A systematic review and meta-analysis of growth mindset interventions: For whom, how, and why might such interventions work?

As growth mindset interventions increase in scope and popularity, scientists and policymakers are asking: Are these interventions effective? To answer this question properly, the field needs to understand the meaningful heterogeneity in effects. In the present systematic review and meta-analysis, we focused on two key moderators with adequate data to test: Subsamples expected to benefit most and implementation fidelity. We also specified a process model that can be generative for theory. We included articles published between 2002 (first mindset intervention) through the end of 2020 that reported an effect for a growth mindset intervention, used a randomized design, and featured at least one of the qualifying outcomes. Our search yielded 53 independent samples testing distinct interventions. We reported cumulative effect sizes for multiple outcomes (i.e., mindsets, motivation, behavior, end results), with a focus on three primary end results (i.e., improved academic achievement, mental health, or social functioning). Multilevel metaregression analyses with targeted subsamples and high fidelity for academic achievement yielded, d = 0.14, 95% CI [.06, .22]; for mental health, d = 0.32, 95% CI [.10, .54]. Results highlighted the extensive variation in effects to be expected from future interventions. Namely, 95% prediction intervals for focal effects ranged from -0.08 to 0.35 for academic achievement and from 0.07 to 0.57 for mental health. The literature is too nascent for moderators for social functioning, but average effects are d = 0.36, 95% CI [.03, .68], 95% PI [-.50, 1.22]. We conclude with a discussion of heterogeneity and the limitations of meta-analyses. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Usability and feasibility of a cognitive-behavioral mobile app for ADHD in adults.

OBJECTIVE: Cognitive-behavioral therapy (CBT) has growing evidence of efficacy for Attention-Deficit/Hyperactivity Disorder (ADHD) in adults. Mobile health apps are promising tools for delivering scalable CBT. In a 7-week open study of Inflow, a CBT-based mobile app, we assessed usability and feasibility to prepare for a randomized controlled trial (RCT). METHOD: 240 adults recruited online completed baseline and usability assessments at 2 (n = 114), 4 (n = 97) and after 7 weeks (n = 95) of Inflow use. 93 participants self-reported ADHD symptoms and impairment at baseline and 7 weeks. RESULTS: Participants rated Inflow's usability favorably, used the app a median of 3.86 times per week, and a majority of those using the app for 7 weeks self-reported decreases in ADHD symptoms and impairment. CONCLUSION: Inflow demonstrated usability and feasibility among users. An RCT will determine whether Inflow is associated with improvement among more rigorously assessed users and beyond non-specific factors.

Growth mindsets and psychological distress: A meta-analysis.

We investigated if growth mindsets-the belief in the malleable nature of human attributes-are negatively related to psychological distress and if they are positively related to treatment value and active coping. In the meta-analysis, we included articles published between 1988 and 2019, written in English, that reported on mindsets as well as a qualifying dependent variable and included information required to calculate an effect size. With a random effects approach, meta-analytic results (k = 72 samples, N = 17,692) demonstrated that mindsets relate, albeit with minimal effects, to distress, treatment and coping. Specifically, there is a negative relation between growth mindsets and psychological distress (r = -0.220), a positive relation between growth mindsets and treatment value (r = 0.137) and a positive relation between growth mindsets and active coping (r = 0.207). Differences in mindset domain, assessment method of mindsets and timing of assessments moderated effects. There were not differences based on operationalization of psychological distress outcome or sample characteristics (i.e., developmental stage, diagnostic status, ethnicity). We discuss theoretical and practical applications of the findings.

Development and Evaluation of the ADHD Cognitions Scale for Adults.

Objective: The clinical literature on ADHD in adults suggests that "overly positive" or optimistic cognitions may contribute to impairment and failure to use self-regulation skills in this population, yet the research literature on this topic is limited. We developed the ADHD Cognitions Scale (ACS), a brief self-report measure of ADHD-related thoughts, and evaluated its psychometric properties. Method: We collected self-report measures, inculding the ACS, from two large community samples (Ns = 262, 304). Results: The measure demonstrated a one-factor solution that replicated in the second sample. Evidence of good internal consistency and also convergent and divergent validity was obtained for both samples. Scores on the ACS correlated with functional impairment, time management problems, and avoidant coping strategies. Conclusion: With additional study, the ACS may be useful to identify and track maladaptive ADHD-related cognitions during cognitive-behavioral treatment, and to further study the role of these thoughts in ADHD-related impairment.

