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Spikes in symptom severity are noted for adolescents with attention deficit/hyperactivity disorder (ADHD) at the transitions to middle and high school that are attributed to developmental maladjustment. This study evaluated the effectiveness of high-intensity (HI; 412 hr, $4,373 per participant) versus low-intensity (LI; 24 hr, $97 per participant) skills-based summer intervention delivered to adolescents with ADHD by local school district staff. Participants were 325 ethnically diverse rising sixth and ninth graders with ADHD randomized to HI versus LI (n = 218) or recruited into an untreated comparison group (n = 107). Group × Time 1-year outcome trajectories were compared using linear mixed models. Both interventions possessed high fidelity and were viewed by families as enjoyable and beneficial. Youth attendance was higher for HI (~80%) versus LI (~45%). Parent training attendance was uniform across groups (~50%). Parent and student attendance did not impact trajectories. Primary benefits of HI over LI were to note taking (d = .50), parent contingency management (d = .43), and parent-rated ADHD symptoms (d = .40-.46; ninth grade only). Secondary analyses suggested that HI may produce additional benefits compared to no treatment for home organization skills (HI vs. untreated d = .54), parent-teen conflict (HI vs. untreated d = .39), and grade point average (HI vs. untreated d = .47, ninth grade only). Summer HI treatment was superior to LI in engagement and uptake of certain skills. However, the extent to which these medium benefits on a limited number of outcomes justify high costs compared to LI remains an open question. Delivering treatment during the summer instead of school year may limit generalizability.

Objective: This study evaluates a parent-teen skills-based therapy for attention deficit/hyperactivity disorder (ADHD) blended with motivational interviewing (MI) to enhance family engagement. Supporting Teens' Autonomy Daily (STAND) is an adolescent-specific treatment for ADHD that targets empirically identified adolescent (i.e., organization, time management, and planning, or OTP skills) and parent-based (i.e., monitoring and contingency management) mechanisms of long-term outcome through individual parent-teen sessions., Method: The current randomized trial (N = 128) evaluates efficacy at posttreatment and 6-month follow-up. Participants were ethnically diverse teens (7.7% non-Hispanic White, 10.8% African American, 78.5% Hispanic, 3.0% other) randomly assigned to STAND or Treatment As Usual (TAU)., Results: Primary findings were that (1) STAND was delivered in an MI-adherent fashion and most families fully engaged in treatment (85% completed); (2) STAND produced a range of significant acute effects on ADHD symptoms, OTP skills, homework behavior, parent-teen contracting, implementation of home privileges, parenting stress, and daily homework recording; and (3) 6 months after treatment ceased, effects on ADHD symptom severity, OTP skills, and parenting stress maintained, while parent use of contracting and privilege implementation strategies, as well as teen daily homework recording and homework behavior gains, were not maintained., Conclusion: Skills-based behavior therapy blended with MI is an acutely efficacious treatment for adolescents with ADHD although more work is needed to establish the nature of long-term effects. (PsycINFO Database Record, ((c) 2016 APA, all rights reserved).)

Smith, Waschbusch, Willoughby, and Evans (2000) reviewed a small treatment literature on ADHD in adolescents and concluded that methylphenidate stimulant medication was a well-established treatment and behavior therapy (BT) demonstrated preliminary efficacy. This review extends and updates the findings of the prior one based on the previous 15years of research. Studies published since 1999 were identified and coded using standard criteria and effect sizes were calculated where appropriate. Highlights of the last 15years of research include an expansion of pharmacological treatment options and developmentally appropriate psychosocial treatment packages for adolescents with ADHD. Additionally, nonstimulant medications (e.g., atomoxetine) are now approved for the treatment of ADHD in adolescence. The review concludes that medication and BT produce a similar range of therapeutic effects on the symptoms of adolescents with ADHD. However, results suggest that BT may produce greater overall benefits on measures of impairment. There was no evidence that cognitive enhancement trainings, such as working memory training or neurofeedback improved the functioning of adolescents with ADHD. Whether to use medication, BT, or their combination to treat an adolescent with ADHD is complicated and we provide evidence-informed guidelines for treatment selection. The reviewed evidence does not support current American Academy of Pediatrics and American Academy of Child and Adolescent Psychiatry professional guidelines, which state that stimulant medication is the preferred treatment for adolescents with ADHD. Recommendations for assessment, practice guidelines, and future research are discussed., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

