Journal of Clinical Child & Adolescent Psychology

ISSN: 1537-4416 (Print) 1537-4424 (Online) Journal homepage: https://www.tandfonline.com/loi/hcap20

Future Directions for Psychosocial Interventions

for Children and Adolescents with ADHD

George J. DuPaul, Steven W. Evans, Jennifer A. Mautone, Julie Sarno Owens &
Thomas J. Power

To cite this article: George J. DuPaul, Steven W. Evans, Jennifer A. Mautone, Julie Sarno Owens
& Thomas J. Power (2020) Future Directions for Psychosocial Interventions for Children and
Adolescents with ADHD, Journal of Clinical Child & Adolescent Psychology, 49:1, 134-145, DOI:
10.1080/15374416.2019.1689825

To link to this article: https://doi.org/10.1080/15374416.2019.1689825

Published online: 04 Dec 2019.

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Journal of Clinical Child & Adolescent Psychology, 49(1), 134–145, 2020
Copyright © Society of Clinical Child & Adolescent Psychology
ISSN: 1537-4416 print/1537-4424 online
DOI: https://doi.org/10.1080/15374416.2019.1689825

FUTURE DIRECTIONS

Future Directions for Psychosocial Interventions for

Children and Adolescents with ADHD
George J. DuPaul
Department of Education and Human Services, Lehigh University

Steven W. Evans
Department of Psychology, Ohio University

Jennifer A. Mautone
Department of Pediatrics, Children’s Hospital of Philadelphia and Perelman School of Medicine,
University of Pennsylvania

Julie Sarno Owens

Department of Psychology, Ohio University

Thomas J. Power
Department of Pediatrics, Children’s Hospital of Philadelphia and Perelman School of Medicine,
University of Pennsylvania

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, imple-
mentation, 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.

Address correspondence to George J. DuPaul, School Psychology

Program, College of Education, Lehigh University, 111 Research Drive,
Bethlehem, PA 18015. E-mail: gjd3@lehigh.edu
Color versions of one or more of the figures in the article can be found
online at www.tandfonline.com/hcap.
Children and adolescents with attention-deficit/hyperactivity
disorder (ADHD) experience significant deficits in academic
and/or social functioning that typically begin early in life and
extend into emerging adulthood and beyond (American