Investigating Resilience to Depression in Adults With ADHD.

OBJECTIVE: ADHD is associated with elevated rates of comorbid depressive disorders, yet the nature and development of this comorbidity remain understudied. We hypothesized that a longer period of prior ADHD treatment, being less likely to engage in maladaptive cognitive/behavioral coping strategies, and less severe ADHD symptoms would predict greater likelihood of lifetime resilience to depression. METHOD: Seventy-seven adults with ADHD completed diagnostic interviews, clinician-administered symptom rating scales, a stressful life events measure, and self-report questionnaires. We used logistic regression analyses to identify factors associated with resilience to depression. RESULTS: Adults with more extensive ADHD treatment histories were more likely to be resilient to depression. Those who were less likely to report ruminative thinking patterns and cognitive-behavioral avoidance were also more resilient. Severity of current or childhood ADHD symptoms and recent negative life events did not predict resilience. CONCLUSION: Results identify protective factors that may promote the resiliency to ADHD-depression comorbidity.

Meta-analysis of cognitive-behavioral treatments for adult ADHD.

OBJECTIVE: We conducted a meta-analysis of cognitive-behavioral treatment (CBT) studies for adult attention-deficit/hyperactivity disorder (ADHD), examining effects versus control and effects pre-to-post treatment to maximize the clinical and research utility of findings from this growing literature. METHOD: Eligible studies tested adults meeting criteria for Diagnostic and Statistical Manual of Mental Disorders ADHD as determined by interview or using a standardized rating scale and measured ADHD symptoms or related impairment at baseline and posttreatment. We analyzed data from 32 studies from published and unpublished sources available through December 2015. Effect size calculations included up to 896 participants. RESULTS: Using a random effects model, we found that CBTs had medium-to-large effects from pre- to posttreatment (self-reported ADHD symptoms: g = 1.00; 95% confidence interval [CI: 0.84, 1.16]; self-reported functioning g = .73; 95% CI [0.46, 1.00]) and small-to-medium effects versus control (g = .65; 95% CI [0.44, 0.86] for symptoms, .51; 95% CI [0.23, 0.79] for functioning). Effect sizes were heterogeneous for most outcome measures. Studies with active control groups showed smaller effect sizes. Neither participant medication status nor treatment format moderated pre-to-post treatment effects, and longer treatments were not associated with better outcomes. CONCLUSIONS: Current CBTs for adult ADHD show comparable effect sizes to behavioral treatments for children with ADHD, which are considered well-established treatments. Future treatment development could focus on identifying empirically supported principles of treatment-related change for adults with ADHD. We encourage researchers to report future findings in a way that is amenable to meta-analytic review. (PsycINFO Database Record

Is the Relationship Between ADHD Symptoms and Binge Eating Mediated by Impulsivity?

OBJECTIVE: Individuals with ADHD may be at risk of developing binge eating disorder (BED). Impulsivity correlates with both BED and ADHD; however, more research is needed to explore whether impulsivity plays an underlying role in the observed relationship between ADHD and BED. METHOD: Questionnaires were used to assess ADHD and BED symptoms. Multiple questionnaires and a behavioral task were used to assess impulsivity in undiagnosed undergraduate participants (n = 50). RESULTS: Expected correlations were found among ADHD symptoms, BED tendencies, and measures of impulsivity with the exception of impulsivity on the behavioral task and BED symptoms; however, none of the measures of impulsivity were found to be significant mediators between ADHD and BED symptoms. CONCLUSION: Although impulsivity may play an important role in the interrelationship of ADHD and binge eating, other factors may also be critical in the development of this comorbidity. Investigation of this research question in clinical samples is needed.

Incautiously Optimistic: Positively-Valenced Cognitive Avoidance in Adult ADHD.

