Non-pharmacological interventions for ADHD in puberty

Transcript: Margaret Sibley – Non-pharmacological interventions for ADHD in puberty

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[00:00:03] Hello, my name is Maggie Sibley and I'm a psychologist at the University of Washington School of Medicine in Seattle and Seattle Children's Hospital. And today I'll be speaking about clinical advances in non-pharmacological treatment for adolescent ADHD. And I'm very happy to be presenting to you today. Why is the developmental period of adolescence so important in the treatment of ADHD? We can see here that the gap between the level of impairment experienced by individuals with ADHD and their peers without ADHD widens across the years leading up to the transition to adulthood and then beyond the transition to adulthood. And so this is a really important period where the experiences of people with ADHD starts to become markedly different than their peers.

[00:01:07] At least in the U.S. context, the transition to adulthood is associated for people with ADHD with 11 times higher risk to be both unemployed and not in school at age 19. Among those that do go to college, there's a high risk for course failure and dropout from university. And there's more frequent employment instability, changing jobs, becoming fired if you have ADHD than if you don't during this age group. For people who are employed, they are earning lower wages than their peers and their supervisors are rating them less favorably. They're more likely to live at home with family rather than to be living independently on their own as a young adult. Less likely to have savings account or a credit card to be financially healthy. And they have higher rates of food and housing instability. Lower life satisfaction, higher rates of depression and heavier use of substance, especially marijuana and in some cases alcohol.

[00:02:25] Because this young adult period is so challenging for people with ADHD, there's this real importance of being able to prevent those problems by successfully treating ADHD in adolescence and helping teenagers with ADHD develop the skills and the abilities that they need to successfully launch into adulthood. During the adolescent period, ADHD begins to be a little bit more complex than it was in childhood. There's new problems that emerge that are associated with having ADHD as an adolescent. For example, problems with sleep, problems with overuse of digital media, problems with depression, disengagement from school, use of substances, failing to get coursework done, having problems with your family members, conflict with parents. And with these new areas of difficulty in life, we see an importance of treating teenagers with ADHD. But we also see during the same period of life that there is a reduction in the number of people who are treated.

[00:03:47] And there are teenagers who many times no longer want to take their medication. This is data from the MTA study, which is a big North American study of children with ADHD as they grew up. And what you can see here is from the time they were approximately nine years old to the time that they were approximately 16 years old, almost all of them stopped taking their medication. And this trend actually continues as they go into adulthood. So you have this dilemma where you have higher severity problems and lower utilization of treatment at the same time, which often creates a real period of chaos and instability in the life of youth with ADHD. If we try to understand a little bit about why adolescents with ADHD stop taking medication or are uninterested in going into psychosocial treatment, we can see that it's generally across different types of treatment that they hold the same opinion. And if you look at what their parents say and their teachers say and their health care providers say, they would all like the teenager to be receiving treatment, but the teenagers got the different opinion.

[00:05:11] They're not as interested. And if you work with them in a psychological context doing a therapy, either family therapy or individual or parent-based cognitive behavioral therapy, you see the disengagement and disinterest in treatment in that setting as well. This is a study done about 30 years ago now by Russ Barkley, but he showed something fairly simple, which is when you just worked with the parents of the teenagers, they were pretty highly engaged in the treatment. But when you brought the teenager in and also worked with them as well, you see a reduction in the engagement. And so it's this challenge that teenagers are old enough that we should probably be working with them directly now instead of using a parent training model. And at the same time, as soon as you start working with them directly, it can often lead to an aversive experience for the parent or for the teen. And together, they both decide it's maybe not worth it to do these services because it's causing so much stress and conflict. And so we have to understand how to overcome that.

[00:06:27] There have been several reviews of the literature on adolescent ADHD treatment. And last year, my research team published an update on that where we did a systematic review across categories of treatment to understand in the randomized controlled trials what the outcomes were specifically in the adolescent age group for different treatments. And so I want to share with you a little bit about what is effective for teenagers with ADHD and then we'll get a little bit more detailed about the components of those effective treatments and the strategies for engaging adolescents with ADHD. So this is a very recent review. And we were able to find a lot of RCTs in this study. And in specifically, we were able to find 28 RCTs that looked at medication, 23 on cognitive behavioral therapy, 5 on digital interventions like cognitive training, 3 on physical activity, 3 on brain stimulation, 1 on neurofeedback, 1 on nutrient supplementation, and 1 on occupational therapy.

