A randomized controlled trial of CBT therapy for adults with ADHD with and without medication.
ABSTRACT Previous studies of psychological treatment in adults with ADHD have not controlled for medication status and include either medicated participants or mixed samples of medicated and unmedicated participants. The objective of this study is to examine whether use of medication improves outcome of therapy.
This was a secondary analysis comparing 23 participants randomized to CBT and Dextroamphetamine vs. 25 participants randomized to CBT and placebo. Both patients and investigators were blind to treatment assignment. Two co-primary outcomes were used: ADHD symptoms on the ADHD-RS-Inv completed by the investigator and improvement in functioning as reported by the patient on the Sheehan Disability Scale.
Both groups showed robust improvement in both symptoms and functioning, but the use of medication did not significantly improve outcome over and above use of CBT and placebo.
This study replicates previous work demonstrating that CBT is an effective treatment for ADHD in adults. Within the limits of this pilot, secondary analysis we were not able to demonstrate that medication significantly augments the outcome of CBT therapy for adults with ADHD. The study was funded by GlaxoSmithKline, Clinical Trials Registry #GSK707.
Article: Clinical Relevance of the Primary Findings of the MTA: Success Rates Based on Severity of ADHD and ODD Symptoms at the End of Treatment[show abstract] [hide abstract]
ABSTRACT: ObjectivesTo develop a categorical outcome measure related to clinical decisions and to perform secondary analyses to supplement the primary analyses of the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA).MethodEnd-of-treatment status was summarized by averaging the parent and teacher ratings of attention-deficit/hyperactivity disorder and oppositional defiant disorder symptoms on the Swanson, Nolan, and Pelham, version IV (SNAP-IV) scale, and low symptom-severity (“Just a Little”) on this continuous measure was set as a clinical cutoff to form a categorical outcome measure reflecting successful treatment. Three orthogonal comparisons of the treatment groups (combined treatment [Comb], medication management [MedMgt], behavioral treatment [Beh], and community comparison [CC]) evaluated hypotheses about the MTA medication algorithm (“Comb + MedMgt versus Beh + CC”), multimodality superiority (“Comb versus MedMgt”), and psychosocial substitution (“Beh versus CC”).ResultsThe summary of SNAP-IV ratings across sources and domains increased the precision of measurement by 30%. The secondary analyses of group differences in success rates (Comb = 68%; MedMgt = 56%; Beh = 34%; CC = 25%) confirmed the large effect of the MTA medication algorithm and a smaller effect of multimodality superiority, which was now statistically significant (p < .05). The psychosocial substitution effect remained negligible and nonsignificant.ConclusionThese secondary analyses confirm the primary findings and clarify clinical decisions about the choice between multimodal and unimodal treatment with medication.Journal of the American Academy of Child & Adolescent Psychiatry 02/2001; · 6.44 Impact Factor
[show abstract] [hide abstract]
ABSTRACT: We examine the dynamics of DNA molecules in mixed flows where the ratio of vorticity to strain rate may be slightly above or below unity via Brownian dynamics simulation. We find that the chain dynamics in these flows are dramatically different than those found for simple shear flow. When the strain rate exceeds vorticity, the dynamics are found to be driven by the extra amount of straining. For vorticity-dominated flows, a periodicity in chain extension is observed with considerable chain deformation.Physical Review E 08/2002; 66(1 Pt 1):011915. · 2.26 Impact Factor
Article: Meta-analysis of the efficacy of methylphenidate for treating adult attention-deficit/hyperactivity disorder.[show abstract] [hide abstract]
ABSTRACT: This article reviews the efficacy of methylphenidate (MPH) for adult attention-deficit/hyperactivity disorder (ADHD). A literature search identified double-blind placebo-controlled MPH treatment studies of ADHD adults. Meta-analysis estimated the pooled effect size for MPH treatment and tested for publication bias. Meta-analysis regression assessed the influence of study design features on medication effects. Six trials met criteria and were included in this meta-analysis. These studies included a total of 140 MPH-treated ADHD adults and 113 placebo-treated ADHD adults. The mean effect size of 0.9 was statistically significant and there was no evidence of publication bias. Larger MPH effect sizes were associated with physician ratings of outcome and use of higher doses. When treatment is optimized to high doses, the effect size for MPH in adults was 1.3. We found strong support for the assertion that MPH is efficacious for treating adult ADHD. Because the degree of efficacy of MPH in treating ADHD adults is similar to what has been reported from meta-analyses of the child and adolescent literature, our work provides further assurance to clinicians that the diagnosis of ADHD can be validly applied in adulthood.Journal of Clinical Psychopharmacology 03/2004; 24(1):24-9. · 4.10 Impact Factor
RESEARCH ARTICLEOpen Access
A randomized controlled trial of CBT therapy for
adults with ADHD with and without medication
Margaret Weiss1*, Candice Murray2, Michael Wasdell3, Brian Greenfield4, Lauren Giles5and Lily Hechtman4
Background: Previous studies of psychological treatment in adults with ADHD have not controlled for medication
status and include either medicated participants or mixed samples of medicated and unmedicated participants.
