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ADHD Institute Register

9 Sep 2021

DuPaul G et al. Drug Des Dev Ther 2021; 15: 3561-3572

Multi-component training interventions such as the Challenging Horizons Program (CHP)* have been shown to improve organisation skills and academic functioning of middle-school students with ADHD; however, few studies have investigated treatment for high-school students with ADHD. This study investigated how CHP, adapted for high school, improves proximal and distal academic outcomes in high-school students with ADHD in the USA, through 6-month follow-up relative to a community care (CC) condition.

Students in Grades 9–11 were recruited over 2 consecutive years (2015–2016) from four public high schools in Ohio and 3 consecutive years (2015–2017) from six public schools in Pennsylvania. Amongst other inclusion criteria, study participants were required to meet diagnostic criteria for at least one presentation of ADHD based on the Parent-Children’s Interview for Psychiatric Syndromes or teaching ratings on the ADHD Rating Scale, as well as endorsing six symptoms of inattention or hyperactivity/impulsivity. Eligible participants were stratified by gender and randomly assigned to either CHP or CC. The CHP included twice-weekly individual in-school coaching sessions, at least monthly collaborative problem-solving sessions between the student and their coach§, and 10 evening group sessions offered separately for adolescents and parents. Participants who were randomised to the CC condition were given a list of available resources in their community, including locally available providers of child and family psychosocial and pharmacological interventions. Some CC participants also received individual or group counselling (48%), parent counselling (9.6%) and family therapy (12%). Parent-, teacher- and self-report ratings of organisation skills and academic performance, report card grades and achievement tests were collected using multiple scales and scoring systems, across multiple occasions.

In total, 186 adolescents participated in this study, and were randomly assigned to either CHP (n=92; 80% male; mean [standard deviation (SD)] age 15.0 [0.8] years) or CC (n=94; 78% male; mean [SD] age 15.1 [0.9] years). The CHP and CC groups consisted of equivalent proportions of adolescents receiving medication for ADHD, special education, or education accommodations. Intent-to-treat analysis revealed that CHP, as compared with CC conditions, led to significant improvements that were small to medium in magnitude (d range=0.32–0.58), represented faster improvements over time, and were maintained into the following school year in parent-rated organisation skills, parent-rated homework performance and, to some extent, grades. The effect size of CHP at 6-month follow-up showed a d range of 0.32– 0.58 for organisational skills and 0.40–0.44 for homework performance.

The effect of CHP on grades was small; however, it was associated with a less steep decline in grades than that found for CC. There were no statistically significant CHP effects on teacher- or self-reported ratings of academic and classroom performance. In contrast, the pattern of scores used to measure these outcomes showed separation between CHP and CC over the course of the treatment year. Trajectories for teacher and adolescent ratings were similar to trajectories for report card grades, with some separation between CHP and CC during the treatment year followed by convergence in the follow-up school year. Furthermore, group differences were relatively small in magnitude (School Functioning Scale rating post-treatment: d=0.17 and d=0.38 for teachers and adolescents, respectively).

There were several limitations associated with this study. Firstly, the nature of the intent-to-treat analysis could result in underestimation of CHP effects that may be associated with completion of a critical percentage of treatment sessions (Schultz et al, 2017) and/or dosage (Evans et al, 2014). Another concern raised by the authors was that school holidays and weather may have impacted the consistency of CHP treatment delivery. Furthermore, the small range of geographical locations of participants may limit the external validity of the findings. Evaluation of how treatment outcomes varied by student gender, race or ethnicity was not conducted, which may limit the generalisability of the results. Finally, potential bias of parent ratings must also be considered.

The authors concluded that school-based training interventions such as CHP may lead to improvements in academic enablers such as assignment tracking, organisation of materials and homework completion. The authors also proposed that CHP may prevent declines in academic performance typically exhibited by high school students with ADHD, and noted the critical importance of effective intervention during children’s developmental stages. Further examination of CHP for the treatment of significant impairment associated with ADHD in adolescents was recommended by the authors.

Read more about the effects of school-based intervention on academic functioning in adolescents with ADHD here


*The Challenging Horizons Program (CHP) is a school-based intervention for young adolescents with ADHD, focusing on academic and social impairment (Evans et al, 2016)
The Parent-Children’s Interview for Psychiatric Syndromes (P-ChIPS) is a highly structured interview designed for use by trained lay interviewers for children aged 6–18 years, which screens for 20 Axis I disorders as well as psychosocial stressors (Weller et al, 2000)
The ADHD Rating Scale-5 is an 18-item rating tool used to assess ADHD symptoms in children and adolescents (DuPaul et al, 2016)
§CHP coaches were female clinicians who were either completing graduate training in clinical or school psychology or who held graduate degrees in school counselling. All coaches received training prior to beginning the program and received 60 minutes of individual supervision from a licensed psychologist (the primary investigators) weekly
The School Functioning Scale (SFS) is a 9-item measure designed to efficiently obtain teacher perceptions of indicators of high-school student performance across academic, behavioural and social functioning (DuPaul et al, 2019)

Disclaimer: the views expressed here are the views of the author(s) and not those of Takeda.

DuPaul GJ, Evans SW, Allan D, et al. High school teacher ratings of academic, social, and behavioral difficulties: factor structure and normative data for the School Functioning Scale. Sch Psychol 2019; 34: 479-491.

DuPaul GJ, Evans SW, Sarno Owens J, et al. School-based intervention for adolescents with attention-deficit/hyperactivity disorder: effects on academic functioning. J Sch Psychol 2021; 87: 48-63.

DuPaul GJ, Power TJ, Anastopoulos AD, et al. ADHD Rating Scale-5 for Children and Adolescents: Checklists, Norms, and Clinical InterpretationNew York, NY: Guilford Press, 2016.

Evans SW, Schultz BK, DeMars CE. High school–based treatment for adolescents with attention deficit/hyperactivity disorder: results from a pilot study examining outcomes and dosage. School Psych Rev 2014; 43: 185-202.

Evans SW, Langberg JM, Schultz BK, et al. Evaluation of a school-based treatment program for young adolescents with ADHD. J Consult Clin Psychol 2016; 84: 15-30.

Schultz BK, Evans SW, Langberg JM, et al. Outcomes for adolescents who comply with long-term psychosocial treatment for ADHD. J Consult Clin Psychol 2017; 85: 250-261.

Weller EB, Weller RA, Fristad MA, at al. Children’s Interview for Psychiatric Syndromes (ChIPS). J Am Acad Child Adolesc Psychiatry 2000; 39: 76-84.

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