[00:07:46] So our systematic review was only reviewing English language studies. And this is what we found in the literature with any timeframe. So we went all the way back to I think the 1970s was our earlier studies. Now, we're not focused on pharmacological treatment in this talk. So I'm not going to be discussing the results of the medication portion of this review. However, there was convincing efficacy for medications on the ADHD core symptom outcomes. So that was a major conclusion of this review. I'm going to mostly be focusing on the 23 CBT RCTs and what we learned from them in the following slides. Because for every other category of non-pharmacological treatment that you see on this slide, essentially there was no evidence of efficacy or there was only one study with preliminary efficacy that hadn't been replicated. And so there was no conclusions to be drawn about the effectiveness being established for any of these other categories in the adolescent age group at this point, which may in some cases point to a need for more studies.

[00:09:09] And in other cases, we may feel fairly confident that there doesn't seem to be an effect there. But so I'll focus on something that would be usable to this audience, which is what can you do in the context of CBT to make it maximally effective for adolescents with ADHD. Now, this is a very busy slide and it is not my intention that people look at this and read it carefully. Actually, the most interesting way to think about this slide may actually be just by sitting back a little bit and squinting your eyes and noticing all of the green and white checker boxes all over. Because this is a graph that highlights the different components of each treatment that was studied in the RCTs that we identified. And it highlights the diversity of what is being referred to as CBT for ADHD, specifically in this case in adolescents. And it highlights that these packages are not monolithic. They have all kinds of things in them. And they do seem to have some common elements, but also a lot more places where they're different.

[00:10:30] So some of them are group treatments, some of them are one-on-one, some of them involve the parent, some of them involve the youth, some of them involve both. Some of them focus on operant behavioral strategies like using contingency management and incentives. Others are more focused on teaching behavioral skills like organization skills or communication skills or cognitive restructuring skills. Some of them are starting now to use some of engagement-focused approaches like motivational interviewing. Others are not. And so when we think about what we see in the literature about CBT, when we see mixed effects, we shouldn't be too surprised because these are very different packages. I think they ranged in the number of hours to one and a half hours of care to over 400. So there's a lot of diversity in dose as well in these research studies. So that's very important to think about that we can get past thinking of CBT as one thing, but understand that its effects might be dependent on various features of it.

[00:11:53] In our review, we looked separately at several different categories of outcomes to understand what we know about CBT's efficacy. And I highlighted in yellow for you the studies that are testing a CBT. When we look at ADHD core symptom outcomes, what we can see is that there was mixed evidence of the effect sizes. So at the very top, we have our largest effect sizes. If you look down at the bottom, you can see how large those effect sizes are. And in some cases, there were impacts on ADHD core symptoms that were over a standard deviation above the mean or close to a standard deviation above the mean. But in other cases, those effects were smaller. And in fact, in a few cases, they were fairly negligible. So there's mixed evidence of whether ADHD core symptoms reduce compared to a control in a CBT trial. And so this is the outcome where medication had a clearer and more meaningful impact and more consistent impact than CBT on the core symptoms.

[00:13:10] But some of the packages on the slide before were doing better than others at impacting this outcome. This is the place where the CBT seemed to be most robust. Again, I highlighted the CBT effects here and the other ones that aren't highlighted represent mostly medications. You can see compared to the last slide where almost every treatment RCT that we looked at included some sort of ADHD core symptom outcome. Here, actually, many of the RCTs on medication, they don't include an impairment index in their outcome battery. And so we actually don't have good information on whether or not the impairment domain improves with medication. So we need more research that includes that measure. But the couple of studies that we did see an impairment measure included, they did not have meaningful effects. So we're not going to conclude anything based on that. But there isn't compelling evidence at this point that medication is making a big impact on impairments.

[00:14:27] It perhaps is, but people need to include that in their study batteries. Instead, we see pretty compelling evidence with very large effect sizes. If you look down at the bottom that the CBTs are impacting impairment. So this is not too surprising to me because that's how we've always framed and conceptualized the CBT is that it doesn't necessarily eliminate the core symptoms, but it teaches people how to effectively live their life with the core symptoms, sometimes being elevated. So as for example, if you know you're a forgetful person, medication might actually reduce your forgetfulness in daily life because of its impacts on cognition. But if you do CBT and you learn all kinds of systems for writing things down and develop a habit around writing things down, if you are having memory difficulties, they're going to have less of a problematic impact in your life because you've learned how to mitigate or prevent that forgetfulness from undermining your functioning. And that's the idea of how CBT works. The other place where we saw strong effects for CBT was on executive function skills.

