Psychosocial Interventions

in Attention-Deficit/
H y p e r a c t i v i t y D i s o rd e r : Update
Kevin M. Antshel, PhD

KEYWORDS
 ADHD  Psychosocial  Behavioral  Treatment  Child  Adolescent

KEY POINTS
 Medications are useful for managing the symptoms of attention-deficit/hyperactivity
disorder (ADHD), but are less effective for improving functioning.
 Psychosocial interventions for child/adolescent ADHD target functional impairments as
the intervention goal, and rely heavily on behavioral therapy techniques and operant
conditioning principles.
 Behavioral parent training, elementary school–based interventions that rely on behavioral
modification, intensive multimodal middle- and high-school interventions that rely on
teaching skills and operant conditioning principles, in addition to an intensive summer
treatment program are the most evidence-based psychosocial interventions for managing
pediatric ADHD.
 While showing some promise, more research is needed on nontraditional social skills
training for children and cognitive-behavioral treatment interventions for adolescents
before recommendations can be made.
 Psychosocial interventions should be used in conjunction with medication management.

INTRODUCTION

Attention-deficit/hyperactivity disorder (ADHD) is the most common reason for referral

to child and adolescent psychiatry clinics, and affects approximately 5% to 10% of
youth worldwide.1,2 The defining features of ADHD include developmentally inappro-
priate and impairing levels of inattention and/or hyperactivity-impulsivity that begin
before age 12 years and cannot be better explained by other factors (eg, anxiety, defi-
ance).3 The academic,4 social,5 and family6,7 domains are generally the most impaired
in children with ADHD. Once considered to be a condition that children outgrew in
adolescence,8 there is now compelling evidence that ADHD often continues into
adolescence and adulthood.9,10 Though sometimes portrayed as a benign condition

The author does not have any financial disclosures or conflicts of interest to report.
Department of Psychology, Syracuse University, 802 University Avenue, Syracuse, NY 13244, USA
E-mail address: kmantshe@syr.edu

Child Adolesc Psychiatric Clin N Am 24 (2015) 79–97

http://dx.doi.org/10.1016/j.chc.2014.08.002 childpsych.theclinics.com
1056-4993/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
80 Antshel

Abbreviations

ADHD Attention-deficit/hyperactivity disorder

BPT Behavioral parent training
CBT Cognitive-behavioral treatment
CHP Challenging Horizons Program
DRC Daily report card
HOPS Homework, Organization, and Planning Skills program
IEP Individualized education plan
MTA Multimodal Treatment of ADHD study
SST Social skills training
STP Summer treatment program

in the popular media,11 ADHD is an impairing psychiatric disorder that imparts consid-
erable lifetime economic costs (medical, education, legal, and so forth) that rival the
costs for major depressive disorder and stroke.12

