction, negative effects, and adverse events were explored descriptively. All statistical analyses were performed using jamovi (version 2.4; The jamovi project) [R core team. R: A language and environment for statistical computing. 2022. URL: https://www.R-project.org [Accessed 2025-04-21] 58,Jamovi. The jamovi project. 2023. URL: https://jamovi.org [Accessed 2025-04-21] 59]. Mixed models were run using the GAMLj module [Gallucci M. GAMLj: general analyses for linear models. 2024. URL: https://gamlj.github.io [Accessed 2025-04-21] 60]. Jacobson-Truax classifications and RCI were calculated using the JTRCI R package [Kruijt AW. Obtain and plot Jacobson-Truax and reliable change indices. 2019. URL: https://rdrr.io/github/AWKruijt/JT-RCI/man/JTRCI.html [Accessed 2025-05-23] 61].

Inductive qualitative content analysis [Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. Nov 2005;15(9):1277-1288. [CrossRef] [Medline]62] was used to explore data from participants’ responses to the open-ended questions postintervention. The analysis was conducted by SH and KBW, under the supervision of MO. SH and KBW were final-year psychologist students at the time of the analysis. They had completed basic training in CBT and previously assisted MO in developing the treatment content. The analysis followed the procedure outlined by Krippendorff [Krippendorff K. Content Analysis: An Introduction to Its Methodology. SAGE Publications, Inc; 2019. [CrossRef] ISBN: 978-1-5063-9566-163]. First, data were sampled from the participants, using the open-ended questions. Data were unitized, using the original wording of the participants and discarding data not relevant to the research questions. Then, the units of meaning were coded inductively, using the analysts’ own understanding of the context. Finally, the codes were clustered, maintaining internal homogeneity and external heterogeneity between the final categories.

Ethical Considerations

This study was approved by the Swedish ethical review authority (diary nos.: 2022-04370-01 and 2022-07214-02), and all procedures followed relevant national and institutional guidelines. Informed consent was obtained digitally from all participants via the secure iTerapi platform, prior to the submission of interest in participation. Participants were provided with written information about the study, data handling, and their rights, and were encouraged to contact the principal investigator (FJ) with any questions before consenting. Study data were handled in pseudonymized form using a coded key, accessible only to the research team. All personal data were stored securely on encrypted servers or encrypted researcher devices (eg, university computers), either within the treatment platform or Stockholm University’s approved storage systems. No financial compensation was provided to participants. No identifiable images or personal information is shown in the manuscript or Multimedia Appendix 1.


Main Analyses

A mixed model revealed a statistically significant effect of time from screening to postintervention on the main outcome measure AAQoL (F1,29.4=28.2; P<.001), corresponding to a large effect (d=0.84). This indicates an improved average quality of life among the participants. Mixed models also revealed statistically significant effects of time from screening to postintervention on the secondary outcome measures, all indicating lower average symptom levels among participants. The results of the mixed models, with corresponding effect sizes Cohen d, are shown in Table 4. Estimated marginal means are shown in Figure 1 and Table S1 in

Multimedia Appendix 1

Estimated marginal means, follow-up means, and Jacobson-Truax plots.

PDF File, 165 KBMultimedia Appendix 1.

Table 4. Results from linear mixed models estimating changes in all outcome measures from screening to postintervention in a single-arm pilot trial of a guided web-based stress management intervention for working adults with attention-deficit/hyperactivity disorder in Sweden.
MeasureF test (df)P valueCohen d
AAQoLa28.2 (1, 29.4)<.0010.84
ASRSb35.6 (1, 29.8)<.0010.98
ASRS (Inattention)30.9 (1, 30.8)<.0011.12
ASRS (H/I)28.8 (1, 28.8)<.0010.72
PSS-10c17.3 (1, 31.5)<.0010.83
PSS-10 (Negative)28.6 (1, 31.0)<.0011.01
KEDSd26.1 (1, 33.5)<.0011.12
PHQ-9e22.4 (1, 33.0)<.0011.25
GAD-7f53.1 (1, 28.7)<.0011.70

aAAQoL: Adult Attention-Deficit/Hyperactivity Disorder Quality of Life.

bASRS: Adult Attention-Deficit/Hyperactivity Disorder Self-Report Scale.

cPSS-10: Perceived Stress Scale-10.

dKEDS: Karolinska Exhaustion Disorder Scale.

ePHQ-9: Patient Health Questionnaire-9.

fGAD-7: Generalized Anxiety Disorder 7-item Scale.

