Improving the efficacy and effectiveness of evidence-based psychosocial interventions for attention-deficit/hyperactivity disorder (ADHD) in children and adolescents.

Attention-deficit/hyperactivity disorder (ADHD) is a prevalent, chronic, and impairing mental health disorder of childhood. Decades of empirical research has established a strong evidence-based intervention armamentarium for ADHD; however, limitations exist in regards to efficacy and effectiveness of these interventions. We provide an overview of select evidence-based interventions for children and adolescents, highlighting potential approaches to further improving the efficacy and effectiveness of these interventions. We conclude with broader recommendations for interventions, including considerations to moderators and under-explored intervention target areas as well as avenues to improve access and availability of evidence-based interventions through leveraging underutilized workforces and leveraging technology.

Implementation of Research in Community Mental Health Centers: The Challenge of Provider Engagement.

Conducting clinical research in public sector community mental health centers (CMHCs) can be challenging. The purpose of this report is to describe the challenges our research team encountered in engaging CMHC providers in a clinical trial aimed at testing an intervention to improve parent activation and engagement in their child's behavioral healthcare. We discuss the intervention we aimed to test, the challenges we encountered engaging providers, and the barriers to engagement that we identified. The barriers included restrictive inclusion criteria, an ambitious randomized controlled design, a dyadic (provider-parent) recruitment plan, a requirement to record provider-parent sessions, and high day-to-day practice demands on providers. The strategies we used to address the barriers and a discussion of the "trade-offs" these strategies introduced are presented. Improving provider engagement in research in CMHCs can avoid research delays or termination of studies and ultimately mitigate an early blockage in the research-to-practice pipeline.

Single and Combined Effects of Multiple Intensities of Behavioral Modification and Methylphenidate for Children with ADHD in the Home Setting.

Behavioral treatment, stimulants, and their combination are the recommended treatments for childhood attention-deficit/hyperactivity disorder (ADHD). The current study utilizes within-subjects manipulations of multiple doses of methylphenidate (placebo, 0.15, 0.30, and 0.60 mg/kg/dose t.i.d.) and intensities of behavioral modification (no, low, and high intensity) in the summer treatment program (STP) and home settings. Outcomes are evaluated in the home setting. Participants were 153 children (ages 5-12) diagnosed with ADHD. In alignment with experimental conditions implemented during the STP day, parents implemented behavioral modification levels in three-week intervals, child medication status varied daily, and the orders were randomized. Parents provided daily reports of child behavior, impairment, and symptoms and self-reported parenting stress and self-efficacy. At the end of the study, parents reported treatment preferences. Stimulant medication led to significant improvements across all outcome variables with higher doses resulting in greater improvement. Behavioral treatment significantly improved child individualized goal attainment, symptoms, and impairment in the home setting and parenting stress and self-efficacy. Effect sizes indicate that behavioral treatment combined with a low-medium dose (0.15 or 0.30 mg/kg/dose) of medication results in equivalent or superior outcomes compared to a higher dose (0.60 mg/kg/dose) of medication alone. This pattern was seen across outcomes. Parents overwhelmingly reported preferring treatment with a behavioral component as a first-choice treatment (99%). Results underscore the need to consider dosing as well as parent preference when utilizing combined treatment approaches. This study provides further evidence that combining behavioral treatment and stimulant medication may reduce the stimulant dose needed for beneficial effects.

Intervention and Implementation Characteristics to Enhance Father Engagement: A Systematic Review of Parenting Interventions.

