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Objective: The authors investigated the efficacy of a 12-week manualized meta-cognitive therapy group intervention designed
to enhance time management, organization, and planning in adults with attention
deficit hyperactivity disorder (ADHD).
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Method
Design
Eighty-eight adults rigorously diagnosed as having ADHD were
stratified by use of ADHD medications (stimulants or atomoxajp.psychiatryonline.org
959
Sessio n 1
Participants are
oriented to:
Methods
(behavioral and
cognitivebehavioral)
Expectations
(regular and
punctual
attendance,
confidentiality)
Program format
Sessio n s 26
Each session addresses one or more time- and
task-management topics, including:
Time awareness
Facilitation of task initiation and completion
by dismantling tasks into manageable parts
Contingent self-reward
Scheduling and prioritizing
Maintaining motivation by visualizing
long-term reward
Review of traditional cognitive-behavioral
therapy methods to target depressogenic and
anxiogenic automatic thoughts that
undermine efficient self-management
etine) and otherwise randomly assigned to receive either metacognitive therapy or supportive therapy; the latter was intended
to control for nonspecific therapeutic effects of a group intervention. Response was assessed immediately before and after treatment via a structured interview completed by an independent
(blind) evaluator and by questionnaires completed by the patient
and a significant other. Each group consisted of six to eight participants. One meta-cognitive therapy and one supportive therapy
group intervention were run concurrently in a cohort to ensure
that the groups were matched on the percentage receiving ADHD
medications and were equivalent with respect to environmental
changes (e.g., seasonal and holiday periods).
The study was approved by the Mount Sinai School of Medicine Institutional Review Board, and all participants provided informed written consent to participate.
Participants
Prospective participants were referred from New York area
medical and psychiatric clinics, ADHD advocacy and self-help
groups, community psychiatrists and primary care physicians,
university health services, and postings on clinical trials web sites.
Participants had to be between the ages of 18 and 65 and have
a DSM-IV diagnosis of ADHD, predominantly inattentive or combined subtype. Exclusion criteria were active substance abuse or
dependence; suicidality; overtly hostile or aggressive behavior
likely to alienate group members; asocial characteristics (e.g.,
pervasive developmental disorder); cognitive disability (estimated
IQ <80); psychosis; borderline personality disorder; Alzheimers
disease or other dementia; overt neurological disorder; and a
childhood history of abuse or trauma or other severe psychiatric
condition that confounded ascertainment of childhood ADHD
symptoms. Patients with other axis I psychiatric disorders were
eligible for participation. Individuals receiving psychotropic medication had to be stabilized on a given drug for at least 2 months
and on a given dose for at least 1 month. Patients were instructed
to defer nonessential changes in their therapeutic regimen (either
medication or psychotherapy) until the end of treatment.
Assessments
Diagnostic assessments. The diagnosis of ADHD was based
on the Conners Adult ADHD Diagnostic Interview for DSM-IV
(CAADID; 21). Also required was a T-score of at least 65 (93rd
percentile) on the DSM-IV inattention subscale of the Conners
Adult ADHD Rating ScalesSelf-Report: Long Version (CAARS-S;
22, 23) and a T-score of 63 (90th percentile) on the inattention/
memory subscale. The latter subscale consists largely of items
that gauge the severity of the difficulties in time management
and organizational functions that constitute the focus of meta-
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Sessio n s 79
Implementation
and maintenance
of organizational
systems
Session s 10 11
Planning,
guided by
flow-charting of
goals and
subcomponents
Session 12
Summarize and
reinforce
participants
progress
Highlight areas
for continued
practice/
improvement
Provide
participants
with a pithy
summary of
strategies
Meta-Cognitive Therapy
Principles of meta-cognitive therapy. In meta-cognitive
therapy, cognitive-behavioral principles are employed to 1)
provide contingent self-reward (e.g., for completing an aversive
Am J Psychiatry 167:8, August 2010
%
71
N
26
%
61
3
4
23
15
7
9
51
33
6
8
12
17
14
19
28
39
1
2
40
2
0
2
4
89
4
0
2
1
34
3
3
5
2
79
7
8
20
2
17
6
33
22
44
4
38
13
73
49
10
6
26
1
31
23
23
14
61
2
72
54
3
3
4
7
2
2
7
4
6
7
7
7
9
16
4
4
16
9
13
16
6
4
4
3
7
6
3
3
4
2
14
10
10
7
17
14
7
7
10
5
14
31
25
13
Mean
41.04
16.40
119.23
31
69
56
29
SD
11.59
1.74
11.47
Age (years)
Education (years)
WAIS-III abbreviated IQ
Conners Adult ADHD Rating ScalesSelf-Report,
Long Form
Inattention/memory subscale
79.62
7.25
DSM-IV inattentive subscale
82.82
11.77
DSM-IV hyperactive-impulsive subscale
64.87
13.43
Beck Depression Inventory
10.89
9.44
Rosenberg Self-Esteem Inventory
17.20
5.07
a
Ascertained on the basis of self-report.
