Implementation resources to support teachers' use of behavioral classroom interventions: protocol of a randomized pilot trial.

BACKGROUND: Teacher-delivered behavioral classroom management interventions are effective for students with or at-risk for attention-deficit/hyperactivity disorder (ADHD) or other disruptive behavior challenges, but they can be difficult for teachers to use in the classroom. In this study, we will pilot test a package of implementation strategies to support teachers in using behavioral classroom interventions for students with ADHD symptoms. METHODS: We will use a 2-group, randomized controlled trial to compare outcomes for teachers who receive Positive Behavior Management Implementation Resources (PBMIR), a theory and data-driven implementation resource package designed to increase teacher implementation of behavioral classroom management interventions, with those who do not receive this additional implementation support. We will measure teacher implementation outcomes (e.g., observed fidelity to behavioral classroom interventions) and student clinical outcomes (e.g., ADHD-related impairment, ADHD symptoms, student-teacher relationship, academic performance) before and after an 8-week intervention period for both groups; we will also measure teacher-reported acceptability, appropriateness, and feasibility for the PBMIR group following the intervention period. DISCUSSION: If there is preliminary evidence of feasibility and effectiveness, this pilot study will provide the foundation for evaluation the PBMIR at a larger scale and the potential to improve outcomes for students with or at risk for ADHD. TRIAL REGISTRATION: This clinical trial was registered at ClinicalTrials.gov. ( https://clinicaltrials.gov/ ) on 8/5/2022 which was prior to the time of first participant enrollment. The registration number is: NCT05489081.

Barriers and Facilitators to Teachers' Use of Behavioral Classroom Interventions.

Multi-tiered behavioral classroom interventions are particularly important for students with or at risk for ADHD or other externalizing behaviors. Teachers often use these interventions infrequently or not as designed, and little is known about the barriers and facilitators to their use, especially from the teachers' perspective. Using an exploratory sequential approach, we first used semi-structured qualitative interviews to identify teacher-reported barriers and facilitators to using three Tier 1 and one Tier 2 behavioral classroom interventions with students with ADHD symptoms (Study 1). Then, we identified which barriers and facilitators were most frequently endorsed on a survey (Study 2). The types of barriers and facilitators that emerged from semi-structured interviews included teachers' beliefs about behavioral classroom interventions (i.e., about their effectiveness or the consequences of using them) that motivated teachers or reduced their motivation to use them, as well as factors that interfered or assisted with execution in the moment. The most frequently endorsed barriers were being distracted or forgetting due to competing demands, and feeling "stressed, frustrated, or burned out;" frequently endorsed facilitators included having a strong student-teacher relationship and having built the habit of using the intervention. Together, these results identify specific, malleable factors that can be targeted when supporting teachers in using Tier 1 and Tier 2 behavioral classroom interventions for students with ADHD symptoms. Supplementary Information: The online version contains supplementary material available at 10.1007/s12310-022-09524-3.

Real-World Crash Circumstances Among Newly Licensed Adolescent Drivers With and Without Attention-Deficit/Hyperactivity Disorder.

PURPOSE: Adolescents with attention-deficit/hyperactivity disorder (ADHD) have 30%-40% higher crash rates. However, we still do not understand which factors underlie heightened crash risk and if crash circumstances differ for drivers with ADHD. We compared prevalences of crash responsibility, driver actions, and crash types among adolescent and young adult drivers with and without ADHD who crashed within 48 months of licensure. METHODS: In this exploratory retrospective cohort study, we identified patients of Children's Hospital of Philadelphia's (CHOP) New Jersey (NJ) primary care locations who were born between 1987 and 2000, NJ residents, had their last CHOP visit ≥ age 12 years, and acquired a driver's license. We linked CHOP electronic health records to NJ's licensing and crash databases. ADHD diagnosis was based on International Classification of Diseases, Ninth Revision, Clinical Modification/International Classification of Diseases, Tenth Revision, Clinical Modification codes. Prevalence ratios were estimated using generalized estimating equation log-binomial regression. RESULTS: We identified 934 drivers with ADHD in 1,308 crashes and 5,158 drivers without ADHD in 6,676 crashes. Within 48 months postlicensure, drivers with ADHD were more likely to be at fault for their crash (prevalence ratio: 1.09 [1.05-1.14]) and noted as inattentive (1.15 [1.07-1.23]). With the exception that drivers with ADHD were less likely to crash while making a left/U-turn, we did not find substantial differences in crash types by diagnosis. Analyses also suggest females with ADHD may have a higher risk of colliding with a nonmotor vehicle and crashing due to unsafe speed than females without ADHD. DISCUSSION: The results suggest crash circumstances do not widely differ for drivers with and without ADHD but highlight several factors that may be particularly challenging for young drivers with ADHD.