FRONT-LINE INTERVENTIONS FOR ATTENTION-DEFICIT/HYPERACTIVITY DISORDER

Given the chronic nature of ADHD, both pharmacologic and psychosocial interven-
tions are used to manage the disorder. A front-line intervention is stimulant medica-
tions, which are effective in approximately 80% of youth with ADHD.13 Stimulant
side effects can include decreased appetite and increased sleep-onset latencies
and, while positively affecting the core ADHD symptoms (eg, inattention, impulsivity),
stimulants generally do not normalize peer relationships,14 lessen family dysfunc-
tion,15 or improve academic achievement.16 The use of conjoint psychosocial treat-
ments with ADHD medications can result in the need for lower doses of each form
of treatment.17 Parents are also more accepting of and interested in treatments that
include psychosocial components.18 For all these reasons, psychosocial interventions
have continued to play a prominent role in the management of youth with ADHD.
For the purposes of this article, psychosocial interventions are defined as any inter-
vention that stresses psychological or social factors rather than biological variables.
This is not to say that biological treatments (eg, medication, dietary modifications)
do not have a place in ADHD management; most treatment guidelines recommend
medication as a front-line intervention.19 Several stimulant (eg, methylphenidate,
amphetamine salts) and nonstimulant medications (eg, guanfacine, atomoxetine) are
approved by the US Food and Drug Administration for ADHD management, with large
effect sizes (Cohen d 5 0.9) reported for stimulant medications.20 Likewise, although
with smaller effect sizes (Cohen d 5 0.3), dietary interventions, including single
nutrient supplements,21 multinutrient supplements,22,23 and supplementation with
omega-3 fatty acids,24–27 have received more empirical attention in the past 10 years
and are now used more in ADHD management. Nonetheless, these biological inter-
ventions are not be considered in this review.
Biological treatments such as stimulant medications explicitly target ADHD symp-
toms, not functional impairments. However, it is functional impairments, not symp-
toms, which compel parents to seek treatment for ADHD.28 As a group, the
psychosocial interventions reviewed herein target functional impairments as the inter-
vention goal.
In addition to this common factor, the psychosocial interventions for ADHD man-
agement considered in this article all share another common factor: the heavy reliance
on behavioral therapy techniques and operant conditioning principles. Research
demonstrating that children with ADHD are less responsive to inconsistent, delayed,
 Psychosocial Interventions in ADHD 81

or weak reinforcement, and are less responsive to punishment cues,29,30 supports the
usefulness of behavioral therapy techniques and operant conditioning principles in
ADHD. Barkley’s31 theory of ADHD as a problem in response inhibition and self-
regulation, with the secondary consequences this may create for their poor self-
motivation to persist at assigned tasks, provides a theoretically based rationale for
the use of behaviorally based interventions with ADHD. Barkley’s theoretic stance is
that these psychosocial interventions are not being done primarily to increase skills
that children with ADHD may appear to lack, but are being used to enhance the defi-
cient self-motivation and working memory of these children to help them demonstrate
what they already know. From this perspective, ADHD is a disorder of performance,
not of knowledge of skills. Thus, psychosocial interventions are used to cue the use
of such skills at key points of performance in natural settings, and to motivate their
display through the use of artificial consequences that ordinarily do not exist at those
points of performance in natural settings.

Parent Training in Behavioral Management

Behavioral parent training (BPT) programs (also referred to as parent management
training or parent training) are effective for children with disruptive behaviors whether
or not the children have co-occurring inattention/hyperactive-impulsive symp-
toms.32,33 Although nonspecific to ADHD, BPT programs also seem to be efficacious
for children with ADHD34–44 yet are somewhat less effective for adolescents with
ADHD.45 Three separate reviews in the past 15 years46–48 have concluded that BPT
is a well-established evidence-based treatment for managing ADHD in children.
There is a variety of BPT programs that have been studied with ADHD children,
including Cunningham’s COPE program (Community Parent Education Program49),
Webster-Stratton’s The Incredible Years,50 and Barkley’s Defiant Children.51 Other pro-
grams used with oppositional or noncompliant children, some of whom undoubtedly
also have ADHD, are Eyberg’s Parent-Child Interaction Therapy52 and Sanders’ Triple
P (positive parenting program),53 which have demonstrated efficacy according to a
meta-analysis of the literature.54 All of these programs are founded on a social learning
model of disruptive child behavior (disrupted parenting and social coercion), and all
have demonstrated efficacy for disruptive children, including those with ADHD.34
BPT programs generally consist of weekly training sessions, either in groups of par-
ents or with individuals, each focusing on a discrete operant conditioning technique.
These methods can be grouped into 3 basic types of procedure:
1. Those that manipulate the environmental events that may precede or surround a
child’s tasks/activities so as to increase positive or negative behavior (ie, parental
commands, task demands, teacher instructions, and so forth)
2. Those that may restructure the tasks to be done (reduce work quotas, insert more
interesting task materials, and so forth)
3. Those that manipulate the nature of the consequences for child behavior in that
setting (ie, attention, praise, token reinforcement, punishment, and so forth)
For example, Webster-Stratton’s Incredible Years50 curriculum for school-aged
children consists of a minimum of twelve 2-hour weekly group sessions that focuses
on such topics as:
a. Providing positive parental attention and special time
b. Engaging in social, emotion, and persistence coaching
c. Utilizing effective praise and encouragement
d. Using tangible reward programs to motivate your child
82 Antshel