Clinicians who conduct cognitive-behavioral therapy (CBT) targeting attention-deficit/hyperactivity disorder (ADHD) in adulthood have noted that their patients sometimes verbalize overly positive automatic thoughts and set overly optimistic goals. These cognitions are frequently related to failure to engage in compensatory behavioral strategies emphasized in CBT. In this paper, we offer a functional analysis of this problematic pattern, positively-valenced cognitive avoidance, and suggest methods for addressing it within CBT for adult ADHD. We propose that maladaptive positive cognitions function to relieve aversive emotions in the short-term and are therefore negatively reinforced but that, in the long-term, they are associated with decreased likelihood of active coping and increased patterns of behavioral avoidance. Drawing on techniques from Behavioral Activation (BA), we offer a case example to illustrate these concepts and describe step-by-step methods for clinicians to help patients recognize avoidant patterns and engage in more active coping.

Adult attention deficit hyperactivity disorder symptoms and five-factor model traits in a clinical sample: a structural equation modeling approach.

Relationships among attention deficit hyperactivity disorder (ADHD) symptoms and adult personality traits have not been examined in larger clinically diagnosed samples. We collected multisource ADHD symptom and self-report NEO Five-Factor Inventory (Costa and McCrae [Odessa, FL: Psychological Assessment Resources, Inc, 1992) data from 117 adults with ADHD and tested symptom-trait associations using structural equation modeling. The final model fit the data. Inattention was positively associated with neuroticism and negatively associated with conscientiousness. On the basis of ADHD expression in adulthood, hyperactivity and impulsivity were estimated as separate constructs and showed differential relationships to extraversion and agreeableness. A significant positive relationship between hyperactivity and conscientiousness arose in the context of other pathways. ADHD symptoms are reliably associated with personality traits, suggesting a complex interplay across development that warrants prospective study into adulthood.

Does executive functioning (EF) predict depression in clinic-referred adults? EF tests vs. rating scales.

BACKGROUND: Deficits in executive functioning (EF) are implicated in neurobiological and cognitive-processing theories of depression. EF deficits are also associated with Attention-deficit/hyperactivity disorder (ADHD) in adults, who are also at increased risk for depressive disorders. Given debate about the ecological validity of laboratory measures of EF, we investigated the relationship between depression diagnoses and symptoms and EF as measured by both rating scales and tests in a sample of adults referred for evaluation of adult ADHD. METHOD: Data from two groups of adults recruited from an ADHD specialty clinic were analyzed together: Adults diagnosed with ADHD (N=146) and a clinical control group of adults referred for adult ADHD assessment but not diagnosed with the disorder ADHD (N=97). EF was assessed using a rating scale of EF deficits in daily life and a battery of tests tapping various EF constructs. Depression was assessed using current and lifetime SCID diagnoses (major depression, dysthymia) and self-report symptom ratings. RESULTS: EF as assessed via rating scale predicted depression across measures even when controlling for current anxiety and impairment. Self-Management to Time and Self-Organization and Problem-Solving showed the most robust relationships. EF tests were weakly and inconsistently related to depression measures. LIMITATIONS: Prospective studies are needed to rigorously evaluate EF problems as true risk factors for depressive onset. CONCLUSIONS: EF problems in everyday life were important predictors of depression. Researchers and clinicians should consistently assess for the ADHD-depression comorbidity. Clinicians should consider incorporating strategies to address EF deficits when treating people with depression.

Depression in Adults with Attention-Deficit/Hyperactivity Disorder (ADHD): The Mediating Role of Cognitive-Behavioral Factors.

Adults with Attention-Deficit/Hyperactivity Disorder (ADHD) are at increased risk for depressive disorders but little is known about the potential cognitive and behavioral mechanisms of risk that could shape treatment. This study evaluated the degree to which cognitive-behavioral constructs associated with depression and its treatment-dysfunctional attitudes and cognitive-behavioral avoidance-accounted for variance in depressive symptoms and disorder in adults with ADHD. 77 adults clinically diagnosed with ADHD completed self-report questionnaires, diagnostic interviews, and clinician-administered symptom rating scales. Statistical mediation analysis was employed and indirect effects assessed using bootstrap analysis and bias-corrected confidence intervals. Controlling for recent negative life events, dysfunctional attitudes and cognitive-behavioral avoidance fully accounted for the variance between ADHD symptoms and depressive symptoms. Each independent variable partially mediated the other in accounting for depression symptoms suggesting overlapping and unique variance. Cognitive-behavioral avoidance, however, was more strongly related to meeting diagnostic criteria for a depressive disorder than were dysfunctional attitudes. Processes that are targeted in cognitive behavior therapy (CBT) for depression were associated with symptoms in adults with ADHD. Current CBT approaches for ADHD incorporate active coping skills and cognitive restructuring and such approaches could be further tailored to address the ADHD-depression comorbidity.