Psychiatric Association, 2013; DuPaul & Langberg, 2015).
Symptomatic behaviors of inattention and/or hyperactivity-
impulsivity disrupt development of self-regulation skills;
negatively impact academic performance and achievement;
are associated with higher than average risk for special educa-
tion eligibility, grade retention, and school-dropout; and lead
to problematic relationships with peers and authority figures
(e.g., parents, teachers) (Barkley, Murphy, & Fischer, 2008;
Frazier, Youngstrom, Glutting, & Watkins, 2007; Hechtman,
2017; Mikami, 2010; Normand et al., 2013). Given the rela-
tively high prevalence rate of 8 to 11% for ADHD (Danielson
et al., 2018), this disorder is very costly in terms of health care
and educational expenditures (Chorozoglou et al., 2015; Robb
et al., 2011). Thus, it is critically important that effective
interventions are implemented across home, school, and com-
munity settings to not only reduce ADHD symptoms but also
attenuate potentially chronic functional impairments.
Multiple psychopharmacological and psychosocial
interventions have been established as effective for treat-
ment of ADHD symptoms and associated impairments.
Psychopharmacological regimens primarily include cen-
tral nervous stimulants such as methylphenidate, but also
non-stimulant drugs (e.g., atomoxetine) (Conner, 2015).
In similar fashion, psychosocial treatments including
behavioral parent training, behavioral classroom manage-
ment, behavioral peer interventions, organization training
programs, and, to a lesser extent, academic interventions
are effective and associated with medium to large effects
on ADHD symptoms and related functional impairments
(DuPaul, Eckert, & Vilardo, 2012; Evans, Owens,
Wymbs, & Ray, 2018; Fabiano, Pelham et al., 2009).
For many years, the foundation of psychosocial treatment
for youth with ADHD has been behavioral treatment (Pelham
& Fabiano, 2008). Clinicians trained parents or teachers how
to manipulate contingencies in the home or school setting to
increase the likelihood of children with ADHD following
rules, staying on task, and being productive. Although tech-
niques taught to parents and teachers took many forms (e.g.,
daily report card, token economy, time out from positive
reinforcement), the mechanism of action for most of these
was to manipulate the way that punishment and reinforcement
were provided, make the contingencies consistent and clear to
the child, and track the child’s’ responses. Much of the recent
research on behavioral approaches have been focused on
helping adults learn these techniques and effectively imple-
ment them over time (e.g., Chacko et al., 2008; Fabiano,
Chacko et al., 2009; Owens et al., 2017).
During the last decade, psychosocial treatments for ADHD
have gone beyond behavioral approaches (see Evans, Owens,
& Power, 2019; Evans et al., 2018). The expansion in
approaches has been driven to a large extent by a focus on
developing effective psychosocial treatments for adolescents,
including training interventions (Evans et al., 2016; Langberg,
Epstein, Becker, Girio-Herrera, & Vaughn, 2012), motivational
INTERVENTIONS FOR ADHD 135
interviewing techniques (Sibley et al., 2016), and cognitive
approaches (Boyer, Geurts, Prins, & Van Der Oord, 2015;
Sprich, Safren, Finkelstein, Remmert, & Hammerness, 2016;
Vidal et al., 2015). In addition, family therapy approaches that
were identified as relatively ineffective by Barkley and collea-
gues (Barkley, Edwards, Laneri, Fletcher, & Metevia, 2001),
have been revisited and enhanced for adolescents with ADHD
with some promise (Fabiano et al., 2016; Sibley et al., 2016).
Unfortunately, there is a significant gap between research
and practice such that evidence-based treatment strategies often
are not implemented in community and school settings. For
example, only about 31% of families of children with ADHD
have received behavioral parent training compared to 91%
having ever received psychotropic medication (Danielson,
Visser, Chronis-Tuscano, & DuPaul, 2018). A recent Office of
Inspector General report indicated that 45% of Medicaid-
enrolled children with ADHD who were newly medicated did
not receive behavior therapy as part of their treatment (US
Department of Health and Human Services, 2019). In addition,
only about 32% of students with ADHD are reported to receive
classroom behavior management (DuPaul, Chronis-Tuscano,
Danielson, & Visser, 2019). The underutilization of evidence-
based psychosocial treatment for children with ADHD is likely
due, in part, to the limited training that education, health, and
mental health professionals receive in evidence-based practices,
the scant availability of and access to services, as well as
challenges related to delivery of treatment across systems
(e.g., home, school, healthcare).
The purpose of this article is to identify future research
directions that would support movement from the current, oft-
fragmented, and inconsistently implemented system of care to
a more integrated, multisystemic, longitudinal approach. We
first briefly describe a life course model for ADHD treatment
implementation across family, school, and health care systems.
This model provides a context for prioritizing research initia-
tives. Next, we present a hypothetical case of a young child with
ADHD to describe treatment strategies typically implemented
across settings and the child’s development. We use this case to
illustrate limitations of treatment content and procedures over
time in the context of current knowledge. Finally, we make
specific recommendations for research that address these
limitations.
LIFE COURSE MODEL FOR TREATMENT OF ADHD
We previously proposed a model for treatment of ADHD
that emphasizes a life-course perspective to address the
long-term implications and outcomes of early life experi-