e. How to effectively implement rules, responsibility, and routines

f. Using predictable learning routines and delivering clear limit-setting messages
g. Ignoring misbehavior
h. Using time-outs to calm down
In most BPTs, the initial focus is on the implementation of reinforcement techniques
(eg, positive attention, praise), for 3 primary reasons:
1. The use of reinforcement may result in less disruptive behaviors, thus lessening the
need for punishment techniques
2. The coercive cycle is disrupted by the use of reinforcement
3. It is easier to implement reinforcement than punishment programs consistently and
effectively.

Functional impairments as targets

BPTs such as The Incredible Years do not target ADHD symptoms but rather are
directed at functional impairments.46 For children and adolescents with ADHD, these
functional targets often include improving adherence to parental requests (eg, do
homework at the prescribed time), reducing dependence on parents to manage daily
routines (eg, getting ready for school in the morning) and lessening defiance toward
parental requests. In addition to targeting child functional impairments, BPTs also
aim to address coercive or dysfunctional parenting practices.55 For example, parents
of children with ADHD often demonstrate more negative and less consistent parenting
practices in addition to less positive parenting behaviors.15,56 These coercive parent-
child interaction cycles predict a variety of functional impairments outside of the home
environment.57,58
BPTs are generally efficacious across different races and ethnicities.59 More favor-
able BPT treatment outcomes, however, are associated with parents who attend BPT
sessions regularly and report consistently using the interventions,60,61 as well as those
families in which the parents are optimistic about the child’s ability to improve.62 Intact
families and those with lower levels of parental psychopathology and stress also
generally improve more with BPT.48 Finally, when present, maternal ADHD seems to
significantly limit the outcomes of BPT.63
In addition to the general BPT programs already listed, BPTs have also been devel-
oped that are specific to ADHD areas of impairment. For example, a BPT called
Parental Friendship Coaching has been developed to target social problems. In this
intervention, parents are taught strategies to help promote and reinforce their children
in the engagement of successful peer interactions.64 Likewise, another BPT involves
training parents and teachers to reinforce children contingently for meeting improve-
ment goals for organizational, homework, and school performance.65 This program
also includes the use of a daily report card (DRC) that goes home with the children,
a home-based point system for achieving goals, and the implementation of a home-
work routine. Thus, in addition to the use of general BPTs, several ADHD-specific
BPTs have been developed.

Inadequacies of therapy
Despite the aforementioned benefits of BPTs, several inadequacies exist. First,
despite improvements in ADHD symptoms and increased adherence to parental re-
quests, BPTs do not normalize child functioning. Second, most studies of BPTs
have only assessed outcomes in the months following the BPT, not across years.66
Thus, the maintenance of these effects remains an open question. Finally, the positive
outcomes are generally only observed in the environment where the BPT is focused.
 Psychosocial Interventions in ADHD 83

Interventions used at home therefore typically do not generalize to other settings (eg,
school).67,68

School-Based Interventions
In addition to BPTs, several evidence-based management approaches for ADHD
occur in the school setting. This fact is not surprising, given that school functional im-
pairments are often listed as one of the most impaired domains for children with
ADHD.69,70 For the sake of simplicity, the interventions are organized by target
population.