In recent years, the prevalence rates of children's mental health disorders have increased with current estimates identifying that as many as 15-20% of children meet criteria for a mental health disorder. Unfortunately, the same robust parenting interventions which have long targeted some of the most common and the most treatable child concerns (e.g., externalizing, disruptive behavior, and aggression) have also shown consistently low rates of father engagement. This persistent issue of engagement comes in the wake of an increasingly large body of literature which highlights the unique positive contributions fathers make to children and families when they are engaged in parenting interventions. As the role fathers play in families shifts to become more inclusive of childcare responsibilities and less narrowly defined by financial contributions, it becomes increasingly important to understand how best to engage fathers in interventions that aim to enhance parenting efficacy and family outcomes such as coparenting. The current review examined intervention (e.g., format and setting) and implementation characteristics (e.g., training and agency-level changes) associated with father engagement. Particular attention is paid to studies which described father-specific engagement strategies (e.g., inviting fathers directly, father-only groups, and adapting intervention to incorporate father preferences). A total of 26 articles met inclusion criteria after screening and full-text review. Results indicate that father engagement (i.e., initiating treatment) remains low with 58% of studies either not reporting father engagement or having engagement rates below 50%. More than two-thirds of studies did not include specific father engagement strategies. Those that did focused on changes to treatment format (e.g., including recreational activities), physical treatment setting (e.g., in-home and school), and reducing the number of sessions required for father participation as the most common father-specific engagement strategies. Some studies reported efforts to target racially and ethnically diverse fathers, but review results indicated most participants identified as Non-Hispanic White. Interventions were largely standard behavioral parent training programs (e.g., PCIT and PMT) with few exceptions (e.g., COACHES and cultural adaptations), and very few agencies or programs are systematically making adjustments (e.g., extended clinic hours and changes to treatment format) to engage fathers. Recommendations for future directions of research are discussed including the impact of differential motivation on initial father engagement in treatment, the importance of continuing to support diverse groups of fathers, and the potential for telehealth to address barriers to father engagement.

Waning Immunity Against Respiratory Syncytial Virus During the Coronavirus Disease 2019 Pandemic.

Health jurisdictions have seen a near-disappearance of respiratory syncytial virus (RSV) during the first year of the coronavirus disease 2019 (COVID-19) pandemic. Over this corresponding period, we report a reduction in RSV antibody levels and live virus neutralization in sera from women of childbearing age and infants between May to June 2020 and February to June 2021, in British Columbia (BC), Canada. This supports that antibody immunity against RSV is relatively short-lived and that maintaining optimal antibody levels in infants requires repeated maternal viral exposure. Waning immunity may explain the interseasonal resurgence of RSV cases observed in BC and other countries.

Preferences for Parenting Programs in Head Start: Using Conjoint Analysis to Understand Engagement in Parenting Health Promotion Programs.

The impact of evidence-based parenting health promotion programs is threatened by limited enrollment and attendance. We used a discrete choice experiment (DCE) to examine how Early Head Start and Head Start parents prioritized key attributes of parenting programs when considering potential participation. Utility values and importance scores indicate that parents placed the highest priority on a program that optimized child academic outcomes, and after that, on a program that offered incentives and logistical supports, and maximized potential effects on friendship skills, behavioral skills, and the parent-child relationship. Next, we used simulations or forecasting tools to estimate parents' preferences for types of programs. Sixty-five percent of parents preferred Outcome-focused Programs that fostered parents' understanding and practice of skills, whereas 23% prioritized Enhanced Support Programs offering logistic support, such as incentives, followed by child outcomes. The remaining 12% of parents preferred Format-focused Programs that targeted positive outcomes via one 30-min meeting. Parents preferring Outcome-focused Programs reported higher child prosocial behaviors compared to parents preferring Enhanced Support and Format-focused Programs. Parents preferring Outcome-focused Programs were more likely to be those of 3- and 4-year-old children than of 2-year-olds. Findings challenge the one-size-fits-all approach to offering parenting programs and suggest ways to enhance accessibility and program reach.

Recommendations for Assessment of Social, Emotional, and Behavioral Health for the National Children's Study.

The Social Emotional Behavioral (SEB) Team of the National Children's Study (NCS) was tasked with making recommendations for assessment of important aspects of social-emotional health and function in children. This paper describes the constructs recommended for assessment along with the rationale for their assessment. These constructs, representing aspects of Social Relationships, Social Capital, Temperament, Negative Affect, Externalizing Behavior, Social Competence, Self-efficacy, Self-image, Psychological well-being, Ethnic/racial Socialization, Perceived Discrimination, Sexual Orientation, Religiosity, and Perceived Stress and Resilience were identified as being critical to the understanding of children's health and development from birth to age 21.

Accidental Injuries in Preschoolers: Are We Missing an Opportunity for Early Assessment and Intervention?

