Addressing the complex homework and organization problems faced by students with attention-deficit/hyperactivity disorder (ADHD) must be balanced with ensuring that interventions are feasible to implement. The Homework, Organization, and Planning Skills (HOPS) intervention was developed to be a brief intervention implemented in typical school settings with minimal training/support required for school clinicians. Given this, it is critical to explore how clinician adherence and competency relate to student outcomes. Participants included 107 adolescents with ADHD (Mage = 11.95, SD = 1.04; 69% male; 57% on ADHD medication) who participated in the HOPS intervention. Path analyses examined the relation between clinician adherence (fidelity to session content, session length) and competency (e.g., empathic, enthusiastic, calm, collaborative), controlling for baseline scores of the outcome measure and other relevant therapeutic processes (parent and adolescent engagement, working alliance). Clinician fidelity and competency were inversely related, such that highly competent clinicians had lower fidelity to the HOPS content. Importantly, clinician competency was a significant predictor of fewer parent-reported adolescent organizational problems and a higher percentage of assignments turned in post-HOPS, whereas clinician fidelity was unrelated to treatment outcomes. Session length was inversely related to parent-reported homework performance, such that longer session length was associated with worse homework outcomes. Findings suggest that school clinician competency is an important factor in predicting positive treatment outcomes for youth who participate in school-based homework and organization interventions. Training to help school clinicians improve their competency including being more empathetic, calm, motivating, and collaborative with students, and to help them flexibly implement school-based interventions is warranted.
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Because all the clinicians were newly graduated, White female school counselors, there was not enough clinician diversity in demographic factors to explore these as covariates.
In the larger randomized controlled trial, 113 families were randomized to receive HOPS and 111 started the intervention. Four students did not have recordings for any of their sessions due to one of the school clinicians losing a portion of their audio recordings.
The HOPS fidelity checklists contain a core set of items that assess behaviors that providers implement every session (e.g., completion of checklists, administering points). When new skills were taught and practiced, the checklists were expanded to include additional items. In coding and reviewing the items that were present across all sessions, it quickly became clear that the core set of assessment items consistently happened every session, resulting in little variability in these items. This is not surprising, as HOPS was designed to be highly feasible for providers to implement with minimal training. Therefore, to reduce coder burden, we focused on the sessions that also included teaching and practice of new skills, which captures both the core assessment items (e.g., checklist completion) and the additional items focused on teaching and practicing new skills. Doing so also allowed us to assess fidelity to delivery pace – that is, whether skills were implemented on the timeline specified in the manual.
Abikoff, H., & Gallagher, R. (2008). Assessment and remediation of organizational skills deficits in children with ADHD. In K. McBurnett & L. Pfiffner (Eds), Attention deficit hyperactivity disorder: Concepts, controversies and new directions (pp. 137–152). Taylor & Francis Group.