[00:15:48] So this is not cognitive tasks. This is ratings of executive function behaviors in daily life. Like the BRIEF rating scale, which I think has a Chinese application to it and you may know that scale. And basically this kind of scale, it asks people to rate things like the person's ability to stay on top of deadlines or the person's ability to manage their emotions or their ability to self-regulate in various domains. Their time management skills or organization skills, what actual behaviors related to those areas is observable for the person in daily life. And this is the place where we see very strong effect sizes for CBT. And that's not surprising because those are the skills that are usually focused on in CBT is helping people develop those habits and those systems and those strategies. And then it's not surprising that you see them using them more often when treatment has completed. Overall, a few interesting conclusions from our review is that this has been the last decade has seen an explosion of research on CBT for adolescents with ADHD.

[00:17:10] As you saw on the first slide about the review, it's many more studies on this non-pharmacological treatment compared to any other non-pharmacological treatments and getting close to the number of studies, RCT studies that have been done on medication for ADHD as well. And one of the things that came out of our analysis of the different components of the CBTs is an increasing emphasis on components of treatment that support the engagement of the teen, that solved that problem from the beginning of this talk that we saw where teens didn't want to be there, they weren't interested in participating in treatment and trying to self-improve. And then finally, we see that both medication and CBT are showing positive results in the RCTs but on different indices, so where we see a strong effect on core symptoms and cognitive performance for medication. For CBT, we see a different pathway to improvement. It's more about teaching skills and then perhaps those skills are reducing functional impact of the ADHD symptoms.

[00:18:26] And so theoretically, you know, a combined approach where somebody was both taking the medication and participating in a CBT with a psychologist or other professional would be an approach that would be maximally effective. However, actually, there hasn't been a combined treatment RCT for the adolescent ADHD age group, which is surprising because there have been several in childhood. And, you know, there's some evidence, circumstantial evidence, I would say, that the effects of medication are probably enhanced if a person, if an adolescent is receiving CBT at the same time and vice versa, that the effects of CBT would be enhanced if someone was taking medication. But we have never directly tested that in a randomized control trial. So let's learn a little bit more about what exactly are the concerns for adolescents with ADHD that lead to this problem with engagement. We did a research study in our lab where we had over 800 audio-recorded CBT sessions for our STAND treatment, which I will be showing you a little bit more about in a minute.

[00:19:50] And this is a model where the parents and the teens come in together to work with a therapist with a CBT approach. And we were able to listen to the audio recordings and code different barriers to treatment that were discussed during the sessions and essentially inventory them. And the top ones that we detected in these recordings were just a general low desire for treatment, not being interested in getting better or making changes in one's life for the teen. That was about three out of four teens that were experiencing that. There were also issues on the side of the parent. So we had parents who are tasked with monitoring the teen's application of CBT skills and are supposed to be setting up to provide feedback to the teen and also maybe to provide contingencies or rewards and consequences to the teen. And we saw that the parent often forgot or struggled to do their part. 70% of families this was happening. So it's not just that the teen has low desire, but if the parent is the best opportunity to hold them accountable, even though they have low desire, perhaps give them an incentive to participate and the parent is also not engaging, that's a double problem.

[00:21:19] There was also forgetfulness many times on the part of the teen, the teen holding a belief that they don't need to change, that the low self-efficacy, which basically means they don't believe that change is possible. And parent intrusiveness, which basically is the parent stepping in and doing things for the teen, instead of letting the teen have the experience of trying it themselves. And you can imagine that this is a pattern that evolves over time in families when it seems like the teen is working too slow or needs a lot of reminders to get back on task and then you sort of develop this relationship between the parent and the teen where the parent is directing and guiding everything all the time, which can prevent the teen from developing autonomy, which is a developmental goal of adolescence. So in sum, there are many barriers to treating adolescence with ADHD. I'd say both pharmacologically and non-pharmacologically that we have to keep in mind when we're trying to work with this population. And some of them have to do with the parents and how the parents are thinking about the teen or experiencing thoughts about their own role in the treatment or even many of the parents might have ADHD themselves and are struggling with their own executive functioning, which is often would predict a good response to the treatment if the parent is able to stay organized themselves and provide the proper supports.