OBJECTIVE: Children with attention-deficit/hyperactivity disorder (ADHD) are at risk for accidental injuries, but little is known about age-related changes in early childhood. We predicted that ADHD would be associated with greater frequency and volume of accidental injuries. We explored associations between ADHD and injury types and examined age-related changes within the preschool period. METHODS: Retrospective chart review data of 21,520 preschool children with accidental injury visits within a large pediatric hospital network were examined. We compared children with ADHD (n = 524) and without ADHD (n = 20,996) on number of injury visits by age, total number of injury visits, injury volume, and injury type. RESULTS: Children with ADHD averaged fewer injury visits at age 3 and 90% more visits at age 6. Children with ADHD had injury visits in more years during the 3-6 age. There were no differences in injury volumes. Among patients with an injury visit at age 3, children with ADHD had 6 times the probability of a subsequent visit at age 6. At age 3, children with ADHD were estimated to have 50% fewer injury visits than children without ADHD, but by age 6, children with ADHD had an estimated 74% more injury visits than children without ADHD. Risk for several injury types for children with ADHD exceeded that for patients without ADHD by at least 50%. CONCLUSIONS: Early identification and treatment of preschool ADHD following accidental injury may prevent subsequent injuries. Clinical implications and future directions are discussed with emphasis on the maintenance of parental monitoring into the older preschool years.

Parent Management Training Oregon Model and Family-Based Services as Usual for Behavioral Problems in Youth: A National Randomized Controlled Trial in Denmark.

This randomized control trial used intent-to-treat analyses to compare parent management training-Oregon model (PMTO) (N = 64) to family-based services as usual (SAU) (N = 62) in 3.5-13-year-old children and their families in Denmark. Outcomes were parent report of child internalizing and externalizing problems, parenting efficacy, parenting stress, parent sense of coherence, parent-report of life satisfaction, and parental depressive symptoms. Outcomes were measured at pretreatment, post-treatment, and 18-20 months post-treatment. Results demonstrated that both PMTO and family-based SAU resulted in significant improvements in child externalizing and internalizing problems, parenting efficacy, as well as parent-reported stress and depressive symptoms, life satisfaction, and aspects of sense of cohesion. Effect sizes at post-treatment and follow-up were in the small to moderate range, consistent with prior PMTO evaluations. However, there were no significant differences between PMTO and family-based SAU. Further research on the process and content of family-based SAU is needed to determine how this approach overlaps with and is distinct from PMTO.

Pilot Study of an Online Parent-Training Course for Disruptive Behavior with Live Remote Coaching for Practitioners.

OBJECTIVE: Many clinicians find it challenging to obtain training in evidence-based interventions, including behavioral parent training, which is considered the front-line treatment for children with disruptive behaviors (Chacko et al., 2017). Workshops, ongoing consultation, and feedback provided in person are effective, yet are rarely feasible for clinicians in the field (Fixsen, Blase, Duda, Naoom, & Van Dyke, 2010). The purpose of the present study was to conduct a preliminary assessment of an online tutorial combined with live remote coaching for training mental health professionals in behavioral parent training. METHOD: Participants in this pretest-posttest open trial were 22 clinicians and graduate students (73% female) from around the United States. RESULTS: The web platform operated successfully, and clinicians found the training to be highly satisfactory. Compared to pre-training, participants demonstrated large improvements in knowledge about disruptive behavior and behavioral parent training and performed significantly better on demonstrations of skill in administering behavioral parent-training components. CONCLUSIONS: An online course combined with live remote coaching is a promising methodology for significantly increasing the number of clinicians trained in evidence-based interventions for disruptive behavior in children. Next steps for evaluation and expansion of this training model are discussed.

Randomized Trial of First-Line Behavioral Intervention to Reduce Need for Medication in Children with ADHD.

A study conducted in an analogue summer treatment setting showed that when concurrently receiving behavioral intervention, many children with Attention-Deficit Hyperactivity Disorder (ADHD) did not need medication or maximized responsiveness at very low doses. The present study followed participants in that summer study into the subsequent school year to investigate whether the same pattern would extend to the natural school and home settings. There were 127 unmedicated children with ADHD between the ages of 5 and 13 who were randomly assigned to receive or not receive behavioral consultation (BC) at the start of the school year. Children were evaluated by teachers and parents each week to determine if central nervous system stimulant treatment was needed. Children who received BC were approximately half as likely those who did not (NoBC) to initiate medication use each week at school or home and used lower doses when medicated at school. This produced a 40% reduction in total methylphenidate exposure over the course of the school year. BC and NoBC groups did not significantly differ on end-of-year teacher or parent ratings of behavior, which were positive. Moreover, BC and NoBC groups did not significantly differ in cost of treatment; although children in the BC condition accrued additional costs via the BC, these costs were offset by the associated delay and reduction in medication use. Results add to a growing literature suggesting that the use of low-intensity behavioral intervention as a first-line treatment reduces or eliminates the need for medication in children with ADHD.