The objective of this study is to examine whether use of medication improves outcome of therapy.
Method: This was a secondary analysis comparing 23 participants randomized to CBT and Dextroamphetamine vs.
25 participants randomized to CBT and placebo. Both patients and investigators were blind to treatment
assignment. Two co-primary outcomes were used: ADHD symptoms on the ADHD-RS-Inv completed by the
investigator and improvement in functioning as reported by the patient on the Sheehan Disability Scale.
Results: Both groups showed robust improvement in both symptoms and functioning, but the use of medication
did not significantly improve outcome over and above use of CBT and placebo.
Conclusion: This study replicates previous work demonstrating that CBT is an effective treatment for ADHD in
adults. Within the limits of this pilot, secondary analysis we were not able to demonstrate that medication
significantly augments the outcome of CBT therapy for adults with ADHD. The study was funded by
GlaxoSmithKline, Clinical Trials Registry #GSK707.
Keywords: CBT, Adult, Attention-Deficit/Hyperactivity Disorder, Psychotherapy
Adult ADHD is a common and impairing condition .
Even though medications are very useful in treating
symptoms of ADHD, there are a number of reasons why
psychological treatment may also be required. Clinical
trials of new medications for ADHD have demonstrated
that up to one-quarter of patients will either not respond
or not tolerate the medication, or if they do respond will
improve but not achieve full remission [2,3]. Even when
medication is effective, training in the acquisition of
adaptive life skills may offer additional benefit, especially
when looking at functioning in addition to symptom
outcomes. ADHD throughout the life span is associated
with self-perception of inadequacy and incompetence,
and even if ADHD symptoms improve in adults, poor
self esteem may remain embedded in the patient’s self-
Psychological treatments of ADHD in childhood in
combination with medication shows a small margin of
additional benefit over medication alone, especially in
children with anxiety or other comorbid disorders .
There are however, several reasons to suspect that adults
may be more responsive to psychological interventions
than children. Children may be placed in therapy at the
parents request, where adults are self-referred. By adult-
hood, many patients have obtained greater insight into
their difficulties with ADHD and are receptive to learning
better ways of coping. Children on medication are in
school where they are exposed to demands and training
in attention, where an adult on medication is unlikely to
receive instruction in executive function or other skills.
Previous empirical research in psychological treatment
in ADHD has consistently demonstrated that skills
based therapies are effective for ADHD symptoms and
functioning, despite differences in the details of the ther-
apy offered. This is not true for insight oriented therapy
which, in one study, had deleterious effects . This is
true for individual CBT [7-10] group psychoeducation
* Correspondence: Margaret.email@example.com
1University of British Columbia, Faculty of Medicine, 1488 Gordon Ave, West
Vancouver, BC V7T 1R6, Canada
Full list of author information is available at the end of the article
Weiss et al. BMC Psychiatry 2012, 12:30
© 2012 Weiss et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
and organization training , group cognitive remedia-
tion as used with brain injury patients  and dialecti-
cal behavior therapy (DBT) . Bramham et al.
reported on a group intervention for adults with ADHD
resulted in greater improvement on measures of knowl-
edge about ADHD, self-efficacy and self-esteem than the
control group . Rostain et al. reported robust effects
for individual therapy combined with medication .
All of these treatments were brief, structured, skills
based and included a component where the patient
practiced learned skills in real life situations. While the
effect size on ADHD was large in all studies, depression,
anxiety, anger, and self esteem did not always improve.