The Needs-to-Goals Gap: How informant discrepancies in youth mental health assessments impact service delivery.

Over 60 years of research reveal that informants who observe youth in clinically relevant contexts (e.g., home, school)-typically parents, teachers, and youth clients themselves-often hold discrepant views about that client's needs for mental health services (i.e., informant discrepancies). The last 10 years of research reveal that these discrepancies reflect the reality that (a) youth clients' needs may vary within and across contexts and (b) informants may vary in their expertise for observing youth clients within specific contexts. Accordingly, collecting and interpreting multi-informant data comprise "best practices" in research and clinical care. Yet, professionals across settings (e.g., health, mental health, school) vary in their use of multi-informant data. Specifically, professionals differ in how or to what degree they leverage multi-informant data to determine the goals of services designed to meet youth clients' needs. Further, even when professionals have access to multiple informants' reports, their clinical decisions often signal reliance on one informant's report, thereby omitting reports from other informants. Together, these issues highlight an understudied research-to-practice gap that limits the quality of services for youth. We advance a framework-the Needs-to-Goals Gap-to characterize the role of informant discrepancies in identifying youth clients' needs and the goals of services to meet those needs. This framework connects the utility of multi-informant data with the reality that services often target an array of needs within and across contexts, and that making decisions without accurately integrating multiple informants' reports may result in suboptimal care. We review evidence supporting the framework and outline directions for future research.

Impact of COVID-19 on Youth With ADHD: Predictors and Moderators of Response to Pandemic Restrictions on Daily Life.

We examined COVID-19 symptoms and infection rates, disruptions to functioning, and moderators of pandemic response for 620 youth with ADHD and 614 individually matched controls (70% male; Mage = 12.4) participating in the Adolescent Brain and Cognitive Development study. There were no group differences in COVID-19 infection rate; however, youth with ADHD were more likely to exhibit COVID-19 symptoms (d = 0.25), greater sleep problems (d = -0.52), fear and negative emotions to infection risk (d = -0.56), trouble with remote learning (d = -0.54), rule-breaking behavior related to COVID-19 restrictions (d = -0.23), family conflict (d = -0.13), and were less prepared for the next school year (d = 0.38). Youth with ADHD were less responsive to protective environmental variables (e.g., parental monitoring, school engagement) during the pandemic and may need more specialized support with return to in-person schooling and daily activities.

Sleep Well! An adapted behavioral sleep intervention implemented in urban primary care.

STUDY OBJECTIVES: To describe the adaptation, feasibility, and initial outcomes of Sleep Well!, an intervention for early childhood insomnia and insufficient sleep, designed for families from lower-socioeconomic status backgrounds presenting to large metropolitan primary care sites. METHODS: Fifteen caregiver-child dyads (caregivers: 92.3% mothers, 80.0% Black, 53.3% ≤ 125% US poverty level; children: 73.3% female, 86.7% Black, mean age = 3.0 years) participated in this multimethod, single-arm trial. A family advisory board of caregivers (n = 4) and a clinician advisory board of sleep experts, primary care clinicians, and psychologists (n = 13) provided intervention feedback throughout the pilot. Most adaptations were related to intervention delivery methods, with some related to sleep strategies. At postintervention, caregivers completed surveys on intervention acceptability and cultural humility (primary outcomes) and completed semistructured interviews. Caregivers also reported on child sleep pre- and postintervention. RESULTS: Thirteen (86.6%) families completed Sleep Well! and 12 (80.0%) completed pre- and postintervention measures. Caregivers reported strong intervention acceptability and cultural humility. There were preintervention to postintervention reductions in child sleep problems, bedroom electronics, sleep onset latency, and night awakening frequency and duration. Nighttime sleep duration and overall insufficient sleep also improved. Qualitative data also showed strong intervention acceptability and perceived flexibility, with few participation barriers. CONCLUSIONS: A brief, early childhood behavioral sleep intervention delivered in primary care with families from primarily lower-socioeconomic status backgrounds and/or racially minoritized backgrounds is feasible to implement, with strong retention rates, acceptability, and perceptions of cultural humility. Child sleep improvements are positive and warrant replication in a randomized controlled trial. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Name: Implementing Behavioral Sleep Intervention in Urban Primary Care; URL: https://clinicaltrials.gov/ct2/show/NCT04046341; Identifier: NCT04046341. CITATION: Williamson AA, Okoroji C, Cicalese O, et al. Sleep Well! An adapted behavioral sleep intervention implemented in urban primary care. J Clin Sleep Med. 2022;18(4):1153-1166.

