Article

Efficacy of Meta-Cognitive Therapy for Adult ADHD

Mary V. Solanto, Ph.D.

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).

David J. Marks, Ph.D.

Jeanette Wasserstein, Ph.D.

Method: Eighty-eight clinically referred

adults who met DSM-IV criteria for ADHD
according to clinical and structured diagnostic interviews and standardized
questionnaires were stratified by ADHD
medication use and otherwise randomly
assigned to receive meta-cognitive therapy or supportive psychotherapy in a
group modality. Meta-cognitive therapy
uses cognitive-behavioral principles and
methods to impart skills and strategies
in time management, organization, and
planning and to target depressogenic and
anxiogenic cognitions that undermine effective self-management. The supportive
therapy condition controlled for nonspecific aspects of treatment by providing
support while avoiding discussion of cognitive-behavioral strategies. Therapeutic
response was assessed by an independent
(blind) evaluator via structured interview
before and after treatment as well as by

Katherine Mitchell, Psy.D.

Howard Abikoff, Ph.D.
Jose Ma. J. Alvir, Dr.P.H.
Michele D. Kofman, Ph.D.

self-report and collateral informant behavioral ratings.

Results: General linear models comparing change from baseline between treatments revealed statistically significant
effects for self-report, collateral report,
and independent evaluator ratings of
DSM-IV inattention symptoms. In dichotomous indices of therapeutic response, a
significantly greater proportion of members of the meta-cognitive therapy group
demonstrated improvement compared
with members of the supportive therapy group. Logistic regression examining
group differences in operationally defined response (controlling for baseline
ADHD severity) revealed a robust effect
of treatment group (odds ratio=5.41; 95%
CI=1.7716.55).
Conclusion: Meta-cognitive therapy yielded significantly greater improvements in
dimensional and categorical estimates of
severity of ADHD symptoms compared
with supportive therapy. These findings
support the efficacy of meta-cognitive therapy as a viable psychosocial intervention.
(Am J Psychiatry 2010; 167:958968)

t is now recognized that ADHD, once thought to be

exclusively a childhood disorder, frequently persists into
adulthood, afflicting approximately 4% of the U.S. adult
population (1) and generating significant impairment in
academic, occupational, social, and emotional functioning (2, 3). This impairment may result in completion of
fewer years of education and elevated rates of unemployment, antisocial behavior, interpersonal conflict, marital
separation, and divorce. Adults with ADHD are also at
significantly greater risk for substance use disorders (4) as
well as other comorbid disorders, such as anxiety and depressive disorders (1).
Adult studies of stimulant (5) and nonstimulant (6) medication, paralleling results with children, have found these
agents to be effective in reducing the core symptoms of
ADHD. However, there are limitations associated with drug
treatment. First, little is known about the impact of pharmacotherapy on the functional impairment typically associated with ADHD (7), particularly in time management
and organization. Given the likely underdevelopment of

meta-cognitive skills in these areas in youths with ADHD

(8), drug treatment alone may not be sufficient to remediate these deficits, and explicit skills training in adulthood
may be necessary. Second, 20%50% of adults do not respond to drug treatment or have adverse responses (9),
which highlights the need for additional interventions.
Furthermore, since response to medication treatment
is typically defined as having at least a 30% reduction in
symptoms (9), many patients considered to have responded do not achieve full remission, leaving room for improvement through other modalities. Thus, there is clearly
a need for psychosocial interventions to help adults with
ADHD develop essential self-management skills.
A recent review (10) revealed that there has been limited research on psychosocial treatments for adults with
ADHD. A case series (11) and several open studies of
group (12, 13) and individual (14) cognitive-behavioral
treatments yielded promising results. However, controlled
studies have been limited to trials of group-administered
(15) and individually administered (16) cognitive-be-

This article is the subject of a CME course (p. 1009).

958

ajp.psychiatryonline.org

Am J Psychiatry 167:8, August 2010

SOLANTO, MARKS, WASSERSTEIN, ET AL.

