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Abstract: 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 &y& Elsevier]

Abstract: The current study pilots a low-intensity behavioral intervention for parents and high school students with ADHD that promotes parent-teen collaboration at home and in session (Supporting Teens’ Academic Needs Daily-Group; STAND-G). Twenty-three high school students with ADHD and their parents were randomly assigned to receive an 8-week behavioral treatment beginning in October, January, or March. Weekly data were collected from students’ online grade books for 37weeks of the school year to monitor changes in academic functioning through baseline, posttreatment, and follow-up phases. Students who had not yet received the treatment served as a control group for students who completed treatment. Qualitative and quantitative ratings of satisfaction, improvement, and parent implementation of home-based behavioral strategies were collected. Results indicated parent and teen satisfaction with STAND-G, parent compliance with intervention strategies, and a range of parent-rated therapeutic benefits (i.e., organization and time-management skills, academic conscientiousness, parent-teen communication, adolescent autonomy). Findings for the objective grade book data were mixed, with Group 2 (January), but not Group 1 (October), displaying identifiable acute improvements relative to control students. However, both groups evaluated at follow-up displayed meaningful improvements in the percentage of work turned in up to 2months out of treatment. With these results in mind, we discuss the importance of tailoring interventions to the lives of high school students with ADHD and the future of treatment development and delivery for this often underserved population. [Copyright &y& Elsevier]

This article provides a thorough discussion of the proposed DSM-5 changes and their implications for current and future approaches to assessment, identification, and service delivery for children and adolescents with ADHD. Educational and clinical implications are discussed with special attention to the individual impact of the changes, diagnostic prevalence rates, and associated societal costs. Developmental period is considered as an important factor in the potential impact of the DSM-5 changes. The authors conclude that the DSM-5 proposed revisions may improve diagnostic sensitivity and specificity; yet the overall impact of these changes remains largely unknown as many were not empirically validated. The authors suggest that the cumulative impact of the set of changes be considered when finalizing the DSM-5 revisions. [ABSTRACT FROM PUBLISHER]

Adolescents with attention-deficit/hyperactivity disorder (ADHD) experience academic difficulties, but there are limitations to current methods of measuring these problems. The parent-rated Adolescent Academic Problems Checklist (AAPC) is a particularly promising measure, as the items were derived from concerns of parents and teachers of adolescents with ADHD and the scale demonstrates good concurrent validity and treatment sensitivity (Sibley et al. in School Psychology Quarterly, 29(4), 422, 2014; Sibley et al. Journal of Consulting and Clinical Psychology, 84(8), 699, 2016b). Because parents do not observe some academic behaviors queried on the AAPC, they may provide inaccurate responses to some items, leading to measurement error. In the current study, we sought to (1) determine the extent to which parents of adolescents with ADHD possess knowledge of the academic behaviors assessed on the AAPC, (2) determine if the scale maintains the two-factor structure (academic skills and disruptive behavior) and continues to relate to indicators of academic functioning after removing items associated with low parent knowledge, and (3) validate findings with the revised scale in a separate sample of adolescents with ADHD. Results identified five items for which the majority of parents reported little to no knowledge. When removing items with low parental knowledge, the AAPC's model fit was maintained and the two-factor model remained a better fit than the one-factor model. The relationships between the revised subscales and measures of academic functioning remained significant and largely equivalent to the original version. The revised model demonstrated similar fit in the second sample and was also related to indicators of academic functioning. Implications for clinical practice are discussed. [ABSTRACT FROM AUTHOR]

The course of ADHD from childhood up to young adulthood has been characterized in several studies. However, little is known about the course of symptoms into middle age and beyond. This study aims to evaluate predictors of ADHD trajectories in midlife based on three assessments. The follow-up sample comprised 323 adults with ADHD, evaluated at baseline and seven and thirteen years later, from the average ages of 34 up to 47 years old. ADHD status at reassessments was used to characterize trajectories. Demographics, ADHD features, comorbidities, and polygenic scores for ADHD and genetically correlated psychiatric disorders were evaluated to predict ADHD trajectories. Study retention rate was 67% at T2 (n = 216) and 62% at T3 (n = 199). Data from patients evaluated three times showed that 68.8% coursed stable, 25.5% unstable, and 5.7% remission trajectory of ADHD. Women, individuals with more severe syndromes, higher frequency of comorbidities at reassessments, and genetic liability to depression present a higher probability of a stable trajectory. Our findings shed light on midlife ADHD trajectories and their gender, genomic and clinical correlates. [ABSTRACT FROM AUTHOR]

The Summer Treatment Program (STP) is one of the most widely studied psychosocial treatments for children with ADHD and has been adapted for adolescent populations (STP-A). However, there is a discrepancy between small effect sizes of improvement in outcomes and high perceived improvement by parents and adolescents, suggesting that we are not capturing some treatment-related improvements with quantitative pre-post assessments. This study examines parent and young adult perceptions of the impact of participating in the STP-A. Using qualitative interviewing, 22 in-depth interviews were conducted with young adults with ADHD (ages 18–21) and their parents. Informants offered their perspectives of what outcomes they perceived as changing as a result of participating in the STP-A and (2) how (i.e., by what mechanisms) the STP-A produced changes in these outcomes. Self-concept, motivation, executive functioning, parenting practices, and connectedness (e.g., positive interactions with peers and mentors who could provide social support, and encouragement) were reported as key mechanisms to improving functional outcomes with respect to academic, social, and family functioning. Findings highlight that parents and young adults reported improvements in many outcomes and mechanisms that have not been thoroughly measured in past clinical trials of the STP-A or the children's STP. Implications for improving assessment of intervention effects and intervention development are discussed. Highlights: Examined perspectives of the impact of a summer program for adolescents with ADHD. Informants reported benefits that have not been measured in past clinical trials. Novel improvements included self-concept, connectedness, and parental optimism. [ABSTRACT FROM AUTHOR]