An Individual Participant Data Meta-analysis: Behavioral Treatments for Children and Adolescents With Attention-Deficit/Hyperactivity Disorder.

OBJECTIVE: Behavioral interventions are well established treatments for children with attention-deficit/hyperactivity disorder (ADHD). However, insight into moderators of treatment outcome is limited. METHOD: We conducted an individual participant data meta-analysis (IPDMA), including data of randomized controlled behavioral intervention trials for individuals with ADHD <18 years of age. Outcomes were symptoms of ADHD, oppositional defiant disorder (ODD), and conduct disorder (CD) and impairment. Moderators investigated were symptoms and impairment severity, medication use, age, IQ, sex, socioeconomic status, and single parenthood. RESULTS: For raters most proximal to treatment, small- to medium-sized effects of behavioral interventions were found for symptoms of ADHD, inattention, hyperactivity/impulsivity (HI), ODD and CD, and impairment. Blinded outcomes were available only for small preschool subsamples and limited measures. CD symptoms and/or diagnosis moderated outcome on ADHD, HI, ODD, and CD symptoms. Single parenthood moderated ODD outcome, and ADHD severity moderated impairment outcome. Higher baseline CD or ADHD symptoms, a CD diagnosis, and single parenthood were related to worsening of symptoms in the untreated but not in the treated group, indicating a protective rather than an ameliorative effect of behavioral interventions for these children. CONCLUSION: Behavioral treatments are effective for reducing ADHD symptoms, behavioral problems, and impairment as reported by raters most proximal to treatment. Those who have severe CD or ADHD symptoms, a CD diagnosis, or are single parents should be prioritized for treatment, as they may evidence worsening of symptoms in the absence of intervention.

Improving Care Management in Attention-Deficit/Hyperactivity Disorder: An RCT.

OBJECTIVES: To compare the effectiveness of care management combined with a patient portal versus a portal alone for communication among children with attention-deficit/hyperactivity disorder (ADHD). METHODS: Randomized controlled trial conducted at 11 primary care practices. Children aged 5 to 12 years old with ADHD were randomly assigned to care management + portal or portal alone. The portal included parent-reported treatment preferences and goals, medication side effects, and parent- and teacher-reported ADHD symptom scales. Care managers provided education to families; communicated quarterly with parents, teachers, and clinicians; and coordinated care. The main outcome, changes in the Vanderbilt Parent Rating Scale (VPRS) score as a measure of ADHD symptoms, was assessed using intention-to-treat analysis. RESULTS: A total of 303 eligible children (69% male; 46% Black) were randomly assigned, and 273 (90%) completed the study. During the 9-month study, parents in the care management + portal arm communicated inconsistently with care managers (mean 2.2; range 0-6) but similarly used the portal (mean 2.3 vs 2.2) as parents in the portal alone arm. In multivariate models, VPRS scores decreased over time (Adjusted ß = -.015; 95% confidence interval -0.023 to -0.07) in both groups, but there were no intervention-by-time effects (Adjusted ß = .000; 95% confidence interval -0.011 to 0.012) between groups. Children who received ≥2 care management sessions had greater reductions in VPRS scores than those with fewer sessions. CONCLUSIONS: Results did not provide evidence that care management combined with a patient portal was different from portal use alone among children with ADHD. Both groups demonstrated similar reductions in ADHD symptoms. Those families with greater care management engagement demonstrated greater reductions than those with less engagement.

Implementing Group Parent Training in Telepsychology: Lessons Learned During the COVID-19 Pandemic.