Elementary school
Many of the school-based behavioral interventions seek to improve positive behaviors
by understanding the context (antecedents and consequences) of the negative behav-
iors. Negative or off-task behaviors are hypothesized to serve 1 of 4 primary
functions71:
1. Escape or avoidance of a nonpreferred activity or setting
2. Gain access to materials or preferred settings
3. Gain attention
4. Sensory stimulation
Behavioral interventions can be either proactive or reactive. Proactive interventions
(eg, reviewing cafeteria rules, use of cues and prompts) are directed at disruptive
behavior antecedents, thereby making the child with ADHD less likely to engage in
these behaviors. On the other hand, reactive interventions target behavior conse-
quences, reinforcing positive behavior (eg, token economy) and ignoring or punishing
negative behaviors (eg, time-out for aggression).
Concurrently implementing one of more of the reactive and proactive strategies can
lead to more positive outcomes.17,72 Contingent application of reinforcers for reduced
level of activity or increased sustained attention can rapidly alter the levels of these
ADHD symptoms.73 These programs generally incorporate token rewards, as praise
may not be sufficient to increase or maintain normal levels of on-task behavior in chil-
dren with ADHD.74,75 The role of punishment in the management of classroom
behavior in ADHD children has been less well studied. What data exist suggest that
response cost is the most effective punishment technique.74,76 A recent meta-
analysis concluded that behavioral interventions in the school setting are effective,
with overall mean effect sizes in the large range for dependent measures of behavior.77
DRCs are designed to improve communication between the school and home, and
allow the use of both proactive and reactive strategies.78–80 Typically consisting of a
list of well-defined behavioral targets, a DRC provides a vehicle to assess the target
behavior throughout the day. The DRC is then taken home to the parents, who can
administer a predetermined incentive. A recent meta-analysis suggests that the
DRC is an evidence-based intervention for ADHD, with overall mean effect sizes in
the medium range for dependent measures of behavior.81
Similarly to BPT, few studies have assessed for maintenance of these improve-
ments after treatment withdrawal. In addition, none of these studies examined
whether generalization of behavioral control occurred in other school settings where
no treatment procedures were in effect.

Middle school and high school

Educational impairment persists into middle and high school in students with ADHD.82
The most common service provided to adolescents with ADHD is academic
84 Antshel

accommodations (eg, testing accommodations, preferential seating, copies of class

notes) as a function of an individualized education plan (IEP) or Section 504 plan.
These accommodations, however, are not predicated on the notion that the adoles-
cent will develop or improve skills but rather that the expectations are being lowered
to permit the student a better chance at advancement. A recent review reported that
these services are only minimally beneficial to the students.83
Although accommodations are the most common service provided to adolescents
with ADHD, accommodations are not the most effective intervention for middle and
high school students with ADHD. Relative to the literature on interventions for elemen-
tary school–aged children with ADHD, the extant literature on interventions for adoles-
cents with ADHD is less vast and has only really begun to develop in the last 15 years.84
One of the better researched interventions for middle and high school students with
ADHD is the Challenging Horizons Program (CHP), a comprehensive school-based
treatment program that includes interventions targeting social, academic, and family
impairment. Two CHP versions have been evaluated, an after-school model and a
mentoring model.

After-school model The after-school model of CHP is an intensive program provided

over an entire academic year for 150 minutes per session up to 3 days per week. In a
typical CHP intervention, undergraduate students from a local university serve as
counselors, with graduate students or faculty serving as supervisors.
Interventions that are included in the after-school CHP include academic skills
training (eg, organizational training, note-taking instruction, study strategies), an
interpersonal skills group (eg, aim to teach adolescents to understand relationships
between their behavior and their own personal identity, assist students to learn to
monitor and revise interpersonal behavior so that their behavior aligns with their
identity goals), sports skills (eg, provide an opportunity to practice interpersonal
skills), mentoring (eg, brief meetings with CHP counselors that occur at each CHP
session), and monthly parent meetings (eg, parents are provided with information
about ADHD and adolescence, parents receive instruction on effective parenting
practices).