[00:22:53] And some are due to the teen's psychological state, whether that's level of interest or beliefs about themselves and their own ability to be successful. Things that are related to the parent teen relationship like conflict can be a barrier. And so with this treatment landscape, it seems like what the population would want is a treatment that acknowledges and addresses some of these factors so that they can navigate them and have support from the psychotherapist navigating these issues.

[00:23:29] Now, let's back up a little bit and understand exactly what someone might do in session when they are treating an adolescent with ADHD and how that's different from treating a child with ADHD. In our evidence-based childhood treatments for ADHD, the parent is typically the focus. It's behavioral parent training, or in some cases there are models that involve the youth but very focused on the parent as the person who's applying behavioral strategies in order to help manage behaviors at home or at school. They often use point systems in childhood treatments, very heavy focus on using rewards. And many of the treatment studies on behavioral parenting for children with ADHD are focused on reducing disruptive behaviors. So behaviors that are interfering with daily life, straining relationships with adults, and usually the parents and the therapist will determine the treatment targets. They will assess where the child is having the greatest difficulty and then make a decision together about what they need to work on.

[00:24:46] The adolescent treatment's different. So just about every single model I showed you all in that green and white checkerboard graph involves to some extent the parent and the adolescent. And so while we would treat our children by focusing on the parent and we treat our adults by focusing on the individual themselves, adolescents is this transition time. And so it makes sense that we would have some parent involvement and some adolescent involvement to help with that transition. So instead of imposing point systems on the child, the parent and teen are working together to make fair expectations to come up with plans about how things are going to happen and then together to negotiate if there might be any rewards associated with those plans or privileges. For example, having rules about when you can use screens, relative to getting your homework done or other responsibilities. The targets of adolescent focused treatment are much more broad than child ADHD treatment. So to some extent, because there's diverse presenting problems, increasingly diverse presenting problems in this age group, we would be thinking about trying to individualize treatment to the specific concerns of that youth.

[00:26:17] And you see treatments that focus on organization and time management skills, responsible decision making, sleep and wake routine, overcoming motivation difficulties, many things, and more that aren't listed here. And then there's an emphasis on the teen setting goals for themselves instead of having the parent and the therapist decide on the target of treatment. And this is a way to make sure that the treatment is personally meaningful to the adolescent and not just something they're being mandated to do by adults.

[00:27:00] Are there common elements of these different evidence-based treatment approaches for adolescent ADHD? So on the previous review, we looked at kind of that green and white checkerboard and it was a little bit zoomed out. It was bigger picture. It wasn't what specific skills are they working on. But this review that my research team did a few years ago actually went in and looked at the treatment manuals and looked at what the focuses were and what they were doing in the different sessions and looked for things that were in common across the approaches that had an evidence base or had shown positive impact on core ADHD symptoms in the RCTs. And what we found were that there were some common elements. So what they were tending to focus on is organization skills training, time management skills training, an approach that really focuses on practicing the skills and the strategies that people are learning in between sessions and then monitoring progress using measurement-based care principles and finally using operant reinforcement. So basically incentives for practicing the skills at home, usually implemented by the parent.

[00:28:18] These were the common elements. And so if you look at that and you think about, well, what is the main model of a CBT type treatment for adolescents with ADHD? It's basically helping people develop skills and habits that support successful management of their ADHD in daily life through new daily life behaviors and then reinforcing use of those skills through some sort of reward system or daily incentive program. This is a hybrid model between what we do with children and what we do with adults, which makes sense because the adults are really just focused on the first bullet point here, teaching skills to compensate for ADHD symptoms. And the children are really focused on the second bullet point, which is just reinforcing behaviors with an operant behavioral principles. And with the adolescents, we're kind of doing half and half. And that's why this is such a unique time to treat individuals with ADHD. There were several treatment packages that had RCTs that showed strong effects that we identified in this study.

[00:29:43] So two of them are designed to be implemented in schools. And so they are conceptualized as interventions, but they're more of an academic school focused intervention. And that's the challenging horizons after school program. So this is like a very intensive program where kids go to this after school for two hours, several days a week to practice executive function skills with some school personnel. And the hops program, which is less intensive. So in this program, they pull the youth out of class for 20 minutes twice a week and work with them on their executive function skills, again in the school setting. The STAND program, which is the one that my team developed and I'll tell you a little bit more about in a minute, is a clinic-based outpatient intervention where the parent and the teen come in together once a week for a standard one-hour outpatient session with a therapist. And then the cognitive behavioral therapy intervention that was developed at Massachusetts General Hospital in Boston in the United States has one study as well.

