Parent Management of Organization, Time Management, and Planning Deficits among Adolescents with ADHD

Community-Delivered Evidence-Based Practice and Usual Care for Adolescent Attention-Deficit/Hyperactivity Disorder: Examining Mechanistic Outcomes

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.

Transitioning to college with ADHD: a qualitative examination of parental support and the renegotiation of the parent-child relationship

Objective: In the transition to college, students with Attention-Deficit/Hyperactivity Disorder (ADHD) often face difficulties. Parental support may aid in the successful adjustment to college, and a strong parent-child relationship (PCR) may optimize the balance between autonomy and support necessary during this transition. Method: Few studies have examined this; therefore, a qualitative study using Interpretative Phenomenological Analysis (IPA) was conducted. First- and second-year college students with ADHD participated in open-ended, one-on-one interviews (N = 11; 64% women, 91% White). Results: The two broad categories of findings included Parental Support and the Renegotiation of the Parent-Child Relationship. Participants described feeling supported by their parents in the progress toward their short- and long-term goals. Students described this support as helpful when they managed or initiated the contact, but as unhelpful when the parent was perceived as over involved. They described a strong PCR in this transition as helpful to their adjustment and enjoyed the renegotiation of the PCR in terms of their own increased autonomy and responsibility. Many additional themes and sub-themes are described herein. Conclusion: Optimal levels of involvement and support from parents in the context of a strong PCR is beneficial for adjustment to college for those with ADHD. We discuss the clinical implications of our findings, such as therapists helping families transition to college, and working with college students with ADHD on an adaptive renegotiation of the PCR in their transition to adulthood.

Examining the structural equation modeling between intrinsic-motivation, emotion regulation and AHDH: the mediating role of problem-solving, time-management, and behavioral-inhibition

Although Executive Functions has been considered as the main correlation of ADHD few studies have examined the effect of EFs on ADHD symptoms, in the samples with ADHD. This study aimed to examine the structure of EFs on ADHD students in a hypothesized model. After careful screening of ADHD among 1368 university students (with stratified and multistage cluster sampling), out of them, 211 students with ADHD diagnosis were selected purposefully. They received scales on their emotion regulation, motivation, adult ADHD, deficits in EFs, and diagnostic interview. Emotion regulation and intrinsic motivation were considered as input; behavioral-inhibition, time-management, and problem-solving were the mediators and ADHD subscales were as the output variables. Results showed that the model adequately fit the data. The model fit indices were χ2 = 27.081, df = 1, CFI = 0.99, GFI = 0.97, and PGFI = 0.02. The direct effects of intrinsic-motivation and emotion-regulation on all three mediators and indirect effects of them to ADHD subscales were significant. Based on the results, time-management mediated the relationship between motivation and emotion regulation and ADHD. Among EFs, emotion-regulation and intrinsic-motivation had fundamental influence to other aspects of EFs factors such as behavioral-inhibition, time-management, problem-solving, and attention deficit/hyperactivity disorder.

Mediators of psychosocial treatment for adolescent ADHD

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).

Examination of Telemental Health Practices in Caregivers of Children and Adolescents with Mental Illnesses: A Systematic Review

In this systematic review, effects of telemental health (TMH) practices' on caregivers of children/adolescents with mental illnesses were investigated. The literature review included databases, and reference lists of published studies. All studies published until September 2021 were reviewed. Eleven studies were included. Several services were provided via TMH: education, cognitive behavioral therapy (CBT), parent training, caregiver behavior training, family CBT. The effectiveness of TMH interventions on caregivers varied from low to high. Most reproducible findings were on caregivers' satisfaction, stress, therapeutic alliance and caregiver burden. Studies had a low to high bias risk. Most studies had small samples. Results built on the small but growing literature support TMH interventions' promising role in caregivers of children with mental illness. Future studies should estimate outcomes with medium to low effect size. Other caregiver groups, rarely considered in previous studies, should be included. Bias risk should be minimized. Larger, more methodologically rigorous studies should be conducted.

Overprotective Parenting Mediates the Relationship Between Early Childhood ADHD and Anxiety Symptoms: Evidence From a Cross-Sectional and Longitudinal Study

Attention Deficit/Hyperactivity Disorder (ADHD) is often comorbid with anxiety disorders in children. Both ADHD and anxiety in childhood has been linked to overprotective parenting styles. In the current study we examine a model wherein early ADHD symptoms predict overprotective parenting, which in turn predicts anxiety symptoms later in childhood. In Study 1 we utilize cross-sectional data in 102 child/parent dyads between the ages of 5 and 7 years old and Study 2 extends these findings by examining this same mediation model longitudinally in 376 child/parent dyads who were assessed when children were 3, 6, and 9 years old. Results from both studies supported a mediation model wherein the relationship between child ADHD symptoms and child anxiety symptoms was mediated by parental overprotection. This is the first study, to our knowledge, to examine overprotective parenting as a mechanism underlying the heterotypic continuity or sequential comorbidity of ADHD to anxiety symptoms.