Educational researchers and school-based practitioners are increasingly infusing motivational interviewing (MI) into new and existing intervention protocols to provide support to students, parents, teachers, and school administrators. To date, however, the majority of the research in this area has focused on feasibility of implementation rather than fidelity of implementation. In this manuscript, we will present MI fidelity data from 245 audio-recorded conversations with 113 unique caregivers and 20 coaches, who implemented a school-based, positive parenting intervention. The aggregate fidelity scores across coaches, parents, and sessions provide evidence the training and support procedures were effective in assisting school-based personnel to implement MI with reasonable levels of fidelity in practice settings. Further, results suggest that MI fidelity varied between sessions and coaches and that within-coach variation (e.g., session-level variation in the quality of MI delivered) greatly exceeded between-coach variation. Implications for practice and future research are discussed. [ABSTRACT FROM AUTHOR]

Some mothers of children with attention-deficit/hyperactivity disorder (ADHD) present with maladaptive personality profiles (high neuroticism, low conscientiousness). The moderating effect of maternal personality traits on treatment outcomes for childhood ADHD has not been examined. We evaluate whether maternal neuroticism and conscientiousness moderated response in the Multimodal Treatment Study of Children with ADHD. This is one of the first studies of this type. In a randomized controlled trial (RCT), 579 children aged 7–10 (M = 8.5); 19.7% female; 60.8% White with combined-type ADHD were randomly assigned to systematic medication management (MedMgt) alone, comprehensive multicomponent behavioral treatment (Beh), their combination (Comb), or community comparison treatment-as-usual (CC). Latent class analysis and linear mixed effects models included 437 children whose biological mothers completed the NEO Five-Factor Inventory at baseline. A 3-class solution demonstrated best fit for the NEO: MN&MC = moderate neuroticism and conscientiousness (n = 284); HN&LC = high neuroticism, low conscientiousness (n = 83); LN&HC = low neuroticism, high conscientiousness (n = 70). Per parent-reported symptoms, children of mothers with HN&LC, but not LN&HC, had a significantly better response to Beh than to CC; children of mothers with MN&MC and LN&HC, but not HN&LC, responded better to Comb&MedMgt than to Beh&CC. Per teacher-reported symptoms, children of mothers with HN&LC, but not LN&HC, responded significantly better to Comb than to MedMgt. Children of mothers with high neuroticism and low conscientiousness benefited more from behavioral treatments (Beh vs. CC; Comb vs. MedMgt) than other children. Evaluation of maternal personality may aid in treatment selection for children with ADHD, though additional research on this topic is needed. [ABSTRACT FROM AUTHOR]

Childhood attention-deficit/hyperactivity disorder (ADHD) is prospectively linked to substance use and disorder. Depression emerging in adolescence is an understudied risk factor that may explain some of this risk. In the present study, we considered mediating and moderating roles of adolescent depression in explaining this association by using longitudinal data from the prospective 16-year follow-up of the Multimodal Treatment Study of ADHD (MTA). Participants were 547 children diagnosed with DSM-IV ADHD Combined Type, and 258 age- and sex-matched comparison children. In adolescence, depressive symptoms did not exacerbate effects of childhood ADHD on any substance use. For both groups, time-varying and average depressive symptoms were associated with more frequent use of all substances. Prospectively, we found no evidence of depression mediation to adult substance use. However, adolescent depression moderated the association between childhood ADHD and adult marijuana use. Although adults without ADHD histories used marijuana more frequently if they had elevated depressive symptoms in adolescence, marijuana use by adults with ADHD histories was independent of their adolescent depression. In adulthood, depression diagnoses and ADHD persistence continued to operate as independent, additive correlates of substance use risk. Our findings suggest a circumscribed role for depression in substance use risk that adds to, but does not alter or explain, ADHD-related risk. [ABSTRACT FROM AUTHOR]

Objective: To compare educational, occupational, legal, emotional, substance use disorder, and sexual behavior outcomes in young adults with persistent and desistent attention-deficit/hyperactivity disorder (ADHD) symptoms and a local normative comparison group (LNCG) in the Multimodal Treatment Study of Children with ADHD (MTA).Method: Data were collected 12, 14, and 16 years postbaseline (mean age 24.7 years at 16 years postbaseline) from 476 participants with ADHD diagnosed at age 7 to 9 years, and 241 age- and sex-matched classmates. Probands were subgrouped on persistence versus desistence of DSM-5 symptom count. Orthogonal comparisons contrasted ADHD versus LNCG and symptom-persistent (50%) versus symptom-desistent (50%) subgroups. Functional outcomes were measured with standardized and demographic instruments.Results: Three patterns of functional outcomes emerged. Post-secondary education, times fired/quit a job, current income, receiving public assistance, and risky sexual behavior showed the most common pattern: the LNCG group fared best, symptom-persistent ADHD group worst, and symptom-desistent ADHD group between, with the largest effect sizes between LNCG and symptom-persistent ADHD. In the second pattern, seen with emotional outcomes (emotional lability, neuroticism, anxiety disorder, mood disorder) and substance use outcomes, the LNCG and symptom-desistent ADHD group did not differ, but both fared better than the symptom-persistent ADHD group. In the third pattern, noted with jail time (rare), alcohol use disorder (common), and number of jobs held, group differences were not significant. The ADHD group had 10 deaths compared to one death in the LNCG.Conclusion: Adult functioning after childhood ADHD varies by domain and is generally worse when ADHD symptoms persist. It is important to identify factors and interventions that promote better functional outcomes. [ABSTRACT FROM AUTHOR]