Figure 1. Estimated marginal means with 95% CIs for all outcome measures from screening to postintervention in a single-arm pilot trial of a guided web-based stress-management intervention for working adults with attention-deficit/hyperactivity disorder in Sweden. AAQoL: Adult Attention-Deficit/Hyperactivity Disorder Quality of Life; ASRS: Adult Attention-Deficit/Hyperactivity Disorder Self-Report Scale; GAD-7: Generalized Anxiety Disorder 7-item Scale; KEDS: Karolinska Exhaustion Disorder Scale; PHQ-9: Patient Health Questionnaire-9; PSS-10: Perceived Stress Scale-10.

Paired-samples t tests indicate statistically significant differences between week 24 follow-up scores and screening scores on all outcome measures, corresponding to large effect sizes Cohen d. This indicates an improved average quality of life and lower average symptom levels among participants, 12 weeks postintervention. The results of the paired-samples t tests, with corresponding effect sizes Cohen d, are shown in Table 5. LOCF means are shown in Table S2 in

Multimedia Appendix 1

Estimated marginal means, follow-up means, and Jacobson-Truax plots.

PDF File, 165 KBMultimedia Appendix 1.

Table 5. Paired-samples t test results comparing outcome measures between screening and follow-up in a single-arm pilot trial of a guided web-based stress management intervention for working adults with attention-deficit/hyperactivity disorder in Sweden.
Measuret test (df)P valueCohen d
AAQoLa4.32 (35)<.0010.83
ASRSb−5.36 (35)<.0010.82
PSS-10c−5.89 (35)<.0011.12
KEDSd−5.46 (35)<.0010.99
PHQ-9e−5.36 (35)<.0011.31
GAD-7f−5.32 (35)<.0011.13

aAAQoL: Adult Attention-Deficit/Hyperactivity Disorder Quality of Life.

bASRS: Adult Attention-Deficit/Hyperactivity Disorder Self-Report Scale.

cPSS-10: Perceived Stress Scale-10.

dKEDS: Karolinska Exhaustion Disorder Scale.

ePHQ-9: Patient Health Questionnaire-9.

fGAD-7: Generalized Anxiety Disorder 7-item Scale.

Clinical Significance

On the primary outcome measure AAQoL, 6 of the 36 participants were recovered, 1 nonreliably recovered, 7 improved, 20 unchanged, and 2 deteriorated. On the ASRS, 3 participants were recovered, 1 nonreliably recovered, 10 improved, and 22 unchanged. Individual participant outcomes and Jacobson-Truax classifications are shown in Figures S1 and S2 in

Multimedia Appendix 1

Estimated marginal means, follow-up means, and Jacobson-Truax plots.

PDF File, 165 KBMultimedia Appendix 1.

Adherence

There were no explicit dropouts, that is, no participants communicated a premature discontinuation of treatment. However, adherence varied between participants in the case of login frequency, number of modules opened, and number of measurements completed. The mean number of logins was 17.7 (SD 9.28) and the total assessment response rate was 84%. The mean number of modules opened was 9.31 (SD 3.86). All participants but 1 opened the 2 introductory modules, and 29 of the 36 participants opened at least half of the modules. The mean number of messages sent by participants to study staff was 3.4 (SD 2.5).

Analysis of Missing Data

One-way ANOVA showed no statistically significant difference between screening scores of participants who did or did not respond to the measurement at week 12. This indicates that there were no apparent baseline differences between responders and nonresponders.

Negative Effects

Twenty-nine of the 36 participants completed the NEQ-20 at week 12, and 33% (12/36) of the participants reported at least 1 negative effect likely to have been caused by the intervention. The most common negative effects, caused by the intervention or not, were the feeling of more stress (n=10) and the feeling that the treatment did not produce any results (n=5).

