A Randomized Community-Based Trial of Behavior Therapy vs. Usual Care for Adolescent ADHD: Secondary Outcomes and Effects on Comorbidity

• Published in: Behavior therapy 2023-09, Vol.54 (5), p.839-851
• Main Authors: Sibley, Margaret H., Graziano, Paulo A., Coxe, Stefany J., Bickman, Leonard, Martin, Pablo, Flores, Sabrina
• Format: Article
• Language: English
• Subjects: ADHD; Adolescent; Anxiety; Anxiety Disorders; Attention Deficit Disorder with Hyperactivity - therapy; Behavior Therapy; community-based treatment; Comorbidity; Humans; randomized controlled trial
• ISSN: 0005-7894; 1878-1888; 1878-1888
• DOI: 10.1016/j.beth.2023.03.001

•Community treatment for ADHD was most effective when delivered by licensed clinicians.•Behavior therapy for ADHD outperformed usual care for conduct problems and may be particularly effective for these youth.•Clinics might assign adolescent ADHD cases to licensed professionals.•All other comorbidity outcomes did not show group differences between STAND and usual care. Though behavior therapy (BT) for ADHD in adolescence is evidence-based, almost no work examines its implementation and effectiveness in community settings. A recent randomized community-based trial of an evidence-based BT for adolescent ADHD (Supporting Teens’ Autonomy Daily; STAND; N = 278) reported high clinician, parent, and youth acceptability but variable implementation fidelity. Primary outcome analyses suggested no significant differences between STAND and usual care (UC) unless the clinician delivering STAND was licensed. The present study reports secondary outcomes for this trial on indices of comorbidity (anxiety, depression, oppositional defiant disorder, conduct disorder) and ADHD outcomes not targeted by the active treatment (social skills, sluggish cognitive tempo). We also examine whether therapist licensure moderated treatment effects (as in primary outcome analyses). Using intent-to-treat and per protocol linear mixed models, patients randomized to STAND were compared to those randomized to UC over approximately 10 months of follow-up. Group × Time effects revealed that, overall, STAND did not outperform usual care when implemented by community clinicians. However, a Group × Time × Licensure interaction revealed a significant effect on conduct problems when STAND was delivered by licensed clinicians (d = .19–.47). When delivered in community settings, behavior therapy for adolescent ADHD can outperform UC with respect to conduct problems reduction. Community mental health clinics should consider: (1) assigning adolescent ADHD cases to licensed professionals to maximize impact and (2) choosing psychosocial approaches when ADHD presents with comorbid conduct problems. There is also a need to reduce implementation barriers for unlicensed clinicians in community settings.