This study evaluated the social behavior of adolescents with attention deficit hyperactivity disorder (ADHD) in single and mixed gender treatment settings. We collected ratings of social behavior (i.e., prosocial peer interactions, assertiveness, self-management, compliance, physical aggression, relational aggression) during single and mixed gender games within the Summer Treatment Program-Adolescent for 10 girls (M age = 13.17, 80% Hispanic) and 11 boys (M age = 12.89, 54.55% Hispanic). Counselors completed ratings immediately following 10 recreational periods for each adolescent they supervised (5 single gender games, 5 mixed gender games). Gender (female vs. male) × Setting (single vs. mixed gender) ANOVAs were conducted. If a significant interaction emerged, post hoc tests were also conducted. Several Gender × Setting interactions emerged, suggesting that girls benefit more from single gender formats than mixed gender formats. Girls showed more assertiveness, self-management, and compliance in single compared to mixed gender settings. A somewhat different pattern of results emerged for boys, which showed more appropriate social behavior (i.e., self-management, compliance) and less inappropriate social behavior (i.e., physical and relational aggression) in mixed gender settings compared to single gender settings. In contrast to previous ADHD treatment studies, these findings suggest that gender may impact treatment response for adolescents. Therefore, it is important that future studies evaluate whether current treatments for ADHD are appropriate for girls with ADHD and whether gender-specific treatments are necessary to address the unique difficulties of adolescent girls with ADHD.

Objective: The social functioning of adolescents with ADHD is characteristically impaired, yet almost no interventions effectively address the peer relationships of these youth. This study evaluates the preliminary effects of a video-feedback intervention on the social behavior of a 16-year-old male with ADHD-combined type in the context of a summer treatment program for youth with ADHD., Method: The intervention was administered in a teen-run business meeting designed to mimic the context of group-based activities such as student government, service clubs, and group projects. During each video-feedback session, the adolescent viewed a 5-min clip of his behavior in the previous business meeting, rated the appropriateness of his own social behavior in each 30-s interval, and discussed behavior with a summer program counselor., Results: Results indicated that while the video-feedback intervention was in place, the adolescent displayed improvements in social behavior from baseline. Results also indicated that the adolescent exhibited relatively accurate self-perceptions during the intervention period. The authors present preliminary evidence for cross-contextual and cross-temporal generalization., Conclusion: The results of this study and future directions for intervention development are discussed in the context of the broader conversation about how to treat social impairment in adolescents with ADHD.

Objective: There are presently almost no empirically validated treatments for adolescents with ADHD. However, in childhood, behavioral treatments for ADHD typically include behavioral parent training, classroom interventions, and intensive child-directed interventions., Method: The present investigation examines treatment gains following an 8-week intensive summer day treatment program for adolescents with ADHD (STP-A). Baseline measures of functioning and parent improvement ratings were obtained for 34 STP-A participants., Results: Parent ratings indicated that adolescents who attended the STP-A improved across all target domains. Across domains, 63.0% to 90.9% of adolescents improved during the STP-A. There was no evidence of iatrogenic effects during the STP-A. Correlates of treatment response included adolescent effort, oppositional-defiant behavior, and cognitive/scholastic functioning., Conclusion: Findings are discussed with regard to effective treatment delivery for adolescents with ADHD.