OBJECTIVE: We recently transitioned from in-person delivery of a brief behavioral parent intervention to telepsychology delivery to meet families' needs during the COVID-19 pandemic. In this topical review, we describe how we used treatment fidelity as a guiding principle to orient adaptations for telepsychology, as well as preliminary findings and early lessons learned in this implementation. Methods: Using rapid-cycle quality improvement methods, we adapted a brief parent training group (Bootcamp for Attention-Deficit/Hyperactivity Disorder; BC-ADHD) to three groups of caregivers (i.e., 5-7 families) of school-aged children with ADHD (n = 20; 85% males). Families were from the following ethnic backgrounds: 75% White non-Hispanic, 15% White Hispanic, and 10% Black. Clinicians completed measures on their implementation experience. Observers completed measures on content/process fidelity and attendance. Caregivers completed measures on demographics, treatment satisfaction, and telepsychology experience. RESULTS: Telepsychology BC-ADHD can be implemented with comparably high levels of content and process fidelity and treatment satisfaction to in-person groups; and it appears to be feasible and acceptable to caregivers. Caregiver and clinician qualitative feedback revealed themes of appreciating the convenience of telepsychology, while experiencing some challenges in relating to others and sharing over video. CONCLUSIONS: When treatment fidelity is used as a guiding tool, telepsychology parent training groups can be delivered with high fidelity and appear to be acceptable and feasible to caregivers and clinicians. Future research using larger and more diverse samples, multimethod and multi-informant measurement approaches, and controlled designs is needed to further assess the generalizability and efficacy of telepsychology parent training groups.

Behavioral Health Screening: Validation of a Strength-Based Approach.

OBJECTIVE: To evaluate the validity of the Behavioral Health Checklist (BHCL) strength-based factor scores and the extent to which this factor has a buffering effect on the relationship between behavioral health symptom severity and children's social problems. METHOD: The parents of 1,392 children aged 4 to 12 completed the BHCL and Child Behavior Checklist (CBCL) during sick and well-child visits to urban and suburban primary care practices affiliated with a large children's hospital. RESULTS: Findings support a single, strength-based factor on the BHCL, and the structure was largely invariant across race, sex, and socioeconomic status. Increased psychopathology symptoms (internalizing, externalizing, and attention-deficit hyperactivity disorder) and lower levels of strengths predicted increased social problems (p < 0.001). Moreover, the interaction terms were statistically significant in all analyses, suggesting that higher levels of strengths may buffer the deleterious impact of psychopathology symptoms on social problems. Post hoc analyses indicated that the buffering influence of strengths on the relationship between psychopathology symptoms and social problems was clinically meaningful except in the older sample for the relationship between externalizing and social problems. CONCLUSION: The findings support the validity of a strength-based factor of the BHCL and indicate that this factor has a buffering effect on the association between the degree of child mental health symptoms and level of social impairment. This factor, in combination with the problem-focused factors of the BHCL, provides a balanced approach to screening children's mental health functioning.

Early Childhood Sleep Intervention in Urban Primary Care: Caregiver and Clinician Perspectives.

BACKGROUND: Despite significant income-related disparities in pediatric sleep, few early childhood sleep interventions have been tailored for or tested with families of lower socio-economic status (SES). This qualitative study assessed caregiver and clinician perspectives to inform adaptation and implementation of evidence-based behavioral sleep interventions in urban primary care with families who are predominantly of lower SES. METHODS: Semi-structured interviews were conducted with (a) 23 caregivers (96% mothers; 83% Black; 65% ≤125% U.S. poverty level) of toddlers and preschoolers with insomnia or insufficient sleep and (b) 22 urban primary care clinicians (physicians, nurse practitioners, social workers, and psychologists; 87% female; 73% White). Guided by the Consolidated Framework for Implementation Research, the interview guide assessed multilevel factors across five domains related to intervention implementation. Qualitative data were analyzed using an integrated approach to identify thematic patterns across participants and domains. RESULTS: Patterns of convergence and divergence in stakeholder perspectives emerged across themes. Participants agreed upon the importance of child sleep and intervention barriers (family work schedules; household and neighborhood factors). Perspectives aligned on intervention (flexibility; collaborative and empowering care) and implementation (caregiver-to-caregiver support and use of technology) facilitators. Clinicians identified many family barriers to treatment engagement, but caregivers perceived few barriers. Clinicians also raised healthcare setting factors that could support (integrated care) or hinder (space and resources) implementation. CONCLUSIONS: Findings point to adaptations to evidence-based early childhood sleep intervention that may be necessary for effective implementation in urban primary care. Such adaptations could potentially reduce significant pediatric sleep-related health disparities.