Isolating metamemory deficits in the self-regulated learning of adults with ADHD.

UNLABELLED: ADHD in adulthood is associated with chronic academic impairments and problems with strategic memory encoding on standardized memory assessments, but little is known about self-regulated learning that might guide intervention. OBJECTIVE: Examine the contribution of metamemory judgment accuracy and use of learning strategies to self-regulated learning in adults with ADHD, focusing on the use of self-testing. METHOD: A total of 34 adults with ADHD and 34 matched controls predicted their memory performance and regulated their learning of paired associates. RESULTS: Adults with ADHD were as accurate as controls at predicting memory performance, despite remembering fewer words. By observation and self-report, they were less likely to use self-testing to learn the pairs. CONCLUSION: Across groups, self-testing was associated with significantly better recall and largely accounted for differences between diagnostic groups. Adults with ADHD often failed to employ a strategy that was associated with improved memory, identifying an intervention target that may improve self-regulated learning.

Description and Demonstration of CBT for ADHD in Adults.

ADHD in adulthood is a valid, prevalent, distressing, and interfering condition. Although medications help treat this disorder, there are often residual symptoms after medication treatment, and, for some patients, they are contraindicated. Compared to other disorders, such as mood and anxiety disorders, there are few resources available for clinicians wishing to conduct cognitive-behavioral treatment for this problem. The present manuscript provides a description of our cognitive-behavioral approach to treat ADHD in adulthood, which we have developed and tested in our clinic (Safren, Otto, et al., 2005), and for which detailed therapist and client guides exist (Safren, Perlman, Sprich, & Otto, 2005; Safren, Sprich, Perlman, & Otto, 2005). To augment the description of treatment, the present article provides video component demonstrations of several core modules that highlight important aspects of this treatment. This description and the accompanying demonstrations are intended as a practical guide to assist therapists wishing to conduct such a treatment in the outpatient setting.

Correspondence and disparity in the self- and other ratings of current and childhood ADHD symptoms and impairment in adults with ADHD.

Experts recommend that clinicians evaluating adults for attention-deficit/hyperactivity disorder (ADHD) obtain information from others who know the patient well. The authors examined correspondence between the self- and other-ratings of ADHD symptoms and impairment using 3 groups of adults recruited on the basis of their severity of ADHD: ADHD diagnosis (n = 146), clinical controls self-referring for ADHD but not diagnosed (n = 97), and community controls (n = 109). The influences of diagnostic group, informant relationship, sex of participant, IQ, and comorbid anxiety and depression on self-informant disparities were also examined. Results indicated moderate to high agreement (.59-.80) between self and others on current functioning and slightly lower levels (.53-.75) between self- and parent ratings of childhood functioning. Examination of difference scores between self- and other ratings revealed small mean disparities (-0.1 to +5.0 points) but substantial variation (SDs = -2.4 to 8.9 points) for both current and childhood ratings. Clinic referrals not diagnosed with ADHD, particularly women, had higher disparities than was evident in the ADHD and community groups. Age, IQ, and education were not associated with disparities in most ratings. Higher anxiety, in contrast, was associated with greater disparities on all current and childhood measures of both ADHD and impairment.

Cognitive behavioral therapy vs relaxation with educational support for medication-treated adults with ADHD and persistent symptoms: a randomized controlled trial.