To identify barriers to behavior therapy for adolescent ADHD (Supporting Teens' Autonomy Daily; STAND) and understand the relationship between barriers and treatment engagement. A mixed-method design with qualitative coding of 822 audio-recorded therapy sessions attended by 121 adolescents with ADHD (ages 11–16; 72.7% male, 77.7% Latinx, 7.4% African-American, 11.6% White, non-Latinx) and parents. Grounded theory methodology identified barriers articulated by parents and adolescents in session. Barriers were sorted by subtype (cognitive/attitudinal, behavioral, logistical) and subject (parent, teen, dyad). Frequency and variety of barriers were calculated by treatment phase (engagement, skills, planning). Generalized linear models and generalized estimating equations examined between-phase differences in frequency of each barrier and relationships between barriers frequency, subtype, subject, and phase on engagement (attendance and homework completion). Coding revealed twenty-five engagement barriers (ten cognitive/attitudinal, eleven behavioral, four logistical). Common barriers were: low adolescent desire (72.5%), parent failure to monitor skill application (69.4%), adolescent forgetfulness (60.3%), and adolescent belief that no change is needed (56.2%). Barriers were most commonly cognitive/attitudinal, teen-related, and occurring in STAND's planning phase. Poorer engagement was associated with cognitive/attitudinal, engagement phase, and dyadic barriers. Higher engagement in treatment was predicted by more frequent behavioral, logistical, parent, and skills/planning phase barriers. Baseline assessment of barriers may promote individualized engagement strategies for adolescent ADHD treatment. Cognitive/attitudinal barriers should be targeted at treatment outset using evidence-based engagement strategies (e.g., Motivational Interviewing). Behavioral and logistical barriers should be addressed when planning and reviewing application of skills. [ABSTRACT FROM AUTHOR]

• Community treatment for ADHD was most effective when delivered by licensed clinicians. • Behavior therapy for ADHD outperformed usual care for conduct problems and may be particularly effective for these youth. • Clinics might assign adolescent ADHD cases to licensed professionals. • All other comorbidity outcomes did not show group differences between STAND and usual care. Though behavior therapy (BT) for ADHD in adolescence is evidence-based, almost no work examines its implementation and effectiveness in community settings. A recent randomized community-based trial of an evidence-based BT for adolescent ADHD (Supporting Teens' Autonomy Daily; STAND; N = 278) reported high clinician, parent, and youth acceptability but variable implementation fidelity. Primary outcome analyses suggested no significant differences between STAND and usual care (UC) unless the clinician delivering STAND was licensed. The present study reports secondary outcomes for this trial on indices of comorbidity (anxiety, depression, oppositional defiant disorder, conduct disorder) and ADHD outcomes not targeted by the active treatment (social skills, sluggish cognitive tempo). We also examine whether therapist licensure moderated treatment effects (as in primary outcome analyses). Using intent-to-treat and per protocol linear mixed models, patients randomized to STAND were compared to those randomized to UC over approximately 10 months of follow-up. Group × Time effects revealed that, overall, STAND did not outperform usual care when implemented by community clinicians. However, a Group × Time × Licensure interaction revealed a significant effect on conduct problems when STAND was delivered by licensed clinicians (d =.19–.47). When delivered in community settings, behavior therapy for adolescent ADHD can outperform UC with respect to conduct problems reduction. Community mental health clinics should consider: (1) assigning adolescent ADHD cases to licensed professionals to maximize impact and (2) choosing psychosocial approaches when ADHD presents with comorbid conduct problems. There is also a need to reduce implementation barriers for unlicensed clinicians in community settings. [ABSTRACT FROM AUTHOR]