The early pilot studies had various methodological lim-
itations including small sample size, with open without
blinded raters, and/or did not control for comorbidity
There are now four manuals for psychological treatment
of adults with ADHD, which enable replication and use of
these interventions by clinicians [16-19]. The last year has
seen the publication of three randomized controlled trials
of CBT that are methodologically rigorous in diagnosis,
use of objective outcomes, blinded raters and comparison
with a non-specific form of treatment [17,20,21]. Solanto
did not find that stratification by medication status chan-
ged her findings . These studies demonstrated defini-
tively that both individual and group administered CBT
treatment for adults with ADHD is highly effective.
At the present time a seven site study in Germany is
specifically addressing the issue of the relative benefits of
medication alone, psychological treatment alone or combi-
nation therapy . The therapy used in Philipsen’s study
is an extension of the pilot work of Hesslinger using DBT.
It remains unclear from previous studies which included
either medicated or a mixed sample of medicated and
unmedicated patients, whether therapy vs. medication tar-
get different outcomes., There is some evidence that ther-
apy adds significantly to the functional and/or symptom
outcome of medication alone. Wilens found that the addi-
tion of CBT improved outcomes in patients who had a
partial response to medication . Safren has examined
whether the addition of therapy augments the improve-
ment obtained with medication alone [8,9] and found that
combination therapy was superior to medication alone.
Emilsson found that CBT and medication was superior to
treatment as usual and medication .
None of these research studies ask the opposite ques-
tion: does medication add significantly to the functional
and/or symptom outcome of therapy alone? To answer
this question it is necessary to compare the outcome of
patients who receive therapy and medication to patients
who receive therapy and placebo, since there is going to
be a strong halo effect of knowing you are on a medica-
tion to treat ADHD.
All of the trials cited above demonstrated that CBT is
effective, and can augment the effect of medication
alone. However, none of these studies controls for the
effect of medication on therapy outcome. We do not
know whether symptom remission with medication is a
prerequisite for the ability to acquire skills in therapy.
Nor do we know if medication and therapy target symp-
toms and functioning respectively, or if both modalities
have a comparable effect on either outcome. The objec-
tive of the study reported here is to determine whether
CBT psychotherapy in combination with medication is
superior to CBT psychotherapy and placebo in mitigat-
ing core symptoms of ADHD and functioning.
This was a five site randomized, placebo-controlled, par-
allel-group study conducted in the United States and
Canada. The method of the primary outcome study is
previously described in detail . The primary outcome
was a randomized placebo controlled study of the efficacy
of stimulant, antidepressant, or both in combination with
CBT. ADHD symptoms responded to stimulant, and
mood/anxiety symptoms responded to antidepressant. A
lifetime history of a mood disorder significantly attenu-
ated the likelihood of response to stimulant.
The design of the secondary analyses reported here was
planned a priori in the study protocol. Patients rando-
mized to psychological treatment with stimulant (CBT/
DEX) were compared to patients randomized to psycho-
logical treatment and placebo (CBT/PLB) to determine if
the addition of stimulant led to a more robust response
in ADHD. Both patients and therapists were blind to
treatment assignment. Patients were block randomized in
groups of four by a pharmacist independent of the study
protocol prior to obtaining baseline measures using a
computer generated randomization program. Block ran-
domization was used to assure that there would be a
sufficient sample within each group at the five sites.
Participants were recruited from the patient pool in the
ADHD clinics at the Montreal Children’s Hospital, Chil-
dren’s and Women’s Health Centre in British Columbia,
Yale University, Centre for Addictions and Mental
Health, Toronto, and Duke University Medical Centre.
The study data was collected between 2000 and 2002.
All participants were between 18 and 66 years of age
with a primary diagnosis of ADHD confirmed by the
Conners’ ADHD Diagnostic Interview . Patients with
severe comorbidities that required treatment in their
own right such as eating disorders, substance abuse,
Weiss et al. BMC Psychiatry 2012, 12:30
Page 2 of 8
organic neurological conditions, psychosis, or suicidal
ideation were excluded. Other comorbid conditions
common in adults with ADHD such as learning disabil-
ity, oppositional defiant disorder, depression or anxiety
were included. Comorbidity was measured with the
SCID-1 as well as by clinician diagnosis in the patient’s
medical record. There were no significant demographic
differences between the treatment groups on age or gen-
der. The mean age for the CBT+DEX group was
35.3 years, SD 10.4; vs. CBT+PLB 35.9 years, SD 9.4
(t(46) = .20, p = .84). The CBT+DEX group was 65.2%
male vs. CBT+PLB 80% male (Χ2(1,N = 48) = 1.33,
p = .25) (Figure 1).