ences on health, psychological, and educational outcomes
of individuals with ADHD across the life span (Evans,
Owens, Mautone, DuPaul, & Power, 2014). In contrast to
prevailing models of care that focus on service delivery to
individuals emphasizing short-term symptom reduction, the
136 DUPAUL ET AL.
life-course model prioritizes helping youth with ADHD
improve competencies and develop into independent,
healthy adults who achieve occupational, personal, and
recreational success. Briefly, this model is comprised of
four layers of services including (1) foundational strategies
to establish appropriate structure and supports in home and
school (e.g., parent-teacher communication), (2) psychoso-
cial interventions to increase competencies and address
impairments in academic, behavioral, and social function-
ing (e.g., organization interventions), (3) medication treat-
ment, and (4) accommodations to adapt environments to
children’s limitations (i.e., reductions in expectations).
These layers represent the sequence within which services
should be delivered and combined over time and across
systems and settings. The life course model includes seven
principles for service delivery including the need to: (a)
understand contextual and cultural factors, (b) promote
treatment engagement of parents and youth, (c) tailor inter-
ventions to child’s developmental level, (d) design inter-
ventions to meet individual child and family needs, (e)
facilitate alliances within and between systems, (f) offer
implementation supports for intervention providers, and (g)
conduct progress monitoring to evaluate treatment
response. The hypothetical case below describes common
barriers faced by families as they attempt to receive treat-
ment for ADHD across their child’s development, high-
lighting the need for a life course approach to care and
closures in the research-to-practice gap.
THE CASE OF “JAMES”
James is a boy who lives with his biological parents and
two siblings (9-year-old brother, 2-year-old sister) in
a small urban community in the northeastern US. Since
toddlerhood, James displayed significant inattention and
hyperactive-impulsive behaviors across home and school
settings such that he was expelled from two different pre-
schools due to his disruptive activity. Based on this history,
when James was four, his primary care provider diagnosed
James with ADHD and oppositional defiant disorder
(ODD) and suggested that James start a low-dose of
a psychostimulant medication. Because his mother knew
her neighbor had a bad experience with this type of med-
ication, she declined to fill the prescription.
James experienced significant academic (low report card
grades, inconsistent work completion) and behavioral (e.g.,
inattention to instructions, disruptive verbal and physical
actions) difficulties as he entered and progressed through
elementary school. He also experienced a great deal of
difficulty making and keeping friends. His teachers
attempted a variety of interventions including token rein-
forcement programs and daily behavior report card sys-
tems; however, none of these were implemented in
a sustained fashion with consistency across school years,
and James’s parents were not routinely included in plan
development. James began receiving psychostimulant med-
ication from his primary care provider when he was
in second grade with treatment continuing in various for-
mulations and dosages throughout his school years.
Although medication reduced his ADHD symptoms to
a significant degree, he continued to experience consider-
able academic and social impairment. In addition, his par-
ents were reluctant to let school personnel know about
James’s medication treatment, i.e., there was a significant
disconnect between home and school systems of care for
James.
In middle and high school, James exhibited increasing
difficulties with organization, and study and time manage-
ment skills. With school personnel assistance, James’s par-
ents intermittently implemented homework management
programs (i.e., inconsistent treatment fidelity). School
counselors also met with James periodically to help him
with his study skills and time management. By high school,
James started to develop symptoms of depression (negative
self-cognitions, withdrawal from social activities). Despite
these various treatment efforts over the years, he experi-
enced consistent difficulties with school grades, building
and maintaining friendships, and developing recreational
interests beyond social media and video games. Stated
differently, although the combination of psychosocial treat-
ment strategies and medication led to periodic improve-
ments in James’s ADHD symptoms and related
impairments, these were never sustained over time nor
was his functioning normalized (i.e., commensurate with
academic and social functioning of his peers). Failure to
achieve and sustain substantial gains may have been due to
several factors including lack of access to evidence-based
care (e.g., behavioral parent training), inconsistent treat-
ment implementation fidelity, as well as inherent limitations
of extant short-term treatment strategies (e.g., effects unli-
kely to generalize across settings and over time without
direct programming that is cross-situational and sustained).
The impact of treatment on James’s development also may
have been limited by inconsistent collaboration and com-
munication across home, school, healthcare, and commu-
nity systems. These are among the many areas that should
be prioritized for empirical investigation to enhance out-
comes for children like James.
RECOMMENDATIONS FOR FUTURE RESEARCH
IN TREATMENT DEVELOPMENT AND
EVALUATION
Given the limitations highlighted in the case of James, we
offer three recommendations within the realm of treatment
development and evaluation and three recommendations
 INTERVENTIONS FOR ADHD 137