We utilized qualitative methodology to characterize potential long-term effects (therapeutic and iatrogenic) of behavior therapy for adolescents with ADHD. Forty-two in-depth interviews were conducted with adolescents with ADHD and parents, 4 years post-treatment. Grounded theory methods identified and reported prevalence of themes. All reported long-term effects were classified as benefits; no iatrogenic effects were noted. Long-term impact themes reported for a majority of participants included: development of organization skills (81.0%), enhanced motivation (57.1%), improved self-awareness (57.1%), improved parental knowledge of ADHD (76.2%), increased parent autonomy granting (61.9%), enhanced parental engagement with the youth (52.4%), and improved parent-teen relationships (52.4%). Fourteen themes were present for smaller subsamples, including reduced need for medication (3 of 9 medicated participants). Experimental studies of behavior therapy for adolescent ADHD should measure themes detected herein and directly test the possibility of long-term treatment effects. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to understand patient characteristics that predict engagement barriers during behavior therapy for ADHD. Method: Participants were 121 adolescents with ADHD and parents who received evidence-based behavior therapy for ADHD. Multiple regression examined relationships between six independent variables and frequency of barriers. Results: ODD comorbidity and parental ADHD predicted higher frequency of overall barriers. With respect to barriers subtypes, these variables also predicted higher frequencies of cognitive, teen, early-treatment and mid-treatment barriers. Late-treatment, ODD predicted higher frequency of barriers, while minority status predicted lower barriers. Conclusions: Adolescents diagnosed with ADHD and comorbid ODD, or who have parents that are also diagnosed with ADHD, are at greatest risk for engagement barriers during behavior therapy. During all phases of treatment, this patient subgroup would benefit from enhancements to standard behavior therapy that focus on therapeutic engagement—particularly targeting teen beliefs about treatment. [ABSTRACT FROM AUTHOR]

Objective: To identify patient- and treatment-level factors that predict intervention engagement and outcome for adolescents with attention-deficit/hyperactivity disorder (ADHD), guiding efforts to enhance care.Method: Integrative data analysis was used to pool data from 4 randomized controlled trials of adolescent ADHD treatment with participants (N = 854) receiving various evidence-based behavioral therapy packages in 5 treatment arms (standard [STANDARD], comprehensive [COMP], engagement-focused [ENGAGE]), community-based usual care (UC), or no treatment (NOTX). Participants also displayed varying medication use patterns (negligible, inconsistent, consistent) during the trial. Regression and latent growth curve analyses examined treatment- and patient-level predictors of engagement and outcome.Results: Compared with COMP, ENGAGE was associated with higher parent engagement in behavioral therapy (d = 1.35-1.73) when delivered in university, but not community, clinics. Under some conditions, ENGAGE also predicted youth engagement in behavioral therapy (d = 1.21) and lower likelihood of negligible medication use (odds ratio = 0.49 compared with NOTX). UC was associated with poorer parent engagement compared with COMP (d = -0.59) and negligible medication use (odds ratio = 2.29) compared with NOTX. Compared with COMP, ENGAGE (in university settings) was consistently associated with larger ADHD symptom improvements (d = 0.41-0.83) at 6-month follow-up and sometimes associated with larger grade point average (d = 0.68) and parent-teen conflict (d = 0.41) improvements. Consistent medication use during behavioral therapy was associated with larger improvements in ADHD symptoms (d = 0.28) and parent-teen conflict (d = 0.25-0.36). An ADHD+internalizing clinical profile predicted larger improvements in grade point average (d = 0.45). Family adversity predicted poorer parent and youth engagement (rate ratio = 0.90-0.95), negligible medication use (odds ratio = 1.22), and smaller improvements in grade point average (d = -0.23). African American race predicted smaller improvements in parent-teen conflict (d = -0.49).Conclusion: Engagement-focused behavioral therapy and consistent medication use most frequently predicted stronger clinical engagement and outcomes for adolescents with ADHD. Youths who are African American or who experience family adversity may demonstrate treatment-related disparities for certain outcomes; youths with ADHD+internalizing symptoms may demonstrate excellent academic outcomes following behavioral therapy.Data Sharing: The full ADHD TIDAL dataset is publicly available through the National Data Archive (https://nda.nih.gov), including a data dictionary. The study protocol is also publicly available: https://doi.org/10.1186/s12888-020-02734-6. [ABSTRACT FROM AUTHOR]