Mentoring model In an attempt to improve the feasibility of the CHP, the CHP men-
toring model was designed to provide a subset of the after-school model CHP inter-
ventions during the standard academic day. School mental health professionals (eg,
social workers, school psychologists) and teachers meet weekly with the adolescents
to provide the academic skills training interventions. Extant data from 3 randomized
trials support the efficacy of the CHP, especially the after-school model for middle
school students.85–89
Homework, Organization, and Planning Skills Program Another relatively well-
researched intervention for adolescents with ADHD is the Homework, Organization,
and Planning Skills (HOPS) program, originally developed as an extension of the
CHP. As the name implies, the HOPS program focuses exclusively on teaching orga-
nization, time management, and planning skills to middle and high school students
with ADHD. The HOPS intervention is administered by a school-based mental health
professional in sixteen 20-minute sessions that occur during the standard academic
day. The entire HOPS intervention is delivered over the course of one semester, begin-
ning with twice-weekly meetings and tapering to weekly meetings approximately
halfway through the intervention. The HOPS intervention also includes two 1-hour
“family” meetings that the adolescent and his/her parents/guardians attend with the
school-based mental health professional. The primary purpose of these meetings is
 Psychosocial Interventions in ADHD 85

to discuss and refine the home-based reinforcement system that all HOPS partici-
pants have in place at the beginning of the intervention.
Several randomized intervention trials have supported the efficacy of the HOPS
intervention, especially with regard to parent ratings of adolescent organization and
time-management/planning skills.90–92 In both the CHP and HOPS studies, approxi-
mately 70% of participants were taking ADHD medications while receiving the inter-
ventions, yet none of the studies reported an association between medication use
and outcome.85,91

Summer Treatment Program

An evidence-based multimodality intervention program for managing ADHD is the
summer treatment program (STP) developed by Pelham and Hoza.93 Markedly
different to the clinic-based or school-based interventions already described, an
STP is a package of intensive interventions that engage the child in a camp-like
setting. This program includes 5 major components of treatment:
1. Parent training in child behavior management
2. Classroom implementation of behavior modification techniques
3. Academic and sports skills practice and tutoring
4. Social skills training (typically involving sports)
5. Stimulant medication
Most of these interventions rely on operant conditioning and social learning princi-
ples that are delivered by adults (eg, camp counselors, teachers, parents) in the child’s
natural environment.
Most STPs are a 6- to 8-week program for school-aged children and adolescents.
The children are placed into age-matched groups of approximately 12, and the groups
remain together for the duration of the STP. Contingency management interventions
are used continuously throughout the camp day, and a DRC accompanies every
child/adolescent when they leave for the day. In addition to the child-focused interven-
tions, weekly BPT sessions are provided for the parents.
STP participants who are prescribed medication receive their customary doses. A
feature of the STP is that if parents desire, a child may have an ecologically valid,
controlled evaluation of the stimulant effectiveness as part of the STP. Several studies
have indicated that STP participants require lower doses of stimulant medication when
participating in the STP, even when delivered in a modified, less intensive fashion.17,94
STPs have a substantial research base; more than 15 randomized controlled trials
(either between-group or crossover design) have been completed, which support the ef-
ficacy of STPs.47 The STP was included in the largest previous intervention study of
ADHD, the Multimodal Treatment of ADHD (MTA) Study.79 Most of these previous STP
intervention studies were directed at academic (eg, work completion, adherence to
rules, improved note taking) and social functional outcomes (peer and adult interactions).

PSYCHOSOCIAL INTERVENTIONS REQUIRING FURTHER STUDY BEFORE

RECOMMENDATIONS CAN BE MADE
Clinic-Based Cognitive-Behavioral Treatment for Adolescents
Although once believed to be effective for children with ADHD,95 neither cognitive-
behavioral treatment (CBT) nor cognitive therapy has much research support in pedi-
atric ADHD.73,96–99 Meta-analyses of CBT have typically reported the effect sizes to be
less than one-third of a standard deviation.98 Because of its limited efficacy, CBT was
not included in the MTA treatment protocols.
86 Antshel