CONTEXT: Attention-deficit/hyperactivity disorder (ADHD) in adulthood is a prevalent, distressing, and impairing condition that is not fully treated by pharmacotherapy alone and lacks evidence-based psychosocial treatments. OBJECTIVE: To test cognitive behavioral therapy for ADHD in adults treated with medication but who still have clinically significant symptoms. DESIGN, SETTING, AND PATIENTS: Randomized controlled trial assessing the efficacy of cognitive behavioral therapy for 86 symptomatic adults with ADHD who were already being treated with medication. The study was conducted at a US hospital between November 2004 and June 2008 (follow-up was conducted through July 2009). Of the 86 patients randomized, 79 completed treatment and 70 completed the follow-up assessments. INTERVENTIONS: Patients were randomized to 12 individual sessions of either cognitive behavioral therapy or relaxation with educational support (which is an attention-matched comparison). MAIN OUTCOME MEASURES: The primary measures were ADHD symptoms rated by an assessor (ADHD rating scale and Clinical Global Impression scale) at baseline, posttreatment, and at 6- and 12-month follow-up. The assessor was blinded to treatment condition assignment. The secondary outcome measure was self-report of ADHD symptoms. RESULTS: Cognitive behavioral therapy achieved lower posttreatment scores on both the Clinical Global Impression scale (magnitude -0.0531; 95% confidence interval [CI], -1.01 to -0.05; P = .03) and the ADHD rating scale (magnitude -4.631; 95% CI, -8.30 to -0.963; P = .02) compared with relaxation with educational support. Throughout treatment, self-reported symptoms were also significantly more improved for cognitive behavioral therapy (beta = -0.41; 95% CI, -0.64 to -0.17; P <001), and there were more treatment responders in cognitive behavioral therapy for both the Clinical Global Impression scale (53% vs 23%; odds ratio [OR], 3.80; 95% CI, 1.50 to 9.59; P = .01) and the ADHD rating scale (67% vs 33%; OR, 4.29; 95% CI, 1.74 to 10.58; P = .002). Responders and partial responders in the cognitive behavioral therapy condition maintained their gains over 6 and 12 months. CONCLUSION: Among adults with persistent ADHD symptoms treated with medication, the use of cognitive behavioral therapy compared with relaxation with educational support resulted in improved ADHD symptoms, which were maintained at 12 months. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00118911.

Current status of cognitive behavioral therapy for adult attention-deficit hyperactivity disorder.

Attention-deficit/hyperactivity disorder (ADHD) is a valid and impairing psychological disorder that persists into adulthood in a majority of cases and is associated with chronic functional impairment and increased rates of comorbidity. Cognitive behavioral therapy (CBT) approaches for this disorder have emerged recently, and available evidence from open and randomized controlled trials suggests that these approaches are promising in producing significant symptom reduction. A conceptual model of how CBT may work for ADHD is reviewed along with existing efficacy studies. A preliminary comparison of effect sizes across intervention packages suggests that targeted learning and practice of specific behavioral compensatory strategies may be a critical active ingredient in CBT for adult ADHD. The article concludes with a discussion of future directions and critical questions that must be addressed in this area of clinical research.

Life impairments in adults with medication-treated ADHD.

OBJECTIVE: In developing psychosocial approaches to augment outcomes for medication-treated adults with ADHD, it is important to understand what types of life-impairments are most affected by continued ADHD symptoms that occur despite medication treatment. This may assist in delineating targets for interventions, as well as assessments of functional outcomes that are sensitive to change in this population. METHOD: The sample consists of 105 adults with ADHD presenting for entry into clinical trials of CBT for residual ADHD. Life impairments are rated by a clinician using the LIFE-RIFT, which has subscales for work impairment, interpersonal impairment, life-satisfaction, and recreation, ADHD symptoms using the ADHD Rating Scale, overall ADHD severity using the clinical global impression, and associated distress using the Hamilton Depression and Anxiety Rating Scales. RESULTS: The most problematic impairments are in the domain of work, followed by interpersonal. Generally, the subscales of the LIFE-RIFT are associated, at the bivariate level, with all 4 symptom indices. Work and interpersonal impairments are uniquely associated with overall severity of ADHD symptoms using both the CGI and the ADHD Rating Scale. However interpersonal and life-satisfaction impairments are uniquely associated with depression, and life-satisfaction is uniquely associated with anxiety. CONCLUSION: In medication-treated adults with ADHD, work and interpersonal impairments appear to be the most problematic areas of life-impairment, which are uniquely associated with ADHD severity. Life-satisfaction appears to be uniquely associated with distress as defined by anxiety and depression symptoms, with interpersonal impairments also playing a role. Psychosocial treatments for medication treated adults should target work and interpersonal domains and should include skills for managing associated distress.

Self-reported ADHD symptoms among college students: item positioning affects symptom endorsement rates.