Treatment Satisfaction

Twenty-nine of the 36 participants completed the treatment satisfaction questionnaire at week 12. The results are shown in Table 6.

Table 6. Self-rated treatment satisfaction at postintervention (week 12) among participants in a guided web-based stress management intervention for working adults with attention-deficit/hyperactivity disorder in Sweden.a
ItemsValues, mean (SD)
1. How do you assess the quality of the treatment you have received?2.90 (0.67)
2. To what extent have the modules been relevant to you and your areas of concern?3.03 (0.63)
3. How satisfied are you with the opportunity to ask questions about the content of the modules?3.48 (0.63)
4. How satisfied are you with the length of the treatment?3.14 (0.74)
5. Has the treatment helped you to better cope with your problems?3.00 (0.60)
6. Overall, how satisfied are you with the treatment you have received?3.03 (0.63)
7. If a friend needed similar help, would you recommend our treatment to him or her?3.17 (0.60)

a1=dissatisfied, 2=indifferent, 3=mostly satisfied, and 4=very satisfied.

Qualitative Results

Twenty-seven of the 36 participants answered the open-ended questions about their experiences of the intervention. Qualitative content analysis yielded 2 main categories and 7 subcategories that describe the participants’ experiences. These are shown in Table 7.

Table 7. Main categories and subcategories from qualitative content analysis of participants’ written feedback at postintervention in a pilot trial of a guided web-based stress management intervention for adults with attention-deficit/hyperactivity disorder in Sweden.
Categories and subcategoriesContent
Helpful parts of the intervention
CommunicationGood, inviting, effective, appreciated reminders.
“Very good. Generous and inviting, with personal feedback provided when necessary in the follow-up surveys” (Participant G).
Module contentGood, relevant, concise, easy to understand, some particularly appreciated content.
“That I could see connections between performance-based self-esteem and stress. Reminded of the importance of recovery, which I apparently had completely skipped” (Participant B).
Treatment platformGood, easy to navigate, modules (continuous publication, optional modules), login (secure).
“Great setup regarding how the modules were released and the opportunity to choose what felt relevant” (Participant C).
Desired development of the program
More structureChecklists, guidance, templates, check-ins, clearer guidance, one thing at a time, control questions, too little structure toward the end, emphasize that tasks are not followed up, difficult without a deadline.
“Having treatment over the internet was both good and bad for me. It would have been helpful if what I did was somehow checked off. One of my difficulties is getting things done without a deadline. At the same time, perhaps I wouldn’t have had the opportunity to complete all tasks if there were deadlines” (Participant C).
More audiovisualLayout, more user-friendly, visual materials, audio for tired eyes, being able to listen, images.
“In a way, it’s nice that the graphics are incredibly stripped down and boring, although maybe not so inspiring. Could certainly have benefited from a little more love” (Participant I).
Clinician supportVideo calls, personal contact, short digital check-ins, clinician support for structure.
“A brief conversation that provides drive to continue” (Participant J).
Technical functionalityEasier navigation, writing directly on the platform, filling in directly on the platform, digital workbook, more interactive.
“More templates and mandatory check-ins. Checklists are very helpful” (Participant K).

The purpose of this study was to evaluate the feasibility, acceptability, and effects of a web-based stress management program developed specifically for adults with ADHD. The results showed statistically significant improvements on all outcome measures, from preintervention screening to postintervention and follow-up assessments. The change in mean self-reported quality of life from screening to postintervention corresponds to a large effect, while changes in mean scores on secondary outcome measures correspond to medium-to-large effects. Participants expressed satisfaction with the program content, platform, and communication. More structure, support, audiovisual content, and technical improvements were requested.