School-based intervention for adolescents with attention-deficit/hyperactivity disorder: Effects on academic functioning

Multi-component training interventions such as the Challenging Horizons Program (CHP) improve organization skills and academic functioning of middle school students with attention-deficit/hyperactivity disorder (ADHD); however, few studies have investigated treatment for high school students. We explored the extent to which CHP adapted for high school would improve proximal (e.g., organization skills, homework performance) and distal (e.g., report card grades) academic outcomes through 6-month follow-up relative to a community care (CC) condition. Participants included 186 adolescents who were randomly assigned to CHP (n = 92; 80% male; M age = 15.0; SD = 0.8) or CC (n = 94; 78% male; M age = 15.1; SD = 0.9) with CHP delivered over one school year. Parent, teacher, and self-report ratings of organization skills and academic performance, report card grades, and achievement tests were collected across multiple occasions. Intent-to-treat analyses using hierarchical linear modeling revealed significant improvements of small to medium magnitude (d range = 0.32 to 0.58) for parent-rated organization skills, homework performance, and academic functioning at 6-month follow-up. CHP effect on grades was small, but associated with a less steep decline than that found for CC. No statistically significant effects on teacher or self-report ratings were obtained. CHP appears efficacious for ameliorating organization skills and homework performance deficits exhibited by high school students with ADHD and can protect against decline in report card grades experienced by these students. CHP may require supplementation with academic skills instruction for some students and may need implementation beyond one school year to produce durable effects.

Four-Year Follow-Up of High versus Low Intensity Summer Treatment for Adolescents with ADHD

OBJECTIVE

Despite an emergence of psychosocial treatments for adolescent ADHD, their long-term effects are unknown.

METHOD

We examine four-year outcomes of a randomized controlled trial (N = 218) comparing high-intensity (HI; 412 h, $4,373 per participant) versus low-intensity (LI; 24 h, $97 per participant) skills-based summer intervention delivered to adolescents with ADHD at two secondary school transitions (6th/9th grade). Quantitative and qualitative analyses evaluated group×time and group×grade×time effects on 4-year outcomes.

RESULTS

Relative to LI, a single dose of HI had modest but lasting effects on teen organization skills (d =.40) and ADHD symptoms (9th grade only: d =.27 to.31) at 4-year follow-up. There was no long-term incremental effect of HI (vs. LI) for parent-teen conflict, GPA, or parent use of contingency management. Treatment appeared most effective when delivered to older adolescents (i.e., 9th versus 6th grade), suggesting the long-term impact of ADHD treatment may increase with age. Qualitative data corroborated that the primary long-term benefit of HI (vs. LI) treatment was to organization skills; many of the remaining perceived benefits were to parent and teen psychological variables (i.e., increased self-esteem, self-awareness, parental optimism). HI offered no incremental benefit to long-term educational or clinical service utilization or costs.

CONCLUSIONS

Modest therapeutic benefits of adolescent ADHD treatment are maintained long term. However, HI treatment did not impact outcomes that could defray the intervention's high costs ($4,373) compared to LI treatment ($97).

The ADHD teen integrative data analysis longitudinal (TIDAL) dataset: background, methodology, and aims

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.

Implementing Parent-Teen Motivational Interviewing + Behavior Therapy for ADHD in Community Mental Health

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 .

High versus Low Intensity Summer Treatment for ADHD Delivered at Secondary School Transitions

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.

Parent-Teen Group versus Dyadic Treatment for Adolescent ADHD: What Works for Whom?

