Revisiting the Percentage of K-12 Students in Need of Preventive Interventions in Schools in a "Peri-COVID" Era: Implications for the Implementation of Tiered Programming.

As the public health framework has been implemented in schools through multi-tiered systems of support, as in Positive Behavioral Interventions and Supports (PBIS), a prominent interpretation has been that 80% of students will benefit from universal or Tier 1 schoolwide behavior support, around 15% will require added selective or Tier 2 targeted support, and 5% will require the more intensive selective or Tier 3 intervention. The PBIS framework also emphasizes the use of tiered logic, with strengthened efforts at the universal and selective levels when student behavioral or mental health needs exceed expected levels. The prediction that 5% of students will require indicated support was based mostly on students at risk for discipline encounters (i.e., office discipline referral data) and, more recently, systematic screening data, but this percentage remains an interpretation of the public health framework. Further, epidemiologic data over the past decade show that rates of childhood mental health disorders have risen and are even higher now as schools struggle to recover from the COVID-19 pandemic-much higher than 15% and 5% for selective and indicated levels. Thus, we believe it is time to revisit projections of the number of students in need of Tier 2 and Tier 3 support. In this position paper, we review the evidence for escalating youth mental health needs and discuss the implications for the tiered prevention framework in schools. We describe strategies to expand the availability of preventive intervention supports beyond Tier 1 efforts and conclude with recommendations for practice, policy, and research in this peri-COVID recovery era.

Acceptability and playability of an organization training videogame for young adolescents with ADHD: The development of ATHEMOS.

An estimated 8.7% to 9.8% of school-age children in the United States have attention deficit hyperactivity disorder (ADHD), affecting 4.3 to 4.9 million public school students. ADHD is a costly disorder that often goes untreated, especially among adolescents. Accessible computer-based programs have emerged to address the neurocognitive deficits of ADHD, but results to date have been disappointing. In this study, we tested the acceptability, playability, and user satisfaction of a novel planning/organization skills training game, called "ATHEMOS," based on an established psychosocial treatment package (i.e., Challenging Horizons Program). We conducted eight focus groups during a three-year development period, using feedback from 72 young adolescents with ADHD to iteratively improve the game. Then, during a pilot study in the fourth year, we collected data from 16 young adolescents who played the game as part of a 6- to 16-week school-based intervention. Our findings suggest that the serious game resulted in acceptability and playability ratings only moderately below that of recreational games (δ = -0.40). Critically, average perceptions remained positive when delivered within a school-based ADHD intervention over several weeks or months, with strong overall user satisfaction. Boys found the game more acceptable than girls, with ratings near that of recreational games (δ = -0.23). We conclude that computer-assisted behavior interventions appeal to adolescents with ADHD and offer a potentially promising treatment delivery method in schools.

Mental Health Services in North Carolina's Public Schools.

Most school-age children who receive mental health services do so in their public schools, but the scope and quality of those services can vary. This article describes current school mental health efforts in North Carolina, as well as policy initiatives that could shape those practices in the coming years.

Outcomes for adolescents who comply with long-term psychosocial treatment for ADHD.

OBJECTIVE: We conducted a large (N = 216) multisite clinical trial of the Challenging Horizons Program (CHP)-a yearlong afterschool program that provides academic and interpersonal skills training for adolescents with attention-deficit/hyperactivity disorder. Intent-to-treat analyses suggest that, as predicted, the CHP resulted in significant reductions in problem behaviors and academic impairment when compared to community care. However, attendance in the CHP ranged from zero to 60 sessions, raising questions about optimal dosing. METHOD: To evaluate the impact of treatment compliance, complier average causal effect modeling was used to compare participants who attended 80% or more of sessions to an estimate of outcomes for comparable control participants. RESULTS: Treatment compliers exhibited medium to large benefits (ds = 0.56 to 2.00) in organization, disruptive behaviors, homework performance, and grades relative to comparable control estimates, with results persisting 6 months after treatment ended. However, compliance had little impact on social skills. CONCLUSIONS: Students most in need of treatment were most likely to comply, resulting in significant benefits in relation to comparable control participants who experienced deteriorating outcomes over time. Difficulties relating to dose-response estimation and the potentially confounding influence of treatment acceptability, accessibility, and client motivation are discussed. (PsycINFO Database Record

Trajectories and Predictors of Response to the Challenging Horizons Program for Adolescents With ADHD.

The Challenging Horizons After School Program is one of the only psychosocial interventions developed specifically for adolescents with attention-deficit/hyperactivity disorder (ADHD) that has demonstrated efficacy in multiple randomized controlled trials. To date, however, all research with the intervention has evaluated outcomes at the group level, and it is unclear whether all adolescents respond similarly, or if the intervention is particularly well suited for certain adolescents with ADHD. This type of information is needed to guide stakeholders in making informed choices as part of dissemination and implementation efforts. The purpose of this study was to evaluate trajectories of response to intervention for a large sample of middle-school age adolescents with ADHD (grades 6-8) who received the after-school intervention (N=112). An additional goal of the study was to evaluate potential predictors of response trajectories, focusing on determining what factors best distinguished between intervention responders and nonresponders. Latent trajectory analyses consistently revealed four or five distinct classes. Depending on the outcome, between 16% and 46% of participants made large improvements, moving into the normal range of functioning, and between 26% and 65% of participants made small or negligible improvements. Multivariate predictor analyses revealed that a strong counselor/adolescent working alliance rated from the adolescent perspective and lower levels of parenting stress and parent-adolescent conflict consistently predicted an increased likelihood of intervention response. Implications of these findings for disseminating the after school intervention and for further intervention development are discussed.