Background The Multimodal Treatment Study ( MTA) began as a 14-month randomized clinical trial of behavioral and pharmacological treatments of 579 children (7-10 years of age) diagnosed with attention-deficit/hyperactivity disorder ( ADHD)-combined type. It transitioned into an observational long-term follow-up of 515 cases consented for continuation and 289 classmates (258 without ADHD) added as a local normative comparison group ( LNCG), with assessments 2-16 years after baseline. Methods Primary (symptom severity) and secondary (adult height) outcomes in adulthood were specified. Treatment was monitored to age 18, and naturalistic subgroups were formed based on three patterns of long-term use of stimulant medication (Consistent, Inconsistent, and Negligible). For the follow-up, hypothesis-generating analyses were performed on outcomes in early adulthood (at 25 years of age). Planned comparisons were used to estimate ADHD- LNCG differences reflecting persistence of symptoms and naturalistic subgroup differences reflecting benefit (symptom reduction) and cost (height suppression) associated with extended use of medication. Results For ratings of symptom severity, the ADHD- LNCG comparison was statistically significant for the parent/self-report average (0.51 ± 0.04, p < .0001, d = 1.11), documenting symptom persistence, and for the parent/self-report difference (0.21 ± 0.04, p < .0001, d = .60), documenting source discrepancy, but the comparisons of naturalistic subgroups reflecting medication effects were not significant. For adult height, the ADHD group was 1.29 ± 0.55 cm shorter than the LNCG ( p < .01, d = .21), and the comparisons of the naturalistic subgroups were significant: the treated group with the Consistent or Inconsistent pattern was 2.55 ± 0.73 cm shorter than the subgroup with the Negligible pattern ( p < .0005, d = .42), and within the treated group, the subgroup with the Consistent pattern was 2.36 ± 1.13 cm shorter than the subgroup with the Inconsistent pattern ( p < .04, d = .38). Conclusions In the MTA follow-up into adulthood, the ADHD group showed symptom persistence compared to local norms from the LNCG. Within naturalistic subgroups of ADHD cases, extended use of medication was associated with suppression of adult height but not with reduction of symptom severity. [ABSTRACT FROM AUTHOR]

Objective: Recent results from the Multimodal Treatment Study of Attention-Deficit/Hyperactivity Disorder (ADHD; MTA) have demonstrated impairments in several functioning domains in adults with childhood ADHD. The childhood predictors of these adult functional outcomes are not adequately understood. The objective of the present study was to determine the effects of childhood demographic, clinical, and family factors on adult functional outcomes in individuals with and without childhood ADHD from the MTA cohort.Method: Regressions were used to determine associations of childhood factors (age range 7-10 years) of family income, IQ, comorbidity (internalizing, externalizing, and total number of non-ADHD diagnoses), parenting styles, parental education, number of household members, parental marital problems, parent-child relationships, and ADHD symptom severity with adult outcomes (mean age 25 years) of occupational functioning, educational attainment, emotional functioning, sexual behavior, and justice involvement in participants with (n = 579) and without (n = 258) ADHD.Results: Predictors of adult functional outcomes in ADHD included clinical factors such as baseline ADHD severity, IQ, and comorbidity; demographic factors such as family income, number of household members and parental education; and family factors such as parental monitoring and parental marital problems. Predictors of adult outcomes were generally comparable for children with and without ADHD.Conclusion: Childhood ADHD symptoms, IQ, and household income levels are important predictors of adult functional outcomes. Management of these areas early on, through timely treatments for ADHD symptoms, and providing additional support to children with lower IQ and from households with low incomes, could assist in improving adult functioning. [ABSTRACT FROM AUTHOR]

Objective: To determine childhood factors that predict attention-deficit/hyperactivity disorder (ADHD) persistence and desistence in adulthood.Method: Regression analyses were used to determine associations between childhood factors and adult ADHD symptom persistence in 453 participants (mean age, 25 years) from the Multimodal Treatment Study of Children with ADHD (MTA). Childhood IQ, total number of comorbidities, child-perceived parenting practices, child-perceived parent-child relationships, parental mental health problems, marital problems of parents, household income levels, and parental education were assessed at a mean age of 8 years in all participants. Adult ADHD persistence was defined using DSM-5 symptom counts either with or without impairment, as well as mean ADHD symptom scores on the Conners' Adult ADHD Rating Scale (CAARS). Age, sex, MTA site, and childhood ADHD symptoms were covaried.Results: The most important childhood predictors of adult ADHD symptom persistence were initial ADHD symptom severity (odds ratio [OR] = 1.89, standard error [SE] = 0.28, p = .025), comorbidities (OR = 1.19, SE = 0.07, p = .018), and parental mental health problems (OR = 1.30, SE = 0.09, p = .003). Childhood IQ, socioeconomic status, parental education, and parent-child relationships showed no associations with adult ADHD symptom persistence.Conclusion: Initial ADHD symptom severity, parental mental health, and childhood comorbidity affect persistence of ADHD symptoms into adulthood. Addressing these areas early may assist in reducing adult ADHD persistence and functioning problems. [ABSTRACT FROM AUTHOR]

The current study aims to evaluate the effectiveness of a high-intensity (HI) versus a low-intensity (LI) skills-based summer intervention delivered to adolescents with ADHD by school staff in improving depressive symptoms, anxiety symptoms, social problems, and self-esteem. Participants were 325 ethnically diverse rising sixth and ninth graders with ADHD randomized to an HI versus an LI intervention ( n = 218) or recruited into an untreated comparison group ( n = 107). Group x time and group x grade x time one-year outcome trajectories were compared using linear mixed models. Across the transitional year (sixth or ninth grade), adolescents in the HI group were found to experience significantly greater decreases in depressive symptoms ( p =  .022, d = .25) compared to the LI group. There was no significant impact of the HI intervention (vs. LI) on anxiety symptoms ( p =  .070, d =  .29), social problems ( p =  .054, d =  .34), or self-esteem ( p =  .837, d = 0.21); however, secondary analyses of the non-randomized untreated comparison group indicated a significant effect of HI versus the untreated comparison group on social problems ( p =  .009, d =  43). These significant treatment effects suggest that comprehensive academic and organizational skills interventions for adolescents with ADHD may have a secondary impact of relieving adolescent depression for teens with this comorbidity. Given mixed evidence for the efficacy of the HI intervention on social skills, future work should further evaluate this effect.