Little is known about processes through which behavior therapy (BT) for adolescent ADHD improves outcomes. The purpose of this study was to build a theoretical model for the processes through which a BT for adolescent ADHD (Supporting Teens' Autonomy Daily; STAND) impacts functioning. Seventy-eight audio recordings from a standard therapeutic task in the final STAND session were analyzed as parents and adolescents (ages 11-16) reflected upon what changed during STAND and why. Qualitative coding sorted parent and teen statements into orthogonal categories of perceived changes. Network analysis examined inter-relations between categories. Results indicated twenty-one categories of perceived change areas. Parent use of behavioral strategies, adolescent motivation, and adolescent organization skills were central nodes in the network of perceived changes, with strong relations to academic and parent-teen relationship outcomes. A model is proposed in which skills training in STAND increases parent behavioral strategy use and teen organization skills, while Motivational Interviewing (MI) in STAND increase parent behavioral strategy use and initial adolescent motivation. In turn, parent behavioral strategy use is proposed to further reinforce teen motivation through contingency management, thereby increasing teen application of organization skills to daily life. As a result of improved teen motivation and organization skills, the model proposes that ADHD symptoms, academic problems, and parent-teen conflict abate. We discuss secondary mechanisms and outcomes in this model, the possibility of person-specific processes, implications for community-based adaptation of STAND, and plans to validate this conceptual model using sophisticated mediational models. [ABSTRACT FROM AUTHOR]

Despite the promise of psychosocial interventions for adolescent Attention Deficit Hyperactivity Disorder (ADHD), there are no studies that examine their implementation in community mental health contexts. In this study, we evaluate the implementation of community-based Supporting Teens' Autonomy Daily (STAND), a parent-teen Motivational Interviewing + Behavior Therapy intervention for adolescents with ADHD. Adolescents with ADHD (N = 225), who were clients at four community mental health agencies, received treatment from 82 therapists. There was double randomization of adolescents and therapists to STAND or Usual Care (UC). Nearly all therapists randomized to STAND completed the training and regularly attended supervision, rating STAND as acceptable and lower burden than UC practices. In the STAND group, MI competence and implementation were lower than in university trials (benchmark range, 19.5% for reflection to question ratio to 83.1% for technical globals). MI integrity in the STAND group was significantly higher than UC across most MITI indices. Content fidelity was adequate in STAND's engagement and skills phases (76.4–85.0%), but not its planning phase (24.4%). Therapists commonly neglected weekly review of goals and home practice and deviated from manualized pace and sequencing of therapy tasks. Learning MI was more challenging for bilingual therapists and therapists with more years of experience. STAND was delivered with higher integrity in earlier sessions and office-based sessions. Discussion identifies future directions for exporting adolescent ADHD interventions to community settings. Patient outcome data for this trial is presented elsewhere. Trial Registration: NCT02694939 www.clinicaltrials.gov. [ABSTRACT FROM AUTHOR]

Evidence-based behavior therapy for adolescent ADHD faces implementation challenges in real-world settings. The purpose of this trial was to investigate the relationship between implementation fidelity and outcomes among adolescents receiving services in the active treatment arm (N = 114; Motivational Interviewing [MI]-enhanced parent-teen behavior therapy) of a community-based randomized trial of adolescent ADHD treatment. Participants received therapy from community clinicians (N = 44) at four agencies in a large, ethnically diverse metropolitan setting. Therapists provided self-report of session-by-session adherence to content fidelity checklists and audio recordings of sample sessions that were coded for MI integrity. Parents provided report of ADHD symptoms and family impairment at baseline, posttreatment, and follow-up, while academic records were obtained directly from the local school district. Results indicated that content fidelity significantly waned across the 10 manualized sessions (d = -1.23); these trends were steepest when therapy was delivered outside the office-setting and parent attendance was low. Community therapist self-report of content fidelity predicted significantly greater improvements in academic impairment from baseline to follow-up. MI delivery quality was not associated with improved outcomes; contrary to hypotheses, lower MI relational scores predicted significantly greater improvements in family impairment over time. Findings indicate that community-based outcomes for evidence-based ADHD treatment are enhanced when treatment is implemented with fidelity. Future work should revise community-based implementation strategies for adolescent ADHD treatment to prevent declines in fidelity over time, thereby improving outcomes. [ABSTRACT FROM AUTHOR]