b
Signi cant difference between groups, 2=10.75, p=0.013.
c
Ascertained on the basis of Conners Adult ADHD Diagnostic Interview for DSM-IV.
15
28
23
15
Mean
42.37
15.98
114.07
35
65
54
35
SD
12.09
2.23
14.10
79.67
84.93
65.88
11.60
18.55
6.56
6.30
14.11
8.56
5.42
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Mean
Posttreatment
SD
Mean
SD
Least Squares
Mean Changea
95% CI
Supportive Therapy
The supportive therapy condition was designed to control for
nonspecific elements of the meta-cognitive therapy program,
including session and treatment duration (2 hours per week for
12 weeks), group support and validation, therapist attention,
and psychoeducation, but without the didactic strategies and
exercises contained in the meta-cognitive therapy program. A
manual delineated the techniques and strategies that were prohibited and permitted to the therapist during supportive therapy sessions.
Program structure. Each supportive therapy series commenced
with a brief discussion of the program orientation and the
role of the therapist as an educator and facilitator. The group
was characterized as a mechanism for providing information
(e.g., addressing and dispelling myths), uniting around shared
experiences, and fostering a network of support.
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Fidelity Ratings
Therapist competence and adherence to the treatment protocols were rated on a checklist (available from the authors on
request) developed following the recommendations of Waltz et al.
(34). All treatment sessions were taped, and four sessions from
each 12-session series were randomly selected to be rated by a
therapist experienced in cognitive-behavioral therapy (48 tapes
in all). Comparison of ratings revealed no differences between
groups in mean ratings of therapist competence and also indicated that there were no instances of contamination of the supportive therapy condition by use of behavioral or cognitive-behavioral
interventions.
Am J Psychiatry 167:8, August 2010
Posttreatment
Least Squares
Mean Changea
95% CI
4.71
3.16
10.33
2.3*
1.0*
0.9
1.0, 3.6
0.1, 1.9
2.0, 3.9
2.7***
2.2***
4.8*
0.9, 4.6
0.9, 3.5
0.8, 8.7
76.80
78.64
11.00
11.52
8.8*
1.26
5.6, 12.0
2.0, 4.6
0.3
4.13
4.2, 4.7
0.5, 8.7
28.98
9.08
8.88
0.65
19.50
24.67
7.16
5.63
0.70
5.86
9.5*
2.3*
0.2
0.1
1.3
Mean
SD
Mean
18.33
10.58
74.33
3.55
2.59
9.67
16.18
9.70
73.19
85.72
80.71
9.53
9.24
37.87
11.34
8.45
0.50
18.37
22.57
8.12
5.20
0.64
5.62
SD
Data Analyses
The treatment groups were compared on baseline characteristics using t tests for continuous variables and chi-square
tests for categorical variables. Because the treatments were conducted in groups, we investigated the intracluster correlation
due to group, cohort, and group leader in the outcome change
(pre- minus posttreatment) measures, controlling for the pretreatment measure. These analyses were conducted using mixed
models that specified group, cohort, and group leader as random
effects. General linear modeling was used to compare the degree of change in the two treatment groups, controlling for the
pretreatment measure. Models that included the interaction of
treatment with the pretreatment measure were also run to assess
whether any effects of treatment differed by pretreatment symptom severity. Additional models also incorporated interactions of
treatment with potential moderators of treatment response, including demographic characteristics, comorbid diagnoses, and
medication status.