FIGURE 1. Participant Progress Through the Phases of the Trial Comparing Meta-Cognitive Therapy and Supportive Therapy for the Treatment of ADHD
Assessed for eligibility (N=355)
Excluded (N=267)
Ineligible via phone screen (N=50)
Incomplete questionnaires (N=39)
Ineligible via questionnaires (N=54)
Withdrew prior to completed evaluation (N=40)
Ineligible based on evaluation (N=63)
Withdrew before randomization (N=21)
Randomized (N=88)

Assigned to receive meta-cognitive

therapy (N=45)
Received intervention (N=45)

Assigned to receive supportive

therapy (N=43)
Received intervention (N=43)

Did not complete treatment (N=6)

Made proscribed medication change (N=1)

Did not complete treatment (N=12)

Made proscribed medication change (N=4)

All data were analyzed both with (N=45)

and without (N=38) noncompleters and
medication changers

All data were analyzed both with (N=43)

and without (N=27) noncompleters and
medication changers

havioral interventions, each compared to a waiting list

control condition. In both cases, significantly greater improvement in core ADHD symptoms was observed in the
treated group. Yet, while these studies yielded large effect
sizes in the treated group and controlled for the passage of
time, they enrolled small samples (1522 participants per
condition) and did not control for nonspecific effects of
treatment (e.g., therapist support), which may exert powerful effects on treatment response (17, 18).
Over the past decade our group has been developing,
studying, and refining meta-cognitive therapy, a group-administered intervention that incorporates cognitive-behavioral principles and was designed to foster the development
of executive self-management skills. We chose to focus on
time management and organization because difficulties in
the attentional domain are more prevalent than those in the
hyperactive-impulsive domain among adults with ADHD
and are most consistently related to clinician ratings of severity of illness and impairment (19). Moreover, our clinical
experience indicates that problems with impulsivity, social
behavior, and mood control are common only to a subset
of patients and require a different intervention format. The
group format was selected because 1) the skills and strategies to be imparted lend themselves to semistructured presentation; 2) the group format provides opportunities for
positive modeling, social reinforcement, and social support;
and 3) the group is a cost-effective treatment delivery mode.
Am J Psychiatry 167:8, August 2010

Our first study of meta-cognitive therapy (20) found that

adults who completed our manualized group program
showed robust change from baseline to posttreatment assessment on standardized self-report measures of ADHD
symptoms and executive skills. Given these positive results,
we undertook the present study to rigorously examine the
efficacy of meta-cognitive therapy by comparing self-report,
observer report, and independent evaluator ratings of patients who received meta-cognitive therapy and patients who
received supportive therapy. We postulated greater positive
change in the meta-cognitive therapy group than in the supportive therapy group. We further hypothesized that patients
concurrently receiving medication to treat ADHD would
show an enhanced positive response to meta-cognitive
therapy because the medication would allow them to focus
better, process and retain more during the therapy sessions,
and facilitate the practice of strategies between sessions. Finally, we hypothesized that by improving functioning, metacognitive therapy would enhance feelings of efficacy and
competence, thereby yielding secondary improvements in
comorbid symptoms of anxiety and depression.

Method
Design
Eighty-eight adults rigorously diagnosed as having ADHD were
stratified by use of ADHD medications (stimulants or atomoxajp.psychiatryonline.org

