Engagement Barriers to Behavior Therapy for Adolescent ADHD

• Published in: Journal of clinical child and adolescent psychology 2023-11, Vol.52 (6), p.834-849
• Main Authors: Sibley, Margaret H., Link, Kara, Torres Antunez, Gissell, Greenwood, Lydia
• Format: Article
• Language: English
• Subjects: Adolescent; Adolescent Behavior - psychology; Adolescents; African Americans; Attention Deficit Disorder with Hyperactivity - psychology; Attention Deficit Disorder with Hyperactivity - therapy; Attention deficit hyperactivity disorder; Attitudes; Autonomy; Barriers; Behavior modification; Behavior Therapy; Coding; Cognitive-behavioral factors; Evidence-based medicine; Female; Forgetfulness; Generalized linear models; Grounded theory; Homework; Humans; Interviews; Linear analysis; Male; Mixed methods research; Motivational Interviewing; Parents - psychology; Skills; Teenagers
• ISSN: 1537-4416; 1537-4424; 1537-4424
• DOI: 10.1080/15374416.2022.2025597

To identify barriers to behavior therapy for adolescent ADHD (Supporting Teens' Autonomy Daily; STAND) and understand the relationship between barriers and treatment engagement. A mixed-method design with qualitative coding of 822 audio-recorded therapy sessions attended by 121 adolescents with ADHD (ages 11-16; 72.7% male, 77.7% Latinx, 7.4% African-American, 11.6% White, non-Latinx) and parents. Grounded theory methodology identified barriers articulated by parents and adolescents in session. Barriers were sorted by subtype (cognitive/attitudinal, behavioral, logistical) and subject (parent, teen, dyad). Frequency and variety of barriers were calculated by treatment phase (engagement, skills, planning). Generalized linear models and generalized estimating equations examined between-phase differences in frequency of each barrier and relationships between barriers frequency, subtype, subject, and phase on engagement (attendance and homework completion). Coding revealed twenty-five engagement barriers (ten cognitive/attitudinal, eleven behavioral, four logistical). Common barriers were: low adolescent desire (72.5%), parent failure to monitor skill application (69.4%), adolescent forgetfulness (60.3%), and adolescent belief that no change is needed (56.2%). Barriers were most commonly cognitive/attitudinal, teen-related, and occurring in STAND's planning phase. Poorer engagement was associated with cognitive/attitudinal, engagement phase, and dyadic barriers. Higher engagement in treatment was predicted by more frequent behavioral, logistical, parent, and skills/planning phase barriers. Baseline assessment of barriers may promote individualized engagement strategies for adolescent ADHD treatment. Cognitive/attitudinal barriers should be targeted at treatment outset using evidence-based engagement strategies (e.g., Motivational Interviewing). Behavioral and logistical barriers should be addressed when planning and reviewing application of skills.