Background: Attention-deficit/hyperactivity disorder (ADHD) treatment utilization among adolescents is highly variable. This article describes pharmacological and nonpharmacological treatment utilization in a community sample of primarily Latinx and/or Black adolescents with ADHD ( N  = 218), followed longitudinally for 4 years, from early adolescence until approximately age 17 ( M  = 16.80, standard deviation = 1.65). Methods: Electronic surveys administered between 2012 and 2019 queried parent and youth reports of medication initiation, persistence, diversion, and misuse, as well as reasons for desistence. Nonpharmacological treatment utilization (including complementary and alternative treatments) was also measured. Results: Results indicated that: (1) the majority of the sample sought treatment for ADHD in their community, (2) rates of psychosocial treatment utilization were higher than medication utilization, (3) approximately half of the medicated sample discontinued community-administered ADHD medication during the follow-up period, most frequently citing tolerability issues and concerns that they were "tired of taking" medication, and (4) medication misuse consisted of youth diversion and parent utilization of teen medication, but both were reported at low rates. Race/ethnicity did not predict treatment utilization patterns, but lower family adversity and psychiatric comorbidity predicted persistence of medication use over time. Conclusions: ADHD treatment engagement efforts for Latinx and/or Black adolescents might link treatment to goals valued by the youth, address concerns related to medication tolerability, and promote secure monitoring of medication. Nonpharmacological treatments for ADHD may be more palatable to Latinx and Black youth with ADHD, and efforts to engage youth with ADHD in treatment should consider offering medication and psychosocial treatment options.

The course of childhood-onset attention deficit hyperactivity disorder (ADHD) varies across individuals; some will experience persistent symptoms while others' symptoms fluctuate or remit. We describe the longitudinal course of ADHD symptoms and associated clinical characteristics in adolescents with childhood-onset ADHD. Participants (aged 6-12 at baseline) from the Longitudinal Assessment of Manic Symptoms (LAMS) study who met DSM criteria for ADHD prior to age 12 were evaluated annually with the Kiddie Schedule for Affective Disorders and Schizophrenia for eight years. At each timepoint, participants were categorized as meeting ADHD criteria, subthreshold criteria, or not having ADHD. Stability of course was defined by whether participants experienced consistent ADHD symptoms, fluctuating symptoms, or remission. The persistence of the symptoms was defined by symptom status at the final two follow-ups (stable ADHD, stable remission, stable partial remission, unstable). Of 685 baseline participants, 431 had childhood-onset ADHD and at least two follow-ups. Half had a consistent course of ADHD, nearly 40% had a remitting course, and the remaining participants had a fluctuating course. More than half of participants met criteria for ADHD at the end of their participation; about 30% demonstrated stable full remission, 15% had unstable symptoms, and one had stable partial remission. Participants with a persistent course and stable ADHD outcome reported the highest number of symptoms and were most impaired. This work builds on earlier studies that describe fluctuating symptoms in young people with childhood-onset ADHD. Results emphasize the importance of ongoing monitoring and detailed assessment of factors likely to influence course and outcome to help young people with childhood-onset ADHD., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Previous research suggests that routine psychosocial care for adolescents with attention-deficit/hyperactivity disorder (ADHD) is an eclectic and individualized mix of diluted evidence-based practices (EBPs) and low-value approaches. This study evaluated the extent to which a community-delivered EBP and usual care (UC) for adolescents with ADHD produce differential changes in theorized behavioral, psychological, and cognitive mechanisms of ADHD. A randomized community-based trial was conducted with double randomization of adolescent and community therapists to EBP delivery supports (Supporting Teens' Autonomy Daily [STAND]) versus UC delivery. Participants were 278 culturally diverse adolescents (ages 11-17) with ADHD and caregivers. Mechanistic outcomes were measured at baseline, post-treatment, and follow-up using parent-rated, observational, and task-based measures. Results using linear mixed models indicated that UC demonstrated superior effects on parent-rated and task-based executive functioning relative to STAND. However, STAND demonstrated superior effects on adolescent motivation and reducing parental intrusiveness relative to UC when it was delivered by licensed therapists. Mechanisms of community-delivered STAND and UC appear to differ. UC potency may occur through improved executive functioning, whereas STAND potency may occur through improved teen motivation and reducing low-value parenting practices. However, when delivered by unlicensed, community-based therapists, STAND did not enact proposed mechanisms. Future adaptations of community-delivered EBPs for ADHD should increase supports for unlicensed therapists, who comprise the majority of the community mental health workforce., (Copyright © 2023. Published by Elsevier Ltd.)

