ADHD, Substance Use Disorders
Conditions
Keywords
ADHD, Adolescents, Substance Use Disorders
Brief 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.
Interventions
BEHAVIORALMedication Integration Protocol (MIP)
BEHAVIORALChanging Academic Support in the Home for Adolescents with ADHD (CASH-AA)
Sponsors
Patient-Centered Outcomes Research Institute
The National Center on Addiction and Substance Abuse at Columbia University
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
SINGLE (Subject)
Eligibility
Sex/Gender
ALL
Age
12 Years to 18 Years
Healthy volunteers
No
Inclusion criteria
* Primary caregiver able to participate in treatment * Adolescent meets DSM-5 diagnostic criteria for ADHD * Adolescents who are substance users (50% of sample) meet ASAM criteria for non-intensive outpatient services * Adolescent not enrolled in any other behavioral treatment * Caregiver expresses desire, and adolescent expresses willingness, to participate in outpatient treatment * Family has health benefits that meet the requirements of study treatment sites, all of which accept a broad range of insurance plans including Medicaid.
Exclusion criteria
* Intellectual Disability or Autism-Spectrum Disorder * Medical/psychiatric illness requiring hospitalization * Current psychotic symptoms; active suicidal ideation * Severe substance use problems that require immediate relief (detox or residential placement)
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Change From Baseline in Symptoms: ADHD Symptoms (Inattention, Hyperactivity/Impulsivity) and Comorbid Problems (Conduct and Mood Problems, Substance Use). | Baseline to One Year | ADHD Symptoms were assessed using the Mini International Neuropsychiatric Interview (Version 5.0). A count of symptoms (range 0-14) was utilized with higher numbers represent more symptoms. Delinquency was assessed using the National Youth Survey Self-Report Delinquency Scale (SRD). A count of delinquent acts was utilized (range 0-68) with higher numbers represent more delinquent acts. Substance Use was captured with the Comprehensive Addiction Severity Index for Adolescents. Total score was utilized (range 0-60) with higher numbers represent greater substance use. Externalizing and Internalizing Symptoms were measured with the Child Behavior Checklist. Higher scores correspond to more symptoms; scores on each item range from 0 to 2, and the study variable was calculated by summing items within each scale (externalizing scale range = 0 - 62 units on a scale; internalizing scale range = 0-64 units on a scale). |
| Change From Baseline in Quality of Life. Improvements in Executive Functioning and School Functioning. | Baseline to One Year | Executive Functioning was measured with two subscales (self-regulation and self-organization) of the Behavior Rating Inventory of Executive Function. Higher scores correspond to greater difficulty with behavior regulation and organization; scores on each item range from 0 to 2, and the study variable was calculated by summing the scores in each scale (23 items per scale; range 0-46 per scale). School Functioning was measured three ways: Self-report grades which was coded to reflect 1=Mostly As, 2=As and Bs, 3=Mostly Bs, 4=Bs and Cs, 5=Mostly Cs. Academic Self-Efficacy was measured using four dichotomous items from the Motivated Strategies for Learning Questionnaire, 1 = endorsing self-efficacy, 0 = no self-efficacy (range =0-4). Homework problems checklist. Higher scores indicate more problems with homework; scores on each item range from 0 to 3; the study variable was calculated by summing the 11 scale items (total score range = 0-33). |
| Treatment Attendance. | One Year | Treatment Attendance \[sum of the total number of individual, family, and group sessions attended\] and Medication Management Sessions \[total number of sessions attended\] were collected from agency records. Medication Use, coded as 1 = on or 0 = off medication at each follow-up point, was captured with the Services Assessment for Children and Adolescents |
Countries
United States
Participant flow
Recruitment details
Participants were recruited from 5 partnering treatment clinics from March 2015 to February 2018.
Participants by arm
| Arm | Count |
|---|---|
| Behavioral Only- Treatment All participants will receive behavioral interventions (CASH-AA): family psycho-education 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.
Changing Academic Support in the Home for Adolescents with ADHD (CASH-AA) | 53 |
| Integrated Treatment About 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.
