J Am Acad Child Adolesc Psychiatry. 2021 Apr 12:S0890-8567(21)00228-8. doi: 10.1016/j.jaac.2021.03.017. Online ahead of print.
OBJECTIVE: To identify patient and treatment-level factors that predict intervention engagement and outcome for adolescents with attention-deficit/hyperactivity disorder (ADHD), guiding efforts to enhance care.
METHOD: Integrative Data Analysis (IDA) was used to pool data from four randomized controlled trials of adolescent ADHD treatment with participants (N=854) receiving various evidence-based behavior therapy packages (standard; STANDARD, comprehensive; COMP, engagement-focused; ENGAGE), community-based usual care (UC), or no treatment (NOTX). Participants also displayed varying medication use patterns (negligible, inconsistent, consistent) during the trial. Regression and latent growth curve analyses examined treatment- and patient-level predictors of engagement and outcome.
RESULTS: Compared to COMP, ENGAGE was associated with higher parent engagement in behavior therapy (d=1.35 to 1.73) when delivered in university, but not community, clinics. Under some conditions, ENGAGE also predicted youth engagement in behavior therapy (d=1.21) and lower likelihood of negligible medication use (OR=.49; compared to NOTX). UC was associated with poorer parent engagement compared to COMP (d=-.59) and negligible medication use (OR=2.29) compared to NOTX. Compared to COMP, ENGAGE (in university settings) was consistently associated with larger ADHD symptom improvements (d=.41 to .83) at six-month follow-up and sometimes associated with larger GPA (d=.68) and parent-teen conflict (d=.41) improvements. Consistent medication during behavior therapy was associated with larger improvements in ADHD symptoms (d=.28) and parent-teen conflict (d=.25 to .36). An ADHD+internalizing clinical profile predicted larger improvements in GPA (d=.45). Family adversity predicted poorer parent and youth engagement (RR=.90-.95), negligible medication use (OR=1.22), and smaller improvements in GPA (d=-.23). African-American race predicted smaller improvements in parent-teen conflict (d=-.49).
CONCLUSION: Engagement-focused behavior therapy and consistent medication use most frequently predicted stronger clinical engagement and outcomes for adolescents with ADHD. Youth who are African-American or face family adversity may experience treatment-related disparities for certain outcomes; youth with ADHD+internalizing symptoms may demonstrate excellent academic outcomes following behavior therapy.