Longitudinal Patterns of Community-Based Treatment Utilization Among Ethnically and Racially Diverse Adolescents with Attention-Deficit/Hyperactivity Disorder

Abstract

Background:

Attention-deficit/hyperactivity disorder (ADHD) treatment utilization among adolescents is highly variable. This article describes pharmacological and nonpharmacological treatment utilization in a community sample of primarily Latinx and/or Black adolescents with ADHD (N = 218), followed longitudinally for 4 years, from early adolescence until approximately age 17 (M = 16.80, standard deviation = 1.65).

Methods:

Electronic surveys administered between 2012 and 2019 queried parent and youth reports of medication initiation, persistence, diversion, and misuse, as well as reasons for desistence. Nonpharmacological treatment utilization (including complementary and alternative treatments) was also measured.

Results:

Results indicated that: (1) the majority of the sample sought treatment for ADHD in their community, (2) rates of psychosocial treatment utilization were higher than medication utilization, (3) approximately half of the medicated sample discontinued community-administered ADHD medication during the follow-up period, most frequently citing tolerability issues and concerns that they were “tired of taking” medication, and (4) medication misuse consisted of youth diversion and parent utilization of teen medication, but both were reported at low rates. Race/ethnicity did not predict treatment utilization patterns, but lower family adversity and psychiatric comorbidity predicted persistence of medication use over time.

Conclusions:

ADHD treatment engagement efforts for Latinx and/or Black adolescents might link treatment to goals valued by the youth, address concerns related to medication tolerability, and promote secure monitoring of medication. Nonpharmacological treatments for ADHD may be more palatable to Latinx and Black youth with ADHD, and efforts to engage youth with ADHD in treatment should consider offering medication and psychosocial treatment options.

Introduction

Attention-deficit/hyperactivity disorder (ADHD) is an often chronic neurodevelopmental disorder typically identified in early school years by parents or teachers with defining symptoms of inattention, hyperactivity, and impulsivity (American Psychiatric Association, 2013; Visser et al., 2015). Global prevalence rates of ADHD are estimated to range from 5% to 7% for children and adolescents (Polanczyk et al., 2007; Willcutt, 2012). Marked racial, ethnic, and socioeconomic disparities in diagnosis and treatment for ADHD indicate a continued need to understand service utilization patterns in minority and disadvantaged community samples, which have been under-represented from many North American clinical trials (Turner et al., 2022), including those of ADHD treatments.

Medication disengagement among adolescents with ADHD

Across age groups, adolescents in the United States have the highest prevalence rates of a current ADHD diagnosis (Danielson et al., 2018), suggesting it as a crucial period for treatment. However, adolescents are often hesitant to accept any form of ADHD treatment (e.g., pharmacological, counseling, behavioral therapy) (Bussing et al., 2012). ADHD medication utilization declines during adolescence compared to children under the age of 12 (Brinkman et al., 2018; Danielson et al., 2018; Molina et al., 2009). In general, poor adherence to ADHD medication is associated with negative medication perceptions, fear of side effects, social stigma, and perceived inefficacy of medication (Brikell et al., 2021; Brinkman et al., 2018; Gajria et al., 2014; Khan and Aslani, 2020; Toomey et al., 2012). However, less is specifically known about why adolescents specifically discontinue treatment, particularly among minority youth. Gaining an understanding of the motivations that lead adolescents to discontinue treatment could aid in developing treatment programs that promote adherence and persistence of medication.

In the most detailed study on this topic, Brinkman et al. (2018) reported that most youth (59.8%) who received childhood ADHD medication in the Multimodal Treatment of ADHD (MTA) study desisted between ages 13–18, with very few (13.2%) resuming medication by study endpoint. Adolescence as a sensitive period for medication discontinuation is further illustrated by studies showing declining treatment adherence across the high school years (Newlove-Delgado et al., 2018; Rao et al., 2021). Research on factors that influence premature discontinuation of stimulants should consider patient-specific characteristics. There is some evidence treatment disengagement that occurs at higher rates among ethnic/racial minority youth (Cummings et al., 2017); however, minority youth are notably under-represented in research (Turner et al., 2022) and may experience unique reasons for treatment discontinuation. For example, cultural norms (e.g., beliefs that ADHD-like behaviors are explained by nonbiological factors such as poor parenting or bad character) are shown to lead to parental skepticism about ADHD medication (Glasofer et al., 2021).