Longitudinal evaluation of the importance of homework assignment completion for the academic performance of middle school students with ADHD.

The primary goal of this study was to longitudinally evaluate the homework assignment completion patterns of middle school age adolescents with ADHD, their associations with academic performance, and malleable predictors of homework assignment completion. Analyses were conducted on a sample of 104 middle school students comprehensively diagnosed with ADHD and followed for 18 months. Multiple teachers for each student provided information about the percentage of homework assignments turned in at five separate time points and school grades were collected quarterly. Results showed that agreement between teachers with respect to students assignment completion was high, with an intraclass correlation of .879 at baseline. Students with ADHD were turning in an average of 12% fewer assignments each academic quarter in comparison to teacher-reported classroom averages. Regression analyses revealed a robust association between the percentage of assignments turned in at baseline and school grades 18 months later, even after controlling for baseline grades, achievement (reading and math), intelligence, family income, and race. Cross-lag analyses demonstrated that the association between assignment completion and grades was reciprocal, with assignment completion negatively impacting grades and low grades in turn being associated with decreased future homework completion. Parent ratings of homework materials management abilities at baseline significantly predicted the percentage of assignments turned in as reported by teachers 18 months later. These findings demonstrate that homework assignment completion problems are persistent across time and an important intervention target for adolescents with ADHD.

Evaluation of a school-based treatment program for young adolescents with ADHD.

OBJECTIVE: This study compared 2 school-based training interventions for adolescents with attention deficit-hyperactivity disorder (ADHD): the Challenging Horizons Program-after school version (CHP-AS) and Challenging Horizons Program-mentoring version (CHP-M) with each other and with a community care (CC) condition. METHOD: Participants were 326 students (sixth through eighth grade) diagnosed with ADHD. Interventions were conducted for 1 academic year. CHP-AS occurred twice weekly and included organization, social functioning, and academic study skills interventions. In CHP-M, students were paired with a mentor (e.g., teacher) who was trained by a consultant and delivered a subset of the CHP-AS interventions during school. No direct intervention was provided in CC. Participants were assessed at pretreatment, 4 occasions during the intervention year, posttreatment, and at a 6-month follow-up. RESULTS: Intent-to-treatment analyses using hierarchical linear modeling to compare outcomes between the 3 conditions indicate participation in the CHP-AS intervention is associated with moderate effect size improvements in parent-rated organization and time-management skills, homework problems, and ADHD symptoms of inattention, and with small improvements in overall academic functioning and grade point average (GPA). These improvements were in comparison to CC and to CHP-M. Gains were sustained into the next school year and even increased in magnitude for several of the measures. CONCLUSIONS: The CHP-AS program leads to significant benefits for adolescents with ADHD compared with the services provided in the CHP-M and CC. The persistence of improvements over time supports the use of training interventions that teach skills for adolescents.

Effectiveness of the Challenging Horizons After-School Program for young adolescents with ADHD.

There are no empirically supported psychosocial treatments for adolescents with attention-deficit hyperactivity disorder (ADHD). This study examined the treatment benefits of the Challenging Horizons Program (CHP), a psychosocial treatment program designed to address the impairment and symptoms associated with this disorder in young adolescents. In addition to evaluating social and academic functioning outcomes, two critical questions from previous studies pertaining to the timing, duration, and family involvement in treatment were addressed. Forty-nine students recruited in two cohorts were randomly assigned to receive either the CHP or a community care condition. Outcomes suggested that students who received the CHP improved compared to students in the control condition on measures of symptoms and impairment. Implications related to timing, duration, and family involvement are reported, as well as recommendations for future studies.

Potential Mechanisms of Action in the Treatment of Social Impairment and Disorganization in Adolescents with ADHD.

Two important domains that can be impaired in adolescents with ADHD are organization and social functioning; however, the development of interventions to target these areas in adolescents is in the early stages. Currently, small efficacy trials are beginning to be used to conduct preliminary tests on the proposed mechanisms of action for these interventions. These two studies examined the efficacy of organization and social functioning interventions for adolescents with ADHD, as well as the potential mechanisms of action for each intervention. Results from the organization intervention provide support for a significant relationship between performance on the organization checklist and overall GPA; however, there was no meaningful pattern of relationships between achieving mastery of the organization tasks and grades within quarter. Further, results from the social functioning intervention support a moderate relationship between performance on process measures of response to the intervention and outcome measures of social functioning. Results of this study provide implications for modifications to the measures and intervention procedures in future research.

Psychosocial interventions used to treat children with ADHD: safety and efficacy.

Although stimulant therapy is the most common treatment for attention-deficit/hyperactivity disorder (ADHD) in children, it is not always effective in reducing behavioral symptoms. As a result, research on psychosocial interventions has progressed in recent years. This article provides a synopsis of psychosocial interventions for childhood ADHD, with an emphasis on basic behavior management principles, evidence-based interventions, and safety issues. Developmental issues that distinguish psychosocial interventions for children and adolescents are highlighted, and practical recommendations for collaborating with mental health professionals are provided.