There is a growing body of literature suggesting that CBT can be effective for man-
aging adult ADHD.100–111 Adult ADHD CBT interventions are focused on skill building
and teaching specific skills,112 and are more heavily skewed toward teaching behav-
ioral techniques than changing cognitions. While behavioral therapy has been well
researched for adolescents with ADHD,113 far less empirical attention has been
devoted to CBT in adolescents with ADHD, possibly because of previous findings indi-
cating that children and adolescents with ADHD are “treatment refractory” to any
“cognitive” intervention.114
Within the past few years, one clinic-based adolescent ADHD CBT intervention trial
that concurrently incorporated principles of contingency management reported
modestly positive outcomes on several functional domains.115 Other recent clinic-
based (not school-based) intervention studies with adolescents with ADHD have
included CBT components, and have reported positive results on several functional
domains.116–118 In addition, secondary analyses in the clinic-based Treatment of
Adolescent Depression Study119 examined the role of comorbid ADHD as a moderator
of treatment outcomes in adolescent depression. Data from these analyses suggested
that comorbid ADHD did not negatively affect CBT response in adolescents with
depression.120 Likewise, in a clinic-based study of adolescent anxiety disorders, co-
morbid ADHD did not affect CBT treatment outcomes.121 Thus, there is some reason
to suggest that larger clinic-based trials for CBT in adolescent ADHD may be worthy of
consideration.

Social Skills Training

Social impairments are a prominent feature of ADHD3 and are likely to manifest as be-
ing a sore loser and/or interrupting ongoing conversations.122 Social skills training
(SST) has been traditionally conducted in groups held in a clinic setting, and is pred-
icated on the belief that children with ADHD lack the core skills to demonstrate proso-
cial behaviors.123 Social skills taught in SST for children with ADHD include topics
such as taking turns, initiating and maintaining conversation, and emotion awareness
and regulation.124 The extant literature suggests that traditional clinic-based SST for
ADHD can improve social functioning in the group setting,125,126 but with poor gener-
alization to the home and school environments.127–130 In fact, 2 recent reviews of
psychosocial treatments for children with ADHD have concluded that traditional
clinic-based SST is ineffective for ADHD.46,47
Barkley’s31 theoretic model of ADHD posits that ADHD is not a knowledge deficit as
much as the disorder is a performance disorder. Thus, teaching additional skills to
children with ADHD is not so much the issue as is assisting them to perform the skills
they have when it would be useful to do so. Rather than in a clinic setting, this instruc-
tion should likely also occur at the point of performance (the place and time in the nat-
ural setting) where such skills are most likely to prove useful to the long-term social
acceptance of the individual.
Although traditional clinic-based SST has not been proved to be effective for
improving the social impairments that often accompany ADHD, several alternative
SST interventions have been developed in the past 10 years that emphasize instruc-
tion at the point of performance. Rather than focusing on the children, training parents,
STP counselors, and/or teachers to provide in vivo reminders and incentives to chil-
dren with ADHD to carry out socially skilled behaviors with real peers has been a focus
of these alternative approaches.64,93,126,130–134 Several of these alternative SST ap-
proaches involve no child treatment component, instead focusing exclusively on
training parents64 or teachers135 to administer the social skills knowledge instruction
and provide the contingencies necessary to permit skill generalization. In addition to
 Psychosocial Interventions in ADHD 87

working with teachers, one of the more novel SST approaches, MOSAIC (Making
Socially Accepting Inclusive Classrooms), includes training for teachers on how to
encourage non-ADHD peers to be accepting of children with ADHD.135
At this point further research is needed before considering if these alternative SST
approaches should be recommended as a front-line psychosocial intervention.
However, compared with traditional, clinic-based SST programs, these alternative
approaches appear to be more promising.

SUMMARY AND FUTURE DIRECTIONS

ADHD is conceptualized now as a largely chronic disorder for most, but not all chil-
dren, similar in some respects to chronic medical disorders such as diabetes or
phenylketonuria. Stimulant medications are a front-line intervention for managing
ADHD in children and adolescents. In addition to the use of medication, psychosocial
interventions that seem most promising, and thus should be included in a combined
treatment program, include contingency management methods applied in classrooms
and elsewhere (STPs), training of parents (BPT) in these same methods to be used in
the home and community settings, and comprehensive school-based treatment pro-
grams (CHP, HOPS). Evidence for CBT for adolescents and alternative child SST pro-
grams focused more on parents and teachers appears promising, but requires further
research before stronger recommendations can be made.