Attention-deficit/hyperactivity disorder (ADHD; also known as hyperkinetic disorder) is a common neurodevelopmental condition that affects children and adults worldwide. ADHD has a predominantly genetic aetiology that involves common and rare genetic variants. Some environmental correlates of the disorder have been discovered but causation has been difficult to establish. The heterogeneity of the condition is evident in the diverse presentation of symptoms and levels of impairment, the numerous co-occurring mental and physical conditions, the various domains of neurocognitive impairment, and extensive minor structural and functional brain differences. The diagnosis of ADHD is reliable and valid when evaluated with standard diagnostic criteria. Curative treatments for ADHD do not exist but evidence-based treatments substantially reduce symptoms and/or functional impairment. Medications are effective for core symptoms and are usually well tolerated. Some non-pharmacological treatments are valuable, especially for improving adaptive functioning. Clinical and neurobiological research is ongoing and could lead to the creation of personalized diagnostic and therapeutic approaches for this disorder., (© 2024. Springer Nature Limited.)

There has been increasing interest in applying integrative data analysis (IDA) to analyze data across multiple studies to increase sample size and statistical power. Measures of a construct are frequently not consistent across studies. This article provides a tutorial on the complex decisions that occur when conducting harmonization of measures for an IDA, including item selection, response coding, and modeling decisions. We analyzed caregivers' self-reported data from the ADHD Teen Integrative Data Analysis Longitudinal (ADHD TIDAL) dataset; data from 621 of 854 caregivers were available. We used moderated nonlinear factor analysis (MNLFA) to harmonize items reflecting depressive symptoms. Items were drawn from the Symptom Checklist 90-Revised, the Patient Health Questionnaire-9, and the World Health Organization Quality of Life questionnaire. Conducting IDA often requires more programming skills (e.g., Mplus), statistical knowledge (e.g., IRT framework), and complex decision-making processes than single-study analyses and meta-analyses. Through this paper, we described how we evaluated item characteristics, determined differences across studies, and created a single harmonized factor score that can be used to analyze data across all four studies. We also presented our questions, challenges, and decision-making processes; for example, we explained the thought process and course of actions when models did not converge. This tutorial provides a resource to support prevention scientists to generate harmonized variables accounting for sample and study differences., (© 2022. Society for Prevention Research.)

Objective: To identify barriers to behavior therapy for adolescent ADHD (Supporting Teens' Autonomy Daily; STAND) and understand the relationship between barriers and treatment engagement., Method: 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)., Results: 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., Conclusions: 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.

Background: Youth with ADHD are at risk of academic impairments, dropping out of high school, and dysfunction in young adulthood. Interventions delivered early in high school could prevent these harmful outcomes, yet few high school students with ADHD receive treatment due to limited access to intervention providers. This study will test a peer-delivered intervention (STRIPES) for general education 9th grade students with impairing ADHD symptoms., Methods: A type 1 hybrid effectiveness-implementation design will be used to evaluate the effectiveness of STRIPES and explore the intervention's implementability. Analyses will test the impact of STRIPES vs. enhanced school services control on target mechanisms and determine whether differences in basic cognitive profiles moderate intervention response. The acceptability and feasibility of STRIPES and treatment moderators will also be examined., Discussion: This study will generate knowledge about the effectiveness and implementability of STRIPES, which will inform dissemination efforts in the future. A peer-delivered high school intervention for organization, time management, and planning skills can provide accessible and feasible treatment targeting declines in academic motivation, grades, and attendance during the ninth-grade year., Trial Registration: This study is registered on OSF Registries (10.17605/OSF.IO/Q8V6S)., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Introduction: Uptake of attention deficit hyperactivity disorder (ADHD) treatments is low in primary care. A quasi-experimental study assessed the impact of a primary care-based engagement intervention to improve ADHD treatment use., Method: Families of children with ADHD from four pediatric clinics were invited to participate in a two-stage intervention. The first step was an assessment battery to assess functioning and identify goals, followed by an in-office engagement session run by primary care staff., Results: Of the 636 invited families, 184 (28.9%) completed ratings, with 95 (51%) families completing the engagement session. ADHD office visits varied based on the number of steps completed (0-2). ADHD prescriptions decreased over time in families completing neither step but increased for children previously unmedicated whose parents completed either step. Families completing both steps had the highest rates of nonmedication ADHD treatments., Discussion: A brief two-step engagement intervention was associated with increased uptake of ADHD treatments., (Copyright © 2023 National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2023 Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd. All rights reserved.)

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., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: Complementary and alternative treatments (CATs) for ADHD have proliferated over the past decade; however, their safety and efficacy remain uncertain. We completed a systematic review and meta-analyses across CAT domains., Methods: Systematic search and data extraction identified randomized controlled trials for pediatric ADHD (ages 3-19 years) that included probably blind ADHD symptom outcome measures. We evaluated basic (RCT of a CAT compared with sham/placebo, attention/active control, treatment as usual, and waitlist control), complementary (RCTs comparing an evidence-based treatment with a CAT and the same evidence-based treatment), and alternative (evidence-based treatment to CAT) efficacy. Random-effect meta-analyses were conducted when at least 3 blinded studies were identified for a specific CAT domain., Results: Eighty-seven of 2253 nonduplicate screened manuscripts met inclusion criteria. No study reported significantly greater adverse effects for CATs than controls; naturopathy reported fewer adverse effects than evidence-based treatments but did not demonstrate basic efficacy. In the systematic review of basic efficacy, evidence of effectiveness was mixed but replicated previous evidence for the possible efficacy of cognitive training, neurofeedback, and essential fatty acid supplementation for certain patients. With respect to alternative and complementary efficacy, no CAT outperformed or enhanced evidence-based treatments (stimulant medications and behavioral therapy) when replication was required. Individual meta-analyses indicated that cognitive training was the only CAT that demonstrated overall basic efficacy ( SMD = 0.216; p = 0.032)., Conclusion: Clinicians may cautiously recommend (but monitor) cognitive training when evidence-based treatments are not feasible or effective for a patient. Additional studies are needed to further understand the potential of CAT domains., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

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.