Abikoff, H., Gallagher, R., Wells, K. C., Murray, D. W., Huang, L., Lu, F., & Petkova, E. (2013). Remediating organizational functioning in children with ADHD: Immediate and long-term effects from a randomized controlled trial. Journal of Consulting and Clinical Psychology, 81, 113–128. https://doi.org/10.1037/a0029648
Adams, A. S., Soumerai, S. B., Lomas, J., & Ross-Degnan, D. (1999). Evidence of self-report bias in assessing adherence to guidelines. International Journal for Quality in Health Care, 11, 187–192. https://doi.org/10.1093/intqhc/11.3.187
Barber, J. P., Crits-Christoph, P., & Luborsky, L. (1996). Effects of therapist adherence and competence on patient outcome in brief dynamic therapy. Journal of Consulting and Clinical Psychology, 64(3), 619–622. https://doi.org/10.1037/0022-006X.64.3.619
Bikic, A., Reichow, B., McCauley, S. A., Ibrahim, K., & Sukhodolsky, D. G. (2017). Meta-analysis of organizational skills interventions for children and adolescents with attention-deficit/hyperactivity disorder. Clinical Psychology Review, 52, 108–123. https://doi.org/10.1016/j.cpr.2016.12.004
Blackburn, I. M., James, I. A., Milne, D. L., Baker, C., Standart, S., Garland, A., & Reichelt, F. K. (2001). The revised cognitive therapy scale (CTS-R): psychometric properties. Behavioural and Cognitive Psychotherapy, 29, 431–446. https://doi.org/10.1017/S1352465801004040
Boyer, B. E., Geurts, H. M., Prins, P. J., & Van der Oord, S. (2015). Two novel CBTs for adolescents with ADHD: The value of planning skills. European Child & Adolescent Psychiatry, 24, 1075–1090. https://doi.org/10.1007/s00787-014-0661-5
Brady, C. E., Evans, S. W., Berlin, K. S., Bunford, N., & Kern, L. (2012). Evaluating school impairment with adolescents using the classroom performance survey. School Psychology Review, 41, 429–444. https://doi.org/10.1080/02796015.2012.12087498
Breaux, R. P., Langberg, J. M., Bourchtein, E., Eadeh, H. M., Molitor, S. J., & Smith, Z. R. (2019). Brief homework intervention for adolescents with ADHD: Trajectories and predictors of response. School Psychology, 34, 201–211. https://doi.org/10.1037/spq0000287
Breaux, R. P., Langberg, J. M., McLeod, B. D., Molitor, S. J., Smith, Z. R., Bourchtein, E., & Green, C. D. (2018). The importance of therapeutic processes in school-based psychosocial treatment of homework problems in adolescents with ADHD. Journal of Consulting and Clinical Psychology, 86, 427–438. https://doi.org/10.1037/ccp0000300
Breitenstein, S. M., Gross, D., Garvey, C. A., Hill, C., Fogg, L., & Resnick, B. (2010). Implementation fidelity in community-based interventions. Research in Nursing & Health, 33, 164–173. https://doi.org/10.1002/nur.20373
Byrne, B. M. (2013). Structural equation modeling with Mplus: Basic concepts, applications, and programming. Routledge.
Clarke, A. T., Marshall, S. A., Mautone, J. A., Soffer, S. L., Jones, H. A., Costigan, T. E., Patterson, A., Jawad, A. F., & Power, T. J. (2015). Parent attendance and homework adherence predict response to a family–school intervention for children with ADHD. Journal of Clinical Child Adolescent Psychology, 44(1), 58–67. https://doi.org/10.1080/15374416.2013.794697
Cohen, J. (1988). Statistical power analyses for the social sciences. Lawrence Erlbauni Associates.
Creed, T. A., Wolk, C. B., Feinberg, B., Evans, A. C., & Beck, A. T. (2016). Beyond the label: Relationship between community therapists’ self-report of a cognitive behavioral therapy orientation and observed skills. Administration and Policy in Mental Health and Mental Health Services Research, 43(1), 36–43. https://doi.org/10.1007/s10488-014-0618-5
Crits-Christoph, P., Gibbons, M. B., Hamilton, J., Ring-Kurtz, S., & Gallop, R. (2011). The dependability of alliance assessments: The alliance–outcome correlation is larger than you might think. Journal of Consulting and Clinical Psychology, 79, 267–278. https://doi.org/10.1037/a0023668
Diggle, P., Diggle, P. J., Heagerty, P., Liang, K. Y., Heagerty, P. J., & Zeger, S. (2002). Analysis of longitudinal data. Oxford University Press.
DuPaul, G. J., & Langberg, J. M. (2014). Educational impairments in children with ADHD. In R. A. Barkley (Ed.), Attention-deficit/hyperactivity disorder: A handbook for diagnosis and treatment (4th ed.). Guilford.
DuPaul, G. J. and Stoner, G. 2003. ADHD in the schools. Guilford.