Objective: This study tests the effectiveness of parent-teen psychotherapy for adolescent attention-deficit/hyperactivity disorder (ADHD) (Supporting Teens' Autonomy Daily [STAND]) versus usual care (UC) in 4 community clinics.Method: A randomized clinical trial was conducted with double randomization of adolescents and therapists to STAND versus UC. Participants were 278 culturally diverse adolescents diagnosed with DSM-5 ADHD at baseline and 82 community therapists. Seven primary outcomes were assessed at baseline (BL), posttreatment (PT; mean = 5.11 months post-BL, SD = 2.26), and follow-up (FU; mean = 9.81 months post-BL, SD = 2.50): inattention (IN; parent/teacher-rated), academics (parent-rated/official records), family functioning (parent/adolescent-rated), and disciplinary records. Treatment engagement indicated consumer fit (eg, number or sessions received, percentage of sessions attended by parent, satisfaction). The impact of treatment on concurrent medication use was also examined. Service delivery features were examined as moderators of outcome.Results: Intent-to-treat (N = 278) analyses indicated no significant group × time effects. STAND only led to superior outcomes when therapists were licensed (22% of sample) versus unlicensed (parent-rated IN: p < .001, d = 1.08; parent-rated academic impairment: p = .010, d = 1.17). Compared to UC, STAND was associated with greater parent participation (p < .001, d = 0.88) and higher scores on certain indices of parent satisfaction. STAND also was associated with superior medication engagement over time compared to UC (odds ratio = 7.18).Conclusion: Evidence-based psychosocial treatment for adolescent ADHD did not outperform UC on outcome trajectories despite improving some indices of treatment engagement. STAND requires additional adaptation for community contexts.Clinical Trial Registration Information: STAND Community Trial (STAND); https://clinicaltrials.gov/; NCT02694939. [ABSTRACT FROM AUTHOR]

Abstract: Although adolescents with attention-deficit/hyperactivity disorder (ADHD) experience serious life impairment (Molina et al., 2009; Wolraich et al., 2005), very few effective psychosocial interventions exist to treat this population (Pelham & Fabiano, 2008; Smith, Waschbusch, Willoughby, & Evans, 2000). Intensive child-directed interventions are an important component in the treatment of childhood ADHD (Pelham et al., 2005), yet no study exists that fully evaluates an intensive adolescent-directed intervention. The current investigation is a pilot study of 19 adolescents with ADHD (age range: 11-16) who participated in an 8-week intensive Summer Treatment Program–Adolescent (STP-A) during the summer of 2009. The program was developed to address specific difficulties associated with ADHD in adolescence. As such, the program was designed to be ecologically valid, age appropriate, and parent-involved. Results suggest that almost all adolescents who attended the STP-A benefitted from the program according to parent, self, and staff ratings and objective measures. These ratings also indicated that participants showed moderate improvement in each of the 6 domains targeted by treatment (i.e., conduct problems, adult-directed defiance, social functioning, inattention/disorganization, mood/well-being, and academic skills). All parents indicated that both they and their children benefitted from the program and all but 1 parent indicated that the STP-A was more effective than the treatments they had utilized in the past. A case example is presented to illustrate typical improvement patterns during the STP-A. Discussion addresses the role of the STP-A in the treatment of ADHD in adolescence. [Copyright &y& Elsevier]