Integrated Treatment for Adolescents With ADHD

Attention-Deficit/Hyperactivity Disorder (ADHD) exists in 20-50% of the 3 million
adolescents annually enrolled in outpatient mental health and substance use treatment.
Adolescents with ADHD present deficits in attention, self-regulation, and social competence
that significantly impede achievement of developmental and educational milestones. Currently
there are only two evidence-based treatment options for this age group: academic training
and stimulant medications. Both options remain vastly underutilized. Academic training is
not available in most school settings and rarely implemented in clinical care. Similarly,
ADHD medications are rarely utilized with adolescents in primary or specialty care for a
host of reasons related to stigma, misinformation about effects and side effects, and
adolescent autonomy issues. Moreover, the widespread fragmentation of pharmacological versus
behavioral services prevents families from making informed treatment selections.

The primary objective of this randomized parametric trial is to compare the effectiveness of
behavioral only versus integrated (behavioral plus medication decision-making) interventions
for adolescents with ADHD in outpatient behavioral services. The behavioral intervention,
Changing Academic Support in the Home for Adolescents with ADHD (CASH-AA), contains three
components: ADHD psychoeducation, family-based motivational interventions, and academic
training. The medication decision-making intervention, Medication Integration Protocol
(MIP), contain three components: psychoeducation about ADHD medication, family
decision-making, and medication management. The study will compare the effects of two
legitimate treatment options for adolescents with ADHD on service utilization, behavioral
symptoms, and quality of life. It will generate new evidence on patient-centered treatment
selection that aligns with family-specific principles and treatment goals.

This parametric comparative trial will randomly assign 140 inner-city adolescents with ADHD
to (1) CASH-AA Only or (2) CASH-AA + MIP. Treatment will occur in community behavioral
health clinics. All participants will receive behavioral interventions (CASH-AA): family
psychoeducation in ADHD symptoms, executive functioning, and developmental impacts;
family-based motivation and ADHD accommodation interventions; and academic training focused
on home environment support and organizational skills. Half of the participants will also
receive medication decision-making interventions (MIP): ADHD medication psychoeducation,
family decision-making interventions, and (for those who elect to start medication)
coordinated medication management. Half of the sample will have comorbid substance use
problems. Treatment will occur in three community clinics; therapists will be randomly
assigned to study condition. Caregivers and adolescents will complete assessments at
baseline, 3, 6, and 12-month follow-up. Multilevel modeling will compare the effectiveness
of each condition on key patient and service use outcomes. Patient-centered analyses will
explore differential treatment effects based on (a) Medication decision (yes/no); (b)
Substance use comorbidity (yes/no); (c) Race/Ethnicity (Hispanic, African American).

Quantitative outcome analyses will test for service use effects, symptom reduction, and
quality of life improvements that are primary reasons for seeking clinical services.
Qualitative interviews will document family-specific rationale for decisions about
medication, compliance with behavioral and medication interventions, and suggestions for
improving services and service integration. Note that families assigned to CASH-AA Only will
retain the option of pursuing ADHD medication through treatment-as-usual procedures at their
respective clinic. Similarly, families assigned to CASH-AA + MIP will not be required to
start ADHD medication. Instead, they will receive informed-choice interventions and can
choose when and if to start medication; the study will assess the impact of these decisions
on clinical outcomes.

If proven efficacious, the CASH-AA and MIP protocols could be rapidly disseminated
individually or as an integrated protocol into routine behavioral healthcare settings. The
protocols can also be readily combined with other behavioral treatments to form a
multicomponent treatment package for adolescents with co-occurring behavior problems. In
addition, the family-based, patient-centered CASH-AA and MIP protocols could be delivered in
conjunction with other family-based treatments or with individual approaches that flexibly
include caregivers in multiple treatment sessions. This makes CASH-AA and MIP highly
efficient clinical resources for addressing ADHD-related problems in any outpatient setting
that serves adolescents and their families.