Adolescence is also a critical period for emergent comorbidities among youth with ADHD, including oppositional defiant disorder, anxiety disorders, mood disorders, and conduct disorders (Mohammadi et al., 2021). To our knowledge, there is limited research evaluating the impact of psychiatric comorbidity on adolescent ADHD treatment patterns. Some studies suggest that taking psychoactive medications for comorbidities generally increases adherence to ADHD medications (Bhang et al., 2017; Treuer et al., 2016). However, racial and ethnic minority youth may be less likely to use psychoactive medications for comorbid disorders, requiring this question to be re-examined in Latinx and Black samples.

Adolescent diversion of ADHD medications

In addition to adolescent medication disengagement, misuse of ADHD medication is another developmental issue when treating adolescents with ADHD (Khan and Aslani, 2020). There is limited research about diversion of stimulants (i.e., selling, trading, giving away, loaning) and misuse by patients themselves (McCabe et al., 2011). Previous research suggests that prescribed stimulant medication for ADHD compared to other prescribed medications have higher prevalence rates of being diverted (McCabe et al., 2011; Wilens et al., 2006). In late adolescence and young adulthood, previous research has suggested that diversion rates range between 1% and 11% and being approached to divert prescribed stimulant medication is higher ranging from 7% to 25% for those with prescribed stimulant medication for ADHD (McCabe et al., 2011; Molina et al., 2021; Wilens et al., 2006).

Previous research also has suggested that a proportion of parents (11%) of children prescribed ADHD medication have taken their child's ADHD medication (Pham et al., 2017). Recent work suggests that there may be variable misuse (diversion and abuse) of ADHD medication depending on social context (McCabe et al., 2023). Comorbid psychiatric disorder, particularly comorbid externalizing problems, also may influence whether a youth diverts their prescriptions (Wilens et al., 2006). Most work examining diversion of stimulant medication has been conducted in primarily White samples. Thus, there is a need to examine medication misuse patterns, as well as medication disengagement, samples of minority adolescents with ADHD.

Use of adolescent nonpharmacological treatments

Research on utilization of nonpharmacological treatments for ADHD (i.e., evidence-based cognitive-behaviorally-based treatments, alternative treatments with limited evidence) is scarcer than for pharmacological treatments. Although some research suggests that minority youth with ADHD are less likely to receive nonpharmacological treatment than their White peers (Cummings et al., 2017; Eiraldi et al., 2006), other studies suggest that minority families prefer psychosocial treatment to medication (Arcia et al., 2004; McLeod et al., 2007). In community settings, nonpharmacological treatments for adolescent ADHD may include both evidence-based practices and nonevidence-based approaches (Sibley et al., 2022b). Evidence-based psychosocial treatment for adolescent ADHD includes common elements such as organization and time management skill training and operant reinforcement of target behaviors through parent-administered rewards (Rios-Davis et al., 2023).

Previous research has suggested that the most common alternative treatments for ADHD in the community are meditation, yoga, breathing exercises, chiropractic adjustment, guided imagery, and progressive relaxation (Wang et al., 2020), with more recent arrival of cognitive training, neurofeedback, and brain stimulation as novel treatment categories (Sibley et al., 2023). Although some of these treatments demonstrate promise, most have not yet demonstrated efficacy in controlled research trials (Sibley et al., 2023). There is almost no research on utilization of nonpharmacological treatments for adolescent ADHD (both evidence-based and alternative) in samples of primarily minority youth.