Durlak, J. A. (2009). How to select, calculate, and interpret effect sizes. Journal of Pediatric Psychology, 34, 917–928. https://doi.org/10.1093/jpepsy/jsp004
Evans, S. W., Langberg, J., Raggi, V., Allen, J., & Buvinger, E. C. (2005). Development of a school-based treatment program for middle school youth with ADHD. Journal of Attention Disorders, 9, 343–353. https://doi.org/10.1177/1087054705279305
Evans, S. W., Langberg, J. M., Schultz, B. K., Vaughn, A., Altaye, M., Marshall, S. A., & Zoromski, A. K. (2016). Evaluation of a school-based treatment program for young adolescents with ADHD. Journal of Consulting and Clinical Psychology, 84, 15–30. https://doi.org/10.1037/ccp0000057
Evans, S. W., Serpell, Z., & White, C. (2005b). The transition to middle school: Preparing for challenge and success. Attention! Magazine (CHADD), 29–31.
Forgatch, M. S., Patterson, G. R., & DeGarmo, D. S. (2005). Evaluating fidelity: Predictive validity for a measure of competent adherence to the Oregon model of parent management training. Behavior Therapy, 36, 3–13. https://doi.org/10.1016/S0005-7894(05)80049-8
Frazier, T. W., Youngstrom, E. A., Glutting, J. J., & Watkins, M. W. (2007). ADHD and achievement: Meta-analysis of the child, adolescent, and adult literatures and a concomitant study with college students. Journal of Learning Disabilities, 40, 49–65. https://doi.org/10.1177/00222194070400010401
Green, C. D., Dvorsky, M. R., Langberg, J. M., Jones, H. A., & Floyd, A. L. (2020). The impact of social determinants of health on the efficacy of school-based interventions for adolescents with ADHD. School Mental Health, Advanced Online Publication. https://doi.org/10.1007/s12310-020-09367-w
Hallgren, K. A. (2012). Computing inter-rater reliability for observational data: an overview and tutorial. Tutorials in Quantitative Methods for Psychology, 8(1), 23–34.
Hatcher, R. L., & Gillaspy, J. A. (2006). Development and validation of a revised short version of the working alliance inventory. Psychotherapy Research, 16, 12–25. https://doi.org/10.1080/10503300500352500
Hogue, A., Henderson, C. E., Dauber, S., Barajas, P. C., Fried, A., & Liddle, H. A. (2008). Treatment adherence, competence, and outcome in individual and family therapy for adolescent behavior problems. Journal of Consulting and Clinical Psychology, 76, 544–555. https://doi.org/10.1037/0022-006X.76.4.544
Karver, M. S., Handelsman, J. B., Fields, S., & Bickman, L. (2005). A theoretical model of common process factors in youth and family therapy. Mental Health Services Research, 7, 35–51. https://doi.org/10.1007/s11020-005-1964-4
Kendall, P. C., Chu, B., Gifford, A., Hayes, C., & Nauta, M. (1998). Breathing life into a manual: Flexibility and creativity with manual-based treatments. Cognitive and Behavioral Practice, 5(2), 177–198. https://doi.org/10.1016/S1077-7229(98)80004-7
Langberg, J. M., Becker, S. P., Epstein, J. N., Vaughn, A. J., & Girio-Herrera, E. (2013). Predictors of response and mechanisms of change in an organizational skills intervention for students with ADHD. Journal of Child and Family Studies, 22, 1000–1012. https://doi.org/10.1007/s10826-012-9662-5
Langberg, J. M., Dvorsky, M. R., Molitor, S. J., Bourchtein, E., Eddy, L. D., Smith, Z. R., & Eadeh, H. M. (2018). Overcoming the research-to-practice gap: A randomized trial with two brief homework and organization interventions for students with ADHD as implemented by school mental health providers. Journal of Consulting and Clinical Psychology, 86, 39–55. https://doi.org/10.1037/ccp0000265
Langberg, J. M., Dvorsky, M. R., Molitor, S. J., Bourchtein, E., Eddy, L. D., Smith, Z., & Evans, S. W. (2016). Longitudinal evaluation of the importance of homework assignment completion for the academic performance of middle school students with ADHD. Journal of School Psychology, 55, 27–38. https://doi.org/10.1016/j.jsp.2015.12.004