Harnessing Wise Interventions to Advance the Potency and Reach of Youth Mental Health Services.

Despite progress in research on evidence-based treatments (EBTs) for youth psychopathology, many youths with mental health needs do not receive services, and EBTs are not always effective for those who access them. Wise interventions (WIs) may help address needs for more disseminable, potent youth mental health interventions. WIs are single-component, social-psychological interventions designed to foster adaptive meaning-making. They have improved health-related and interpersonal youth outcomes, yet their potential to reduce youth psychopathology has not been systematically explored. Accordingly, we conducted a systematic, descriptive review characterizing WIs' potential to reduce youth mental health problems. Across 25 RCTs (N = 9219 youths, ages 11-19) testing 13 intervention types, 7 WIs qualified as "Well-Established," "Probably Efficacious," or "Possibly Efficacious" for reducing one or more types of youth psychopathology, relative to controls. Among these, 5 WIs significantly reduced youth depressive symptoms; 3, general psychological distress; and 1 each, eating problems, anxiety, and substance use. Three of these 7 WIs were self-administered by youths, and four by trained interventionists; collectively, they were 30-168 min in length and targeted clinic-referred and non-referred samples in clinical, school, and laboratory settings. Overall, certain WIs show promise in reducing mild-to-severe youth psychopathology. Given their brevity and low cost relative to traditional (i.e., therapist-delivered, 12- to 16-week, clinic-based) EBTs, WIs may represent beneficial additions to the youth mental healthcare ecosystem. Priorities for future research are proposed, including testing WIs for parents, younger children, and externalizing problems; as EBT adjuncts; and in schools and primary care clinics to increase access to brief, effective supports.

Adolescent Gender and Age Differences in Responsiveness to Functional Family Therapy.

The current study contributes to a sparse literature on moderators of Functional Family Therapy (FFT) by examining whether responsiveness to FFT, measured by a broad range of outcomes, varies by adolescent gender, age, and their interaction. This study was informed by 687 families (n, adolescents = 581; n, caregivers = 933) and utilized a pre-post comparison design. Fixed-effects regressions with gender, age, and their interaction included as explanatory variables were conducted to calculate the average change in youth mental health, callous-unemotional traits, academic outcomes, substance use, and family functioning. Moderation analyses revealed that according to parent report, girls had significantly greater improvements in peer problems and family functioning, and boys benefited more in increased liking of school. There were differential effects by age, such that older youth had less beneficial mental health outcomes and a smaller decrease in frequency of hash use. The gender by age interaction was significant for adolescents' report of mental health and family functioning outcomes, which suggests that girls benefit from FFT less than boys during early adolescence, but benefit more than boys in late adolescence. This finding adds to literature which has evidenced that family functioning is particularly important for girls by suggesting that FFT is important for improving older girls' mental health and family functioning in particular. The study's results expand the examination of outcomes of FFT to include academic outcomes, and provide insight into key factors that should be considered in addressing adolescent behavioral problems and family functioning.

El presente estudio contribuye a una bibliografía escasa sobre los moderadores de la terapia familiar funcional (TFF) analizando si la capacidad de respuesta a la TFF, medida por una amplia gama de parámetros, varía según el género, la edad y la interacción de los adolescentes. Este estudio se valió de 687 familias (n, adolescentes=581; n, cuidadores= 933) y utilizó un diseño de comparación previa y posterior. Se llevaron a cabo regresiones de efecto fijo con el género, la edad y su interacción incluidos como variables explicativas a fin de calcular el cambio promedio en la salud mental, los rasgos de insensibilidad emocional, los resultados académicos, el consumo de sustancias y el funcionamiento familiar de los jóvenes. Los análisis de moderación revelaron que de acuerdo con el informe de los padres, las niñas tuvieron mejoras considerablemente mayores en los problemas con los pares y el funcionamiento familiar, y los niños se beneficiaron más en el mayor agrado de la escuela. Hubo efectos diferenciales según la edad, de modo que los jóvenes de más edad tuvieron menos resultados beneficiosos en la salud mental y una disminución más pequeña en la frecuencia del consumo de hachís. La interacción del género según la edad fue significativa para los resultados del informe de salud mental y funcionamiento familiar de los adolescentes, que sugiere que las niñas se benefician de la TFF menos que los niños durante la adolescencia temprana, pero se benefician más que los niños en la adolescencia tardía. Este hallazgo aporta a la bibliografía que indica que el funcionamiento familiar es particularmente importante para las niñas, sugiriendo que la TFF es importante para mejorar la salud mental y el funcionamiento familiar de las niñas de más edad en particular. Los resultados del estudio amplían el análisis de los resultados de la TFF para incluir los resultados académicos, y permiten conocer mejor los factores clave que deben tenerse en cuenta a la hora de abordar los problemas conductuales y el funcionamiento familiar de los adolescentes.