The statistically significant increase in self-reported quality of life, corresponding to a large effect, indicates that the participants experienced increased quality of life over the course of the intervention. As previously noted, the cumulative impact of performance impairment, interpersonal challenges, and psychiatric comorbidities significantly diminishes the quality of life of adults with ADHD. The current intervention targets common psychiatric comorbidities among adults with ADHD, with a specific focus on workplace functioning that could affect work performance. Thus, the observed increase in quality of life among the participants, over the course of the intervention, may signify a reversal of this cumulative burden, as supported by concurrent improvements on measures of perceived stress and psychiatric symptoms, corresponding to medium-to-large effects. These findings imply that the intervention’s content and delivery are well suited and beneficial for working adults with ADHD experiencing elevated levels of perceived stress, exhaustion, anxiety, and depression.

The observed pre-post effect sizes on both the AAQoL and the secondary outcome measures of psychiatric symptoms were notably larger than within-group effect sizes reported in previous studies. In the MyADHD studies by Nordby et al [Nordby ES, Kenter RMF, Lundervold AJ, Nordgreen T. A self-guided Internet-delivered intervention for adults with ADHD: a feasibility study. Internet Interv. Sep 2021;25:100416. [CrossRef] [Medline]64] and Kenter et al [Kenter RMF, Gjestad R, Lundervold AJ, Nordgreen T. A self-guided internet-delivered intervention for adults with ADHD: Results from A randomized controlled trial. Internet Interv. Apr 2023;32:100614. [CrossRef] [Medline]32], improvements on the AAQoL corresponded to medium effects (d=0.62 and d=0.60, respectively), compared with d=0.84 in this study. Here, it should be noted that the MyADHD intervention was unguided, without clinician support. This could indicate the potential added value of clinician involvement in web-delivered interventions, enhancing their efficacy beyond what is achievable in unguided formats [Baumeister H, Reichler L, Munzinger M, Lin J. The impact of guidance on Internet-based mental health interventions — A systematic review. Internet Interv. Oct 2014;1(4):205-215. [CrossRef]65]. On PSS measures, Nordby et al [Nordby ES, Kenter RMF, Lundervold AJ, Nordgreen T. A self-guided Internet-delivered intervention for adults with ADHD: a feasibility study. Internet Interv. Sep 2021;25:100416. [CrossRef] [Medline]64] reported d=0.35 (PSS-14), Kenter et al [Kenter RMF, Gjestad R, Lundervold AJ, Nordgreen T. A self-guided internet-delivered intervention for adults with ADHD: Results from A randomized controlled trial. Internet Interv. Apr 2023;32:100614. [CrossRef] [Medline]32] reported d=0.20 (PSS-14), and Moëll et al [Moëll B, Kollberg L, Nasri B, Lindefors N, Kaldo V. Living SMART—a randomized controlled trial of a guided online course teaching adults with ADHD or sub-clinical ADHD to use smartphones to structure their everyday life. Internet Interv. Mar 2015;2(1):24-31. [CrossRef]34] reported d=0.03 (PSS-10), while the means observed by Nasri et al [Nasri B, Cassel M, Enhärje J, et al. Internet delivered cognitive behavioral therapy for adults with ADHD —a randomized controlled trial. Internet Interv. Sep 2023;33:100636. [CrossRef] [Medline]31] correspond to an effect size of d=0.37 (PSS-4), compared with d=0.83 (PSS-10) in this study. Similarly, on the GAD-7 and the PHQ-9, Nordby et al [Nordby ES, Kenter RMF, Lundervold AJ, Nordgreen T. A self-guided Internet-delivered intervention for adults with ADHD: a feasibility study. Internet Interv. Sep 2021;25:100416. [CrossRef] [Medline]64] reported d=0.04 and d=0.32, respectively, compared with d=1.70 and d=1.25 in this study.