Current study

The main purpose of this study is to examine treatment utilization patterns in a primarily racial/ethnic community sample of high school students with ADHD (n = 218) who were systematically diagnosed with ADHD in early adolescence as a part of a randomized controlled treatment study and were followed into high school, 4 years later. Previously, we reported that at 4-year follow-up (4FU), ∼60% of the sample continued to meet full criteria for ADHD, with no impact of treatment assignment or age on this outcome. With respect to efficacy of the study treatment, after controlling for medication use, youth who were randomly assigned to high intensity psychosocial treatment demonstrated a modest but lasting effect on organization skills compared to those who received low intensity psychosocial treatment (Sibley et al., 2022a). Furthermore, age was a significant moderator indicating that treatment was more effective for older versus younger adolescents. This study also reported that there were no significant effects of treatment or treatment × age interactions on medication or psychosocial treatment utilization at 4FU (Sibley et al., 2022a).

Building on our original report, the specific aims of the study were to conduct a more detailed examination of: (1) ADHD medication persistence and discontinuation during the high school years, including treatment duration and reasons for desistence, (2) patterns of medication misuse and diversion by adolescents and their parents, and (3) utilization of nonpharmacological interventions to treat ADHD (both well-established and alternative). For each research question, we also assessed differences between Latinx and Black youth, to assess trends specific to race/ethnicity, as well as the impact of psychiatric comorbidity on utilization patterns.

We hypothesized: (1) low rates of medication utilization and high rates of ADHD medication discontinuation over the course of high school, with negative attitudes toward medication in those that desisted use; (2) misuse and diversion of ADHD medication at modest rates for adolescents and their parents (e.g., Molina et al., 2021); and (3) higher use of nonpharmacological ADHD interventions (both well-established and alternative) versus medication treatment due to higher palatability among adolescent patients. We predicted that Black adolescents would demonstrate lower rates of medication utilization than Latinx adolescents and higher rates of nonpharmacological treatment utilization (Glasofer and Dingley, 2022; Glasofer et al., 2021). We also hypothesized that adolescents with both internalizing and externalizing comorbidities would have higher rates of medication utilization and higher rate of stimulant misuse/diversion than those with simple ADHD. Finally, we predicted that adolescents with both internalizing and externalizing comorbidity profiles will have higher rates of nonpharmacological ADHD treatment utilization due to increased treatment seeking in this population.

Methods

Participants

The present study used data from the 4FU of a randomized controlled trial of high versus low intensity behavior therapy for young adolescents with ADHD (Barney et al., 2022; Sibley et al., 2018; Sibley et al., 2022a). The original study recruited 218 rising sixth and ninth graders who were randomized to high or low intensity behavior therapy for ADHD. Of the 218 participants in the original study, 85.3% (N = 186) remained at the 4FU. The full long-term follow-up sample consisted of 93 initially rising 6th graders (4FU age M = 15.32 standard deviation [SD] = 0.62) and 93 initially rising 9th graders (4FU age M = 18.37, SD = 0.61) (Sibley et al., 2022a) who were in the 9th and 12th grade at 4FU. Out of the 186 participants that were retained at the 4FU, 176 answered the questionnaire that was the focal point of the current research.

Participants included in the original study were required to: (1) meet DSM-IV-TR (American Psychiatric Association, 2000) criteria for ADHD, (2) be matriculating to sixth or ninth grade, (3) display significant academic impairment (at least a “3” on a 0–6 scale teacher Impairment Rating Scale; IRS) (Fabiano et al., 2006), (4) have an estimated IQ >75, and (5) have no history of an autism spectrum disorder. Otherwise, psychiatric comorbidities were permitted. The sample was 73.9% male, 17.4% Black or African American, 72.5% Latinx (any race), 0.9% Asian American, 2.8% Mixed Race, and 6.4% White. There were six participants who endorsed being both Black and Latinx. Parents were 43.1% single, and 43.1% had earned a bachelor's degree. At baseline, 45.9% of youth were receiving medication for ADHD.

Procedures

All procedures of the original study (Sibley et al., 2018) complied with APA ethical standards and were approved by the Florida International University Institutional Review Board and the local school district. For detailed study procedures please see Sibley et al. (2018). All participants received psychosocial treatment (low or high intensity, see Sibley et al., 2018) as a part of the study. All study behavior therapy was discontinued after 1 year, at which point the naturalistic follow-up period began. The study team did not administer or recommend medication; however, all participants were permitted to utilize medication and additional nonpharmacological treatments received in the community, which were monitored and controlled for as appropriate in the study's main outcome analyses (Sibley et al., 2018). Data from the current study were collected 4 years after baseline (3 years after study behavior therapy discontinued; 4FU) using electronic surveys administered to parents and adolescents between 2017 and 2019.