Editorial: Paving the Way Toward Improving Safety Among Drivers With Attention-Deficit/Hyperactivity Disorder.

The ability to drive is important to an individual's participation in modern society, as it enhances independence and social and economic opportunity. However, motor vehicle crashes are a leading cause of injury-related death in the United States-and the leading cause of death among 15- to 24-year-olds. Thus, it is critical that we sequentially identify who may be at inherently higher crash risk and why their crash risk might be higher, with the ultimate goal of implementing comprehensive approaches to promote safe driving practices and to improve safe mobility.

Chronic Care for Attention-Deficit/Hyperactivity Disorder: Clinical Management from Childhood Through Adolescence.

OBJECTIVE: Impairments generally persist when children diagnosed with attention-deficit/hyperactivity disorder (ADHD) mature into adolescence. To examine changes in ADHD care during the transition from childhood to adolescence, we conducted a retrospective, longitudinal cohort study of patients diagnosed with ADHD before the age of 10 years to assess changes from preadolescence through adolescence in (1) frequency by which primary care providers offer ADHD care to patients, (2) range of concerns assessed during patient encounters, and (3) treatments implemented or recommended. METHODS: We identified patients from 3 practices included in a large primary care network who (1) were born between 1996 and 1997, (2) were diagnosed with ADHD before the age of 10 years, and (3) received primary care continuously from age 9 through late adolescence. Clinical care was compared among patients in preadolescence (age 9-11), early adolescence (age 12-14), and late adolescence (age 15-18). RESULTS: Children diagnosed with ADHD before the age of 10 years were less likely to have a documented visit for ADHD during late adolescence (41% of patients) compared with preadolescence (63%, p < 0.001). Evidence of monitoring for depression, suicide, and substance abuse increased from preadolescence to adolescence (p < 0.001) and occurred in about 90% of adolescent patients. However, monitoring for risky sexual activity occurred in only about 50% of adolescents. Discussions of medication diversion and driver readiness were essentially not documented. CONCLUSION: The findings raise concerns about how primary care providers manage adolescents with a history of ADHD. Improving monitoring of risky sexual behavior and driver readiness and providing patient education about medication diversion are needed.

Society for Developmental and Behavioral Pediatrics Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents with Complex Attention-Deficit/Hyperactivity Disorder.

Attention-deficit/hyperactivity disorder (ADHD) is the most common childhood neurodevelopmental disorder and is associated with an array of coexisting conditions that complicate diagnostic assessment and treatment. ADHD and its coexisting conditions may impact function across multiple settings (home, school, peers, community), placing the affected child or adolescent at risk for adverse health and psychosocial outcomes in adulthood. Current practice guidelines focus on the treatment of ADHD in the primary care setting. The Society for Developmental and Behavioral Pediatrics has developed this practice guideline to facilitate integrated, interprofessional assessment and treatment of children and adolescents with "complex ADHD" defined by age (<4 years or presentation at age >12 years), presence of coexisting conditions, moderate to severe functional impairment, diagnostic uncertainty, or inadequate response to treatment.

ADHD Parent and Teacher Symptom Ratings: Differential Item Functioning across Gender, Age, Race, and Ethnicity.

Parent and teacher ratings of the two attention-deficit/hyperactivity disorder (ADHD) symptom dimensions (i.e., inattention, hyperactivity-impulsivity) have been found to differ across child gender, age, race, and ethnicity. Group differences could be due to actual variation in symptomatic behaviors but also could be due to measurement items functioning differently based on child characteristics. This study extended prior investigations establishing measurement invariance at the symptom dimension and item levels, by examining possible measurement variance across child demographic characteristics at the item level (i.e., differential item functioning [DIF]) in two large national samples. Using the Rasch rating scale model (Andrich Psychometrika, 43, 561-73, 1978), we examined DIF of the 18 ADHD symptoms in samples of 2079 children (n = 1037 males) from 5 to 17 years old (M = 10.7; SD = 3.8) rated by parents and 1070 children (n = 535 males) aged from 5 to 17 years old (M = 11.5; SD = 3.5) rated by teachers. All but six ADHD symptom items showed DIF across child age, gender, race (Black vs. White), and ethnicity with more items showing DIF for age than for gender, race, or ethnicity. For child gender and age, more items showed DIF for parent than for teacher ratings. More items showed DIF across racial groups for teacher than for parent ratings. Only two parent- and teacher-rated items showed DIF for ethnicity. Implications of findings for practice, research, and future iterations of ADHD diagnostic criteria are discussed.

