Effectiveness of Motivational Interviewing Enhanced Cognitive Behavior Therapy for Adults with ADHD

About This Grant

Summary/Abstract Non-medication options are necessary for the treatment of adult ADHD due to medication’s inconsistent availability, poor tolerability or palatability for some patients, and limited effects on some meaningful patient outcomes (e.g., impairment, quality of life; Bellato et al., 2025; Coghill et al., 2017). Cognitive behavioral therapy (CBT) is the other evidence-based treatment for adult ADHD (Knouse et al., 2017; Ostinelli et al., 2025) but faces engagement and implementation challenges in real world settings (Gaddis et al., in press; Staley et al., 2024; William et al., 2024). Motivational Interviewing (MI) is a set of therapist techniques that help people explore and accomplish behavior change and has been validated in over 500 RCTs (Miller & Rollnick, 2023). MI has been successfully blended with CBT for adolescents with ADHD to improve engagement and effectiveness outcomes in routine care settings (Sibley et al., 2021a/b). In this study, we propose a randomized hybrid implementation effectiveness trial that serves as the first evaluation of CBT+MI for adult ADHD (versus CBT alone) delivered to 216 adults with ADHD by 72 real world independent psychotherapy providers (double randomization of clients and therapists). The setting of the trial will be the U.S.’s decentralized telepsychology system and providers will be licensed psychologists with a current PsyPact credential. In year 1 of this trial, we will conduct a small pilot open trial (N=6 therapists, N=6 clients) with weekly feedback and end-of-trial focus groups designed to refine remote implementation supports and digitized manual and materials prior to the start of the trial’s RCT phase in years 2-5. Effectiveness outcomes will be measured at baseline, post-treatment, and one-year follow-up and include self and informant reports of ADHD symptoms, impairment, comorbid depression and anxiety symptoms, and quality of life. Target mechanisms will also be measured at these timepoints and include: (1) executive functioning skills, (2) self-concept, and (3) emotion regulation, which will be tested as mediators of effectiveness outcomes. Implementation outcomes will follow Proctor et al., (2009)’s implementation research framework to include multimethod, multidimensional indices of both implementation and engagement outcomes, which will also be measured as mediators of effectiveness outcomes. We will examine client and therapist-level treatment moderators as well as mixed method barriers and facilitators of implementation and engagement (including safety). Cutting edge aspects of this application include a rigorous differential diagnosis process at intake, leveraging this research team’s previously developed therapy process coding system (Sibley et al., 2025), intervention co-designed by adults with ADHD, and enriching the sample with ethnically diverse adults who previously participated in ADHD research as teens and may be treatment ambivalent, rather than eager. Our application is well-aligned with NIMH’s strategic priority of leveraging remote implementation supports to improve the reach of mental health services and expediting the adoption of mental health services by working within existing telehealth infrastructures (NIMH Strategic Framework, 2025).