Results
Sample Characteristics
Of 355 individuals screened, 88 who met full eligibility
criteria were randomly assigned to treatments; 45 were
assigned to meta-cognitive therapy and 43 to supportive
therapy. The two treatment groups did not differ on any
sociodemographic or clinical variables, with the exception of marital status (Table 1). Although this was a largely
well-educated sample, only half were employed full time,
and household income in both groups evenly spanned 10
intervals from $9,999 to $150,000.
Attrition. Five participants in each group dropped out of
treatment. Participants considered not to have completed
Am J Psychiatry 167:8, August 2010
15.5, 3.4
0.3, 4.3
1.7, 1.3
0.3, 0.1
2.7, 0.1
Difference
8.4
0.5
1.4
0.3
0.0
95% CI
16.8, 0.0
3.2, 2.2
0.7, 3.5
0.0, 0.5
1.9, 1.9
963
to complete tasks, disorganization, avoidance of effortful tasks, losing things, and forgetting things. Because of
lower return rates for the CAARS-O scale (in part attributable to limited availability of collaterals), effects on the
CAARS-S and CAARS-O reports were examined in separate
univariate analyses.
The results of general linear modeling comparing
change from baseline between treatment groups, adjusting for the baseline value of the change outcome measure,
are summarized in Table 2, along with the unadjusted preand posttreatment mean values and change scores adjusted for baseline by treatment group.
Only one statistically significant interaction between
baseline score and response to treatment was observed,
and that was on the CAARS-S inattention/memory subscale score. The results of the analysis of change on this
variable are thus presented separately in Table 3 and Figure 3 since there can be no single contrast between treatment groups given the presence of the interaction. The
pattern of treatment contrasts indicated that the larger the
score at baseline (that is, the more severe the symptoms),
the greater the differential improvement observed with
meta-cognitive therapy; this occurred whether the data
were analyzed with or without those who did not complete
the program and those who made proscribed medication
changes (interaction coefficients, 0.66 and 0.72, respectively). Change in the support group, by contrast, was
stable across the entire range of baseline CAARS-S inattention/memory subscale scores. Baseline AISRS inattention
score did not interact with treatment in the analysis comparing change in AISRS following meta-cognitive therapy
versus supportive therapy. With respect to the change in
AISRS inattention score from pre- to posttreatment assessment, controlling for baseline score, Table 2 indicates that
the meta-cognitive therapy group improved by 5.0 points,
whereas the supportive therapy group improved by 2.3
points, a difference between groups of 2.7 (95% CI=0.9
4.6, p<0.005) or 56% of the overall standard deviation of
the change score (SD=4.8). The same pattern (i.e., greater
change in meta-cognitive therapy versus support) was evident on the AISRS time management, organization, and
planning subscale and the CAARS-O inattention subscale.
On all of the foregoing measures, examination of confidence limits revealed significant change from pre- to posttreatment assessment for supportive therapy as well as for
meta-cognitive therapy. On the Brown scales and the On
Time Management Organization and Planning scale, there
was significant change from pre- to posttreatment assessments for supportive therapy as well as for meta-cognitive
therapy. However, the change score difference between
groups was either not significant (Brown scales) or only
marginally significant (On Time Management Organization and Planning scale). The metacognition index of the
Behavior Rating Inventory of Executive FunctionAdult
Version yielded marginally significantly greater improvement in meta-cognitive therapy compared to supportive
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therapy; change in meta-cognitive therapy but not supportive therapy was significant.
Analyses of Measures of Comorbidity
No differences were observed between treatment
groups in pre- to posttreatment assessment change
scores for depression (BDI), self-esteem (Rosenberg SelfEsteem Inventory), or anxiety (HAM-A). With the exception of a small but significant improvement on the BDI
in the supportive therapy condition, examination of
confidence intervals for change scores for each treatment group separately showed no significant effects for
any of these outcome variables. Given that the sample as
a whole scored within normal limits on the BDI, we reexamined the data to ascertain whether there was a significant decrease in BDI score for those individuals who
had a concurrent axis I mood disorder. Analysis of variance (ANOVA) showed that for these participants mean
BDI scores decreased from 17 to 13, yielding a significant
main effect of time (pre- to posttreatment assessment;
F=4.99, df=1, 24, p=0.035) but no interaction with treatment condition. A similar analysis with HAM-A score for
those who had a concurrent anxiety disorder produced
no significant results.
