Integrated Treatment for Adolescents With ADHD
Condition: ADHD; Substance Use Disorders
MeSH terms: Substance-Related Disorders
Study type: Interventional

Summary: 
      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.
    


Intervention name(s): Medication Integration Protocol (MIP); Changing Academic Support in the Home for Adolescents with ADHD (CASH-AA)
Intervention type(s): Behavioral; Behavioral
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Participant)
Primary purpose: Treatment
Keywords: ADHD; Adolescents; Substance Use Disorders