Langberg, J. M., Evans, S. W., Schultz, B. K., Becker, S. P., Altaye, M., & Girio-Herrera, E. (2016). Trajectories and predictors of response to the challenging horizons program for adolescents with ADHD. Behavior Therapy, 47, 339–354. https://doi.org/10.1016/j.beth.2016.01.001
Langberg, J. M., Molina, B. S., Arnold, L. E., Epstein, J. N., Altaye, M., Hinshaw, S. P., & Hechtman, L. (2011). Patterns and predictors of adolescent academic achievement and performance in a sample of children with attention-deficit/hyperactivity disorder. Journal of Clinical Child & Adolescent Psychology, 40, 519–531. https://doi.org/10.1080/15374416.2011.581620
Lever N.A., Lindsey M., O’Brennan L., Weist M.D. (2014) Preservice Training for School Mental Health Clinicians. In: Weist M., Lever N., Bradshaw C., Owens J. (eds) In Handbook of School Mental Health (pp. 45–58). Springer.
Mathieson, F. M., Barnfield, T., & Beaumont, G. (2009). Are we as good as we think we are? Self-assessment versus other forms of assessment of competence in psychotherapy. Cognitive Behaviour Therapist, 2, 43–50. https://doi.org/10.1017/S1754470X08000081
Meyer, K., & Kelley, M. L. (2007). Improving homework in adolescents with attention-deficit/hyperactivity disorder: Self vs. parent monitoring of homework behavior and study skills. Child & Family Behavior Therapy, 29, 25–42. https://doi.org/10.1300/J019v29n04_02
McLeod, B. D., Southam-Gerow, M. A., Tully, C. B., Rodriguez, A., & Smith, M. M. (2013). Making a case for treatment integrity as a psychosocial treatment quality indicator for youth mental health care. Clinical Psychology: Science and Practice, 20(1), 14–32. https://doi.org/10.1111/cpsp.12020
Molitor, S. J., Langberg, J. M., Evans, S. W., Dvorsky, M. R., Bourchtein, E., Eddy, L. D., & Oddo, L. E. (2017). Evaluating the factor validity of the Children’s Organizational Skills Scale in Youth with ADHD. School Mental Health, 9, 143–156. https://doi.org/10.1007/s12310-016-9205-0
Muthén, L.K. and Muthén, B.O. (1998–2017). Mplus User’s Guide. Eighth Edition. Muthén & Muthén.
Orlinsky, D., Heinonen, E., Hartmann, A. (2015). Psychotherapy process research. In: J. D. Wright (Ed.), International Encyclopedia of the Social & Behavioral Sciences, 2nd Edition (pp. 515–520). Elsevier.
Perepletchikova, F., & Kazdin, A. E. (2005). Treatment integrity and therapeutic change: Issues and research recommendations. Clinical Psychology: Science and Practice, 12, 365–383. https://doi.org/10.1093/clipsy.bpi045
Power, T. J., Dombrowski, S. C., Watkins, M. W., Mautone, J. A., & Eagle, J. W. (2007). Assessing children’s homework performance: Development of multi-dimensional, multi-informant rating scales. Journal of School Psychology, 45, 333–348. https://doi.org/10.1016/j.jsp.2007.02.002
Power, T. J., Watkins, M. W., Mautone, J. A., Walcott, C. M., Coutts, M. J., & Sheridan, S. M. (2015). Examining the validity of the Homework performance questionnaire: Multi-informant assessment in elementary and middle school. School Psychology Quarterly, 30, 260–275. https://doi.org/10.1037/spq0000081
Pfiffner, L. J., Villodas, M., Kaiser, N., Rooney, M., & McBurnett, K. (2013). Educational outcomes of a collaborative school–home behavioral intervention for ADHD. School Psychology Quarterly, 28, 25–36. https://doi.org/10.1037/spq0000016
Rooney, M., Hinshaw, S., McBurnett, K., & Pfiffner, L. (2018). Parent adherence in two behavioral treatment strategies for the predominantly inattentive presentation of ADHD. Journal of Clinical Child & Adolescent Psychology, 47(sup1), S233–S241. https://doi.org/10.1080/15374416.2016.1236341
Rounsaville, B. J., O’Malley, S., Foley, S., & Weissman, M. M. (1988). Role of manual-guided training in the conduct and efficacy of interpersonal psychotherapy for depression. Journal of Consulting and Clinical Psychology, 56, 681–688. https://doi.org/10.1037/0022-006X.56.5.681
Sattler, J. M. (2008). Assessment of children: Cognitive foundations. JM Sattler.