Intracluster Correlation
Mixed-model ANOVAs were conducted to adjust for intracluster correlation using group, therapist, and cohort
as clusters. Therapist consistently did not account for any
intracluster correlation. Adjusting for group and cohort
simultaneously as random variables did not affect the significance of the treatment effects noted in Table 2.
Responder Analyses
The data were also examined to determine whether
participants exhibited clinically meaningful change in response to treatment. On the blind structured interview of
DSM-IV inattention symptoms (AISRS inattention items),
a positive response was defined as a decrease of at least
30% (maximum score=27), consistent with the criterion
used in pharmaceutical trials (9). A positive response on
the CAARS-S inattention/memory subscale score was defined as a decrease of at least 10 T-score points (one standard deviation). Seven participants who dropped out and
for whom posttreatment data were not available were conservatively scored as nonresponders on these variables.
On the AISRS inattention items, 19 participants (42.2%)
in the meta-cognitive therapy group met the response
criterion, compared to only five (12%) in the supportive
therapy group (2=10.38, df=1, p=0.002). On the CAARSS inattention/memory subscale, 24 (53%) participants in
the meta-cognitive therapy group and 12 (28%) in the supportive therapy group met the response criterion (2=5.88,
df=1, p=0.018). Logistic regression, with AISRS inattention
score response status as the dependent variable, was performed to control for baseline AISRS inattention score.
Results revealed a significant effect of treatment group on
Am J Psychiatry 167:8, August 2010
Percentile in
Sample
Meta-Cognitive
Therapy Group
(N=41)
5th
25th
50th
75th
95th
4.16
8.50
11.60
14.70
16.56
95% CI
Supportive
Therapy Group
(N=38)
95% CI
0.53, 8.85
5.58, 11.42
9.23, 13.97
11.82, 17.58
13.00, 20.11
6.91
6.62
6.42
6.22
6.10
2.04, 11.77
3.68, 9.56
3.95, 8.89
2.99, 9.45
2.06, 10.14
18
Ch an ge in T-score
16
Meta-Cognitive Therapy
Supportive Therapy
12
10
8
6
4
2
9.51, 4.02
2.27, 6.02
1.75, 8.60
4.15, 12.81
5.08, 15.84
14
2.74
1.88
5.18
8.48
10.46
20
Moderators of Response
95% CI
Difference
68
75
80
Baselin e T-score
85
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Measure
Mean
Session 2
SD
Mean
Baseline
SD
Mean
Session 2
SD
Mean
SD
Helpfulness
2.35
0.734
2.33
0.796
2.41
0.609
2.30
0.696
Con dence
1.83
0.718
2.17
0.718
2.42
0.669
2.23
0.725
a
Based on questions designed for the purpose. The question gauging helpfulness was How helpful do you think this treatment will be for
you? The question on con dence was How con dent would you be in recommending this treatment to a friend who has ADHD? Responses
were recorded on a 4-point Likert scale (0=not at all helpful/con dent, 1=slightly helpful/con dent, 2=moderately helpful/con dent, 3=very
helpful/con dent). There were no signi cant differences between groups.
TABLE 5. Mean Daily Doses of ADHD Medications Among Participants in a Study Comparing Meta-Cognitive Therapy and
Supportive Therapy for the Treatment of ADHDa
Medication and Treatment Group
SD
Methylphenidate
Meta-cognitive therapy
8
51.38
29.5
2090
Supportive therapy
10
49.00
18.4
2780
Amphetamine
Meta-cognitive therapy
5
40.00
23.5
2080
Supportive therapy
7
32.14
19.1
2070
Atomoxetine
Meta-cognitive therapy
6
90.00
16.7
60100
Supportive therapy
3
73.33
30.6
40100
a
For this analysis, doses of dexmethylphenidate (N=2) and lisdexamfetamine (N=2) were converted to equivalent doses of d,l-methylphenidate or amphetamine (Adderall), respectively. Two other patients were taking two different stimulants or a stimulant plus atomoxetine.
In those instances, only the methylphenidate-equivalent dose was entered. In two cases an adequate dose was discontinued before the
midpoint of the program. These patients were not included as adequately dosed. In two cases in which there was a dose change in the
second half of the program, only the dose at the start of the program was recorded.
b
Mean daily doses did not differ signi cantly between treatment groups.
