It has been reported that adolescence is a critical period for determining whether ADHD symptoms that present in childhood persist long-term. Developmental maladjustment experienced during the transition to secondary school can affect struggling adolescents with ADHD, and may lead to course failure, deviant behaviour and school dropout. This US study investigated the effect of a high-intensity (HI)* versus a low-intensity (LI)† summer school programme in sixth (11–12 years old) and ninth graders (14–15 years old) with ADHD. The aim of these 8-week summer programmes was to introduce organisational skills to adolescents and to aid parents in reinforcing these skills at home.
This study included 325 school-referred adolescents with ADHD,‡ who were randomised to either the HI (n=109) or LI (n=109) summer programme, during which they received either 45 hours/week (HI) or 1.5 hours/week (LI) of skills classes/activities, or to an untreated comparison group (n=107). During both the HI and LI summer programmes, parents also received a training curriculum and met one evening per week for 1.5 hours.§ The total cost per student was approximately $4373 for the HI and $97 for the LI summer programme.
Significantly more participants attended the HI compared with the LI summer programme (F[1, 214] = 65.81, p<0.01); however, training attendance by parents was comparable between programmes (F[1, 214 = 3.08], p=0.08). Overall satisfaction with the HI and LI summer programmes was high and similar between participants (p=0.39), although satisfaction was significantly higher in parents of adolescents attending the HI versus the LI summer programme (p<0.01). Participants attending the HI summer programme demonstrated greater improvements in note-taking performance compared with those in the LI summer programme (d=0.5). Improvements in parent contingency management (d=0.43) and parent-rated ADHD symptoms (d=0.40–0.46, for ninth-grade students only) were also greater with the HI programme versus the LI programme. However, there were no acute incremental benefits of HI versus LI on the other outcome measures, including parent-rated ADHD symptom change over time for sixth-grade students.
The authors reported several limitations to this study. Despite the fact that teachers and researchers were blinded to the treatment group, participants and their parents were not blinded and this may have influenced their expectations regarding the effectiveness of the HI and LI summer programmes. Moreover, medication utilisation was not controlled for in this study, and although this study was conducted in a large centralised school district, the majority of participants were Hispanic or African American, which limits the generalisability of these results.
The results of this study suggest that enrolment of adolescents with ADHD in a HI summer programme offers the greatest acute benefit to parent contingency management, adolescent note-taking skills and reduction in ADHD symptoms in ninth-graders. The authors suggested that to minimise costs, a HI summer programme focusing on only those components that contributed to these outcomes may be beneficial, and that future work should investigate whether HI treatment during the school year is better than a HI summer programme. The authors indicated that a 4-year follow-up of this study is currently ongoing to assess the full impact and cost-effectiveness of HI versus LI summer treatment for adolescents with ADHD.
*The HI Summer Treatment Program-Adolescent (STP-A) was an 8-week programme that included 45 hours per week (8:00 to 17:00 on weekdays) of interventions alternating between small- and large-group modules (between 30 to 50 minutes), which focused on materials management, time management, planning, homework completion, note taking, study skills, writing skills, self-monitoring, decision-making, social pragmatics, independent management of responsibilities in a vocational programme, and working with peers to organise a fundraiser and end-of-summer trip
†The LI summer programme was a manualised 8-week organisational skills group, lasting for 1.5 hours per week. Participants and their parents simultaneously attended the group which focused on organisational skills, introduction of new skills, hands-on activities and discussion exercises
‡Referred participants were entering either sixth grade (n=168) or ninth grade (n=157), and attended 134 different schools in the US. Referred students were required to: meet the Diagnostic and Statistical Manual of Mental Disorders – 4th Edition criteria for ADHD; exhibit significant academic impairments (score ≥3 on a 0–6 teacher Impairment Rating Scale); have an IQ >75; and have no history of autism spectrum disorder, however presence of psychiatric comorbidities was permitted
§Parents discussed how to monitor their child’s school performance, set a daily routine, apply behavioural principles to homework and create a parent–teen contract to make home privileges contingent upon responsibilities
Sibley MH, Coxe SJ, Campez M, et al. High versus low intensity summer treatment for ADHD delivered at secondary school transitions. J Clin Child Adolesc Psychol 2018; 47: 248-265.