Ninety-eight adults were entered into the protocol but
of these only those assigned specifically to Problem
Focused Therapy and Dexedrine (PFT+DEX) (N = 23)
or problem focused therapy and placebo (N = 25) were
entered into the protocol. Three subjects discontinued
from PFT+DEX and 2 subjects discontinued from PFT
+PLB. There was no significant association between
study completion and the assignment to a medication
treatment (62% completion) versus placebo treatment
(77% completion). There was no statistically significant
difference between treatment arms in discontinuation
for adverse events overall. There was no significant asso-
ciation between study completion and the assignment to
medication treatment (62% completion) versus placebo
treatment (77% completion).
Two co-primary outcomes were evaluated. Change in
ADHD symptoms from baseline was measured with the
investigator administered ADHD-RS-Inv, a DSM-IV
symptom checklist that has been validated in children
. The investigator rating was based on the patient’s
report on the items of the ADHD-RS-Inv, but could be
modified by actual observation, further questioning in
an interview format asking for specific examples, infor-
mation from collateral informants, and information
derived from other scales such as the patient self report
and collateral informant on the Conners’ Adult ADHD
Rating Scales . Given that the focus of the psycholo-
gical intervention was on functional improvement,
patient functioning was measured by self report on the
Sheehan Disability Scale , a well validated scale mea-
suring social, family and work functioning completed by
the patient .
All patients received individual Cognitive Behavior Ther-
apy (CBT). The psychological treatment was developed
and manualized in a series of weekly telephone conference
calls with the principal investigators (Margaret Weiss, Lily
Hechtman, Keith Conners, Tom Brown, and Umesh Jain)
and the clinicians involved in the study. The manual docu-
mented the approach (structured, skills based, problem
focused), and methods of managing possible challenges in
treatment and provided modules for addressing specific
issues such as emotional dysregulation, sleep, addiction,
anger outbursts and other problems common in ADHD.
The therapy was administered individually for nine ses-
sions. The first session took place following the comple-
tion of titration of medication when the patient was on a
stable dose. This first session provided psychoeducation
explaining ADHD as a neurobiological disorder and help-
ing the patient understand the relationship between
symptoms, his or her life story, and current functional
impairments. Patients were seen in acute treatment every
2 weeks (for 7 sessions) and then twice in follow-up
booster sessions at weeks 15 and 20 (Figure 2).
The Problem Focused Therapy was structured so that
the patient chose one critical problem in their lives, such
as finishing school, fighting with their boss, waking up in
the morning, or conflict in family relations. Whatever the
life problem they selected it was used as a vehicle for
teaching the basic tools required for improved function-
ing. This include cognitive behavior therapy, but it also
included executive functioning skills, problem solving,
prioritizing, learning to self reward, delegating and set-
ting up their environment to optimize their strengths,
working to identify methods of avoiding distraction and
disinhibition, and so on.
The therapy is not unlike the manual developed by
Steve Safren in that the patient selected a particular goal.
While this might vary from patient to patient, in all cases
the limiting skills necessary to meet the goal were com-
parable. For example, one patient selected “being able to
Figure 1 Patient Flow.
Weiss et al. BMC Psychiatry 2012, 12:30
Page 3 of 8
be consistent and to relax” as his goal. To acquire this
objective it was pointed out that he would need to struc-
ture his work time efficiently through a to do list and an
agenda as well as a time for regular exercise and relaxa-
tion and follow this schedule consistently. The skills
developed in the process of working on this particular
problem included use of a computer planner, identifying
leisure as a priority, increasing efficiency at work so as to
free up time, identification of cognitive distortions (“I do
not deserve to exercise if I haven’t got anything done”)
and simple interventions such as assisting him in follow-
ing through in registering with a gym. As new skills
emerge they are identified as such to assist the patient in
generalizing these new coping strategies to other problem
The therapy manual described the psychoeducation ses-
sion, the approach of the therapy, common problems
experienced in therapy with patients with ADHD, and
approaches to the most common problems selected by
patients. Specific modules were developed to be referenced
by the therapy as appropriate for the problem the patient
described. The modules included: anger management,
work functioning, money management, self care (sleep,
nutrition, exercise, driving, substance use), parenting,
organization, time management, stress management,
school, procrastination, marital conflict, emotional lability,
self esteem, money management, and developmental tran-
sitions and role functioning. The manual is available from
the authors upon request.