Mediators of Response
Session attendance and completion of the home exercises in the meta-cognitive therapy group were examined
as potential mediators of change in AISRS inattention
score. Regression analysis indicated that attendance was
not related to response and did not mediate the treatment
effect. However, within the meta-cognitive therapy group,
completion of the home exercises was significantly related to change in AISRS inattention score (F=6.49, df=1, 38,
p=0.015), with a score increase of 0.85 from baseline for
each home exercise completed.
Discussion
This study was designed to assess the efficacy of metacognitive therapy, a cognitive-behavioral intervention, for
the treatment of adult ADHD. Participants randomly assigned to receive meta-cognitive therapy showed greater
improvement on standardized measures of inattention
symptoms, whether self-rated, observer-rated, or rated by
a blind evaluator, than did those in a supportive therapy
condition. The finding on the AISRS structured interview
favoring a clinically significant response for meta-cognitive therapy over supportive therapy (odds ratio=5.41)
provides strong support for the efficacy of this intervention. The fact that groups were initially found to be equivalent in expectation of change suggests that positive expectancy cannot fully account for change. Furthermore,
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the finding that completion of the home exercise was significantly related to treatment response provides evidence
that change was mediated by the active meta-cognitive
therapy treatment components. The same may be said of
the finding that baseline symptom severity was related to
the outcome of meta-cognitive therapy, whereas change
in the supportive therapy condition was constant across
all levels of symptom severity. The significantly higher total rate of noncompletion and medication change in supportive therapy compared to meta-cognitive therapy may
be an indication that patients felt they were deriving less
benefit from this intervention.
Although the magnitude of change on the primary outcome measures strongly favored meta-cognitive therapy,
patients in the supportive therapy group also reported
improvement. It may be that the support in the group reduced demoralization and improved hopefulness, which
in turn motivated participants to tackle their own difficulties or discover solutions through reading, talking to others, or trial and error.
The lack of significant change on measures of comorbidity (BDI, HAM-A, and Rosenberg Self-Esteem Inventory) in meta-cognitive therapy may have been due to
floor effects on these measures, as scores at baseline were,
on average, not in the clinically significant range. Support
for this possibility was generated by a post hoc analysis of
BDI scores for patients with a concurrent mood disorder,
which revealed a significant decrease from pre- to postAm J Psychiatry 167:8, August 2010
ajp.2009.09081123). From th e Departm en t of Psych iatry, Mou n t Sinai Sch ool of Med icin e, New York. Address corresp on den ce an d reprin t requ ests to Dr. Solan to, Departm en t of Psych iatry, Moun t Sin ai
Sch ool of Med icin e, Box 1230, Gu stave Levy Pl., New York, NY 100296574; m ary.solan to@m ssm .edu (e-m ail).
Dr. Solan to has served on th e m ed ical advisory board of Sh ire Ph arm aceu ticals an d h as served as a con sultant an d sp eaker for Orth oMcNeil-Janssen Ph arm aceu ticals. Dr. Ab ikoff h as received research
fu n din g from NIMH, th e Hugh es, Lem berg, an d Hecksch er Fou n dations, Orth o-McNeil, Sh ire, and Eli Lilly, h as served as a con su ltan t to
Sh ire, Eli Lilly, Ceph alon , an d Novartis, an d h as a n an cial in terest in
th e Ch ildren s Organ ization al Skills Scale, pu blish ed by Mu lti-Health
System s. Dr. Alvir is an em ployee of P zer. Drs. Marks, Wasserstein,
Mitch ell, an d Kofm an report n o n an cial relation sh ips w ith com m ercial in terests.
Sup ported by NIMH grant 1R34MH071721 to Dr. Solan to.
Th e au th ors ackn ow ledge th e exp ert con su ltation in research in
cogn itive-b eh avioral th erapy provid ed by Jacqu eline Gollan , Ph .D.,
an d Rich ard Heim b erg, Ph .D. Th ey also ackn ow ledge th e con tribu tions of Megan Wilen s, M.D., an d Heather Goodm an , Ph .D., w h o
served as blin d evalu ators, an d th e assistan ce of Lau ren Kn ickerbocker, M.A., w ith m an u script p rep aration .
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