Future Challenge 1: Treatment Development and Evaluation

Future Challenge 2: Implementation and Dissemination

Primary Care System Family

The Client

Infancy…..Toddlerhood…Childhood….Adolescence…..Young Adulthood.

School System Mental Health System

FIGURE 1 Challenges to psychosocial treatment of youth with ADHD across systems and development.

within the realm of implementation and dissemination (see Behavior Modification

below). Collectively, these recommendations directly
address challenges to psychosocial treatment of ADHD
within and across family, school, primary care, and mental
health systems, affirming the child’s long-term develop-
ment as a priority (see Figure 1).
Recommendation 1: Identify and Leverage
Mechanisms of Change
In order to adequately address the system of care issues,
there needs to be effective treatments and we do not yet
have an adequate arsenal to effectively treat children and
adolescents with ADHD. The development and evaluation
of new treatments is most effective when guided by theory
and evidence of mechanisms of change. A variable can be
considered a mechanism of change that explains why
a treatment works, if the variable is malleable and causally
related to the impairment being treated (Carper, Makover,
& Kendall, 2018; Kazdin, 2007). As we consider the vari-
ety of treatments that have been evaluated for ADHD and
the development of new treatments, it is critical that future
research explicitly focus on identifying mechanisms of
change that account for treatment effects and aligning inter-
vention approaches to impact the identified mechanism.
Using three common treatment approaches described
below, we examine the status of research on mechanisms
of change related to each.
The core elements of a behavioral approach to treatment
have historically focused on the use of operant and classical
conditioning by parents and teachers. Some research exists
indicating that much of the impairment associated with
ADHD reflects a performance deficit, not a skills acquisition
deficit (e.g., Aduen et al., 2018). This finding may explain
why psychoeducation approaches are not effective with these
children (e.g., traditional social skills training; Evans et al.,
2018), but can be effective when taught in the context of an
intensive behavioral program that uses operant conditioning
principles to address performance deficits (Pelham et al.,
2014). In addition, there has been research on malleable
characteristics of children with ADHD that may explain the
effectiveness of behavior modification approaches, such as
reward sensitivity (Tenenbaum et al., 2018; Tripp & Alsop,
2001). Identification and an improved understanding of malle-
able constructs that are causally related to impairment in
children with ADHD will help us improve our behavioral
interventions and their long-term benefits.
Cognitive Strategies
Cognitive or cognitive behavioral therapy (CBT) has an
interesting history for youth with ADHD. The original putative
mechanism of change for CBT was that children with ADHD
were not adequately thoughtful before acting and by teaching
children to think out loud, one could improve their thoughtful-
ness, planning, and problem-solving prior to exhibiting
138 DUPAUL ET AL.
impulsive behaviors (e.g., Meichenbaum & Goodman, 1971).
Although one could teach children with ADHD to do this
during sessions, the skill rarely persisted after leaving the
clinician. CBT reemerged in the last decade as a potential
approach to treating adolescents and adults with ADHD; how-
ever, clinical trials of CBT with adolescents with ADHD have
not resulted in improvements in functioning (e.g., Boyer et al.,
2015; Sprich et al., 2016; Vidal et al., 2015), and the potential
mechanism of change specifically related to ADHD has not
been clearly elucidated. Further, although negative self-
statements are commonly observed in adolescents with
ADHD (like James), and cognitions are likely malleable,
there is not yet evidence to suggest that they are causally related
to the impairment that is specific to ADHD. In fact, it may be
that adolescents and adults with ADHD develop these depres-
sion-related cognitive factors as a result of persistent ADHD-
related impairment over time and these factors are causally
related to the emergence of comorbid depression. This is con-
sistent with recent findings that almost 50% of young adoles-
cents with ADHD experience a decline in their self-worth, and
those with decreasing self-worth were more likely than their
peers with ADHD without decreasing self-worth to have higher
depressive symptoms at age 15 (Dvorsky, Langberg, Becker, &
Evans, 2019). In order to develop effective cognitive interven-
tions for youth with ADHD, there is a critical need to improve
our understanding of cognitive factors that may be causally
related to impairment associated with ADHD and to develop
techniques to effectively change those specific factors. It is
important to consider the possibility that CBT may not be
a fruitful path for adolescents with ADHD. Most disorders
that can be treated effectively with CBT (e.g., anxiety, depres-
sion) involve individuals who think too much (e.g., ruminating,
worry) and their thinking is thought to affect their emotions and
behavior (Beck, Rush, Shaw, & Emery, 1979). Conversely,
adolescents with ADHD tend to not think enough before acting
(i.e., impulsivity) and there are questions about the degree with
which their thoughts adequately shape their behavior. Thus,
changing the nature of their thoughts may not effectively
translate to behavior change.
Training Interventions
Training interventions have emerged as an alternative to
behavior therapy for youth with ADHD. Training interventions
begin with brief psychoeducation about a target skill (e.g.,
materials organization) and the majority of the time after that
is spent with extensive practice and performance feedback. It
has been recommended that for training to be effective, the skill
must be directly applicable to an area of impairment, and
practice with performance feedback must occur frequently
and over an extended period of time (Evans et al., 2018).
Studies with children (Abikoff et al., 2013) and young adoles-
cents (Langberg et al., 2012) with ADHD indicate that training
and behavioral interventions have similar short-term benefits,
but there is evidence unique to training interventions that their
long-term benefits may meaningfully exceed those of other
treatments (Evans et al., 2016). It may be that once skills are
established through a training intervention, they become rou-
tine and persist longer than behaviors shaped by rewards.
Increasing our understanding of the mechanisms for training
interventions can lead to development of optimally effective
approaches. In addition, training interventions have been
applied to relatively few areas of impairment (e.g., study and
organization skills) and evaluating them across the diverse
range of functioning may yield new tools for treatment.
Recommendation 2: Examine Impact of Development
on Treatment Mechanisms and Outcomes
In the first several decades of ADHD treatment research, there
was little focus on developmental level. For example, in the
series of four evidence-based treatment reviews for youth with
ADHD that began in 1998 (Evans, Owens, & Bunford, 2014;
Pelham & Fabiano, 2008; Pelham et al., 1998), it was not until
the most recent version that levels of evidence were differen-
tiated based on ages of participants (Evans et al., 2018). Indeed,
all of the issues addressed previously in the discussion of
mechanisms of change are not static, as mechanisms are likely
to change across development. Thus, it is critical to identify
relevant mechanisms at each stage of development. However,
even if the mechanism remains the same across development,
treatment outcomes may also differ as a function of develop-
ment. For example, one developmental issue is that effect sizes
of behavioral interventions may diminish as children age into
adolescence (Sanders, Kirby, Tellegen, & Day, 2014).
Although it is unlikely that behavioral principles become less
relevant as children age, it is possible that the ability of an adult
to adequately manage the complexities of reinforcement and
punishment that operate in the life of a 15-year-old adolescent
is far less than an adult’s ability to manage these in the life of
a 5-year-old. The complex web of contingencies in the envir-
onment of adolescents means that parents and teachers are
competing with numerous other sources of reinforcement and
punishment (e.g., peer attention, social reputation issues, vari-
ety of achievement goals). Understanding not only the beha-
vioral mechanisms of action, but also those associated with
cognitive and training interventions across development are
likely to lead the field to new and innovative approaches to
treatment.
Recommendation 3: Design Intervention Research
Informed by a Life Course Model
Research clearly indicates that ADHD is a chronic condition.
A childhood diagnosis of ADHD places individuals at risk for
deleterious outcomes in adulthood, regardless of their ADHD
diagnostic status later in life (Hechtman et al., 2016).
Furthermore, the Multimodal Treatment Study of ADHD
(MTA) found that beneficial effects of behavioral and