Although ADHD symptoms were not a primary target of the current intervention, the ASRS means indicate a statistically significant improvement pre-post, corresponding to large effects on the total scale (d=0.98) and the inattention subscale (d=1.12) and a medium effect on the hyperactivity subscale (d=0.72). These effect sizes are more in-line with within-group effect sizes reported in previous studies. Nordby et al [Nordby ES, Kenter RMF, Lundervold AJ, Nordgreen T. A self-guided Internet-delivered intervention for adults with ADHD: a feasibility study. Internet Interv. Sep 2021;25:100416. [CrossRef] [Medline]64] and Kenter et al [Kenter RMF, Gjestad R, Lundervold AJ, Nordgreen T. A self-guided internet-delivered intervention for adults with ADHD: Results from A randomized controlled trial. Internet Interv. Apr 2023;32:100614. [CrossRef] [Medline]32] reported total ASRS effect sizes of d=0.93 and d=0.80, respectively, while the means reported by Nasri et al [Nasri B, Cassel M, Enhärje J, et al. Internet delivered cognitive behavioral therapy for adults with ADHD —a randomized controlled trial. Internet Interv. Sep 2023;33:100636. [CrossRef] [Medline]31] correspond to a smaller effect size of d=0.68. Moëll et al [Moëll B, Kollberg L, Nasri B, Lindefors N, Kaldo V. Living SMART—a randomized controlled trial of a guided online course teaching adults with ADHD or sub-clinical ADHD to use smartphones to structure their everyday life. Internet Interv. Mar 2015;2(1):24-31. [CrossRef]34] reported similarly large effects on the inattention (d=1.18) and hyperactivity (d=0.55) subscales. Again, MyADHD was unguided, and both MyADHD and the web-based course by Moëll et al [Moëll B, Kollberg L, Nasri B, Lindefors N, Kaldo V. Living SMART—a randomized controlled trial of a guided online course teaching adults with ADHD or sub-clinical ADHD to use smartphones to structure their everyday life. Internet Interv. Mar 2015;2(1):24-31. [CrossRef]34] focused primarily on symptoms of inattention. Considering that clinician support may have played a role in the superior outcomes observed in this study compared with unguided interventions, future research could directly compare the efficacy of interventions with and without support, or investigate the potential of generative artificial intelligence acting as a clinician. This could determine whether such technology could enhance intervention effectiveness through personalized support and real-time engagement, particularly for adults with ADHD [Carlbring P, Hadjistavropoulos H, Kleiboer A, Andersson G. A new era in Internet interventions: the advent of Chat-GPT and AI-assisted therapist guidance. Internet Interv. Apr 2023;32:100621. [CrossRef] [Medline]66].

Participants were invited to rate their satisfaction and provide feedback through open-ended questions regarding their experiences with the intervention. Overall, satisfaction scores were positive, particularly regarding the opportunity to inquire about treatment content. Responses to the open-ended questions highlighted participants’ positive perceptions of the communication with the research group, describing it as good, inviting, and effective. Ramsay [Ramsay JR. CBT for adult ADHD: adaptations and hypothesized mechanisms of change. J Cogn Psychother. Feb 2010;24(1):37-45. [CrossRef]25] underscores the therapist’s role in CBT for adult ADHD, validating frustrations and aiding patients in reengaging with the change process. The incorporation of support on demand in the current intervention aimed to mitigate premature discontinuation of treatment due to frustration among the participants. Encouragingly, none of the participants explicitly withdrew from the study, although adherence varied. However, the mean number of modules opened (78%) exceeds the reported number of completed modules for the unguided intervention of Nordby et al (62%) [Nordby ES, Kenter RMF, Lundervold AJ, Nordgreen T. A self-guided Internet-delivered intervention for adults with ADHD: a feasibility study. Internet Interv. Sep 2021;25:100416. [CrossRef] [Medline]64] and Kenter et al (65%) [Kenter RMF, Gjestad R, Lundervold AJ, Nordgreen T. A self-guided internet-delivered intervention for adults with ADHD: Results from A randomized controlled trial. Internet Interv. Apr 2023;32:100614. [CrossRef] [Medline]32], as well as for the guided interventions of Moëll et al (53%) [Moëll B, Kollberg L, Nasri B, Lindefors N, Kaldo V. Living SMART—a randomized controlled trial of a guided online course teaching adults with ADHD or sub-clinical ADHD to use smartphones to structure their everyday life. Internet Interv. Mar 2015;2(1):24-31. [CrossRef]34], Pettersson et al (61%) [Pettersson R, Söderström S, Edlund-Söderström K, Nilsson KW. Internet-based cognitive behavioral therapy for adults with ADHD in outpatient psychiatric care. J Atten Disord. Apr 2017;21(6):508-521. [CrossRef] [Medline]33], and Nasri et al (56%) [Nasri B, Cassel M, Enhärje J, et al. Internet delivered cognitive behavioral therapy for adults with ADHD —a randomized controlled trial. Internet Interv. Sep 2023;33:100636. [CrossRef] [Medline]31]. The average number of messages sent by the participants to study staff was 3.4 messages. This is in-line [Rheker J, Andersson G, Weise C. The role of “on demand” therapist guidance vs. no support in the treatment of tinnitus via the internet: a randomized controlled trial. Internet Interv. May 2015;2(2):189-199. [CrossRef]67] or higher [Käll A, Olsson Lynch C, Sundling K, Furmark T, Carlbring P, Andersson G. Scheduled support versus support on demand in internet-delivered cognitive behavioral therapy for social anxiety disorder: randomized controlled trial. Clin Psychol Eur. Sep 2023;5(3):e11379. [CrossRef] [Medline]68] than in previous iCBT trials with support on demand. However, postintervention, several participants suggested improved and increased support in future development of the program.

