This study investigated treatment engagement barriers encountered during adolescent engagement-focused evidence-based behavioural therapy, Supporting Teens’ Autonomy Daily (STAND), experienced by adolescents with ADHD and their parents. This form of behavioural therapy consists of ten 1-hour weekly sessions attended by the adolescent and parent.
Participants of this study included adolescents with ADHD and their parents, who participated in one of two randomised controlled trials evaluating the efficacy of STAND between 2012 and 2016 (Sibley et al, 2016; Sibley et al, 2020). All participants possessed ≥1 audio recording of a STAND session; all 882 available recordings were utilised in the current study. Grounded theory methodology identified barriers described by parents and adolescents in the session, and the influence of subtype barriers (cognitive/attitudinal, behavioural, logistical), subject barriers (parent, teen, dyad) and phase barriers (engagement, skills/planning) on attendance and homework completion was analysed.
In total, 121 adolescents with ADHD (aged 11–16 years; 72.7% male; 77.7% Latinx) and parents were included in this study. A total of 25 categories of barriers to STAND engagement were identified, including 10 categories of cognitive/attitudinal barriers, 11 behavioural and four logistical; this consisted of 14 teen barriers, six parent barriers and five dyadic barriers. Commonly identified 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%). Observed barriers were most frequently teen-related (d=0.94–1.57), cognitive/attitudinal (d=0.28–1.44) and occurring during STAND’s planning phase (d=0.47–0.87).
The mean (standard deviation) number of STAND sessions attended by participants was 8.71 (2.53) (range 1–10) and 72.7% of participants completed all 10 sessions. The likelihood ratio chi-square test was significant for the subtype [χ2(3)=49.87; p<0.001], subject [χ2(3)=31.35; p<0.001] and phase barriers models [χ2(3)=26.91; p<0.001]. Higher attendance was predicted by:
- Subtype barriers – lower frequency of cognitive/attitudinal barriers (b=−0.02; standard error [SE]=0.01; p<0.001) and higher frequency of behavioural (b=0.02; SE=0.01; p=0.042) and logistical barriers (b=0.31; SE=0.05; p<0.001).
- Subject barriers – higher frequency of parent barriers (b=0.05; SE=0.01; p=0.002) and lower frequency of dyadic barriers (b=−0.16; SE=0.03; p<0.001); frequency of teen barriers did not predict attendance (p=0.184).
- Phase barriers – lower frequency of barriers in the engagement phase (b=−0.20; SE=0.00; p<0.001) and higher frequency of barriers in the skills/planning phases (b=0.02; SE=0.00; p<0.001).
Mean (SD) homework completion scores* were 0.71 (0.20) (range 0–1). For the subtype [χ2(3)=5.23; p=0.156] and subject barriers [χ2(3)=6.65; p=0.084], the overall likelihood ratio chi-square tests were non-significant, as were all predictors. For the phase model, the overall likelihood ratio chi-square test was significant [χ2(3)=7.60; p=0.022]. Higher homework completion was predicted by lower frequency of barriers in the engagement phase (b=−0.19; SE=0.01; p=0.008) but not by frequency of barriers in the skills/planning phase (p=0.947).
With regards to study limitations, it was noted that, as fewer audio recordings were available for families who dropped out in early phases of treatment, bias may have been introduced into analyses that model the relationship between barriers and engagement. There were also indices of engagement not examined in this study due to the absence of a common measure of these indices across the included trials. The authors noted that the sample was mainly comprised of ethnic minority youth, and under-represented older teens relative to younger teens, thus the findings may not be generalisable to individuals outside of these demographics. The observational nature of the study may have introduced inherent limitations, such as barriers that were experienced but not articulated by families, going undetected in this approach.
A wide range of barriers were observed during behavioural therapy sessions, which were either parent-specific, teen-specific or mutual to the dyad. The authors concluded that in adolescent ADHD, key barriers to engagement include adolescent attitudes toward treatment, parent behavioural barriers and logistical challenges during the planning phases of treatment. It was suggested that baseline assessment of barriers in adolescents with ADHD may promote individualised engagement strategies.
Read more about engagement barriers in adolescents with ADHD here
*Providers marked whether homework was fully completed (1 point), partially completed (0.5 points) or not completed (0 points) each week
Disclaimer: The views expressed here are the views of the author(s) and not those of Takeda.
Sibley MH, Graziano PA, Kuriyan AB, et al. Parent-teen behavior therapy + motivational interviewing for adolescents with ADHD. J Consult Clin Psychol 2016; 84: 699-712.
Silbley MH, Link K, Antunez GT, et al. Engagement barriers to behavior therapy for adolescent ADHD. J Clin Child Adolesc Psychol 2022; Epub ahead of print.
Sibley MH, Rodriguez L, Coxe S, et al. Parent-teen group versus dyadic treatment for adolescent ADHD: what works for whom? J Clin Child Adolesc Psychol 2020; 49: 476-492.