Objective: To characterize routine non-pharmacological care for youth with ADHD., Methods: 76 audio-recorded work-samples were collected from community mental health therapists in a large metropolitan area in the United States and were analyzed for operationally defined practice elements commonly included in evidence-based non-pharmacological treatment for ADHD. Analyses characterized community provider practices and examined predictors of using evidence-based (vs.low-value) practices., Results: Individually delivered social skills training was the most commonly detected practice element (31.6% of practice samples). Parent involvement in routine care was uncommon (53.9% of sessions had no parental presence). Core elements of evidence-based practices were rarely delivered (e.g., organization skills training: 18.4% of tapes; operant reinforcement: 13.2%); when evidence-based content was introduced, it was typically implemented at a very low intensity. Patient and provider characteristics did not predict use of evidence-based practices., Conclusions: Routine non-pharmacological care for adolescent ADHD primarily consisted of low value practices such as youth-directed treatment and social skills training with low parent involvement and only occasional therapy homework. To improve quality of care, efforts to de-implement low value practices should be coupled with efforts to implement evidence-based practices (i.e., parent involvement, measurement-based care, organization skills training, use of operant reinforcement)., Competing Interests: MS receives book royalties from Guilford Press for a book on treating ADHD in adolescence using non-pharmacological approaches. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Sibley, Reyes Francisco, Rios-Davis and Graziano.)

Objective: Almost no studies identify mediators of psychosocial interventions for attention deficit/hyperactivity disorder (ADHD)-largely due to design limitations. Understanding mediators can promote streamlined interventions in usual care (UC) settings. When individual studies are insufficient to pursue complex questions, integrative data analysis (IDA) allows researchers to pool raw data from multiple studies to produce cumulative scientific knowledge., Method: We leveraged IDA to pool and harmonize data from four randomized controlled trials of ADHD psychosocial treatment (N = 854) with three time points. Linear growth curve analyses examined the impact of four psychosocial treatment conditions on ADHD symptom outcomes and five candidate mediators (compared to no treatment). To test mediation, we examined whether treatment condition predicted linear growth in the mediator at posttreatment, and if the mediator predicted linear growth in the outcome at follow-up., Results: Compared to no treatment, engagement-focused parent-teen treatment (d = .43-.72; Supporting Teens' Autonomy Daily [STAND]) and community-based usual care (d = .54-.99) led to greatest reductions in parent-rated ADHD symptoms, followed by the Summer Treatment Program-Adolescent (d = .29-.30; STP-A) and standard behavioral parent training + organization skills training (d = .26-.31; BPT/OST). Improvements in organization, time management, and planning skills mediated outcome for all treatments. BPT/OST and STP-A prevented deterioration of social skills, in turn mitigating escalation of ADHD symptoms. Improvements in parent-teen communication skills mediated outcome for STAND, BPT/OST, and the STP-A. Parent contingency management and disruptive classroom behavior were not treatment mediators., Conclusions: Psychosocial treatments for adolescent ADHD primarily improve ADHD symptoms through development of teen organization, time management (OTP), and parent-teen communication skills, as well as slowing deterioration of social skills. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Objective: It is estimated that childhood attention deficit hyperactivity disorder (ADHD) remits by adulthood in approximately 50% of cases; however, this conclusion is typically based on single endpoints, failing to consider longitudinal patterns of ADHD expression. The authors investigated the extent to which children with ADHD experience recovery and variable patterns of remission by adulthood., Methods: Children with ADHD (N=558) in the Multimodal Treatment Study of ADHD (MTA) underwent eight assessments over follow-ups ranging from 2 years (mean age, 10.44 years) to 16 years (mean age, 25.12 years) after baseline. The authors identified participants with fully remitted, partially remitted, and persistent ADHD at each time point on the basis of parent, teacher, and self-reports of ADHD symptoms and impairment, treatment utilization, and substance use and mental disorders. Longitudinal patterns of remission and persistence were identified that considered context and timing., Results: Approximately 30% of children with ADHD experienced full remission at some point during the follow-up period; however, a majority of them (60%) experienced recurrence of ADHD after the initial period of remission. Only 9.1% of the sample demonstrated recovery (sustained remission) by study endpoint, and only 10.8% demonstrated stable ADHD persistence across study time points. Most participants with ADHD (63.8%) had fluctuating periods of remission and recurrence over time., Conclusions: The MTA findings challenge the notion that approximately 50% of children with ADHD outgrow the disorder by adulthood. Most cases demonstrated fluctuating symptoms between childhood and young adulthood. Although intermittent periods of remission can be expected in most cases, 90% of children with ADHD in MTA continued to experience residual symptoms into young adulthood.

Objective: Behavioral interventions are well established treatments for children with attention-deficit/hyperactivity disorder (ADHD). However, insight into moderators of treatment outcome is limited., Method: We conducted an individual participant data meta-analysis (IPDMA), including data of randomized controlled behavioral intervention trials for individuals with ADHD <18 years of age. Outcomes were symptoms of ADHD, oppositional defiant disorder (ODD), and conduct disorder (CD) and impairment. Moderators investigated were symptoms and impairment severity, medication use, age, IQ, sex, socioeconomic status, and single parenthood., Results: For raters most proximal to treatment, small- to medium-sized effects of behavioral interventions were found for symptoms of ADHD, inattention, hyperactivity/impulsivity (HI), ODD and CD, and impairment. Blinded outcomes were available only for small preschool subsamples and limited measures. CD symptoms and/or diagnosis moderated outcome on ADHD, HI, ODD, and CD symptoms. Single parenthood moderated ODD outcome, and ADHD severity moderated impairment outcome. Higher baseline CD or ADHD symptoms, a CD diagnosis, and single parenthood were related to worsening of symptoms in the untreated but not in the treated group, indicating a protective rather than an ameliorative effect of behavioral interventions for these children., Conclusion: Behavioral treatments are effective for reducing ADHD symptoms, behavioral problems, and impairment as reported by raters most proximal to treatment. Those who have severe CD or ADHD symptoms, a CD diagnosis, or are single parents should be prioritized for treatment, as they may evidence worsening of symptoms in the absence of intervention., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2021 American Academy of Child & Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved.)