959

META-COGNITIVE THERAPY FOR ADULT ADHD

FIGURE 2. Meta-Cognitive Therapy Program Sequence

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-

960

ajp.psychiatryonline.org

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

cognitive therapy. The presence of childhood symptoms was

confirmed by at least one of the following: self-report of four
or more childhood symptoms in one domain (inattentive or
hyperactive-impulsive) on the CAADID; report of four or more
symptoms in a given domain on the Childhood Symptom Scale
Other Report (24) by the parent or other adult who knew the
patient in childhood; or report of symptoms of ADHD on school
report cards or a childhood psychological evaluation. Comorbid
conditions were assessed using the Structured Clinical Interview
for DSM-IV Axis I Disorders (25) and the module for borderline
personality disorder from the Structured Clinical Interview for
DSM-IV Axis II Personality Disorders (26). IQ was estimated
using four subtests of the WAIS-III (vocabulary, similarities, block
design, and matrix reasoning), as described by Tellegen and
Briggs (27).
Figure 1 summarizes the flow of participants through each
stage of the study.
Assessments of response to treatment. Patients were
assessed by the independent evaluator before and after
treatment using the Adult ADHD Investigator Symptom Rating
Scale (AISRS), a structured interview developed to assess the
18 DSM-IV symptoms of ADHD (28). Clinician evaluators were
licensed psychologists or board-eligible psychiatrists who had
been trained on the AISRS to a reliability of 0.90. To reduce
rater variance, the same evaluator administered the interview
to a given participant before and after treatment. The symptom
score (03) summed across the nine inattention items served
as one of two primary outcome measures for the study. The
CAARS-S inattention/memory subscale score served as the other
primary outcome measure. In addition, the following self-report
questionnaires were completed before and after treatment:
the Brown Attention-Deficit Disorder Scales (29); the Behavior
Rating Inventory of Executive FunctionAdult Version (30); the
Beck Depression Inventory, 2nd edition (BDI; 31); the Rosenberg
Self-Esteem Inventory (32); and the On Time Management
Organization and Planning scale (possible scores range from
102 to +102), which was developed and previously used in our
program to assess those skills (20). The CAARSObserver Report:
Long Version (CAARS-O) was also completed before and after
treatment by a spouse, partner, family member, or close friend of
the participant, with the participants consent. The independent
evaluator also administered the Hamilton Anxiety Rating Scale
(HAM-A) using a structured instrument (33).

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

SOLANTO, MARKS, WASSERSTEIN, ET AL.

TABLE 1. Demographic and Clinical Characteristics of 88 Participants in a Study Comparing Meta-Cognitive Therapy and
Supportive Therapy for the Treatment of ADHD
Characteristic
Female
Highest degree earned
High school or equivalency diploma
Technical or associates degree
Bachelors degree
Graduate degree
Ethnicitya
Asian
Black
Caucasian
Hispanic
Mixed race
Marital statusb
Married
Divorced
Never married
Cohabiting
Employed (any)
Employed full time
Household income
$0$9,999
$10,000$19,999
$20,000$29,999
$30,000$39,999
$40,000$49,999
$50,000$59,999
$60,000$74,999
$75,000$99,999
$100,000$149,999
$150,000 or more
ADHD subtypec
Combined
Inattentive
Any current anxiety disorder
Any current mood disorder

Meta-Cognitive Therapy Group (N=45)

N
32

%
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.

task); 2) dismantle complex tasks into manageable parts; and 3)

sustain motivation toward distant goals by visualizing long-term
rewards. Traditional cognitive-behavioral methods that challenge
anxiolytic and depressogenic cognitions are also incorporated.
Support from, modeling of, and reinforcement by other group
members and the therapist are important components of the
treatment that serve to stimulate, enhance, and maintain positive
gains.
Am J Psychiatry 167:8, August 2010

Supportive Therapy Group (N=43)

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

Cues to promote generalization and maintenance. The

program also makes use of self-instruction using phrases that
link a problematic situation (cue) with a cognitive response that
provides a solution to that problem. An example is If I am having
trouble getting started (cue), then the first step is too big (solution
is to break task down into parts). Another example, designed to
cue individuals to minimize distracters in their organizational
space, is Out of sight, out of mind. Such phrases are repeated
ajp.psychiatryonline.org

961

META-COGNITIVE THERAPY FOR ADULT ADHD

TABLE 2. Response on Dimensional Measures Among Participants in a Study Comparing Meta-Cognitive Therapy and Supportive Therapy for the Treatment of ADHD
Meta-Cognitive Therapy Group (N=41)
Baseline
Measure