When discussing the results of this study, it is essential to acknowledge the absence of any control group. This means the design did not control for the expectation of benefit, other common factors of digital psychological interventions, or the natural disease progression [Lutz J, Offidani E, Taraboanta L, Lakhan SE, Campellone TR. Appropriate controls for digital therapeutic clinical trials: a narrative review of control conditions in clinical trials of digital therapeutics (DTx) deploying psychosocial, cognitive, or behavioral content. Front Digit Health. 2022;4:823977. [CrossRef] [Medline]69]. Also important to note are the characteristics of the sample, which primarily consisted of highly educated women, with a large majority on psychotropic medication. This may limit the generalizability of the findings to other adult populations with ADHD, particularly men and nonbinary individuals, those with lower levels of education, and those not on psychotropic medication. Predominately female samples are common in iCBT trials, as exemplified by the study by Lindner et al [Lindner P, Nyström MBT, Hassmén P, Andersson G, Carlbring P. Who seeks ICBT for depression and how do they get there? Effects of recruitment source on patient demographics and clinical characteristics. Internet Interv. May 2015;2(2):221-225. [CrossRef]70]. In Sweden, women also show a small majority among adults with ADHD [Diagnostik och läkemedelsbehandling vid ADHD [Diagnosis and pharmacological treatment of ADHD]. Socialstyrelsen. 2023. URL: https:/​/www.​socialstyrelsen.se/​globalassets/​sharepoint-dokument/​artikelkatalog/​ovrigt/​2023-11-8862.​pdf [Accessed 2025-05-22] 71]. However, future trials would benefit from exploring other recruitment strategies, including ones targeting specific populations, to achieve more representative samples. Future trials would also benefit from higher-resolution measures of pharmacological treatment among participants, for example, separating ADHD prescriptions from other psychotropic medication.

Considering the study’s strengths, inclusion criteria were generous and did not exclude individuals with autism, learning disabilities, or psychiatric comorbidities other than severe depression or suicidality. While this makes for a sample more representative of the heterogeneous adult ADHD population, the demographic range is still limited. The outcome measures are well established and psychometrically evaluated. In light of recent criticism of the PSS [Rozental A, Forsström D, Johansson M. A psychometric evaluation of the Swedish translation of the Perceived Stress Scale: a Rasch analysis. BMC Psychiatry. Sep 22, 2023;23(1):690. [CrossRef] [Medline]40], subscale outcomes were reported in the results. The potential issues with the KEDS, recently shown by Lindsäter et al [Lindsäter E, van de Leur JC, Rück C, Hedman-Lagerlöf E, Bianchi R. Psychometric and structural properties of the Karolinska Exhaustion Disorder Scale: a 1,072-patient study. BMC Psychiatry. Sep 2, 2023;23(1):642. [CrossRef] [Medline]41], should be mentioned. However, the scale remains the benchmark for web intervention research in Sweden, and it is supplemented by the other measures included in the study. Concerning the measures, inclusion criteria required only an above-cutoff score on one of the secondary outcome measures. This means that not all participants had elevated levels of stress, exhaustion, anxiety, and depression at screening. This could introduce floor effects, as some participants lacked room for improvement on 1 or more measures. This is also why RCI was calculated and presented for only the AAQoL and the ASRS, relevant for all participants.