Medication Integration Protocol (MIP)
Changing Academic Support in the Home for Adolescents with ADHD (CASH-AA) | 92 |
| Total | 145 |
Baseline characteristics
| Characteristic | Behavioral Only- Treatment | Integrated Treatment | Total |
|---|---|---|---|
| Age, Categorical <=18 years | 53 Participants | 91 Participants | 144 Participants |
| Age, Categorical >=65 years | 0 Participants | 0 Participants | 0 Participants |
| Age, Categorical Between 18 and 65 years | 0 Participants | 1 Participants | 1 Participants |
| Age, Continuous | 15.03 years STANDARD_DEVIATION 1.84 | 14.68 years STANDARD_DEVIATION 1.99 | 14.79 years STANDARD_DEVIATION 1.95 |
| Ethnicity (NIH/OMB) Hispanic or Latino | 21 Participants | 39 Participants | 60 Participants |
| Ethnicity (NIH/OMB) Not Hispanic or Latino | 32 Participants | 52 Participants | 84 Participants |
| Ethnicity (NIH/OMB) Unknown or Not Reported | 0 Participants | 1 Participants | 1 Participants |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Asian | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Black or African American | 7 Participants | 15 Participants | 22 Participants |
| Race (NIH/OMB) More than one race | 2 Participants | 7 Participants | 9 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 19 Participants | 34 Participants | 53 Participants |
| Race (NIH/OMB) White | 25 Participants | 36 Participants | 61 Participants |
| Region of Enrollment United States | 53 participants | 92 participants | 145 participants |
| Sex: Female, Male Female | 9 Participants | 32 Participants | 41 Participants |
| Sex: Female, Male Male | 44 Participants | 60 Participants | 104 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | 0 / 53 | 0 / 92 |
| other Total, other adverse events | 0 / 53 | 0 / 92 |
| serious Total, serious adverse events | 0 / 53 | 0 / 92 |
Outcome results
Primary
Change From Baseline in Quality of Life. Improvements in Executive Functioning and School Functioning.
Executive Functioning was measured with two subscales (self-regulation and self-organization) of the Behavior Rating Inventory of Executive Function. Higher scores correspond to greater difficulty with behavior regulation and organization; scores on each item range from 0 to 2, and the study variable was calculated by summing the scores in each scale (23 items per scale; range 0-46 per scale). School Functioning was measured three ways: Self-report grades which was coded to reflect 1=Mostly As, 2=As and Bs, 3=Mostly Bs, 4=Bs and Cs, 5=Mostly Cs. Academic Self-Efficacy was measured using four dichotomous items from the Motivated Strategies for Learning Questionnaire, 1 = endorsing self-efficacy, 0 = no self-efficacy (range =0-4). Homework problems checklist. Higher scores indicate more problems with homework; scores on each item range from 0 to 3; the study variable was calculated by summing the 11 scale items (total score range = 0-33).
Time frame: Baseline to One Year
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| Behavioral Only- Treatment | Change From Baseline in Quality of Life. Improvements in Executive Functioning and School Functioning. | Self-organization | 25.40 units on a scale | Standard Deviation 5.81 |
| Behavioral Only- Treatment | Change From Baseline in Quality of Life. Improvements in Executive Functioning and School Functioning. | Academic Self-Efficacy | .10 units on a scale | Standard Deviation 0.85 |
| Behavioral Only- Treatment | Change From Baseline in Quality of Life. Improvements in Executive Functioning and School Functioning. | Grades | 4.35 units on a scale | Standard Deviation 1.5 |
| Behavioral Only- Treatment | Change From Baseline in Quality of Life. Improvements in Executive Functioning and School Functioning. | Homework Problems | 14.95 units on a scale | Standard Deviation 9.57 |
| Behavioral Only- Treatment | Change From Baseline in Quality of Life. Improvements in Executive Functioning and School Functioning. | Self-regulation | 48.81 units on a scale | Standard Deviation 12.36 |
| Integrated Treatment | Change From Baseline in Quality of Life. Improvements in Executive Functioning and School Functioning. | Homework Problems | 14.84 units on a scale | Standard Deviation 9.38 |
| Integrated Treatment | Change From Baseline in Quality of Life. Improvements in Executive Functioning and School Functioning. | Self-regulation | 50.94 units on a scale | Standard Deviation 12.98 |
| Integrated Treatment | Change From Baseline in Quality of Life. Improvements in Executive Functioning and School Functioning. | Self-organization | 26.04 units on a scale | Standard Deviation 5.82 |
| Integrated Treatment | Change From Baseline in Quality of Life. Improvements in Executive Functioning and School Functioning. | Grades | 4.50 units on a scale | Standard Deviation 1.6 |
| Integrated Treatment | Change From Baseline in Quality of Life. Improvements in Executive Functioning and School Functioning. | Academic Self-Efficacy | -.04 units on a scale | Standard Deviation 0.78 |
Linear Growth Curve Modeling
Latent Growth Curve Modeling
Linear Growth Curve Modeling
Latent Growth Curve Modeling
Latent Growth Curve Modeling
Primary
Change From Baseline in Symptoms: ADHD Symptoms (Inattention, Hyperactivity/Impulsivity) and Comorbid Problems (Conduct and Mood Problems, Substance Use).
