Margaret H. Sibley’s research while affiliated with Washington School of Psychiatry and other places

Background Understanding the mechanisms of change and between‐family differences in behavioural parenting interventions for children with attention‐deficit/hyperactivity disorder (ADHD) may help personalise interventions. Therefore, we examined whether improvements in parenting are associated with changes in child behaviour and functional outcomes, and how these associations vary based on parents' baseline parenting levels. Methods We collected individual participant data including 19 randomised controlled trials focusing on children with ADHD (n = 1,720). Immediate post‐intervention measures of child ADHD and oppositional behaviour severity, reported by parents and functional impairment reported by either the parent or probably masked clinicians, were treated as outcomes. We estimated pathways from intervention (vs. control) to child outcomes, via immediate post‐intervention parent reports of constructive parenting (e.g. praise), non‐constructive parenting (e.g. physical punishment) and parent–child affection (e.g. warmth), while controlling for baseline values of both child outcomes and parenting levels. Baseline values of each parenting variable were used as moderators of the mediated pathways. Results Improvements in parenting behaviours and parent–child affection immediately following the intervention jointly explained concurrent improvements in children's ADHD severity, oppositional behaviour and functional impairment. Furthermore, when reversing the direction of the pathways, improvements in all child outcomes jointly explained improvements in each aspect of parenting. Improvements in non‐constructive parenting and parent–child affection uniquely accounted for intervention effects on functional impairment, especially for families with higher baseline levels of non‐constructive parenting. Conclusions Our findings might indicate that improvements in both the behavioural and affective aspects of parenting are associated with concurrent reductions in child behaviour problems and functional impairment. However, more research is necessary to explore the potential causal directionality between parenting and child outcomes. Nonetheless, supporting families with poorer parenting skills may be especially important, as reductions in non‐constructive parenting in these families are linked to stronger treatment effects on child functional impairment.

Objective Many treatment engagement challenges are documented for adolescents with ADHD. Across contexts, helping professionals (i.e., therapists, prescribers, educators, coaches) might benefit from an engagement strategy toolbox to facilitate work with adolescents with ADHD and their families. Method The current study describes the development and psychometric testing of the ADHD Engagement Process Code (AEPC), a measure that operationalizes engagement strategies in the context of a blended behavioral/motivational interviewing treatment for adolescent ADHD (Supporting Teens’ Autonomy Daily; STAND). The AEPC also operationalizes in-session parent and adolescent engagement-related behaviors. Behavior counts and global codes were coded for 840 audio-recorded STAND sessions delivered by 21 therapists to 121 adolescents. Subsets of tapes were double coded using the AEPC’s parent, adolescent, and therapist coding systems to assess kappa for line-by-line verbalizations and intraclass correlations for session-level behavior counts and global scores. Construct validity was assessed. We explored low frequency and low variability codes and examined correlations between codes. Results AEPC codes possessed good to excellent inter-rater reliability and strong discriminant validity. Three low frequency codes and one low variability global were identified indicating opportunities for AEPC refinement. Conclusions The AEPC is publicly available ( https://osf.io/kshfy/ ) and offers a library of adolescent-specific codes for those interested in measuring provider, parent, or adolescent engagement behaviors in relevant populations or contexts.

Objectives: Recent studies report a fluctuating course of attention-deficit/ hyperactivity disorder (ADHD) across development characterized by intermittent periods of remission and recurrence. In the Multimodal Treatment of ADHD (MTA) study, we investigated fluctuating ADHD including clinical expression over time, childhood predictors, and between- and within-person associations with factors hypothesized as relevant to remission and recurrence. Methods: Children with DSM-5 ADHD, combined type (N = 483), participating in the MTA adult follow-up were assessed 9 times from baseline (mean age = 8.46) to 16-year follow-up (mean age = 25.12). The fluctuating subgroup (63.8% of sample) was compared to other MTA subgroups on variables of interest over time. Results: The fluctuating subgroup experienced multiple fluctuations over 16 years (mean = 3.58, SD = 1.36) with a 6- to 7-symptom within-person difference between peaks and troughs. Remission periods typically first occurred in adolescence and were associated with higher environmental demands (both between- and within-person), particularly at younger ages. Compared to other groups, the fluctuating subgroup demonstrated moderate clinical severity. In contrast, the stable persistent group (10.8%) was specifically associated with early and lasting risk for mood disorders, substance use problems in adolescence/ young adulthood, low medication utilization, and poorer response to childhood treatment. Protective factors were detected in the recovery group (9.1%; very low parental psychopathology) and the partial remission group (15.6%; higher rates of comorbid anxiety). Conclusions: In the absence of specific risk or protective factors, individuals with ADHD demonstrated meaningful within-individual fluctuations across development. Clinicians should communicate this expectation and monitor fluctuations to trigger as-needed return to care. During remission periods, individuals with ADHD successfully manage increased demands and responsibilities. Trial Registration: ClinicalTrials.gov identifier: NCT00000388.