medication treatment for ADHD implemented during child-
hood were not maintained into adolescence and young adult-
hood (Molina et al., 2009). To address the chronic nature of
ADHD, the need for sustained monitoring of outcomes over
time, the changing presentation of the condition and associated
risks over the course of development, and the need for inter-
vention at various points during development (illustrated in the
case of James), our team has espoused a life course model of
care. This model is complementary with key elements of the
chronic care model, which has been recommended as
a framework for the management of ADHD (American
Academy of Pediatrics [AAP], 2019; Van Cleave & Leslie,
2008). Three components of the chronic care model are espe-
cially relevant for ADHD intervention development: (1) sys-
tems to support population-based care; (2) strategies to
facilitate alliances across systems; and (3) strategies to promote
self-management of one’s own condition.
Systems to Support Population-Based Care
Historically, care for children with ADHD has been
conceptualized at the individual level; services are provided
to one child at a time in a reactive manner by responding to
problems when they emerge (see the case of James). In
contrast, a population-based approach examines the popu-
lation of children served by an agency or organization (e.g.,
school district, primary care network), and tracks outcomes
for all individuals in the population over an extended per-
iod of time. A population-based approach creates opportu-
nities for proactive involvement with children who are
identified as being at risk. Services are provided in the
context of a multi-tiered or multi-layered system of care
to provide the right level of care in the most efficient
manner.
Research in Schools. A considerable body of research
has been conducted in schools to examine how a population-
based approach can be applied. In some school systems, all
students are tracked with regard to reading and math perfor-
mance, and behavioral functioning. Indices of behavioral func-
tioning might include suspensions, office discipline referrals,
and frequent ratings of behavior by teachers using brief check-
lists (Christ, Riley-Tillman, & Chafouleas, 2009). Data from
these tracking methods are used to determine whether: (a) the
child can be supported using evidence-based strategies that can
be readily implemented to the entire classroom (Tier 1); (b)
additional support may be required using brief, but individua-
lized evidence-based practices (Tier 2); or (c) more intensive
evidence-based approaches are needed, which in some cases
might require special education resources (Tier 3; Sugai &
Horner, 2006). Unfortunately, there is very little research on
how to translate assessment results into choice of interventions
or even tiers of interventions.
INTERVENTIONS FOR ADHD 139
Future research should focus on how progress monitoring
data can be used to inform decisions about moving up and
down a tiered (layered) model of service delivery. Using popu-
lation-based data, benchmarks indicating the probability of
achieving positive outcomes at each tier could be proposed
and evaluated. Further, adaptive or sequential multiple assign-
ment randomized trials (SMART) designs (e.g., Pelham et al.,
2016) could be used to test sequences of tiered interventions
and movement to different tiers of care based on response to
intervention and attainment of benchmarks. Such research may
be particularly important during transitions in schooling such as
entry into elementary, promotion to middle or high school, and
transition from high school to early adulthood.
Research in Health Systems. Similar to schools,
a body of research has emerged supporting the use of
a population-based approach for the care of individuals with
chronic illnesses (e.g., asthma, diabetes) or at risk for poor
health outcomes in the context of health systems.
Unfortunately, there has been a striking lack of research to
guide the application of this approach related to pediatric
behavioral health conditions in health systems, including pri-
mary care. Additional research is needed to identify the ele-
ments of an approach targeting all children and adolescents
with ADHD in primary care. For example, electronic systems
are being developed to support the assessment of ADHD and
monitoring of outcomes (Epstein et al., 2011), but we have
much to learn about how data in the electronic health record
(EHR) can be used (e.g., through registries) to support universal
care for children with ADHD and decision making to move to
higher tiers of care when needed.
Strategies to Facilitate Alliances across Systems
Services for children and adolescents with ADHD are
offered in several settings, especially schools, primary care
practices, and mental health agencies (public and private).
Unfortunately, service delivery is fragmented and there is
poor coordination across systems of care, often resulting in
parents being placed in the challenging position of linking
systems (Guevara et al., 2005), as was the case for James.
At least three approaches have been attempted to facilitate
alliances across systems. One approach has been to use
electronic information systems to assess ADHD symptoms
and impairments and monitor outcomes; assess parent-
reported goals for treatment and monitor goal attainment;
and share information across systems of care (i.e., families,
schools, primary care practices; Power et al., 2016).
Because electronic information systems have the potential
to be provided to a large portion of the population of
individuals with ADHD, they have been proposed as part
of universal approaches to care (Power, Mautone, Blum,
Fiks, & Guevara, 2019).
140 DUPAUL ET AL.
