Assessing support for medicine decision making for youth with ADHD who receive therapy / Aaron Hogue, Jacqueline Horan Fisher, Sarah Dauber

BACKGROUND: For childhood attention-deficit/hyperactivity disorder (ADHD), treatments that combine behavioral and pharmacologic interventions have proven to be more efficacious than either behavioral treatment alone or medication alone. Despite the strong evidence base for these 2 treatment types, both remain vastly underused for a host of reasons. Further, combined treatment has not been systematically tested among adolescents. The issue is further compounded by a lack of understanding within the field about comorbidity issues related to substance use (SU) among adolescents with ADHD. OBJECTIVES: The primary objective of this cluster randomized trial was to compare the effectiveness of behavioral-only vs integrated (behavioral plus medication decision-making) interventions for adolescents with ADHD in outpatient services on participant functioning and service use. A secondary objective was to examine patient-centered outcomes with respect to heterogeneity of effects among adolescents with and without SU problems and individual differences in effects on participant functioning based on ADHD medication use. METHODS: A cluster randomized intention-to-treat (ITT) longitudinal design was used to test the effects of behavioral-only vs integrated (behavioral plus medication decision-making) treatment in routine care for all adolescents who met diagnostic criteria for ADHD in 5 outpatient behavioral health clinics. In the behavioral-only condition, therapists were trained in an academic support intervention protocol for adolescents with ADHD focused on homework management and organizational training. In the integrated condition, in addition to academic support interventions, therapists were trained in a family-based medication decision-making protocol. Clinicians were randomly assigned to study condition in a 2:1 ratio favoring the integrated condition. Therapist fidelity to each treatment protocol was assessed via both therapist-report checklists and observation of session recordings. Primary outcomes were ADHD symptoms, comorbid problems, executive functioning, and school functioning. Secondary outcomes were treatment attendance, medication acceptance, and treatment satisfaction. Primary outcomes were analyzed using latent growth curve modeling to examine the impact of treatment condition on change over time in client outcomes. Secondary outcomes were tested via multistep heterogeneity of effects analyses focused on moderator effects. RESULTS: The study enrolled 145 clients (n = 53 behavioral only, n = 92 integrated) treated by 49 therapists (n = 20 in behavioral only, n = 29 in integrated). Adolescent participants were 72% male; 42% White non-Hispanic, 37% Hispanic American, 15% African American, and 6% more than 1 race; and average age was 14.8 years. Therapist participants (N = 49) included 82% women; 63% White non-Hispanic, 29% Hispanic American, and 10% some other race/ethnicity; average postgraduate experience was 5.1 years. All enrolled clients and therapists were included in study analyses (ITT). Therapist self-reports of protocol adherence indicated strong treatment fidelity overall: Observer ratings indicated overall fidelity with regard to delivery of Changing Academic Support in the Home for Adolescents with ADHD (the behavioral protocol for boosting academic outcomes) but not with regard to medication integration protocol fidelity. Analysis of primary outcomes found that for most client outcomes, there were no meaningful differences between treatment conditions. Regarding ADHD symptoms, integrated care produced a greater decline in adolescent-reported ADHD inattentive symptoms. However, there were no differences for adolescent-reported hyperactive symptoms, caregiver-reported inattentive symptoms, or caregiver-reported hyperactive symptoms. Regarding comorbid problems, integrated care produced a greater decline in number of delinquent acts compared with behavioral-only care However, there were no between-group differences for adolescent-report internalizing symptoms, adolescent-report externalizing symptoms, caregiver-report internalizing symptoms, caregiver-report externalizing symptoms, or SU. No between-group differences were found for executive functioning (self-regulation, self-organization), school functioning (school grades, academic self-efficacy, homework problems, minutes spent doing homework), or medication use. Post hoc analyses identified some between-group differences between adolescents who did, vs did not, use substances at baseline. No intervention harms or other adverse events were reported. CONCLUSIONS: Significant additive effects for medication decision-making interventions were found for a minority of the main effects tested and for a minority of the subgroups of adolescents examined in post hoc analyses, across clinical, developmental, and medication outcomes. LIMITATIONS: The number of participating sites was too small to test for site effects. Participating therapists at each site were self-selected, creating some limitations to the generalizability of findings. The 2:1 randomization ratio was not purely achieved due to initially randomized therapists being excluded because they were never assigned a study case (n = 33), as well as the need to assign a small subset of therapists directly to the condition to maintain critical mass for group consultation. In the absence of a no-treatment control group, the magnitude of research assessment effects on client outcome cannot be estimated, although it is presumed to be equally distributed across conditions. Because multiple hypotheses were tested, there is an increased possibility that 1 or more reported analyses represents a chance finding..

Medienart:	E-Book

Erscheinungsjahr:	2020
Erschienen:	Washington, D.C.: Patient-Centered Outcomes Research Institute (PCORI) ; 2020

Reihe:	Final research report

Sprache:	Englisch

Beteiligte Personen:	Hogue, Aaron [VerfasserIn] Fisher, Jacqueline Horan [VerfasserIn] Dauber, Sarah [VerfasserIn]

Links:	www.ncbi.nlm.nih.gov [teilw. kostenfrei]

Themen:	Adolescent Attention Deficit Disorder with Hyperactivity Clinical Decision-Making Combined Modality Therapy

Anmerkungen:	Includes bibliographical references. - Description based on online resource; title from PDF title page (viewed Jan. 25, 2024)

Umfang:	1 online resource (1 PDF file (133 pages)) ; illustrations.

Förderinstitution / Projekttitel:

PPN (Katalog-ID):	1879964538