Mean

Posttreatment
SD

Mean

SD

Least Squares
Mean Changea

95% CI

Adult ADHD Investigator Symptom Rating Scale

Inattention subscale
18.88
3.75
13.71
4.27
5.0*
3.7, 6.3
Time management, organization, and planning subscale
10.98
2.30
7.66
2.83
3.2*
2.3, 4.1
Conners Adult ADHD Rating ScalesObserver: Long Version,
72.47
10.56
66.94
11.64
5.7*
3.1, 8.3
inattention/memory subscaleb,c (T-score)
Brown Attention-De cit Disorder Scale, total score (T-score)
84.73
8.82
75.80
12.63
9.1*
6.0, 12.2
Behavior Rating Inventory of Executive FunctionAdult Ver78.37
8.69
73.83
9.01
5.39*
2.2, 8.6
sion, metacognition indexc (T-score)
On Time Management Organization and Planning scale
40.56
23.87
22.10
20.64
17.9*
23.7, 2.1
Beck Depression Inventory
11.48
9.59
9.66
8.31
1.8
0.1, 3.7
Hamilton Anxiety Rating Scale, total anxiety
9.56
5.37
8.07
5.38
1.2
0.2, 2.7
Observed anxietyd
0.65
0.74
0.50
0.64
0.2
0.0, 0.3
Rosenberg Self-Esteem Inventory
16.93
5.14
18.39
6.02
1.3
2.6, 0.0
*p<0.05. ** p<0.01. *** p<0.001.
a
Least squares mean change is change from baseline (pretreatment minus posttreatment assessments) adjusted for baseline value.
b
Meta-cognitive therapy group, N=34; supportive therapy group, N=27.
c
The difference between groups was no longer signi cant (Conners Adult ADHD Rating ScalesObserver: Long Version, inattention/memory
subscale) or no longer approached signi cance (Behavior Rating Inventory of Executive FunctionAdult Version, metacognition index) after
excluding participants who did not complete the study and those who made proscribed medication changes.
d
This measure refers to anxiety observed and rated by the interviewer during the structured interview used for the Hamilton Anxiety Rating
Scale.
strategically throughout the program so that they become part of
the individuals problem-solving repertoire, thereby enhancing
generalization and maintenance of gains.
Content of meta-cognitive therapy. The sequence of treatment
sessions, displayed in Figure 2, is hierarchical in nature, beginning
with training in specific skills (e.g., mechanics of planner use)
and progressing to higher-order skills that encompass both time
management and organization (i.e., planning).
Session format. The first hour of each 2-hour session is devoted
to a roundtable review of each participants experience with the
most recent home exercise to ascertain and address cognitive,
situational, and emotional obstacles to implementation;
suggest additional or alternative strategies; and address
counterproductive emotional responses. The second half of
each session begins with a presentation of the new topic and
corresponding strategies, followed by an in-session exercise
to illustrate or model each technique. Sessions conclude with
an explanation of the next home exercise and anticipatory
troubleshooting.

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.

962

ajp.psychiatryonline.org

During the initial session, group members were asked to

identify a specific goal to address during the program. Each
subsequent session was subdivided into two segments, with
the initial half devoted to a review of events that transpired
during the preceding week, including challenges or positive
accomplishments; the second portion, when time permitted,
involved a therapist-led discussion of a specific psychoeducational theme, elicited from group members at the outset of the
session. Although the specific topics varied somewhat across
groups, the most typical areas covered included primary symptoms of ADHD; everyday manifestations of ADHD symptoms;
and psychopharmacological treatment. Throughout the various sessions, each therapist responded by providing psychoeducation, offering support and encouragement (e.g., highlighting positive changes and effort), and/or referring the problem
to the group for alternative solutions.

Therapists and Training

Two psychologists who were already highly experienced in
the diagnosis and treatment of ADHD in adults (D.J.M. and J.W.)
were thoroughly trained in meta-cognitive therapy and support
interventions and served as therapists. Each therapist led half
of the meta-cognitive therapy groups and half of the support
groups in randomized sequence.

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

SOLANTO, MARKS, WASSERSTEIN, ET AL.

Supportive Therapy Group (N=40)

