'Meta-Cognitive' Therapy Effective for Adult ADHD

Megan Brooks

March 22, 2010

March 22, 2010 — A 12-week, group-administered, psychological intervention known as "meta-cognitive" therapy is effective in mitigating core inattentive symptoms and enhancing executive self-management skills in a group of largely well-educated adults with attention-deficit/hyperactivity disorder (ADHD).

"We showed superiority of these outcomes compared to [supportive psychotherapy] that controlled for the 'nonspecific' effects of treatment (therapist support and attention, etc)," Mary V. Solanto, PhD, director of the ADHD Center at Mount Sinai Medical Center in New York City, told Medscape Psychiatry.

Steven A. Safren, PhD, director of behavioral medicine and associate professor in psychology in the Department of Psychiatry at Harvard Medical School, Boston, Massachusetts, who was not involved in the study, called it "highly important and innovative. It is the "only one from the US to show that a group psychosocial skills–based approach has potential to assist individuals suffering from this valid, prevalent, impairing, and costly condition," he said.

In the study, 88 adults who met Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria for ADHD were stratified by ADHD medication use and otherwise randomly assigned to therapist-administered meta-cognitive group therapy or supportive group psychotherapy (control).

Meta-cognitive therapy intervention uses cognitive-behavioral principles and methods to teach skills and strategies in time management, organization, and planning and to target depressive and anxious thoughts that undermine effective self-management, Dr. Solanto and colleagues explain in an article in the American Journal of Psychiatry published online March 15.

The supportive psychotherapy control intervention provided support while avoiding discussion of cognitive-behavioral strategies.

Compared with subjects in the supportive therapy group, those in the meta-cognitive therapy group showed greater improvement in inattention whether self-rated, observer rated, or rated by a masked evaluator, the investigators report.

On the inattentive subscale of the Adult ADHD Investigator Symptom Rating Scale (AISRS), the meta-cognitive therapy group improved by 5.0 points compared with 2.3 points in the control group — a between-group difference of 2.7 points (95% confidence interval [CI], 0.9 – 4.6; P < .005) or 56% of the overall standard deviation of the change score (SD, 4.8).

The same pattern (greater change in meta-cognitive therapy vs supportive therapy) was evident on the AISRS time management, organization, and planning subscale and the Conners Adult ADHD Rating Scales–Observer inattention subscale. The more severe the symptoms at baseline, the investigators note, the greater the improvement with meta-cognitive therapy.

Logistic regression examining group differences and controlling for baseline ADHD severity revealed a "robust effect" of treatment group, favoring meta-cognitive therapy (odds ratio, 5.41; 95% CI, 1.77 – 16.55).

"Psychosocial approaches to the treatment of ADHD are greatly understudied compared to the literature available for other DSM-IV Axis I conditions," Dr. Safren said. "This may be because ADHD in adulthood has previously been seen as a controversial diagnosis in adulthood.

"Dr. Solanto's group meta-cognitive approach showed significant effects compared to those in an attention-matched control condition (supportive psychotherapy)," Dr. Safren noted.

"More research is needed," he added, "to replicate and extend such findings, such as studies that examine follow-up effects after treatment discontinuation and studies that more systematically examine the complementary roles of medications and psychosocial approaches.

"However, from the evidence that is available thus far, skills-based psychosocial approaches, such as meta-cognitive therapy and [cognitive-behavioral therapy], appear to be important and useful approaches for this population," Dr. Safren concluded.

The study was supported by a grant from National Institute of Mental Health. Dr. Solanto has served on the medical advisory board of Shire Pharmaceuticals and as a consultant and speaker for Ortho-McNeil-Janssen Pharmaceuticals. Dr. Safren has disclosed no relevant financial relationships.

Am J Psychiatry. Published online March 15, 2010.

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