OBJECTIVE: The effect of manipulating item positioning on self-reported ADHD symptoms was examined. We assessed whether listing DSM-IV ADHD symptoms serially or interspersed affected (a) the correlation between ADHD symptoms and (b) the rate of symptom endorsement. METHOD: In Study 1, an undergraduate sample (n = 102) completed a measure that listed DSM-IV ADHD symptoms serially and a measure that interspersed DSM-IV ADHD items among non-ADHD symptoms. In Study 2, a separate undergraduate sample (n = 240) completed a measure that listed DSM-IV ADHD symptoms serially and another ADHD measure that interspersed DSM-IV ADHD items among non-DSM-IV ADHD items. RESULTS: Item positioning did not affect the correlation between symptoms, but did reveal a significant bias in the rate of symptom endorsements. CONCLUSION: These findings suggest that there is significant variability in ADHD symptom endorsements resulting from item positioning. This effect has implications for clinical assessment and epidemiological research of ADHD among college students.

Attention-Deficit/Hyperactivity Disorder Symptom Profiles in Medication-Treated Adults Entering a Psychosocial Treatment Program.

BACKGROUND: Although medications are the most widely studied effective treatments for adults with attention-deficit/hyperactivity disorder (ADHD), patients treated with medications often have significant residual symptoms that may be amenable to psychosocial intervention. Few studies, however, report on the structure and severity of specific residual ADHD symptoms in adult patients who have been treated with medications. This information may be important in identifying the most important psychosocial treatment targets for medicated adults with ADHD with residual symptoms. OBJECTIVES: Identify which symptoms of ADHD are most frequent and severe for medication-treated adults. Identify meaningful factors underlying self-report and clinician ratings in this group. METHODS: Self-reported and clinician-rated ADHD symptom data from 105 adults in the community already receiving medication treatment who were entering cognitive behavioral therapy studies were examined. First, we examined the frequency and severity of each of the 18 ADHD symptoms that were present in the sample. Second, we conducted exploratory factor analyses of self-reported and clinician-rated ADHD symptoms to best describe the structure of residual symptoms in medication-treated adults, Lastly, we examined the association of the resulting factor scores with clinician-rated global ADHD severity (Clinical Global Impressions) and functional impairment (Global Assessment of Functioning) scales to determine which factors relate to overall severity. RESULTS: The 2 most frequent (self-reported and clinician-rated) residual symptoms were disorganization (85%-88%) and distractibility (74%-83%). Exploratory factor analyses for both self-reported and clinician-rated data yielded a 3-factor model: (1) Hyperactivity/Restlessness, (2) Impulsivity/Poor Prospective Memory, and (3) Inattention. Using multiple regression, the Inattention factor from self-reported and clinician-rated data was most strongly, consistently, and uniquely related to clinician ratings of both illness severity and functioning. CONCLUSIONS: In this sample, disorganization and distractibility were the most frequent and clinically significant residual symptoms; therefore, these should be important targets in psychosocial treatments for this population. Scoring symptom rating scales in medication-treated adults with ADHD using Hyperactivity. Restlessness, Impulsivity/Poor Prospective Memory, and Inattention factors may be more informative with respect to evaluating psychosocial treatment outcome than overall scale scores alone.

Recent developments in the psychosocial treatment of adult ADHD.

Adult attention-deficit/hyperactivity disorder (ADHD) is an increasingly recognized Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV psychiatric disorder associated with significant functional impairment in multiple domains. Although stimulant and other pharmacotherapy regimens have the most empirical support as treatments for ADHD in adults, many adults with the disorder continue to experience significant residual symptoms. In the present manuscript, we review the published studies examining group and individual psychosocial treatments for adult ADHD. We include a discussion of coaching interventions and how they differ from cognitive-behavioral therapy. We conclude that the available data support the use of structured, skills-based psychosocial interventions as a viable treatment for adults with residual symptoms of ADHD. Common elements across the various treatment packages include psychoeducation, training in concrete skills (e.g., organization and planning strategies) and emphasis on outside practice and maintenance of these strategies in daily life. These treatments, however, require further study for replication, extension and refinement. Finally, we suggest future directions for the application of psychosocial treatments to the problems of adults with ADHD.