[00:30:59] And they have a model that's primarily focused on the youth and has the parent join for some of the sessions and some of the time. That their sample was older teens. So it's a model that's maybe something that teens are more appropriate for when they're 16, 17 years old, a little bit older.

[00:31:29] So what we learn essentially is that the effective treatments for adolescents with ADHD, they kind of blend together a few components in order to be effective. They're not simplistic treatments because there is sort of this multifaceted sources of impairment and broad effects of ADHD severity in adolescents. And so it's only going to do part of the job if you do a simple approach. And so here with this more complex approach, we see the two primary things are what we usually call skills training but really just involves identifying helpful behaviors that a person can do to compensate for their ADHD symptoms. So like, for example, getting into the habit of writing things down or taking one, like taking some time every day to reorganize your room and just making sure that's a habit to keep things clean. So we're helping people develop those positive habits and then also blending that with some sort of motivation or engagement components designed to keep the teens motivation present with the treatment.

[00:32:49] Things like goal setting, using a contract where there's incentives and motivational interviewing, which I'll show you a little bit more about now. I can say, you know, in the U.S. context, three of the four treatments that we found efficacy for on the core ADHD symptom outcomes are publicly available and can be purchased. And so I know that the STAND treatment is underway to have a Chinese translation of it and I don't know if the other two have a Chinese translation. But I do know that the Safren and Sprich adult ADHD version of this may have a Chinese translation. So that may be available also. But these are sort of, these are approaches that essentially are available for clinicians to do on their own, right? You can get the materials, you can read it, you can figure out how to do it generally. And so they are available. Now, it's hard to answer questions about which of these treatments works the best because I think they're not supposed to compete against each other. They're different in different ways and different kids might respond better to a certain one depending on their profile and what they need.

[00:34:10] But, and so, and actually, so when I'm working clinically, I often take a little from, you know, different ones to match the needs of a youth. But if you want to, like, put them kind of next to each other and understand, you know, are there any specific benefits of certain packages? I think the main question that's of interest here is, do putting these engagement-focused approaches that focus on motivation and goal-setting and rewards and motivational interviewing, does that help? Because it is a little more effortful for the clinician to use those strategies. And so it would be nice to know if they're worth it and if they're helping. So we did an integrative data analysis where we took four RCTs that were done in our research lab together. They had almost 900 youth that were in one of the four RCTs. And they all had gotten different arms of treatment as a part of these RCTs. So if we pooled all the data together and we used some fancy data analytic approaches to compare them, what we were able to find in this study was that the engagement-focused approaches, which was stand, you can see that in the orange line.

[00:35:30] And the usual care, which is the blue, which is basically one-on-one therapy, those models seem to have the biggest impact on core ADHD symptoms. The group-based treatments, one of them had 400 hours of treatment. It was an old-fashioned behavior therapy program for ADHD. They had less of an impact. And so I think to me this shows that there is a high value of working one-on-one with teens with ADHD versus in a group. And the reason I think that that is, is because there are so many barriers for families to making changes and implementing new habits and routines that the problem-solving support that can be offered in a one-on-one work with the therapist is going to help increase and enhance the effectiveness. And in a group, you get information, you know, you work a little bit with and talk to other families and make some plans for what you want to do, but you don't get as much support on the implementation of those plans. Some of the skills that I think are often included in these treatments are communication skills.

[00:36:48] So here you can see some examples of some family communication skills, eye statements, reflective listening skills, helping them recognize things that lead to conflict in the household, planning positive time with each other, making a plan to de-escalate conflict with each other. So this is part of the work. And then other part is like the organization skills training piece. So helping them keep their materials neat, helping to learn to write things down, learning how to plan things out long-term. If you have a test coming up, how do you manage your time and budget your time appropriately, creating plans for exactly how you'll do your homework and where you'll do your homework and if you're allowed to take breaks and making those types of routines and plans really effective at home. And also helping with some academic skills, like how to study if kids are having trouble with retaining information because of inattention. And then like our STAND treatment, we have a big focus on letting people choose what they want to learn. And so here you can see the menu where they can pick it off the menu on what they're interested in learning.