Baseline

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

Difference Between Least

Squares Mean Change Scores

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

the program additionally included those who missed

more than three sessions; missing a session was defined
as missing at least half of a session. In this category were
one participant in the meta-cognitive therapy group and
seven in the supportive therapy group. Five participants
made proscribed medication changes during the 12week programone in the meta-cognitive therapy group
and four in the supportive therapy group. Posttreatment
outcome data were obtained from all participants except
seven dropouts (four in the meta-cognitive therapy group
and three in the support group).
Those who did not complete the program and those
who made proscribed medication changes constituted
16% of the meta-cognitive therapy group and 37% of the
supportive therapy group (2=5.34, df=1, p=0.02). Participants who completed the program (N=65) were more
likely than those who did not and those who made medication changes to be female (72% compared with 48%,
respectively, 2=4.53, df=1, p=0.03) and to be of the predominantly inattentive subtype (74% compared with 48%,
2=5.21, df=1, p=0.02). Those included and those excluded
from the analyses did not differ with respect to any other
demographic or clinical characteristics.
Analyses of ADHD-Related Measures
The primary outcome measures were the blind structured interview (AISRS) and the CAARS-S inattention/
memory subscale score. We examined effects on the full
AISRS as well as on a subscale of the AISRS inattention
items consisting of five items that most directly reflect
the skills of time management, organization, and planning that are targeted by meta-cognitive therapy: failure
ajp.psychiatryonline.org

963

META-COGNITIVE THERAPY FOR ADULT ADHD

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

964

ajp.psychiatryonline.org

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

SOLANTO, MARKS, WASSERSTEIN, ET AL.

TABLE 3. Change in Conners Adult ADHD Rating ScalesSelf-Report Inattention/Memory Subscore as a Function of Baseline
Score Among Participants in a Study Comparing Meta-Cognitive Therapy and Supportive Therapy for the Treatment of
ADHD
Difference Between Least
Squares Mean Change Score

Least Squares Mean Change Score

Baseline
Subscore
68
75
80
85
88

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

response status (odds ratio=5.41; 95% CI=1.7716.55) favoring meta-cognitive therapy.

18

Ch an ge in T-score

16

Meta-Cognitive Therapy
Supportive Therapy

12
10
8
6
4
2

Am J Psychiatry 167:8, August 2010

9.51, 4.02
2.27, 6.02
1.75, 8.60
4.15, 12.81
5.08, 15.84

14

Expectation of change and treatment credibility were

assessed using two questions (coded on a 4-point Likert
scale) derived from Borkovec and Nau (35) concerning
the anticipated helpfulness of treatment and confidence
in recommending the treatment to another. Group responses were compared before the start of treatment and
again at the end of session 2, after participants had been
exposed to the treatment group methods but before any
actual change due to treatment might have confounded
measurement of expectancy. The results (Table 4) indicated no significant difference between groups at baseline,
nor significant change in either group after exposure to
two treatment sessions.

The following covariates were added one by one to the

general linear model to examine whether these potential
moderators attenuated or interacted with the effects of
treatment: age, gender, ethnicity, education, household
income, marital status, employment status, IQ, ADHD
subtype, ADHD medication, and comorbid depressive
and/or anxiety disorder. In each analysis the effect of meta-cognitive therapy compared with supportive therapy
remained significant while controlling for the covariate,
and in no case did the covariate interact significantly with
the treatment effect.
Of the 88 participants, 49 (56%) were receiving FDAapproved medication for ADHD. Of these, 36 patients (18
in each treatment group) were receiving a minimally ad-

2.74
1.88
5.18
8.48
10.46

20

Expectation of Change and Credibility of Treatments

Moderators of Response

95% CI

FIGURE 3. Change in Conners Adult ADHD Rating Scale

Self-Report Inattention/Memory Subscore as a Function of
Baseline Score in a Study Comparing Meta-Cognitive Therapy and Supportive Therapy for the Treatment of ADHD

Analyses of Participants Who Completed the

Program
The above analyses were repeated excluding all those
who did not complete the program or who made proscribed medication changes. The pattern of significance
across dependent measures was identical to that of the
entire sample except that the effect of treatment was no
longer significant for the CAARS-O inattention subscale, a
result most likely due to the reduction in sample size.