Another approach is to enlist patient navigators to pro-
mote collaborations among systems of care. This approach
has been proposed as a Tier 2 strategy for families and
providers who need an intermediate level of support (Power
et al., 2019). To date, there has been minimal research on
the use of care managers to support care for children with
ADHD and critical components of the role of these
providers.
A third approach, proposed as a Tier 3 strategy, is to
embed evidence-based interventions in the context of inte-
grated methods of service delivery in primary care (Kolko
et al., 2014). Integrated primary care offers a mechanism to
promote collaboration between pediatric providers and
mental health professionals in the delivery of evidence-
based psychosocial and pharmacological interventions.
A limitation is that this approach typically does not pro-
mote connections with schools, although models of inte-
grated care have been adapted to link families, schools, and
pediatric providers (Power et al., 2014). There are many
challenges to research related to this work including the
feasibility and acceptability of these approaches. For exam-
ple, there is evidence that the value of integrating services
may not be widely shared across professional groups. One
study reporting an attempt at integrating teachers’ ratings of
children’s behavior into the medication decisions of psy-
chiatrists reported extreme difficulties getting teachers to
complete ratings and even when ratings were collected,
psychiatrists rarely considered the teacher data when mak-
ing decisions regarding medication treatment (Pliszka et al.,
2003). This is just one example of the substantial research
challenges that need to be addressed when pursuing the
goal of an integrated approach to primary care.
Strategies to Promote Self-Management
Parents have a high level of responsibility for the man-
agement of ADHD, especially when children are young.
Parents can benefit from psychoeducation (Ferrin et al.,
2014), as well as strategies to promote readiness for change
and motivation to pursue services (Nock & Kazdin, 2005).
Although the major focus of efforts to promote parental
empowerment has been on parents of young children with
this condition, it is important to address parents’ ongoing
needs for psychoeducation and motivational support, parti-
cularly during periods when their children are struggling
and resources seem to be lacking. In addition to targeting
parents, starting in the upper elementary years, and cer-
tainly by middle school, youth with ADHD are capable of
assuming some responsibility for the management of their
condition. It is important for them to become aware of their
limitations in paying attention and regulating their beha-
viors and emotions, their need for academic and social
support, and evidence-based strategies to assist them. In
spite of the importance of youth with ADHD to learn how
to manage their own care, there is very little research on
how to promote their empowerment in managing ADHD.
There are exciting opportunities to develop programs to
promote youth empowerment to manage ADHD across
the developmental span from elementary school through
secondary school and into early adulthood.
RECOMMENDATIONS FOR FUTURE RESEARCH
IN IMPLEMENTATION AND DISSEMINATION
The four evidence-based treatment reviews for ADHD (Evans,
Owens, & Bunford, 2014; Evans et al., 2018; Pelham &
Fabiano, 2008; Pelham et al., 1998) that cover over 60 years’
worth of research reveal a striking imbalance toward efficacy
studies relative to effectiveness studies. In the last review, less
than 10% of studies evaluated treatments implemented by
practitioners (i.e., non-research staff). Although efficacy studies
have been critical to the identification of evidence-based treat-
ment (EBTs), with so few effectiveness trials, the next genera-
tion of research should prioritize studying EBTs under
authentic conditions (e.g., with referred rather than recruited
cases, implemented by practitioners rather than research staff).
Implementation research is the scientific study of methods to
promote the systematic adoption of research findings and evi-
dence-based practices into routine practice, with the goal of
improving the quality of care (Eccles & Mittman, 2006). One
example of implementation research involves hybrid effective-
ness-implementation trials wherein both implementation and
treatment outcomes are evaluated simultaneously (Landes,
McBain, & Curran, 2019). In a hybrid design, researchers can
(1) test the effects of a clinical intervention on relevant out-
comes while gathering information on implementation; (2)
simultaneously test a clinical intervention and an implementa-
tion strategy; or (3) test an implementation strategy while
gathering information of a clinical intervention’s impact on
child outcomes. We recommend that the field focus on imple-
mentation science approaches, including hybrid designs, to
study EBTs under authentic conditions to enhance the state of
the science related to EBTs for ADHD in three critical areas:
access, implementation fidelity, and cost-effectiveness.
Recommendation 4: Develop and Evaluate Strategies
that Promote Treatment Access
As described previously, despite strong evidence distinguishing
EBTs from other practices, most children coping with ADHD
lack access to evidence-based psychosocial treatment
(Danielson et al., 2018; DuPaul et al., 2019). In order to have
EBTs make a significant impact on the nearly 7 million youth
struggling with ADHD, the next generation of research must
develop and evaluate strategies for ensuring that EBTs reach
the majority of those affected by the disorder.
One mechanism that can be leveraged to enhance access
to EBTs is technology. There are several examples where