Training Executive, Attention, and Motor Skills (TEAMS): a Preliminary Randomized Clinical Trial of Preschool Youth with ADHD.

This preliminary randomized controlled trial compared Training Executive, Attention and Motor Skills (TEAMS), a played-based intervention for preschool children with attention-deficit/hyperactivity disorder (ADHD), to an active comparison intervention consisting of parent education and support (ClinicalTrials.gov Identifier: NCT01462032). The primary aims were to gauge preliminary efficacy and assist in further development of TEAMS. Four- and 5-year-old children with ADHD were randomly assigned to receive TEAMS (N = 26) or the comparison intervention (N = 26) with blinded assessments by parents, teachers and clinicians ascertained pretreatment, post-treatment, and 1- and 3-months post-treatment. Changes in ADHD severity, impairment, parenting factors, and neuropsychological functioning over time as a function of treatment condition were assessed using the PROC MIXED procedure in SAS. Across most measures, significant main effects for Time emerged; both treatments were associated with reduced ADHD symptoms that persisted for three months post-treatment. There were no significant Treatment effects or Time x Treatment interactions on symptom and impairment measures, suggesting that the magnitude of improvement did not differ between the two interventions. However, significant correlations emerged between the magnitude of behavioral change, as assessed by parents and clinicians, and the amount of time families engaged in TEAMS-related activities during treatment. Across a wide array of parenting and neuropsychological measures, there were few significant group differences over time. TEAMS and other psychosocial interventions appear to provide similar levels of benefit. Play-based interventions like TEAMS represent a potentially viable alternative/addition to current ADHD treatments, particularly for young children, but more research and further development of techniques are necessary.

An International Examination of the Effectiveness of Functional Family Therapy (FFT) in a Danish Community Sample.

Youth behavior problems have increased in prevalence in Scandinavian countries. Functional Family Therapy (FFT) has been shown to be an effective intervention across diverse populations and international contexts. The current study examines the effectiveness of FFT within a Danish-community sample in a pre-post comparison design and includes 687 families. Observed outcomes included both parent- and/or youth- reported domains of youth behavior, family dysfunction, school attendance and performance, and substance use. Significant improvements were found in youth behavior, family functioning, and school-related outcomes (e.g., like of school and truancy) despite experiencing a 60% attrition rate in our sample postintervention. This study provides evidence for the effectiveness of FFT on a wide scale in a Scandinavian context, adding to previous research that supports the transportability of this intervention.

A Multisite, Multidisciplinary Delphi Consensus Study Describing "Usual Care" Intervention Strategies for School-Age to Transition-Age Youth With Autism.

Understanding usual care is important to reduce health disparities and improve the dissemination of evidence-based practices for youth (ages 7-22 years) with autism spectrum disorder (ASD). A barrier to describing "usual ASD care" is the lack of a common vocabulary and inventory of the practices used by a diverse provider field. To address this barrier, we gathered input from expert providers to develop an inventory of usual care practices and assess expert familiarity and perceptions of these practices as interventions for anxiety, externalizing, and social difficulties in ASD. Purposeful sampling recruited 66 expert ASD providers representing multiple disciplines from 5 sites. Via a 2-round Delphi poll, experts reviewed, suggested revisions to and rated 49 literature-derived practices on several dimensions (familiarity, usefulness, common use, research support). A revised list of 55 practices and anonymous summary of group characteristics and ratings was then returned for further review. Results yielded 55 intervention practices, 48 of which were identified as "familiar" approaches by consensus (≥ 75% endorsement). Greater variation was observed in practices identified by consensus as most often used, useful, and research supported, depending upon the target problem. Findings provide an inventory of practices, reflective of the multidisciplinary language and approaches of expert ASD providers. This inventory may be used to better assess what constitutes usual care for youth with ASD in the United States. Moreover, findings offer insights from clinical experts regarding the range and acceptability of practices that may inform and ground treatment research, dissemination, and implementation efforts.