Difference

68

75

80
Baselin e T-score

85

88

equate dose, defined as 20 mg/day of methylphenidate,

20 mg/day of amphetamine, or 40 mg/day of atomoxetine, as determined on the basis of the most recent doseresponse studies in adults (3638). The treatment groups
did not differ significantly in the type, adequacy, or dose of
medication treatment (Table 5). Unexpectedly, adequately
medicated patients did not differ from other patients on
any measure of baseline severity of ADHD symptoms.
Chi-square analysis revealed no difference between these
subsets of patients in response rate to treatments, as defined either on blind structured interview (AISRS) or by
CAARS-S (p>0.05); effect sizes (eta) were 0.033 and 0.053,
respectively. Similarly, ANOVA of dimensional scores on
the CAARS-S inattention/memory subscale showed no
impact of medication on response; the effect size (partial
eta-squared) corresponding to the three-way interaction
among medication, time (pre- to posttreatment assessment), and treatment group was <0.001. The effect size
corresponding to the medication-by-time interaction
(collapsed across treatments) was 0.002. For participants
who completed the study (31 adequately medicated and
39 unmedicated or inadequately medicated patients), effect sizes were similar to those for the full sample.

ajp.psychiatryonline.org

965

META-COGNITIVE THERAPY FOR ADULT ADHD

TABLE 4. Expectation of Change and Credibility of Treatments Among Patients Receiving Meta-Cognitive Therapy or Supportive Therapy as Treatment for ADHD at Baseline and After Two Sessions
Meta-Cognitive Therapy Group
Baseline
a

Measure

Mean

Supportive Therapy Group

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

Mean Daily Doseb (mg)

SD

Daily Dose Range (mg)

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,

966

ajp.psychiatryonline.org

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

SOLANTO, MARKS, WASSERSTEIN, ET AL.

treatment assessment for the combined sample, but no

differential effect of group assignment. A parallel result
was not obtained on the HAM-A for those with concurrent
anxiety disorders.
The failure of medication to act as a treatment moderator may be due to several possible factors. First, we had
not expected that patients receiving adequate medication
would not differ in baseline symptom severity from those
not receiving medication. Given that participants were required to meet entry criteria for minimum levels of severity of symptoms, we may have been effectively selecting
those who were nonresponders or suboptimal responders
to medication. Additionally, although we conducted moderator analyses on a subset of medicated participants who
appeared to be receiving minimally adequate amounts of
medication, doses for these individuals may not have been
adequately titrated and may have been suboptimal. A final possibility is that the program is sufficiently structured
and effective that patients are able to benefit whether or
not they are receiving effective medication. A more rigorous examination of the effects of medication and metacognitive therapy, separately and together, would require
a 22 design in which medication treatment is optimally
titrated for each individual.
Although other demographic and clinical variables did
not have significant effects on outcome, larger samples
with greater statistical power may be needed to fully ascertain the effects of these potential moderating and
mediating variables. In particular, although IQ was not a
moderator of response, the mean IQ in this sample was
above average. A sample with a greater IQ range would
be needed to fully assess the potential moderating effect
of this variable and to gauge the generalizability of these
treatment results to adults across a broader IQ range.
Overall, the results of this study indicate that metacognitive therapy provides significant benefit to patients
with ADHD with respect to inattention symptoms that
reflect the specific functions of time management, organization, and planning. It is the first published study to
formally demonstrate the efficacy of a psychosocial treatment in adults with ADHD compared to a condition that
controlled for the nonspecific effects of therapy. It thereby
represents a noteworthy contribution to a developing literature supporting the benefits of cognitive-behavioral
treatmentwhether delivered in group or individual formatfor the treatment of ADHD in adults. It will be important in future studies to examine the maintenance of
these benefits beyond the termination of treatment and
to determine the relative efficacy of pharmacotherapy and
psychosocial treatments, separately and together, for the
treatment of ADHD.

Presen ted in p art at th e 14th Scien ti c Meetin g of th e In tern ation al

Society for Research in Ch ild and Adolescen t Psych op ath ology, Seattle, Ju n e 1720, 2009. Received Au g. 6, 2009; revision s received
Oct. 27 an d Dec. 1, 2009; accepted Dec. 7, 2009 (d oi: 10.1176/ap pi.

Am 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 .