technology has been pilot tested as a means to enhancing
access to care in primary care offices and schools, yet
additional work is needed. For example, there is emerging
evidence that technology, such as electronic health records
(EHR) with templates specific to ADHD and with remin-
ders for quality care actions can increase the likelihood of
assessment of ADHD and quality documentation of that
assessment (e.g., Johnson et al., 2010). Also as discussed
previously, electronic systems have been developed to
facilitate cross-setting (i.e., primary care offices, schools,
and home) communication to enhance access to evidence-
based assessment and treatment practices (e.g., Epstein
et al., 2011). A promising system embedded in the EHR
is the ADHD Care Assistant (see Power et al., 2016) which
was designed to promote (a) shared decision-making
between family and provider by identifying family goals
and preferences for treatment (Fiks et al., 2012) and asses-
sing goal attainment; and (b) the sharing of information
among parents, educators, and health providers (Michel
et al., 2018). Expanded development and evaluation of
electronic systems such as the ADHD Care Assistant in
the context of pediatric primary care holds the promise of
facilitating access to screening, assessment, and early
detection of ADHD. Indeed, such a system may have sig-
nificantly changed the life course for James and his family.
However, additional study is needed to overcome barriers
to use (e.g., technology support, parent and teacher access
to technology) with a specific focus on uptake and sustain-
ment. Additionally, there is a need for expansion of online
systems to include measures validated for diagnosis and
progress monitoring for preschool and adolescent popula-
tions to enhance access to quality assessment for these
populations.
Technology is also being leveraged to enhance chil-
dren’s access to EBTs in schools. For example, using
hybrid designs, Owens and colleagues (Mixon, Owens,
Hustus, Serrano, & Holdaway, 2019; Owens et al., 2019)
developed and evaluated the Daily Report Card.Online
(DRC.O) system, an interactive online resource that facil-
itates teachers’ knowledge, adoption, and implementation
of a daily report card (DRC) intervention. The DRC.O
mirrors face-to-face consultation through professional
development content (including video models) that teachers
can access at their own time and pace, as well as interactive
mobile-friendly features designed to support teachers as
they develop the DRC, monitor and graph student progress,
and modify the intervention over time. Two studies docu-
ment that, with this technology and very minimal additional
support, a meaningful portion of teachers (39% to 54%) can
adopt and implement at DRC with positive student out-
comes (Mixon et al., 2019; Owens et al., 2019). However,
these were open trials with small samples. Thus, additional
INTERVENTIONS FOR ADHD 141
more rigorous trials of this and other technologies are
needed including study of applications to secondary school
students.
Recommendation 5: Identify Strategies to Optimize
Implementation Fidelity
Despite the presence of clearly delineated manuals and
guidelines for implementation of EBTs for ADHD, many
providers are not trained in EBTs and the fidelity with
which treatments are implemented is known to degrade
when implementation supports and/or accountability are
reduced (e.g., Noell et al., 1997). Thus, if EBTs are not
implemented with high fidelity (as was the case for James),
there is likely little chance that they will impact desired
youth outcomes (e.g., Owens et al., 2018) and ultimately
little value in improving access. Thus, two top priorities for
future research in the area of enhancing intervention fidelity
are the identification of mechanisms for (a) efficient and
effective training of those who can provide EBTs for
ADHD (e.g., teachers, mental health providers, PCPs) and
(b) holding clinicians and teachers accountable for high
quality implementation.
There are multiple viable approaches for enhancing training
and accountability, and perhaps a combination of these
approaches may be necessary. For example, there is emerging
evidence that influential peers within a given social network
(e.g., teachers within a school, providers within an agency) may
be powerful facilitators of enhanced implementation outcomes
(e.g., Atkins et al., 2008). Although not all specific to ADHD,
research is being conducted to determine how influential peers
can be efficiently identified and how these influential leaders
can be leveraged to enhance others’ knowledge, adoption, and
implementation of EBTs (e.g., Cappella & Godfrey, 2019).
Given the chronic nature of ADHD, a particularly compelling
line of research would be to examine how influential peers
could facilitate successful transition of students with ADHD
across grade levels and school settings.
Second, a review of training strategies across disciplines
(Lyon, Stirman, Kerns, & Bruns, 2011) highlights the utility
of several approaches (e.g., coaching, reminders, problem-
based learning) over one-time training in shaping provider
behavior. A critical next step in this research is to examine
the possible mechanisms of change responsible for the associa-
tion between training strategies and improvements in provider
behavior. By understanding the unique processes responsible
for provider behavior change, we may be able to consider
which strategies are unique or redundant so that complimentary
strategies could be combined to maximize outcomes. In addi-
tion, research is needed to examine how such training and
implementation supports can be made feasible and sustainable
by schools and health/mental health agencies.
142 DUPAUL ET AL.
Third, there is evidence that measurement feedback systems
provided to clinicians can enhance child outcomes (e.g.,
Bickman, Kelley, Breda, de Andrade, & Riemer, 2011).
However, this strategy is rarely used in agencies, health sys-
tems, or schools. In addition to identifying methods to increase
the use of measurement feedback systems in key settings, it will
be important to study how the use of technology, influential
peers, effective training and feedback systems could be com-