Role of Psychosocial Therapies

Future research should continue to consider the role that psychosocial therapies will
play in the treatment of ADHD in children and adolescents. A primary and fundamental
research goal for future psychosocial interventions is to specifically target generaliza-
tion and maintenance of treatment gains. Psychosocial treatments, especially behav-
ioral ones, are comparable with medication management in that they produce solid
benefits as long as they are in place. However, most psychosocial treatments for
ADHD yield little evidence of maintenance or generalization once withdrawn.
Barkley refers to many ADHD psychosocial treatments, especially those with signif-
icant behavioral approaches, as “designing prosthetic environments.”136 In Barkley’s
view, behavioral treatments, like hearing aids, wheelchairs, ramps into public facilities,
lower bathroom fixtures, glasses, large print books, and prosthetic limbs for ampu-
tees, are artificial means of altering environments so as to reduce the adverse impact
of a biological handicap on the performance of major life activities.136 Behavioral
methods are prostheses: a means of rearranging environments by artificial means
so as to yield improved participation in major life activities. Once the prostheses are
withdrawn, however, the child is once again impaired. Future research should
continue to consider how best to address this prosthetic dilemma and better promote
maintenance and generalization of treatment effects.
Whereas psychosocial interventions work for many youths with ADHD, not all chil-
dren and adolescents with ADHD respond positively. Future psychosocial research
should continue to consider the mechanisms of change (using treatment-
dismantling approaches) and mediators/moderators of outcomes.

Psychosocial Treatment Accessibility and Portability

There is a crucial need to improve psychosocial treatment portability and accessibility.
The children who need the interventions the most are often from high-risk families that
lack resources.137 In addition to the CHP and HOPS (which are delivered directly in
schools), some recent interventions have moved in this direction.138,139 Likewise, the
88 Antshel

STP model, not feasible for many families, is being piloted in a less intensive version in
after-school, school, and community settings.94 Nonetheless, future research should
continue to focus on improving psychosocial treatment portability and accessibility.
These efforts will likely use various existing technologies (eg, interactive Internet-
based treatment and/or training) applied in a more novel fashion to high-risk groups.

Stigma Effect on Psychosocial Interventions

Normalization of functioning for children and adolescents with ADHD is difficult to
achieve with medications140,141 and psychosocial interventions.10 Nearly all of the
psychosocial interventions have been focused on the child/adolescent and/or training
the parents/teachers. Very few psychosocial interventions have included non-ADHD
peers in an intervention package. Future psychosocial interventions should also
consider the role that stigma plays in affecting psychosocial treatment outcomes
and maintenance. For example, there are many data to suggest that children with
ADHD are stigmatized by typically developing peers,142–145 parents,146–148 and teach-
ers.149 Given the pervasiveness of the stigma that ADHD seems to engender, it is sur-
prising that more interventions have not considered the role that stigma may play in
negatively affecting outcomes (eg, the child with ADHD improves skills, yet others
continue to have negative perceptions of the child). Some work135,150 has begun
recently to explore this domain, although more research should focus on the role of
stigma as a possible moderator of treatment outcomes.

Adolescent Versus Child Treatment Guidelines

Finally, the American Academy of Child and Adolescent Psychiatry practice parame-
ters outline practice guidelines for managing adolescents that are substantively
different to child guidelines.151 Despite this, there have been far fewer psychosocial
research studies that have focused on treating adolescents with ADHD relative to chil-
dren with ADHD152 (and more recently, even adults with ADHD). ADHD and the asso-
ciated functional impairments often persist into adolescence, so there remains a clear
need for effective psychosocial treatments for adolescents with ADHD.

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