Jennifer A. Mautone

A Family-School Intervention for Children with ADHD: Results of a Randomized Clinical Trial.

OBJECTIVE Accumulating evidence highlights the importance of using psychosocial approaches to intervention for children with attention-deficit/hyperactivity disorder (ADHD) that target the family and school, as well as the intersection of family and school. This study evaluated the effectiveness of a family-school intervention, Family-School Success (FSS), designed to improve the family and educational functioning of students in Grades 2-6 who meet criteria for ADHD combined and inattentive types. Key components of FSS were conjoint behavioral consultation, daily report cards, and behavioral homework interventions. METHOD FSS was provided over 12 weekly sessions, which included 6 group sessions, 4 individualized family sessions, and 2 school-based consultations. Participating families were given the choice of placing their children on medication; 43% of children were on medication at the time of random assignment. Children (n = 199) were randomly assigned to FSS or a comparison group controlling for non-specific treatment effects (Coping With ADHD Through Relationships and Education [CARE]). Outcomes were assessed at post-intervention and 3-month follow-up. The analyses controlled for child medication status. RESULTS FSS had a significant effect on the quality of the family-school relationship, homework performance, and parenting behavior. CONCLUSIONS The superiority of FSS was demonstrated even though about 40% of the participants in FSS and CARE were on an optimal dose of medication and there were significant time effects on each measure. This relatively brief intervention produced effect sizes comparable to those of the more intensive Multimodal Treatment Study of Children With ADHD (MTA) behavioral intervention.

Managing Attention-Deficit/Hyperactivity Disorder in Primary Care: A Systematic Analysis of Roles and Challenges

OBJECTIVE. This study was designed to investigate the perceptions of primary care providers about their roles and the challenges of managing attention-deficit/hyperactivity disorder and to evaluate differences between providers who serve families primarily from urban versus suburban settings. METHODS. The ADHD Questionnaire was developed to assess primary care provider views about the extent to which clinical activities that are involved in the management of attention-deficit/hyperactivity disorder are appropriate and feasible in primary care. Participants were asked to rate each of 24 items of the questionnaire twice: first to indicate the appropriateness of the activity given sufficient time and resources and second to indicate feasibility in their actual practice. Informants used a 4-point scale to rate each item for appropriateness and feasibility. RESULTS. An exploratory factor analysis of primary care provider ratings of the appropriateness of clinical activities for managing attention-deficit/hyperactivity disorder identified 4 factors of clinical practice: factor 1, assessing attention-deficit/hyperactivity disorder; factor 2, providing mental health care; factor 3, recommending and monitoring approved medications; and factor 4, recommending nonapproved medications. On a 4-point scale (1 = not appropriate to 4 = very appropriate), mean ratings for items on factor 1, factor 2, and factor 3 were high, indicating that the corresponding domains of practice were viewed as highly appropriate. Feasibility challenges were identified on all factors, but particularly factors 1 and 2. A significant interaction effect, indicating differences between appropriateness and feasibility as a function of setting (urban versus suburban), was identified on factor 1. The challenges of assessing attention-deficit/hyperactivity disorder were greater for urban than for suburban primary care providers. CONCLUSIONS. Primary care providers believe that it is highly appropriate for them to have a role in the management of attention-deficit/hyperactivity disorder. Feasibility issues were particularly salient related to assessing attention-deficit/hyperactivity disorder and providing mental health care. The findings highlight the need not only for additional training of primary care providers but also for practice-based resources to assist with school communication and collaboration with mental health agencies, especially in urban practices.

Parent Attendance and Homework Adherence Predict Response to a Family–School Intervention for Children With ADHD

This study examined the relative contribution of two dimensions of parent engagement, attendance and homework adherence, to parent and child treatment response and explored whether early engagement was a stronger predictor of outcomes than later engagement. The sample consisted of parents of participants (n = 92; M age = 9.4 years, SD = 1.27; 67% male, 69% White) in a 12-session evidence-based family–school intervention for children with attention-deficit/hyperactivity disorder. Attendance was assessed using clinician records, and homework adherence was measured by rating permanent products. Outcomes included parent and teacher ratings of family involvement in education, parenting practices, and child functioning. Accounting for the contributions of baseline scores and attendance, homework adherence was a significant predictor of parental self-efficacy, the parent–teacher relationship, parenting through positive involvement, and the childs inattention to homework and homework productivity. Accounting for the contribution of baseline scores and homework adherence, attendance was a significant predictor of one outcome, the childs academic productivity. Early homework adherence appeared to be more predictive of outcomes than later adherence, whereas attendance did not predict outcomes during either half of treatment. These results indicate that, even in the context of evidence-based practice, it is the extent to which parents actively engage with treatment, rather than the number of sessions they attend, that is most important in predicting intervention response. Because attendance is limited as an index of engagement and a predictor of outcomes, increased efforts to develop interventions to promote parent adherence to behavioral interventions for children are warranted.

Promoting Family and School Success for Children With ADHD: Strengthening Relationships While Building Skills

Children with ADHD typically experience significant impairment at home and school, and their relationships with parents, teachers, and peers often are strained. Psychosocial interventions for ADHD generally focus on behavior change in one environment at a time (i.e., either home or school); however, unisystemic interventions generally are not sufficient. The purpose of this article is to describe a family–school intervention for children with ADHD. In addition, program strategies and theoretical bases are discussed.

Multidimensional Assessment of Homework: An Analysis of Students with ADHD.