Future Directions for Psychosocial Interventions for Children and Adolescents with ADHD.

Multiple psychosocial interventions are efficacious for children and adolescents with attention-deficit/hyperactivity disorder (ADHD) including behavioral parent training, behavioral classroom management, behavioral peer interventions, and organization training programs. Unfortunately, there is a significant gap between research and practice such that evidence-based treatments often are not implemented in community and school settings. Using a life course model for ADHD treatment implementation, we discuss future research directions that support movement from the current, fragmented system of care to a more comprehensive, integrated, and multisystemic approach. Specifically, we offer six recommendations for future research. Within the realm of treatment development and evaluation, we recommend (1) identifying and leveraging mechanisms of change, (2) examining impact of youth development on treatment mechanisms and outcomes, and (3) designing intervention research in the context of a life course model. Within the realm of implementation and dissemination, we recommend investigating strategies to (4) enhance access to evidence-based treatment, (5) optimize implementation fidelity, and (6) examine and optimize costs and cost-effectiveness of psychosocial interventions. Our field needs to go beyond short-term, efficacy trials to reduce symptomatic behaviors conducted under ideal controlled conditions and successfully address the research-to-practice gap by advancing development, evaluation, implementation, and dissemination of evidence-based treatment strategies to ameliorate ADHD-related impairment that can be used with fidelity by parents, teachers, and community health providers.

Implementation of targeted mental health interventions in urban schools: Preliminary findings for impact of training strategy on program fidelity.

School-based mental health programs are increasingly recognized as methods by which to improve children's access to evidence-based practices (EBPs), particularly in urban under resourced communities. School-wide positive behavior interventions and supports (PBIS) is one approach to integrating mental health services into school-based programming; however, school providers require training and support to implement programs as intended. We have conducted a randomized controlled trial to compare two models for training school-based personnel to deliver group EBPs to children at high risk of developing internalizing or externalizing problems. School personnel (N = 24) from 6 schools in a large urban school district were trained with either a basic training and consultation strategy, or an enhanced training and consultation strategy. Preliminary findings show that the enhanced strategy resulted in 9% higher content fidelity than the basic strategy. School personnel who were switched to the basic strategy had slightly lower content fidelity for the last two years of the trial and school personnel who continued to receive basic consultation during the step-down phase saw their fidelity decline. The two conditions did not differ with regard to process fidelity.

Traffic Crashes, Violations, and Suspensions Among Young Drivers With ADHD.

OBJECTIVES: To compare monthly rates of specific types of crashes, violations, and license suspensions over the first years of licensure for drivers with and without attention-deficit/hyperactivity disorder (ADHD). METHODS: We identified patients of New Jersey primary care locations of the Children's Hospital of Philadelphia who were born in 1987-1997, were New Jersey residents, had their last primary care visit at age ≥12 years, and acquired a driver's license (N = 14 936). Electronic health records were linked to New Jersey's licensing, crash, and violation databases. ADHD diagnosis was based on International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes. We calculated monthly per-driver rates of crashes (at fault, alcohol related, nighttime, and with peers), violations, and suspensions. Adjusted rate ratios were estimated by using repeated-measures Poisson regression. RESULTS: Crash rates were higher for drivers with ADHD regardless of licensing age and, in particular, during the first month of licensure (adjusted rate ratio: 1.62 [95% confidence interval: 1.18-2.23]). They also experienced higher rates of specific crash types: their 4-year rate of alcohol-related crashes was 2.1 times that of drivers without ADHD. Finally, drivers with ADHD had higher rates of moving violations (for speeding, seat belt nonuse, and electronic equipment use) and suspensions. In the first year of driving, the rate of alcohol and/or drug violations was 3.6 times higher for adolescents with ADHD. CONCLUSIONS: Adolescents with ADHD are at particularly high crash risk in their initial months of licensure, and engagement in preventable risky driving behaviors may contribute to this elevated risk. Comprehensive preventive approaches that extend beyond current recommendations are critically needed.