The format of each session included review of imple-
mentation of skills from the past week, a review of
symptoms, discussion of success or difficulty with imple-
mentation of the skills already covered, and introduction
of new skills for the week to follow. After much
discussion the manual did not use the term “homework”
to describe practice of skills between sessions, out of
concern that many ADHD patients would have a nega-
tive association with the term. Each session ended with
a plan for how the patient would carry through skills in
the week ahead, and each session began by looking at
the successes and failures to follow through.
The last two sessions (Sessions 8 and 9) were called
boosters and were administered at monthly at week 15
and week 20. These “booster sessions” were meant to
assist the patient in maintaining the changes that had
been established, and to deal with issues of termination
and follow up. The booster sessions highlighted for the
patient the specific skills that had been acquired in deal-
ing with the problem they had chosen and ways in
which the same skill set could also be applied to other
areas of impairment in the patient’s life.
The therapy employed the key principles of CBT in
challenging cognitive distortions such as personalization,
overgeneralization, selective attention, disqualifying bene-
fits, jumping to conclusions, should statements and cata-
strophizing-all of which are common in ADHD adults
. Although the therapy was based on CBT principles
as applied to a real life problem, and although the therapy
was both manualized and sessions were taped, we did
permit therapists to be flexible and draw on other types
of psychological intervention such as behaviour therapy,
interpersonal therapy, environmental restructuring, or
cognitive remediation if the therapist felt they would be
useful or appropriate in addressing the patients chosen
The therapy manual stipulated several points of
method that were used consistently in all cases. The
therapy was brief, highly structured, practical, skills
Figure 2 Treatment Schedule.
Weiss et al. BMC Psychiatry 2012, 12:30
Page 4 of 8
based, and required practice in the patient’s daily life.
Wherever possible or appropriate the therapy provided
instruction on the relationship between ADHD and dys-
functional symptoms. With the consent of patients, ses-
sions were taped and listened to by other therapists
(investigators) to assure some reliability in following the
manual, but no ratings of the sessions were conducted.
When ADHD behaviors themselves interfered with the
progress of treatment (coming late, arguing, failure to
practice, not listening), these behaviors were identified
as part of the ADHD or oppositional diagnosis and
Medication was encapsulated so that patients could not
distinguish active medication from placebo. Stimulant
medication was Dextroamphetamine dosed twice daily.
A double dummy design was used in which placebo was
also dosed twice daily. Medication was titrated by
weekly increments to optimal dose over a four week
period, with the investigator and patient blind to treat-
ment. Optimal dose was defined as a rating on the Clin-
ical Global Impression- Improvement scale of much or
very much improved. Dextroamphetamine was initiated
at 5 mg p.o. b.i.d. and increased to a maximum of
20 mg p.o. b.i.d.
Compliance was monitored and required for both psy-
chotherapy and medication such that patients had to
attend a minimum of 8 of the 9 sessions and take 80% of
medication in order to remain in the protocol. Reminder
calls, and various other forms of assistance were used to
enhance compliance. Medication adherence was mea-
sured by pill counts on the study bottles which were
returned by the patient at each visit.
Patients received a comprehensive evaluation at baseline,
15, and 20 weeks in order to determine if there was a lag
effect differentiating psychological and medication treat-
ment. The study was approved by the hospital review
board and carried out consistent with the Declaration of
Helsinki. All patients completed consent and/or assent as
For each of the dependent variables (ADHD RS-Inv and
Sheehan Disability Scale), a two-way repeated measures
analyses of variance (ANOVA) was conducted with the
within-participants factor being Time (Baseline, Week 15
and Week 20) and the between-participants variable
being CBT and placebo, CBT and Dectroamphetamine.
This ANOVA is an analyses which includes multiple
components. First, it tests to determine if there is a dif-
ference between the treatments overall (main effect-that
is, collapsing/averaging the data for each of the three
time points per treatment group and seeing if one group
was different from the other). Second, the ANOVA tests
if there is a difference across the three repeated measures
at baseline, Week 15 and Week 20 (collapsing the treat-
ment group data to see if overall, there are differences
across time for all subjects). Lastly, the ANOVA deter-
mines if there is an interaction between time and treat-
ment-does group improve over time more than the other
Analyses of both groups as a whole for efficacy of
CBT will be done, if it was found that there are no
between group differences. All analyses were intent to
treat, with last observation carried forward. Given the
total sample size of 48, an alpha of .5, and an effect size
of 1.1 we had a greater than 90% chance of finding a
difference between the groups if there had been one.