Multiple family group service delivery model for children with disruptive behavior disorders: Impact on caregiver stress and depressive symptoms.

Disproportionately high rates of caregiver stress and depression are found among poverty-impacted communities, with high levels of caregiver stress and depression putting youth at heightened risk for the onset and perpetuation of disruptive behavior disorders. The purpose of this study was to examine the effects of a behavioral parent training program called the 4Rs and 2Ss for Strengthening Families Program (4R2S) on caregiver stress and depressive symptoms among 320 youth aged seven to 11 and their families assigned to either the 4R2S or services as usual (SAU) condition. Among caregivers with clinically significant scores at baseline, 4R2S participants manifested significantly reduced scores on the stress and depressive symptom scores to SAU participants at 6-month follow-up. Findings suggest that 4R2S may reduce caregiver stress and depressive symptoms among those caregivers initially manifesting clinically significant levels of stress or depressive symptoms.

Engaging Fathers in Effective Parenting for Preschool Children Using Shared Book Reading: A Randomized Controlled Trial.

Engaging fathers and improving their parenting and, in turn, outcomes for their children in preventive/promotion-focused parenting interventions has been a notable, but understudied, challenge in the field. This study evaluated the effects of a novel intervention, Fathers Supporting Success in Preschoolers: A Community Parent Education Program, which focuses on integrating behavioral parent training with shared book reading (i.e., Dialogic Reading) using key conceptual models (i.e., common elements, deployment model, task shifting) to engage and improve father (i.e., male guardians) and child outcomes. One hundred twenty-six low-income, Spanish-speaking fathers and their children were recruited across three Head Start centers in urban communities and were randomized to the intervention or to a waitlist control condition. Outcomes were obtained before and immediately postintervention and included observed and father-reported parenting and child behaviors, standardized assessments of language, and father self-reported parental stress and depressive symptoms. Attendance data were also collected as a proxy measure of engagement to the intervention. Parenting behaviors (observed and father-reported), child behaviors (father-reported), and language development of the children in the intervention group improved significantly relative to those in the waitlist control condition. Effect sizes (ESs) were in the small to large range across outcomes. Fathers can be engaged in parenting interventions, resulting in improved parent and child outcomes. Greater attention must be given to methods for maximizing parenting within a family and toward developing effective, engaging, and sustainable intervention models for fathers.

Bending the Curve: A Community-Based Behavioral Parent Training Model to Address ADHD-Related Concerns in the Voluntary Sector in Denmark.

Limited access to evidence-based behavioral parent training (BPT) for addressing attention deficit/hyperactivity disorder (ADHD) has been a growing concern internationally. Models to improve access to BPT are needed, particularly those that can be readily implemented in community settings and that leverage the potential workforce to increase capacity to deliver BPT. The purpose of this study was to evaluate a BPT model which included oft-used content, methods, processes of BPT (common-elements), non-professionally delivered (task-shifted/shared) BPT intervention, and an efficient ancillary support system (training, fidelity, and supervision methods) for families of youth with parental concerns about ADHD. In a randomized controlled trial of 161 families of children (79% male; mean age 7.04 [1.55]), the Caring in Chaos (CiC) BPT model, delivered by community volunteers across 12 community-based sites in Denmark, was compared to a wait-list control condition on key child and parent outcomes at immediate post-treatment and 4-month follow-up assessment points. Results suggested that the CiC model led to significantly greater improvement in parenting behavior, parenting sense of competence, child functional impairment, parental stress and parental depressive symptoms compared to the wait list condition at immediate post-treatment, with maintenance of gains in most of these areas at follow-up assessment. No effect of intervention was found on ADHD symptoms. The results of this study suggest that developing efficient BPT intervention models, such as the CiC model, can result in readily implemented interventions by a variety of individuals in community settings. Such models are necessary to bend the curve on addressing unmet needs of families of youth with concerns about ADHD.