Community implementation of evidence-based practices (EBPs) for Attention Deficit/Hyperactivity Disorder (ADHD) is greatly lacking. A recent randomized community-based trial of an EBP for ADHD (Supporting Teens' Autonomy Daily; STAND) demonstrated suboptimal implementation and effectiveness outcomes. In the present study, we conducted an Innovation Tournament (IT) with agency staff stakeholders (N = 26) to identify barriers to successful implementation of STAND and implementation strategies for a revised service delivery model. We conducted member-checking of agency staff-generated ideas with parents (N = 226) and subsequent querying of additional parent (N = 226) and youth-generated (N = 205) strategies to improve care. Go-Zone plots were utilized to identify strategies with the highest feasibility and importance. Practical barriers (i.e., transportation, scheduling difficulties) and parent/youth engagement were the most commonly cited obstacles to successful implementation of STAND in community contexts. Eighteen "winning" implementation strategies were identified that survived member checking. These were classified as train and educate stakeholders (n = 5; e.g., train agency supervisors to deliver supervision, digitize treatment materials and trainings), engage consumers (n = 9; e.g., begin treatment with rapport building sessions, increase psychoeducation), provide interactive assistance (n = 2; e.g., add group supervision, increase roleplay in supervision), and use of evaluative/iterative strategies (n = 2; e.g., perform fidelity checks, supervisor review of session recordings). Parents and youth desired longer duration of treatment and increased focus on maintenance. Strategies will be developed and tested as part of a pilot effectiveness trial designed to refine STAND's service delivery model.Trial Registration NCT02694939 www.clinicaltrials.gov., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

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., Competing Interests: Conflict of Interest Statement Dr. Sibley reports book royalties from Guilford Press for the manualized treatment described in this manuscript., (Copyright © 2021. Published by Elsevier Ltd.)

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 ., (© 2020. Society for Prevention Research.)

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., (Copyright © 2021. Published by Elsevier Ltd.)

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., (Copyright © 2020 American Academy of Child and Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved.)

Objective: ADHD symptom severity appears to be exacerbated during the COVID-19 pandemic. The present study surveyed top problems experienced by adolescents and young adults (A/YAs) with ADHD during the COVID-19 pandemic to identify possible reasons for symptom escalation and potential targets for intervention. We also explored perceived benefits of the pandemic for A/YAs with ADHD., Method: At the outbreak of the COVID-19 pandemic (April-June 2020), we administered self and parent ratings about current and pre-pandemic top problem severity and benefits of the pandemic to a sample of convenience (N = 134 A/YAs with ADHD participating in a prospective longitudinal study)., Results: The most common top problems reported in the sample were social isolation (parent-report: 26.7%; self-report: 41.5%), difficulties engaging in online learning (parent-report: 23.3%, self-report: 20.3%), motivation problems (parent-report: 27.9%), and boredom (self-report: 21.3%). According to parent (d = 0.98) and self-report (d = 1.33), these top problems were more severe during the pandemic than in prior months. Contrary to previous speculation, there was no evidence that pandemic-related changes mitigated ADHD severity. Multi-level models indicated that A/YAs with higher IQs experienced severer top problems exacerbations at the transition to the COVID-19 pandemic., Conclusions: For A/YAs with ADHD, several risk factors for depression and school dropout were incurred during the early months of the COVID-19 pandemic. A/YAs with ADHD should be monitored for school disengagement and depressive symptoms during the COVID-19 pandemic. Recommended interventions attend to reducing risk factors such as increasing social interaction, academic motivation, and behavioral activation among A/YAs with ADHD., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Objective : Recent studies suggest attention-deficit/hyperactivity disorder (ADHD) may emerge post-childhood. We integrate qualitative methods to systematically characterize contextual factors that may (a) delay identification of ADHD in childhood and (b) inform why ADHD symptoms emerge post-childhood. Method : Suspected late-onset ADHD cases from the local normative comparison group of the Multimodal Treatment Study of ADHD completed a qualitative interview (14 young adults and 7 caregivers). Interviews were qualitatively analyzed. Results : We identified five themes. Three themes may attenuate or delay identification of childhood ADHD: external factors (e.g., supportive adults), internal factors (e.g., strong intellectual functioning), and other factors (e.g., dismissive attitudes toward ADHD). Two themes may accompany an increase in ADHD symptoms post-childhood: external factors (e.g., increased external demands) and internal factors (e.g., perceived stress). Conclusion : Clinicians should probe these factors in suspected late-onset cases to address (a) whether, how, and to what extent ADHD was attenuated in childhood and (b) why symptoms emerge post-childhood.

Objective: ADHD is associated with risky sexual behavior and early pregnancy, but few studies have examined mechanisms of risk linking childhood ADHD to early pregnancy. The present study utilized data from the Multimodal Treatment Study of ADHD to examine potential mechanisms that may account for the association between childhood ADHD and becoming pregnant or causing a pregnancy by age 18. Method: Participants were 579 children with ADHD and 289 comparison peers followed over 16 years. Results: Relative to the comparison group, those with childhood ADHD were at more than two times increased risk of early pregnancy. Univariately, persistence of ADHD symptoms, delinquency/substance use, and academic performance/achievement during adolescence each mediated the association between childhood ADHD and early pregnancy. When considered together, only delinquency/substance use remained a significant mediator of this relationship. Conclusion: Findings point toward specific targets of intervention for youth with ADHD to prevent early pregnancy.