Three participants discontinued before the trial ended in
the Dextroamphetamine group and two participants in
the placebo group. Adverse events have been reported in
detail elsewhere . All adverse events were mild to
moderate and there was no statistically significant differ-
ence between the groups.
The means and standard deviations for the ADHD
RS-Inv are presented in Table 1.
Outcome in ADHD is often measured in three ways:
improvement, response and full remission. We elected to
look at the two extremes: patients who showed a signifi-
cant change with treatment even if they did not have a full
response, and patients who achieved normalization. We
defined improvement conservatively as a 25% drop in the
ADHD-RS-Inv score and remission as a mean score less
than or equal to 1 . Using these definitions 63% of
patients improved, and 47% percent of patients achieved
Table 1 and Figure 3 show the mean values for each of
the treatment conditions across the three assessment
times, and shows improvement in ADHD RS-Inv values
across time in both treatment conditions. Independent
samples t tests were conducted comparing the treatments
at each point of time. There were no statistical differ-
ences between groups at baseline or at any other time in
follow up. There was an absolute difference favoring
Table 1 ADHD RS-Inv
Week 15CBT+DEX20.87 9.32 23.21
Week 20 CBT+DEX20.789.6523.39
Weiss et al. BMC Psychiatry 2012, 12:30
Page 5 of 8
CBT+DEX vs. CBT+PLB at each point in treatment, that
did not reach statistical significance. At week 15 the
change score for CBT+DEX was 12.5 vs. 7.9 for CBT
+PLB. This pattern continued such that at week 20 the
decrease in ADHD symptoms for CBT+DEX was 12.6 vs.
CBT+PLB 9.2. There was not a significant interaction
between Time and Treatment, F(2, 46) = 2.21, p = .12.
Testing of the between-participants effect of Treatment
did not show a significant main effect, F(1,46) = 0.63,
p = .43.
Although there was no difference between CBT+DEX
and CBT+PLB, both groups showed robust improve-
ment over time. Tests of within-participants effects
showed a significant effect of Time, F(2,) = 53.72, p <
.001. Given that medication vs. placebo had no differen-
tial impact on outcome, we examined the effect size of
improvement for the sample as a whole to determine
the impact of CBT. The effect size (Cohen’s d using the
pooled SD) based on improvement obtained at 15 weeks
was 1.1. This was maintained at 20 weeks where the
effect size of improvement was unchanged at 1.1.
Results for the Sheehan Disability Scale have been
reported in Table 2.
Mean Sheehan Disability Scale values for each of the
treatment conditions across the three assessment times
are shown in Table 2 and Figure 4. The CBT+DEX group
shows improvement in functioning by Week 15 and this
improvement is sustained at Week 20. The CBT+PLB
group also shows improvement in functioning at Week 15,
but this improvement is attenuated somewhat at Week 20.
Tests of within-participants effects showed a significant
effect of Time, F(1, 46) = 12.70, p < .001, but no significant
interaction between Time and Treatment, F(1, 45) = 0.45,
p = .64. There was not a significant main effect of Treat-
ment on the Sheehan Disability Scale, F(1,45) = 1.73, p =
.20. Given no significant difference between medication
and placebo we calculated the effect size of improvement
in functioning for all participants at 15 weeks which was
.5, and .44 at 20 weeks.
This is the first report of a double blind, randomized
controlled study comparing the efficacy of CBT therapy
with either stimulant or placebo for adults with ADHD
followed over five months. All patients showed significant
improvement, going into remission and maintaining
those gains over the 20 weeks. This supports the work of
Solanto and Safren [17,21] which showed that adults may
benefit from short term, structured CBT therapy.
Furthermore, both therapy and medication treatment
effects were enduring, even when therapy sessions were
being tapered. The effect size of treatment on symptoms
was large and the effect on actual functioning was
Figure 3 ADHD RS-Inv by Time and Treatment.
