Engagement Barriers to Behavior Therapy for Adolescent ADHD

ABSTRACT

Objective

To identify barriers to behavior therapy for adolescent ADHD (Supporting Teens’ Autonomy Daily; STAND) and understand the relationship between barriers and treatment engagement.

Method

A mixed-method design with qualitative coding of 822 audio-recorded therapy sessions attended by 121 adolescents with ADHD (ages 11–16; 72.7% male, 77.7% Latinx, 7.4% African-American, 11.6% White, non-Latinx) and parents. Grounded theory methodology identified barriers articulated by parents and adolescents in session. Barriers were sorted by subtype (cognitive/attitudinal, behavioral, logistical) and subject (parent, teen, dyad). Frequency and variety of barriers were calculated by treatment phase (engagement, skills, planning). Generalized linear models and generalized estimating equations examined between-phase differences in frequency of each barrier and relationships between barriers frequency, subtype, subject, and phase on engagement (attendance and homework completion).

Results

Coding revealed twenty-five engagement barriers (ten cognitive/attitudinal, eleven behavioral, four logistical). Common barriers were: low adolescent desire (72.5%), parent failure to monitor skill application (69.4%), adolescent forgetfulness (60.3%), and adolescent belief that no change is needed (56.2%). Barriers were most commonly cognitive/attitudinal, teen-related, and occurring in STAND’s planning phase. Poorer engagement was associated with cognitive/attitudinal, engagement phase, and dyadic barriers. Higher engagement in treatment was predicted by more frequent behavioral, logistical, parent, and skills/planning phase barriers.

Conclusions

Baseline assessment of barriers may promote individualized engagement strategies for adolescent ADHD treatment. Cognitive/attitudinal barriers should be targeted at treatment outset using evidence-based engagement strategies (e.g., Motivational Interviewing). Behavioral and logistical barriers should be addressed when planning and reviewing application of skills.

Disclosure statement

Dr. Sibley receives book royalties from Guilford Press and video royalties from Vimeo, Inc. for clinician informational material regarding the treatment evaluated herein.

Data availability

The quantitative (but not qualitative) data utilized in this study is publicly available through the National Data Archive: (https://nda.nih.gov), including a data dictionary.

Supplemental data

Supplemental material for this article can be accessed online at https://doi.org/10.1080/15374416.2022.2025597.

Additional information

Funding

This study was funded by the National Institute of Mental Health [R21 MH116499]. It was also funded, in part, R34MH092466 and the Klingenstein Third Generation Foundation.