ADHD Symptoms were assessed using the Mini International Neuropsychiatric Interview (Version 5.0). A count of symptoms (range 0-14) was utilized with higher numbers represent more symptoms. Delinquency was assessed using the National Youth Survey Self-Report Delinquency Scale (SRD). A count of delinquent acts was utilized (range 0-68) with higher numbers represent more delinquent acts. Substance Use was captured with the Comprehensive Addiction Severity Index for Adolescents. Total score was utilized (range 0-60) with higher numbers represent greater substance use. Externalizing and Internalizing Symptoms were measured with the Child Behavior Checklist. Higher scores correspond to more symptoms; scores on each item range from 0 to 2, and the study variable was calculated by summing items within each scale (externalizing scale range = 0 - 62 units on a scale; internalizing scale range = 0-64 units on a scale).
Time frame: Baseline to One Year
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| Behavioral Only- Treatment | Change From Baseline in Symptoms: ADHD Symptoms (Inattention, Hyperactivity/Impulsivity) and Comorbid Problems (Conduct and Mood Problems, Substance Use). | ADHD Symptoms- Hyperactive | 3.23 units on a scale | Standard Deviation 2.6 |
| Behavioral Only- Treatment | Change From Baseline in Symptoms: ADHD Symptoms (Inattention, Hyperactivity/Impulsivity) and Comorbid Problems (Conduct and Mood Problems, Substance Use). | Internalizing Symptoms | 10.20 units on a scale | Standard Deviation 8.83 |
| Behavioral Only- Treatment | Change From Baseline in Symptoms: ADHD Symptoms (Inattention, Hyperactivity/Impulsivity) and Comorbid Problems (Conduct and Mood Problems, Substance Use). | Delinquent Acts | 13.75 units on a scale | Standard Deviation 31.03 |
| Behavioral Only- Treatment | Change From Baseline in Symptoms: ADHD Symptoms (Inattention, Hyperactivity/Impulsivity) and Comorbid Problems (Conduct and Mood Problems, Substance Use). | Externalizing Symptoms | 16.30 units on a scale | Standard Deviation 11.45 |
| Behavioral Only- Treatment | Change From Baseline in Symptoms: ADHD Symptoms (Inattention, Hyperactivity/Impulsivity) and Comorbid Problems (Conduct and Mood Problems, Substance Use). | ADHD Symptoms- Inattentive | 6.42 units on a scale | Standard Deviation 2.43 |
| Integrated Treatment | Change From Baseline in Symptoms: ADHD Symptoms (Inattention, Hyperactivity/Impulsivity) and Comorbid Problems (Conduct and Mood Problems, Substance Use). | Externalizing Symptoms | 16.76 units on a scale | Standard Deviation 12.91 |
| Integrated Treatment | Change From Baseline in Symptoms: ADHD Symptoms (Inattention, Hyperactivity/Impulsivity) and Comorbid Problems (Conduct and Mood Problems, Substance Use). | ADHD Symptoms- Inattentive | 6.90 units on a scale | Standard Deviation 2.43 |
| Integrated Treatment | Change From Baseline in Symptoms: ADHD Symptoms (Inattention, Hyperactivity/Impulsivity) and Comorbid Problems (Conduct and Mood Problems, Substance Use). | ADHD Symptoms- Hyperactive | 4.00 units on a scale | Standard Deviation 3.18 |
| Integrated Treatment | Change From Baseline in Symptoms: ADHD Symptoms (Inattention, Hyperactivity/Impulsivity) and Comorbid Problems (Conduct and Mood Problems, Substance Use). | Delinquent Acts | 5.15 units on a scale | Standard Deviation 8.99 |
| Integrated Treatment | Change From Baseline in Symptoms: ADHD Symptoms (Inattention, Hyperactivity/Impulsivity) and Comorbid Problems (Conduct and Mood Problems, Substance Use). | Internalizing Symptoms | 9.31 units on a scale | Standard Deviation 8.32 |
Latent Growth Curve Modeling
Latent Growth Curve Modeling
p-value: 0.05Latent Growth Curve Modeling
p-value: 0.05Latent Growth Curve Modeling
p-value: 0.05Latent Growth Curve Modeling
Primary
Treatment Attendance.
Treatment Attendance \[sum of the total number of individual, family, and group sessions attended\] and Medication Management Sessions \[total number of sessions attended\] were collected from agency records. Medication Use, coded as 1 = on or 0 = off medication at each follow-up point, was captured with the Services Assessment for Children and Adolescents
Time frame: One Year
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Behavioral Only- Treatment | Treatment Attendance. | 12.8 Sessions | Standard Deviation 11.4 |
| Integrated Treatment | Treatment Attendance. | 19.4 Sessions | Standard Deviation 14.3 |
p-value: 0.56Regression, Linear