Measures

Medication utilization

To measure medication utilization we used an adaptation of the MTA Health Questionnaire, including the alternative treatment list and the “ADHD Med Reasons” (Brinkman et al., 2018). Parents and adolescents completed the questionnaire separately, and reports were combined to construct a comprehensive treatment history. At each time period in the study, parents and adolescents were asked to document all medications taken since their last assessment. Informants documented start and stop dates for medication, condition for which the medication was taken, medication names and dosages, and reasons for stopping ADHD medication usage (from a list of 16 reasons) (Brinkman et al., 2018). Participants were asked to endorse one primary reason for pharmacological ADHD treatment discontinuation. Any discrepancies between parent and adolescent reports were resolved during the research visit. In nine cases, discrepancies were not able to be resolved at the time of data collection and parent-report trumped adolescent report.

ADHD medication misuse and diversion

To analyze rates of misuse and diversion of ADHD medication, parents and adolescents were asked two questions. The first asked if the adolescent had sold or given the ADHD medication to friends, and the second question asked if the parent had taken the adolescent's ADHD medication (yes [1]/no [0]).

Nonpharmacological intervention

On the health questionnaire, informants also received questions regarding if the adolescent had received any psychotherapeutic, educational, or alternative interventions since their last assessment (yes [1]/no [0]) and, if they had, to report the duration of treatment. The survey contained 12 listed alternative treatments and the option to indicate “other” and write in a treatment not listed.

Comorbidity profile

We previously conducted a Latent Profile Analysis (LPA) that analyzed a set of eight clinical variables and identified three presenting problem profiles: ADHD simplex, ADHD+internalizing, and disruptive/disorganized ADHD (Coxe et al., 2021). As previously reported, the “ADHD simplex” profile was characterized by a mix of the ADHD-IN and ADHD-Combined subtypes, moderate impairment levels, and infrequent comorbidities. “ADHD+internalizing” was characterized by higher likelihood of clinically elevated comorbid anxiety and/or depression. The “disruptive/disorganized ADHD” profile was characterized by severe executive function problems, ADHD-C subtype, slightly lower IQ, and frequent disruptive behavior at school.

Family adversity

We adapted a family adversity index from the Rutter Family Adversity Index (Rutter et al., 1975) to fit the sample context and available data using standard methodology for measuring cumulative risk (Atkinson et al., 2015; Evans et al., 2013). Due to the high prevalence of immigrant families in the sample, parental limited English proficiency was added to the index. In addition, we removed paternal incarceration and maternal mental health diagnosis due to a lack of information on these variables in the available dataset. The resulting score (0–4) equally weighed the following risk factors: (1) single parent household, (2) all parents with a high school degree or less (indicator of low socioeconomic status), (3) all parents with limited English proficiency, and (4) greater than two children living in the home. Higher scores on the family adversity index indicated presence of more risk factors.

Analytic plan

All analyses were conducted using SPSS (SPSS, Inc., an IBM Company, Chicago, IL). We computed the number of participants who utilized ADHD medication currently and at any point during the follow-up period, as well as how many participants discontinued ADHD medication during the follow-up period. We also computed the rate of parental and adolescent-perceived endorsement of each reason for medication discontinuation, utilization of nonpharmacological treatments for ADHD, and misuse/diversion of ADHD medication. Chi-square analyses were conducted to analyze potential differences between the three comorbidity profiles ADHD simplex, ADHD+internalizing, and disruptive/disorganized ADHD and any potential differences by race/ethnicity in ADHD medication utilization, parental and adolescent-perceived reasons for medication discontinuation, utilization of nonpharmacological treatments for reduction of ADHD symptoms, and misuse/diversion of ADHD medication. Using logistic regression, we also conducted exploratory analyses within the Latinx subsample to understand whether family adversity was associated with treatment utilization among Latinx youth.