bined to enhance implementation by teachers and clinicians.
Lastly, another innovative mechanism for enhancing quality
and desired child outcomes is via a pay-for-success contract.
Within such a contract, investors offer capital up front, inde-
pendent evaluators are leveraged to assess the extent to which
desired outcomes are achieved (e.g., cost savings are accrued
due to reduction in risk status), and for each success case
achieved, the investors receive a return of the principal plus
a financial benefit. The U.S. Department of Education has
launched several pay-for-success contract projects (https://
www2.ed.gov/about/inits/ed/pay-for-success/index.html),
some of which are demonstrating promise within rigorous
randomized designs (https://ssir.org/articles/entry/pay_for_suc
cess_is_working_in_utah). Similarly, health systems are imple-
menting this type of arrangement by focusing on value-based
payments through accountable care organizations (i.e., health
practices receive lump sums based on patients served and
patient outcomes; Rawal & McCabe, 2016). Thus, the impact
of pay-for-success contracts to optimize ADHD treatment fide-
lity in health and school settings is a potentially fruitful line for
effectiveness research.
Recommendation 6: Examine and Optimize
Cost-Effectiveness
As early as the 1998 review (Pelham et al., 1998), research-
ers were recommending analyses to reveal the relative costs
and cost effectiveness of behavioral as compared to phar-
macological treatments. In the ensuing decade, studies
examined the cost-effectiveness of medication management
and behavioral intervention as prescribed in the Multi-
modal Treatment Study for ADHD (Foster et al., 2007;
Jensen et al., 2001). These studies provided important
advancements in our knowledge of cost; however, costs
were estimated using treatments provided in the MTA
study, which are not replicable and not available in most
communities.
Addressing this limitation (i.e., using less intensive
treatment protocols), Page et al. (2016) examined the rela-
tive cost effectiveness of behavioral, pharmacological, and
combined interventions employed in a sequential, adaptive
trial investigating the sequencing and enhancement of treat-
ment for children with ADHD (Pelham et al., 2016).
Findings suggest that starting with a low dose behavioral
intervention was less costly ($961) for one year of treat-
ment and more effective in changing impairment in
functioning than beginning treatment with a low dose of
pharmacological intervention ($1,689). This study is the
first to examine treatment sequencing and offers support
for the proposed layers in the life course model. However,
many more questions about cost remain. For example, from
a school perspective, administrators could benefit from
knowing the relative cost-effectiveness of various universal
school-wide or classwide approaches in preventing the
need for more intensive services, or the relative cost-
effectiveness of using classroom interventions versus
accommodations. School and clinic administrators also
could benefit from knowing the relative cost-effectiveness
of various models (e.g., technology-driven, one-time train-
ing, ongoing consultation) of professional development and
implementation supports for teachers and clinicians.
Further, to date, published research only reveals cost effec-
tiveness for elementary students; future studies are needed
for preschool and adolescent populations, as treatments and
risk profiles differ from those for elementary school
students.
CONCLUSIONS
Given the chronicity of symptoms and impairment asso-
ciated with ADHD, it is critically important that effec-
tive treatment strategies are implemented across home,
school, and community settings to reduce symptoms
and, most importantly, enhance educational and social
functioning over time (see Figure 1). Although multiple
psychosocial intervention approaches have been found
efficacious in the context of controlled investigations,
these treatments often are not implemented with suffi-
cient fidelity and/or consistently across systems and
time in community and school settings, as was demon-
strated by the case of James. Using a life course model
as context, we propose six research directions to
address major challenges to treatment development,
evaluation, implementation, and dissemination.
Priorities for psychosocial treatment development and
evaluation are to identify and leverage mechanisms of
change, examine and address the impact of child devel-
opmental status on treatment mechanisms and out-
comes, and design intervention research informed by
a life course model. Treatment implementation and dis-
semination investigations should leverage implementa-
tion science methods to develop and evaluate strategies
that promote access to evidence-based treatment, opti-
mize treatment fidelity in community and school set-
tings, and optimize costs and cost-effectiveness of
psychosocial interventions.
To support this work, investigators should consider
funding mechanisms such as Clinical Trials to Test the
Effectiveness of Treatment Preventive, and Services

Interventions offered by the National Institute of Mental
Health (https://grants.nih.gov/grants/guide/rfa-files/RFA-
MH-18-701.html) that are designed to support trials that
examine effectiveness of interventions and possible
mechanisms of action. Alternative sources of funding that
place a priority on effectiveness and implementation
research are the Institute of Education Sciences and the
Patient-Centered Outcomes Research Institute. Our field
needs to go beyond short-term, efficacy trials to reduce
ADHD symptoms conducted under ideal controlled condi-
tions and successfully address the research-to-practice gap
by advancing development, evaluation, implementation,
and dissemination of evidence-based treatment strategies
to ameliorate functional impairment that can be used with
fidelity by parents, teachers, and community health provi-
ders. By focusing research in these directions, we can
substantially improve outcomes for youth with ADHD
like James.
DISCLOSURE STATEMENT
No potential conflict of interest was reported by the
authors.
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