The intervention was based on previous interventions that have been shown efficacious for ADHD symptoms and common ADHD comorbidities. The intervention content was designed with ADHD theory and mechanisms of change in mind. The development of the intervention was also preceded by interviews with adults with ADHD, regarding workplace functioning and the intervention proposition. From the results of this study, it is clear that the intervention has the potential to be helpful for adults with ADHD who are experiencing stress, exhaustion, anxiety, and depression. Based on this, and the feedback provided by the participants, the intervention will be revised before being further evaluated in an RCT. If proven helpful and effective, the intervention could be developed further and possibly disseminated to a broader population through routine health care or as a stand-alone product, such as an app, as exemplified in the studies by Selaskowski et al [Selaskowski B, Reiland M, Schulze M, et al. Chatbot-supported psychoeducation in adult attention-deficit hyperactivity disorder: randomised controlled trial. BJPsych Open. Oct 13, 2023;9(6):e192. [CrossRef] [Medline]72] and Seery et al [Seery C, Cochrane RH, Mulcahy M, Kilbride K, Wrigley M, Bramham J. “A one-stop shop”: real-world use and app-users’ experiences of a psychoeducational smartphone app for adults with ADHD. Internet Interv. Mar 2025;39:100807. [CrossRef] [Medline]73].

Acknowledgments

We would like to thank Riksförbundet Attention for help in recruitment to the study. We used ChatGPT solely for language refinement and not for content creation. All intellectual contributions, including study design, data analysis, and interpretation of findings, are our own. We take full responsibility for the accuracy and originality of the manuscript.

Data Availability

Data from this study are not publicly available because they contain information that could compromise research participant privacy. However, data are archived for at least 10 years in compliance with Stockholm University regulations. Requests for any data should be addressed to the corresponding author.

Authors' Contributions

MO and AR initiated the idea for the study. Funding was secured by MO, AR, YG, PC, and FJ, with FJ as the main applicant and principal investigator for the project. The purpose, research aims, and design were further conceptualized by YG, PC, and FJ. GA provided resources and software for recruitment and data collection. Investigation and formal analysis were conducted by MO, KBW, and SH, with support from the remaining authors. The original draft was written by MO, KBW, and SH. Important revisions were suggested by AR, YG, PC, GA, and FJ. The final manuscript was approved by all authors.

Conflicts of Interest

None declared.

Multimedia Appendix 1

Estimated marginal means, follow-up means, and Jacobson-Truax plots.

PDF File, 165 KB

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AAQoL: Adult Attention-Deficit/Hyperactivity Disorder Quality of Life Scale
ADHD: attention-deficit/hyperactivity disorder
ASRS: Adult Attention-Deficit/Hyperactivity Disorder Self-Report Scale
CBT: cognitive behavioral therapy
GAD-7: Generalized Anxiety Disorder 7-item Scale
iCBT: internet-delivered cognitive behavioral therapy
KEDS: Karolinska Exhaustion Disorder Scale
LOCF: last observation carried forward
NEQ: Negative Effects Questionnaire
PHQ-9: Patient Health Questionnaire
PSS: Perceived Stress Scale
RCI: reliable change index
RCT: randomized controlled trial


Edited by Amaryllis Mavragani; submitted 11.09.24; peer-reviewed by L Sorensen, Victoria Nimmo-Smith; final revised version received 23.03.25; accepted 02.04.25; published 29.05.25.

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© Martin Oscarsson, Sandra Hammarbäck, Karolina Blom Wiberg, Alexander Rozental, Ylva Ginsberg, Per Carlbring, Gerhard Andersson, Fredrik Jönsson. Originally published in JMIR Formative Research (https://formative.jmir.org), 29.5.2025.

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