Predictors of Treatment Engagement and Outcome among Adolescents with Attention-Deficit/Hyperactivity Disorder: An Integrative Data Analysis.
Sibley MH, Coxe SJ, Stein MA, Meinzer MC, Valente M.
J Am Acad Child Adolesc Psychiatry. 2021 Apr 12:S0890-8567(21)00228-8.
Commentary* by Dr. Margaret Weiss: This is a remarkable study. It addresses 3 critical clinical issues: optimizing adolescent treatment, the effectiveness of offering optimized care to facilitate engagement, and the impact of race.
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.
* Abstracts are selected for their clinical relevance by Dr. Margaret Weiss, Director of Clinical Research, Child Psychiatry, Cambridge Health Alliance, Harvard University. Her commentary reflects her own opinion. It is not approved or necessarily representative of the CADDRA board.