References
1. Kessler RC, Adler L, Barkley R, Biederman J, Conners CK, Demler O, Faraone SV, Greenhill LL, Howes MJ, Secnik K, Spencer T,
Ustun TB, Walters EE, Zaslavsky AM: The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry 2006;
163:716723
2. Barkley RA, Fischer M, Smallish L, Fletcher K: Young adult outcome of hyperactive children: adaptive functioning in major
life areas. J Am Acad Child Adolesc Psychiatry 2006; 45:192
202
3. Biederman J, Monuteaux MC, Mick F, Spencer T, Wilens TE, Silva
JM, Snyder LE, Faraone SV: Young adult outcome of attention
deficit hyperactivity disorder: a controlled 10-year follow-up
study. Psychol Med 2006; 36:167179
4. Wilens TE, Biederman J, Mick E, Faraone SV, Spencer T: Attention deficit hyperactivity disorder (ADHD) is associated with
early onset substance use disorders. J Nerv Ment Dis 1997;
185:475482
5. Spencer T, Biederman J, Wilens T, Doyle R, Surman C, Prince J,
Mick E, Alcardi M, Herzig K, Faraone S: A large, double-blind,
randomized clinical trial of methylphenidate in the treatment
of adults with attention-deficit/hyperactivity disorder. Biol Psychiatry 2005; 57:456463
6. Michelson D, Adler L, Spencer T, Reimherr FW, West SA, Allen
AJ, Kelsey D, Wernicke J, Dietrich A, Milton D: Atomoxetine in
adults with ADHD: two randomized, placebo-controlled studies. Biol Psychiatry 2003; 15:112120
7. Wolf LE, Wasserstein J: Adult ADHD: concluding thoughts. Ann
NY Acad Sci 2001; 931:396408
8. Douglas VI: Cognitive control processes in attention-deficit/
hyperactivity disorder, in Handbook of Disruptive Behavior
Disorders. Edited by Quay HC, Hogan AE. New York, Kluwer
Academic/Plenum Publishers, 1999, pp 105138
9. Wilens TE, Spencer TJ, Biederman J: A review of the pharmacotherapy of adults with attention-deficit/hyperactivity disorder.
J Atten Disord 2002; 5:189202
10. Weiss M, Safren SA, Solanto MV, Hechtman L, Rostain AL, Ramsay JR, Murray C: Research forum on psychological treatment
of adults with ADHD. J Atten Disord 2008; 11:642651
11. McDermott SP, Wilens TE: Cognitive therapy for adults with
ADHD, in Attention Deficit Disorders and Comorbidities in Children, Adolescents, and Adults. Edited by Brown T. Washington,
DC, American Psychiatric Press, 2000, pp 569606

ajp.psychiatryonline.org

967

META-COGNITIVE THERAPY FOR ADULT ADHD

12. Hesslinger B, Tebartz van Elst L, Nyberg E, Dykierek P, Richter

H, Berner M, Ebert I: Psychotherapy of attention deficit hyperactivity disorder in adults: a pilot study using a structured
skills training program. Eur Arch Psychiatry Clin Neurosci 2002;
252:177184
13. Virta M, Vedenpaa A, Gronroos N, Chydenius E, Partinen M,
Vataja R, Kaski M, Iivanainen M: Adults with ADHD benefit
from cognitive-behaviorally oriented group rehabilitation: a
study of 29 participants. J Atten Disord 2008; 12:218226
14. Rostain AL, Ramsay JR: A combined treatment approach for
adults with ADHD: results of an open study of 43 patients. J
Atten Disord 2006; 10:150159
15. Stevenson CS, Whitmont S, Bornholt L, Livesey D, Stevenson
RJ: A cognitive remediation programme for adults with attention deficit hyperactivity disorder. Aust NZ J Psychiatry 2002;
36:610616
16. Safren SA, Otto MW, Sprich S, Winett CL, Wilens TE, Biederman
JJ: Cognitive-behavioral therapy for ADHD in medication-treated adults with continued symptoms. Behav Res Ther 2005;
43:831842
17. Roberts AH, Kewman DG, Mercier L, Hovell M: The power of
nonspecific effects in healing: implications for psychosocial
and biological treatments. Clin Psychol Rev 1993; 13:375
391
18. Ilardi SS, Craighead WE: The role of nonspecific factors in cognitive-behavior therapy for depression. Clinical Psychology: Science and Practice 1994; 1:138155
19. Knouse LE, Sprich S, Cooper-Vince C, Safren SA: ADHD symptom profiles in medication-treated adults entering a psychosocial treatment program. Journal of ADHD and Related Disorders 2009; 1:3447
20. Solanto MV, Marks DJ, Mitchell K, Wasserstein J, Kofman MD:
Development of a new psychosocial treatment for adults with
AD/HD. J Atten Disord 2008; 11:728736
21. Epstein JN, Johnson DE, Conners CK: Conners Adult ADHD
Diagnostic Interview for DSM-IV. North Tonawanda, NY, MultiHealth Systems, 2001
22. Conners CK, Erhardt D, Epstein JN, Parker JDA, Sitarenios G,
Sparrow E: Self-ratings of ADHD symptoms in adults, I: factor
structure and normative data. J Atten Disord 1999; 3:141
151
23. Erhardt D, Epstein JN, Conners CK, Parker JDA, Sitarenios G:
Self-ratings of ADHD symptoms in adults, II: reliability, validity,
and diagnostic sensitivity. J Atten Disord 1999; 3:153158
24. Barkley RA, Murphy KR: Attention-Deficit Hyperactivity Disorder: A Clinical Workbook. New York, Guilford Press, 1998

