How Do Different Treatments for Teen ADHD Impact Key Skills and Behaviors?

What you need to know

• This study compared two types of treatment for teens with ADHD: an evidence-based program called STAND and typical community care.
• Overall, STAND did not outperform typical care on measures of executive function, motivation, or parenting behaviors.
• STAND led to some improvements in teen motivation and reduced intrusive parenting when delivered by licensed therapists.
• Typical community care showed greater improvements in some executive function skills compared to STAND.
• The effectiveness of ADHD treatments may depend on who delivers them and how they are implemented in community settings.

Background on ADHD and treatment approaches

Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental condition that affects about 9.4% of children and teens. It is characterized by problems with attention, hyperactivity, and impulsivity that interfere with daily functioning. ADHD can have significant negative impacts into adulthood if left untreated, so effective interventions during childhood and adolescence are crucial.

While stimulant medications are considered the first-line treatment for ADHD, they don’t seem to have much effect on deficits in executive function (EF) and motivation that are common in ADHD. Executive function refers to cognitive skills like planning, organization, time management, and self-control. Motivational issues in ADHD can include things like difficulty sustaining effort on tasks and preferring immediate over delayed rewards.

Because of this, psychosocial (non-medication) treatments have been developed to target these areas. Some evidence-based psychosocial treatments for teen ADHD focus on teaching organizational and time management skills while also working with parents on using rewards and consequences effectively. These treatments have shown promise in controlled research settings.

However, we know less about how these evidence-based treatments compare to typical community care when implemented in real-world settings. This study aimed to examine this question by comparing an evidence-based program called Supporting Teens’ Autonomy Daily (STAND) to usual care provided in community mental health clinics.

The STAND program vs. usual care

STAND is a 10-week program attended by both teens and parents. It combines skill instruction with motivational interviewing techniques and guided behavioral contracting between parents and teens. Key components include:

• Increasing awareness of personal values and goals
• Identifying strengths
• Teaching organizational and time management skills
• Parent training in behavioral strategies
• Improving parent-teen communication
• Developing daily routines and habits

Usual care, on the other hand, was found to be more eclectic and varied. It tended to involve:

• More individual sessions with just the teen (vs. parent involvement)
• A focus on social skills training
• Less emphasis on organization skills or rewards/consequences
• Lower intensity delivery of evidence-based practices when used

How the study was conducted

The study included 278 diverse adolescents ages 11-17 with ADHD and their caregivers. They were randomly assigned to either receive STAND or usual care at community mental health clinics. Importantly, the therapists delivering the treatments were also randomly assigned to provide either STAND or usual care.

The researchers measured several outcomes before treatment, right after treatment ended (about 5 months later), and at a follow-up about 4-5 months after that. These included:

• Executive function skills (rated by parents and measured by tasks)
• Teen motivation and readiness to change
• Parenting behaviors
• Parent-teen interactions
• Organization and planning behaviors

They were particularly interested in how these “mechanistic outcomes” - the underlying skills and behaviors thought to drive improvements in ADHD symptoms - might differ between the two treatment approaches.

Key findings

Overall effectiveness

Contrary to what the researchers expected, STAND did not outperform usual care on most of the outcomes measured. Both treatments led to some improvements over time, but there were few differences between the two approaches overall.

Executive function

Surprisingly, usual care actually showed greater improvements than STAND in some areas of executive function:

• Parent ratings of teen metacognition (skills like working memory, planning, and organization) improved more with usual care.
• On task-based measures, teens in usual care showed bigger gains in inhibition (the ability to control impulses) and cognitive flexibility (the ability to switch between tasks or ideas).

The researchers suggest a few potential reasons for this unexpected finding:

1. Usual care therapists may have had more flexibility to address other issues (like anxiety or depression) that can also impact executive function.

2. The more intensive nature of STAND, with its focus on behavior change, may have temporarily increased cognitive load for teens.

3. Usual care involved more individual sessions, which may have allowed for more direct work on cognitive skills.

Motivation and readiness for change

There were no significant differences between STAND and usual care in improving teen motivation or readiness to change overall. However, an important exception emerged when looking at who delivered the treatment.

The impact of therapist characteristics

A key finding was that STAND showed better results than usual care on some outcomes, but only when delivered by licensed therapists. Specifically, when STAND was provided by licensed therapists:

• Teens showed greater improvements in readiness to change
• Parents reduced intrusive behaviors more (like excessive reminding or doing things for teens)

This suggests that the effectiveness of evidence-based programs like STAND may depend heavily on who implements them. Licensed therapists may be better equipped to deliver the more complex components of STAND effectively.

What do these findings mean?

This study highlights the challenges of implementing evidence-based treatments in real-world community settings. A few key takeaways emerge:

1. Evidence-based programs may not always outperform typical care when delivered in community clinics. The intensity and quality of implementation likely matters a great deal.

2. Who delivers the treatment appears to be crucial. Licensed therapists may be better prepared to implement more complex evidence-based approaches effectively.

3. Typical community care for ADHD, while variable, seems to lead to some improvements in important areas like executive function. Understanding what works well in usual care could inform future treatment development.

4. Improving teen motivation and reducing intrusive parenting may be particularly important targets for ADHD treatment in community settings. These areas showed the most promise for STAND when delivered by skilled therapists.

5. More support and training may be needed for unlicensed therapists, who make up a large portion of the community mental health workforce, to implement evidence-based treatments effectively.

Conclusions

• Evidence-based treatments for teen ADHD may not always outperform usual care when implemented in community settings.
• The effectiveness of treatments likely depends heavily on how they are delivered and by whom.
• Both evidence-based programs and typical care can lead to improvements in important skills and behaviors for teens with ADHD.
• Future efforts to improve ADHD treatment in community settings should focus on better supporting all types of therapists to deliver high-quality care.

This research underscores the complexity of treating ADHD in adolescence and the importance of continued efforts to bridge the gap between controlled research settings and real-world clinical practice. By better understanding what works in different contexts, we can continue to improve outcomes for teens with ADHD and their families.