The goal of this study was to evaluate the comparative efficacy of 2 clinic-based psychosocial treatment modalities for adolescent attention deficit/hyperactivity disorder (ADHD) and identify characteristics that facilitate patient-modality matching. Culturally diverse adolescents with ADHD (N = 123) were randomized to 1 of 2 versions of a parent-teen psychosocial treatment for ADHD (Supporting Teens' Autonomy Daily [STAND]): (a) group parent and adolescent skills training or (b) dyadic skills training blended with motivational interviewing. Participants were assessed at baseline, posttreatment, and 6-month follow-up on ADHD symptom severity and functional treatment targets. Differences in therapy process and cost were documented. Modality differences in outcome were examined using linear mixed and general linear models. Each modality successfully engaged the proposed therapy processes. Dyadic and group STAND produced equivalent overall outcomes. However, the dyadic modality demonstrated superior efficacy when parents had elevated ADHD or depression symptoms or high conflict with the teen. Families with lower parent education level and higher parental depression showed lower overall attendance; married parents were more likely to attend dyadic STAND (vs. group). Naturalistic stimulant medication did not influence treatment outcome. At less than one third of the cost of dyadic treatment, group models may be an economical option for treating parents and adolescents with ADHD. Screening adolescents with ADHD for parental psychopathology and parent-teen conflict may allow clinics to match higher risk patients to more personalized approaches that can enhance efficacy.

Relational impairments, sluggish cognitive tempo, and severe inattention are associated with elevated self-rated depressive symptoms in adolescents with ADHD

This study examines how ADHD-related symptoms and impairments interact to predict depression symptoms in young adolescents with ADHD. A sample of 342 adolescents (71% male, mean age = 13 years old) with DSM-IV-TR diagnosed ADHD completed baseline clinical assessments upon entry to a psychosocial treatment study for ADHD. Ratings of ADHD and sluggish cognitive tempo (SCT) symptoms, and social and academic impairment were obtained from parents, while ratings of depressive symptoms and conflict with parents were obtained from youth. Among adolescents with ADHD, elevated depressive symptoms were associated with higher SCT symptom severity, lower hyperactive/impulsive (HI) symptom severity, higher social impairments, higher conflict with parents, and lower academic problems. Interaction effects indicated that clinically significant depressive symptoms were most likely to occur when high levels of parent-youth conflict were present along with high inattentive (IN) symptoms, high SCT, and/or low HI. Among children and adolescents with ADHD, depression prevention efforts might target IN/SCT symptom management, as well as improving interpersonal relationships with parents and peers. Future work is needed to verify these findings longitudinally.

Delivering Parent-Teen Therapy for ADHD through Videoconferencing: A Preliminary Investigation

Adolescents with ADHD demonstrate notoriously poor treatment utilization. Barriers to access have been partially addressed through tailored therapy content and therapist delivery style; yet, additional challenges to engaging this population remain. To leverage modern technology in support of this aim, the current study investigates parent-teen therapy for ADHD delivered over a videoconferencing format. In this preliminary feasibility study, teens and parents (N=20) received an empirically supported dyadic therapy that incorporates skills-based modules with motivational interviewing. The videoconferencing interface was deemed feasible with nearly all families completing treatment. Acceptable therapeutic alliance was reported and key mechanisms of change were engaged (i.e., adolescent motivation to meet goals, parent strategy implementation). Families reported high satisfaction, despite minor disturbances associated with delivering therapy via videoconferencing. Treatment integrity and fidelity were acceptable, though slightly reduced compared to clinic-based trials of the same protocol. Therapists perceived that videoconferencing enhanced treatment for 50% of families. Reductions in participant ADHD symptoms and organization, time management, and planning problems from baseline to post-treatment were noted by parents and teachers. However, open trial results of this study should be interpreted with caution due to their uncontrolled and preliminary nature.

Delivering Parent-Teen Therapy for ADHD through Videoconferencing: A Preliminary Investigation

Adolescents with ADHD demonstrate notoriously poor treatment utilization. Barriers to access have been partially addressed through tailored therapy content and therapist delivery style; yet, additional challenges to engaging this population remain. To leverage modern technology in support of this aim, the current study investigates parent-teen therapy for ADHD delivered over a videoconferencing format. In this preliminary feasibility study, teens and parents (N=20) received an empirically supported dyadic therapy that incorporates skills-based modules with motivational interviewing. The videoconferencing interface was deemed feasible with nearly all families completing treatment. Acceptable therapeutic alliance was reported and key mechanisms of change were engaged (i.e., adolescent motivation to meet goals, parent strategy implementation). Families reported high satisfaction, despite minor disturbances associated with delivering therapy via videoconferencing. Treatment integrity and fidelity were acceptable, though slightly reduced compared to clinic-based trials of the same protocol. Therapists perceived that videoconferencing enhanced treatment for 50% of families. Reductions in participant ADHD symptoms and organization, time management, and planning problems from baseline to post-treatment were noted by parents and teachers. However, open trial results of this study should be interpreted with caution due to their uncontrolled and preliminary nature.