Table 2 Sheehan Disability Scale
Time Treatment Mean SD N*
BaselineCBT+DEX18.8182 7.39 22 .29
CBT+PLB 20.88005.87 25
Week 15CBT+DEX 14.77278.65 22 .31
CBT+PLB17.3600 8.19 25
Week 20CBT+DEX 14.63649.0722 .15
CBT+PLB 18.24007.78 25
*One subject in CBT/DEX did not provide data at week 15 and was excluded
from the analyses
Figure 4 Sheehan Disability Scale by Time and Treatment.
Weiss et al. BMC Psychiatry 2012, 12:30
Page 6 of 8
Although the power analyses demonstrates that we
were adequately powered to show a difference if medica-
tion impacted outcome, it is impossible to prove the
null hypothesis. It can be stated that if there is such an
effect it would take a large sample size to demonstrate
it, and its clinical relevance to the majority of patients
would be modest. Nonetheless, we recognize it is never
possible to prove the null hypothesis, and that absence
of evidence is not evidence of absence. A limitation of
our design is it is impossible to distinguish the extent to
which the outcome of placebo/stimulant and CBT
represents a specific effect of either intervention. We
did not control for site to site differences. Therapy was
administered by more than ten therapists, and although
all the therapists participated in development of the
manual and sessions were taped and listened to by
therapists across sites, there was no attempt made to
guarantee treatment fidelity. This limits the capacity to
replicate the findings of this study. The findings are
likely to be generalizable in that the population came
from five very different geographic regions, and the
range of functioning of the patients was highly variable
and consistent with the population seen in ADHD. The
study cannot tell us the extent to which medication or
therapy effects endured beyond the five months of the
study. The study failed to demonstrate that medication
and therapy was statistically superior to therapy alone,
but failure to find a difference is not akin to demon-
This study supports previous findings that adults with
ADHD are responsive to CBT intervention. It extends
previous research in demonstrating that the impact of
CBT can be demonstrated in both response of core
symptoms and functioning, whether administered with
stimulants or placebo. This is the first randomized, pla-
cebo controlled study to demonstrate that where CBT
augments the effect of medication, we were not able to
demonstrate that medication impacts on the capacity to
learn the skills taught in CBT. This suggests that CBT
therapy can be effective in adults with ADHD, even in
patients who are not able to use stimulants.
Unlike findings on combination therapy vs. medication
alone in children CBT , this study suggests that CBT
is an effective treatment for adults with ADHD with or
without stimulant therapy. Future research is needed to
replicate the power and methodology of the Multimodal
Treatment of ADHD study in children in an adult popu-
lation. It is possible that when children are medicated
they are in learning environments where they can
acquire the attention skills they need. By contrast, adults
who have had ADHD as children and continue to have
ADHD, may be quite different to children in that the
key issue is no longer simply remission of symptoms,
but providing them with the opportunity to aquire the
attention skills they failed to develop in childhood.
1University of British Columbia, Faculty of Medicine, 1488 Gordon Ave, West
Vancouver, BC V7T 1R6, Canada.2Provincial ADHD Program, BC Mental
Health and Addictions Services, Box 178, 4500 Oak St., Vancouver, BC V6H
3N1, Canada.3Bridepoint Health, 14 St. Matthews Road, Toronto, ON M4M
2B5, Canada.4McGill University Faculty of Medicine, Montreal Children’s
Hospital, 2300 Tupper St, Montreal, QC H3H 1P3, Canada.5University of
British Columbia, Department of Psychiatry, 1488 Gordon Avenue, West
Vancouver, BC V7T 1R6, Canada.
MW was the lead author and conceptualized the design of the analyses.
MW designed and carried out the statistical analyses. BG helped design and
carry through the CBT treatment and edited each version of the manuscript
to reflect its clinical relevance. LG coordinated the research, and participated
in writing the paper to assure it was consistent with the CONSORT design.
LH designed the research, and participated in every aspect of the study
from its inception and the production of this manuscript. All authors read
and approved the final manuscript.
This project was funded by GlaxoSmithKline. Margaret Weiss and Lily
Hechtman have received honoraria, speaking fees, consultation fees and
research funds from Eli Lilly, Purdue, Janssen, and Shire but do not hold
stocks in any pharmaceutical company. There are no other competing
interests by these or the other authors.
Received: 29 August 2011 Accepted: 5 April 2012
Published: 5 April 2012
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The pre-publication history for this paper can be accessed here:
Cite this article as: Weiss et al.: A randomized controlled trial of CBT
therapy for adults with ADHD with and without medication. BMC
Psychiatry 2012 12:30.
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