Individuals with ADHD are at risk for substance use initiation in adolescence and escalation to problematic use in adulthood. Little is known about the impact of psychosocial ADHD treatment on substance use. Based on existing theory, both therapeutic (i.e., through reducing symptoms and impairments) and iatrogenic effects (i.e., through improved social functioning) of psychosocial treatment for ADHD on adolescent substance use initiation are plausible. A primarily ethnic/racial minority sample (~ 95% Latinx or Black) of rising ninth grade students with ADHD (n = 106) were randomly assigned to receive high intensity (i.e., Summer Treatment Program-Adolescent, parent training, and school consultation) or lower intensity (parent training, organization skills training, and school consultation) intervention the summer before entering high school. Participants were followed four-years post-baseline and substance use was documented. Analyses tested treatment effects on substance use initiation (alcohol and/or marijuana) and mediators of main effects. After controlling for covariates, participants assigned to HI (37.5%) were significantly more likely than LI (18.6%) to initiate substance use by end of high school, indicating an iatrogenic effect of HI treatment. No significant mediators were detected. Post-hoc exploration of moderators suggested that youth with elevated Posttraumatic Stress Disorder (PTSD) symptoms may have experienced a benefit of HI treatment on substance use whereas youth without elevated PTSD symptoms experienced iatrogenic effects. Large, well-powered, samples should examine moderated mediational models to better understand who is most risk for iatrogenic effects of ADHD psychosocial treatment and why. Clinicians delivering psychosocial treatment to adolescents with ADHD should monitor for potential iatrogenic effects.

Though ADHD is the most common pediatric diagnosis in community mental health clinics (CMHCs), little is known about its diagnostic accuracy in these settings. We characterize CMHC diagnostic patterns for ADHD and common comorbidities with attention to gender and racial/ethnic disparities and the impact of misdiagnosis on evidence-based treatment implementation. Culturally diverse adolescents with a primary diagnosis of ADHD (N=278) completed comprehensive research team diagnostic assessments. Concurrently, they were assessed at one of four CMHCs in a large United States city. CMHC psychiatric diagnoses were obtained from electronic health records and compared to best practices research diagnoses. Mixed methods analyses characterized diagnostic agreement, racial/ethnic and gender disparities, and the effect of missed ADHD diagnoses on treatment implementation, as well as agency staff perceptions of barriers and facilitators to accurate diagnosis. Diagnostic agreement was unacceptable for all diagnoses (k=.02 to .19). CMHCs provided an ADHD diagnosis to 65.4% of best practices diagnosed participants. Female gender and White race were associated with missed ADHD diagnoses (often in favor of depressive or adjustment disorders) and CMHCs demonstrated overdiagnosis of conduct disorder (CD) in African American youth. Missed ADHD diagnoses predicted clinician deviation from evidence-based treatment for ADHD. Agency stakeholders noted systemic barriers and clinician beliefs and biases that may contribute to diagnostic inaccuracy and made suggestions for future practice. CMHCs might review their ADHD diagnostic practices to identify contributors to misdiagnosis, such as racial and gender biases, clinician inexperience, and systemic disincentives for careful diagnosis. Adopting systematic diagnostic practices such as pursuing parent and teacher ratings, consulting the DSM when diagnosing, and integrating supervisors into diagnostic process may be helpful.

Background Attention Deficit/Hyperactivity Disorder (ADHD) demonstrates unique developmental manifestations in adolescence with implications for optimized, age‐appropriate treatment. This 10‐year update is the third in a series of systematic reviews examining the efficacy and safety of adolescent ADHD treatments. We broadly examined efficacy on ADHD symptoms, impairments, and other reported outcomes. Acute and long‐term efficacy, and treatment moderators, were considered. Method We performed PubMed, EMBASE, and PsycINFO searches for articles published or in press from 2013 to 2024, integrated with hand search and randomized controlled trials (RCTs) identified in this series' earlier reviews. RCTs examining the safety or efficacy of interventions delivered to adolescents (ages 10.0–19.9) with a diagnosis of ADHD were included. Study characteristics were extracted and reviewed, quality of evidence was assessed using GRADE, and effect sizes were calculated for individual studies and illustrated using forest plots. Results Sixty‐three RCTs were identified. Quality of evidence ranged from high (medication; k = 29) to very low (nutrient supplementation, neurofeedback, occupational therapy; k = 1 each). Medications demonstrated consistent strong impact on ADHD symptoms and inconsistent impact on impairment. Diverse cognitive/behavioral treatments (C/BTs) demonstrated inconsistent impact on ADHD symptoms but strong and consistent impact on impairment and executive function skills, plus moderate benefits on internalizing symptoms. No interventions demonstrated significant safety concerns. Long‐term maintenance (up to 3 years post‐treatment) was demonstrated for C/BTs, though moderate quality of evidence was noted because participants cannot be fully blinded to receipt of treatment. Conclusions The effects of C/BTs and medication appear complementary, not duplicative. Combining medication and C/BT is advised at treatment outset to maximize engagement, maintenance, and response breadth (i.e. improving both ADHD symptoms/cognitive performance and coping skills/functional impairments). Engagement strategies (e.g. motivational interviewing) may facilitate uptake. Novel treatments do not yet demonstrate effects on ADHD symptoms or impairments in adolescents but remain a promising area for research.