[00:38:04] And there's also a cognitive restructuring piece. Like most of this is around procrastination or motivation, but basically noticing the interfering thoughts you have that are related to your ADHD. Like I don't want to do this. It's boring and be able to replace it with an adaptive thought that helps promote a positive behavior. And then in the behavioral sense, age appropriate application of the operant conditioning principles. So we would do a parent-teen contract where the parent and the adolescent will come together. They'll come up with a compromise about maybe the behavior's homework, right? Like, okay, yes, I agree to do two hours of homework each day, but I would like in exchange, like I would like to be able to have my video games for longer in the evening afterwards if I did my homework so that they can come up with plans that they both agree to. And you can see a contract would be something that they would have all these details of and they would write the responsibilities and then they would write down the privileges that might come after the responsibilities and what the parent's role is as well in monitoring the contract. Finally, I'll just hit on some of these engagement-focused components so you know what they look like.

[00:39:22] So here you can see that we, to review, we have both parent and youth roadblocks to treatment that might have to do with their view of if treatment can be effective and what their role is, it's in it and how motivated they are. And so we use motivational interviewing in order to promote effective engagement in the treatment. And specifically, we blend motivational interviewing with the CBT at the same time. And this allows us to make the family develop a sense of autonomy in terms of what would work best for them, help build their self-efficacy by being really positive feedback-oriented and then showing and expressing empathy for what they're struggling with. It also is a collaborative approach where you sort of, instead of being the expert, you work kind of like equals with the family so that they feel like you're coming alongside them. And it also has a technical component where we notice their intentions and language about change and we give that language a lot of attention instead of their talk about self-doubt. We would give that less attention.

[00:40:40] And it helps also people self-explore what are their personal goals, what are their values, what are their priorities. And so you can really anchor the treatment skills and strategies to those specific things that people are interested in achieving and obtaining in their life. And then also really being forward in positive focus with reinforcing positive steps being taken in treatment. And then when people forget to do things instead of framing it as non-adherence, we frame it as an opportunity to learn more about yourself and what you need to be successful. We might do something like this where we show people a worksheet with different things that a youth might value like learning to drive a car, more privacy, getting better grades, getting into a good university, making more friends, and we have the youth point to what they're most interested in learning about and working on to find personal meaning in the treatment. We use a strength-based approach and we let them choose what they want to work on and so that they have the opportunity to specifically be working on things they're interested in. And they set personal goals. The parent sets goals for themselves as a parent instead of setting a goal for the youth and the youth sets their own goals and it should be something they're genuinely interested in.

[00:41:58] And I mentioned the menu earlier. We also let parents learn psychoeducation about how it's hard to parent a teen with ADHD instead of telling them how they are. We let them reflect on the material and share with us whether they're experiencing any of these difficulties. And then finally, we provide a lot of support on following through on therapy homework. And so this might mean extensive planning of exactly how you're going to practice things at home and then really walking through ahead of time and problem-solving the barriers before they happen. And so this is what the treatment that we use is. It's STAND. And essentially I've described this to you already but it's a parent and a teen that come in for about 10 to 12 weeks. We really focus on the engagement piece first and then we teach the different skills. And then we believe that if we do the motivational interviewing with the family they'll be more likely to use the skills. And with both a parent using the skills more often the teen using the skills more often and both having an enhanced sense of motivation this is the ingredients that together combine to have the best effects in a treatment.

[00:43:16] We spend a few sessions just on engagement using the components I just described. And then we would teach skills to folks so that they would be able to develop some new habits and get an idea of what they like to focus on. And then we would launch into what we would call a planning phase where they would plan out how they're going to continue long term to use those skills. Okay. And I did have some extra slides here that I don't think I have time to about whether this can be delivered as a group. I think the short story is yes but it's a little bit less effective. So basically if there are certain folks who really don't seem to do well in a group if the parent has ADHD themselves we would recommend the individual approach like STAND if the parent has depression as well and if there's high parenting conflict and really this is because we think that the treatments are most some people really need that one-on-one support essentially. Okay. So in conclusion there's a difference between child and adolescent CBTs or non pharmacological treatments for ADHD and really among those differences is the importance of focusing on engagement for the teens.

[00:44:32] The most effective treatments seem to put the parent and the teen both together in the room that hybrid approach to treatment where we focus on helping the teen develop new competencies and habits and the parents learn strategies to kind of keep the kids doing those things long term. I wanted to thank everyone for their time and for allowing me to present today and here's my website if anyone is interested in getting in touch with me you can do that either through my email address or through my website. So thank you so much.

Margaret Sibley
University of Washington
Seattle, USA