Background: The Attention Deficit Hyperactivity Disorder (ADHD) Teen Integrative Data Analysis Longitudinal (TIDAL) dataset integrates data from four randomized trials., Method: Participants with ADHD (N = 854; 72.5% male, 92.5% racial/ethnic minority, ages 10-17) were assessed three times across 12 months. Data includes parent, self, and teacher ratings, observations, and school records. The battery was harmonized using an Integrative Data Analysis (IDA) approach to form variables that assign unique values to all participants., Results: The data will be used to investigate: (1) profiles that organize the heterogeneous population into clinically meaningful subgroups, (2) whether these profiles predict treatment response, (3) heterogeneity in treatment response and variables that predict this response, (4) how treatment characteristics and adjunctive supports predict treatment response, and (5) mediators of treatment and whether these mechanisms are moderated by treatment characteristics., Conclusions: The ADHD TIDAL Dataset will be openly shared with the field to maximize its utility.

The objective of this study is to evaluate support for three hypotheses about the etiology of adolescent-onset ADHD symptoms: (1) a "cool" cognitive load hypothesis, (2) a "hot" rewards processing hypothesis, and (3) a trauma exposure hypothesis. Participants (N = 50) were drawn from two public high schools in a culturally diverse metropolitan area. A detailed procedure for identifying and confirming late-onset ADHD cases is described. Adolescents with late-onset ADHD (n = 15) were identified and compared to childhood-onset (n = 17) and non-ADHD classmates (n = 18). Adolescents and parents completed measures of neurocognition, rewards' processing, clinical profile, and environmental demands. Late-onset cases were clinically and neurocognitively indistinguishable from childhood-onset cases; however, they experienced higher demands from parents (d = 1.09). Compared to the non-ADHD group, late-onset cases showed significant deficits in metacognition (d = 1.25) and academic motivation (d = 0.80), as well as a pronounced history of multiple trauma exposure (OR 11.82). At 1-year follow-up, ADHD persisted in 67.7% of late-onset cases. Late-onset cases (26.7%) were more likely than childhood-onset cases (0.0%) to transfer to alternative schools by 1-year follow-up. Multiple factors may contribute to adolescent-onset ADHD. Adolescents with metacognition and motivation deficits may be at greatest risk for the late-onset ADHD phenotype, particularly in highly demanding environments. Exposure to traumatic stress may play a key role in the exacerbation of existing deficits or onset of new symptoms. Late-onset ADHD was persistent in most cases and associated with higher risk for school disengagement than childhood-onset ADHD. Further work is needed to better understand the etiologies of late-onset ADHD symptoms.

This study tested whether early and developmentally atypical substance use mediates risk for adult substance use among children with attention-deficit/hyperactivity disorder (ADHD), and whether that risk is substance-specific. Participants were children with ADHD previously enrolled in a randomized controlled trial (RCT), and a demographically similar non-ADHD group, assessed at 2 through 16 years after the original RCT baseline. Self-reports of heavy drinking, marijuana use, daily smoking, and other illicit drug use were collected at follow-ups to establish atypically early and frequent use. Models estimated statistically mediated effects of childhood ADHD on adult substance use via early substance involvement, with planned comparisons to evaluate substance specificity. Results supported the mediation hypothesis, showing that childhood ADHD was associated with more frequent adult substance use via early substance involvement for marijuana, cigarettes, illicit drugs, and to a lesser extent, alcohol. Mediation was not escalated by comorbid childhood conduct disorder or oppositional defiant disorder except for early use of nonmarijuana illicit drugs. Substance-specificity in the mediational pathway was largely absent except for cigarette use, where ADHD-related early smoking most strongly predicted adult daily smoking. Findings from this study provide new evidence that atypically early substance use associated with childhood ADHD signals important cross-drug vulnerability by early adulthood, but cigarette use at a young age is especially associated with increased risk for habitual (daily) smoking specifically. Efforts to prevent, delay, or reduce substance experimentation should occur early and focus on factors relevant to multiple drugs of abuse in this at-risk population. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Attention-Deficit/Hyperactivity Disorder (ADHD) is associated with academic failure in high school; however the underpinnings of these difficulties are insufficiently understood. This study examined deficits in self-regulated learning in a sample of high school students with ADHD (n = 32) compared to demographically similar classmates without ADHD (n = 18). A multimethod battery of self and parent rating scales and cognitive tasks measured aspects of intrinsic motivation, extrinsic motivation, and goal-directed executive functions. A multiple regression modeled predictors of current Grade Point Average (GPA). Results indicated that high school students with ADHD placed lower value on academics (d = .99), were less likely to use goal-setting strategies (d = .95), possessed lower levels of metacognition (d = 1.86), and showed significant deficits in task-based cognitive flexibility (d = .80). After controlling for covariates, the set of self-regulated learning variables explained 23% of the variance in GPA, with metacognition (6% of variance explained) and cognitive flexibility (7% of variance explained) serving as significant predictors of outcome. Findings suggest that higher-order executive function deficits play a critical role in the academic functioning of high school students and students with ADHD show large deficits in these areas. Thus, interventions that target metacognition and cognitive flexibility (i.e., the ability to think through decisions before acting, inhibit automatic responses, and make effective decisions for a desired goal) may be particularly promising to remediate ADHD-related academic problems in high school., (Copyright © 2019 Society for the Study of School Psychology. Published by Elsevier Ltd. All rights reserved.)