Shaw, B. F., Elkin, I., Yamaguchi, J., Olmsted, M., Vallis, T. M., Dobson, K. S., Lowery, A., Sotsky, S. M., Watkins, J. T., & Imber, S. D. (1999). Therapist competence ratings in relation to clinical outcome in cognitive therapy of depression. Journal of Consulting and Clinical Psychology, 67, 837–846. https://doi.org/10.1037/0022-006X.67.6.837
Sibley, M. H., Graziano, P. A., Kuriyan, A. B., Coxe, S., Pelham, W. E., Rodriguez, L., & Ward, A. (2016). Parent–teen behavior therapy+ motivational interviewing for adolescents with ADHD. Journal of Consulting and Clinical Psychology, 84, 699–712. https://doi.org/10.1037/ccp0000106
Stein, K. F., Sargent, J. T., & Rafaels, N. (2007). Intervention research: Establishing fidelity of the independent variable in nursing clinical trials. Nursing Research, 56, 54–62.
Villodas, M. T., McBurnett, K., Kaiser, N., Rooney, M., & Pfiffner, L. J. (2014). Additive effects of parent adherence on social and behavioral outcomes of a collaborative school–home behavioral intervention for ADHD. Child Psychiatry & Human Development, 45, 348–360. https://doi.org/10.1007/s10578-013-0405-7
Wampold, B. E. (2015). How important are the common factors in psychotherapy? An update. World Psychiatry, 14, 270–277. https://doi.org/10.1002/wps.20238
Webb, C. A., DeRubeis, R. J., & Barber, J. P. (2010). Therapist adherence/competence and treatment outcome: A meta-analytic review. Journal of Consulting and Clinical Psychology, 78, 200–211. https://doi.org/10.1037/a0018912
Wechsler, D. (2003). Wechsler intelligence scale for children-WISC-IV. Psychological Corporation.
Weller, E. B., Weller, R. A., Fristad, M. A., Rooney, M. T., & Schecter, J. (2000). Children's interview for psychiatric syndromes (ChIPS). Journal of the American Academy of Child & Adolescent Psychiatry, 39(1), 76–84. https://doi.org/10.1097/00004583-200001000-00019
Wolraich, M. L., Lambert, W., Doffing, M. A., Bickman, L., Simmons, T., & Worley, K. (2003). Psychometric properties of the Vanderbilt ADHD diagnostic parent rating scale in a referred population. Journal of Pediatric Psychology, 28, 559–568. https://doi.org/10.1093/jpepsy/jsg046
We would like to thank the families, teachers, graduate students, project coordinators, and school clinicians who made this research possible.
This study was supported by the Institute of Education Sciences, US Department of Education, through Grant R305A130011 to Virginia Commonwealth University and the senior author. The opinions expressed are those of the authors and do not represent views of the Institute or the US Department of Education.
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Breaux, R., Willis, K.D., Eadeh, HM. et al. Exploration of Clinician Adherence and Competency as Predictors of Treatment Outcomes in a School-Based Homework and Organization Intervention for Students with ADHD. School Mental Health (2021). https://doi.org/10.1007/s12310-021-09430-0
- School mental health