968

ajp.psychiatryonline.org

25. First MB, Spitzer RL, Gibbon M, Williams JBW: Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version,
Patient Edition (SCID-I/P). New York, New York State Psychiatric
Institute, Biometrics Research, November 2002
26. First MB, Gibbon M, Spitzer RL, Williams JBW, Benjamin LS:
Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II). Washington, DC, American Psychiatric Press, 1997
27. Tellegen A, Briggs PF: Old wine, new skins: grouping Wechsler
subtests into new scales. J Consult Clin Psychol 1967; 31:499
506
28. Adler LA, Spencer T, Biederman J: Adult ADHD Investigator
Symptom Rating ScaleAISRS. Boston, Massachusetts General
Hospital; and New York, New York University School of Medicine, 2003
29. Brown TE: Attention-Deficit Disorder Scales Manual. San Antonio, Tex, Psychological Corp, 1996
30. Roth RM, Isquith PK, Gioia GA: Behavior Rating Inventory of
Executive FunctionAdult Version (BRIEF-A). Lutz, Fla, Psychological Assessment Resources, 2005
31. Beck AT, Steer RA, Brown GK: Beck Depression Inventory, 2nd
ed, Manual. San Antonio, Tex, Psychological Corp, 1996
32. Rosenberg M: Society and the Adolescent Self-Image. Princeton, NJ, Princeton University Press, 1965
33. Shear MK, Vander Bilt J, Rucci P, Endicott J, Lydiard B, Otto MW,
Pollack MH, Chandler L, Williams J, Ali A, Frank DM: Reliability
and validity of a structured interview guide for the Hamilton
Anxiety Rating Scale (SIGH-A). Depress Anxiety 2001; 13:166178
34. Waltz J, Addis ME, Koerner K, Jacobson NS: Testing the integrity of a psychotherapy protocol: assessment of adherence and
competence. J Consult Clin Psychol 1993; 61:620630
35. Borkovec TD, Nau SD: Credibility of analogue therapy rationales. J Behav Ther Exp Psychiatry 1972; 3:257260
36. Spencer TJ, Adler LA, McGough JJ, Muniz R, Jiang H, Pestreich,
L (Adult ADHD Research Group): Efficacy and safety of dexmethylphenidate extended-release capsules in adults with
attention-deficit/hyperactivity disorder. Biol Psychiatry 2007;
61:13801387
37. Medori R, Ramos-Quiroga A, Casas M, Kooij JJS, Niemela A,
Trott G-E, Lee E, Buitelaar JK: A randomized, placebo-controlled trial of three fixed dosages of prolonged-release OROS
methylphenidate in adults with attention-deficit/hyperactivity
disorder. Biol Psychiatry 2008; 63:981989
38. Weisler RH, Biederman J, Spencer TJ, Wilens TE, Faraone SV,
Chrisman AK, Read SC, Tulloch SJ: Mixed amphetamine salts
extended-release in the treatment of adult ADHD: a randomized, controlled trial. CNS Spectr 2006; 11:625639

Am J Psychiatry 167:8, August 2010