Objective: Homework can have beneficial effects for students; however, it presents challenges, particularly for students with attention problems. Although effective homework interventions exist, intervention development and evaluation has been hampered by the lack of psychometrically sound measures. The primary purpose of this study was to evaluate the construct validity of the Homework Performance Questionnaire (HPQ), Parent and Teacher Versions, in a sample of children with ADHD. A secondary purpose was to examine variations in homework performance as a function of individual characteristics, such as academic achievement, quality of the family–school relationship, and child’s diagnostic status. Method: The sample included 91 children (34% female) with ADHD in Grades 2 to 6. Measures included parent and teacher ratings of homework performance and the quality of the parent–teacher relationship as well as direct assessment of child academic achievement and homework performance (i.e., samples of completed assignments). Correlational analyses were used to examine construct validity, and ANOVAs were used to evaluate group differences. Results: Each factor of the HPQ had a significant relationship with other measures of relevant constructs. There were no significant differences in homework performance between groups for ADHD subtype, medication status, or comorbidity, with the exception of learning disability. Children with ADHD and learning disabilities had significantly lower teacher ratings of academic competence. Conclusion: Results of the present study suggest that HPQ scores may be used to make valid inferences about the homework performance of children with attention problems. These rating scales may be helpful in progress monitoring and evaluating intervention effectiveness.

Strategies for Implementing Evidence-Based Psychosocial Interventions for Children with Attention-Deficit/Hyperactivity Disorder

An extensive amount of research has demonstrated the effectiveness of psychosocial interventions for children with ADHD. Historically, the research has focused on interventions targeting problems in the home or school setting, but more recent research has highlighted the importance of family – school partnerships and conjoint approaches to intervention involving family and school. Effective approaches to psychosocial intervention consist of strategies to address performance deficits, promote adaptive behavior, and improve children’s self-control and academic and social skills. Considerable evidence exists to indicate that combined approaches are more effective in reducing ADHD symptoms and related academic and social impairments than separate treatments.

Toward a Comprehensive Life-Course Model of Care for Youth with Attention-Deficit/Hyperactivity Disorder

Students with ADHD and other emotional and behavioral disorders exhibit serious social, behavioral and academic problems in school and are at elevated risk for many poor long-term outcomes. Although there are models and guidelines for organizing services for these youth and guiding intervention decisions, we propose that they have limitations and some prioritize short-term benefits. As an alternative to these models, we propose a life-course model that is founded on establishing a priority for services that will enhance long-term competencies and help students independently meet age-appropriate expectations. The life-course model organizes services into four layers of care and guided by seven principles of service delivery. We provide the rationale for the model and describe its application to care for school and community based services for children and adolescents with ADHD.

Examining the Validity of the Homework Performance Questionnaire: Multi-Informant Assessment in Elementary and Middle School

Methods for measuring homework performance have been limited primarily to parent reports of homework deficits. The Homework Performance Questionnaire (HPQ) was developed to assess the homework functioning of students in Grades 1 to 8 from the perspective of both teachers and parents. The purpose of this study was to examine the factorial validity of teacher and parent versions of this scale, and to evaluate gender and grade-level differences in factor scores. The HPQ was administered in 4 states from varying regions of the United States. The validation sample consisted of students (n = 511) for whom both parent and teacher ratings were obtained (52% female, mean of 9.5 years of age, 79% non-Hispanic, and 78% White). The cross-validation sample included 1,450 parent ratings and 166 teacher ratings with similar demographic characteristics. The results of confirmatory factor analyses demonstrated that the best-fitting model for teachers was a bifactor solution including a general factor and 2 orthogonal factors, referring to student self-regulation and competence. The best-fitting model for parents was also a bifactor solution, including a general factor and 3 orthogonal factors, referring to student self-regulation, student competence, and teacher support of homework. Gender differences were identified for the general and self-regulation factors of both versions. Overall, the findings provide strong support for the HPQ as a multi-informant, multidimensional measure of homework performance that has utility for the assessment of elementary and middle school students.

Promoting Early Intervention Referral Through a Randomized Controlled Home-Visiting Program

The MOM Program is a randomized, controlled trial of an intervention to promote mothers’ care for the health and development of their children, including accessing early intervention (EI) services. Study aims were to determine whether, relative to controls, this intervention increased receipt of and referral to EI services. Mothers (N = 302) living in high-poverty regions were recruited after having given birth to healthy infants and were randomized to the intervention (n = 152) or control (n = 150) group. Those in the intervention group received up to 11 home visits to promote well-child visits and referral to EI. Children in the intervention group were referred to and received EI services significantly more often than those in the control group. Maternal depression and age of the mother were significantly associated with referral to, and receipt of, EI.

Ethical and legal issues in integrated care settings: Case examples from pediatric primary care.

There is a growing recognition that integrated primary care (IPC) services can address longstanding sociodemographic disparities in access to and utilization of behavioral health services. At the same time, there has been increasing attention to the complex ethical and legal considerations that can emerge for psychologists working in these interdisciplinary settings. There are challenging ethical dilemmas that arise when providing services to youth and their caregivers involved in IPC services. Unfortunately, although some ethical guidelines and case illustrations relevant to IPC are available, very few focus on the pediatric IPC context. The purpose of this article is to examine salient ethical and legal dilemmas that may emerge in pediatric IPC practice. These issues are examined through the use of 4 case illustrations that collectively address issues related to consent for services among pediatric populations, confidentiality, scope of practice for the pediatric IPC psychologist, and multiple relationships. We apply an adapted ethical decision-making framework (Kanzler, Goodie, Hunter, Glotfelter, & Bodart, 2013) to highlight practice points drawn from each of these cases. Throughout this article, we reference the American Psychological Association’s 2010 ethics code and 2015 guidelines for primary care practice competencies, while highlighting clinical practice points and directions for future research. We also discuss similarities and differences between the American Psychological Association (APA, 2010) and American Medical Association (AMA, 2012) ethics codes and standards of care.