Results

ADHD treatment utilization

During the follow-up period, 80.7% of the sample received any treatment for ADHD in their communities. Of the participants, 19.3% (34 of 176) did not receive any form of ADHD treatment (pharmacological or nonpharmacological). Multimodal (combined) treatment was pursued by 50.6% (89 of 176) of participants, while unimodal treatment was pursued by 29.5% (52 of 176) of participants.

ADHD medication utilization

Of the sample, 43.8% (77 of 176) received ADHD medication in their communities during the follow-up period. Forty (53.3%) received an Amphetamine derivative stimulant medication, and 33 (44.0%) received a Methylphenidate derivative stimulant medication (5 participants indicated taking both an Amphetamine derivative and Methylphenidate derivative). Two participants (2.7%) had taken a nonstimulant medication (one participant indicated taking both a nonstimulant and an amphetamine derivative). At the time of follow-up assessment, 29.5% (52 of 176) of the sample (or 67.5% of those who were medicated in the follow-up period; 52 of the 77) were currently taking ADHD medication. However, 10 of these individuals stopped medication for a prolonged period during the follow-up and restarted. Thus, 45.5% of those who had received ADHD medication in the follow-up period (35 of the 77) had discontinued an ADHD medication before the 4FU, but only 25 of the 77 permanently desisted.

Parents reported the mean age at which adolescents discontinued ADHD pharmacological treatment as 15.39 (SD = 2.12). The chi-square analysis of the three comorbidity profiles (ADHD simplex, ADHD+internalizing, and disruptive/disorganized ADHD) in ADHD medication utilization was significant for participants that had stopped taking ADHD medication during the follow-up period, χ²(2, N = 79) = 7.18, p = 0.029. The ADHD simplex had the highest rates of ADHD medication discontinuation (55.3%) at the 4FU. ADHD+internalizing had the lowest rates of ADHD medication discontinuation (11.1%) at 4FU. There was no significant difference in ADHD medication utilization based on racial/ethnic background. However, within Latinx participants, medication utilization during the follow-up period was associated with lower levels of family adversity at baseline (b = 0.37, standard error = 0.18, p = 0.037).

ADHD discontinuation reasons

There was high variability in parent and adolescent reasons for medication desistence (Table 1); however, top parent-reported reasons for medication discontinuation were that the teen “was tired of taking it” (31.8%) and “made the teen feel drugged” (18.2%). According to self-report by adolescents the top reasons endorsed for medication discontinuation were “was tired of taking it” (25.8%) and “my parent decided to stop it” (16.1%). There was no significant difference in discontinuation reasons based on comorbidity profile or racial/ethnic background.

Table 1.

Parental and Adolescent Reasons for Attention-Deficit/Hyperactivity Disorder Medication Discontinuation

	Parents (%)	Adolescents (%)
Was tired of taking it	31.8	25.8
Made the teen feel ‘drugged” (e.g., “zoned out,” lifeless, like a zombie, no personality)	18.2	9.7
Made the teen feel bad physically (e.g., nauseous, thirsty, hard to sleep, shaky, tired, and/or mouth was dry)	9.1	9.7
Stopped for the summer and never started again	9.1	0
It was not helping	9.1	6.5
Learned to manage without it	4.5	9.7
Was doing so well he/she no longer needed it	4.5	6.5
Made the teen feel moody (e.g., irritable, angry, anxious, restless, and/or depressed)	4.5	6.5
Made it hard to make friends or friends didn't like him/her as much when he/she took it	4.5	3.2
Doctor refused to prescribe it anymore	4.5	3.2
Insurance stopped paying for it	0	3.2
I felt embarrassed	0	0
It cost too much	0	0
There was no doctor available to prescribe it	0	0
Kept forgetting to take it	0	0
As a parent, I decided to stop it/My parent decided to stop it	0	16.1

ADHD medication misuse and diversion

Combining both parent and self-reports, a total of 3 of the 77 (3.9%) adolescents who were prescribed ADHD medication were reported to have diverted their medication to peers. Three participants of the 77 who received ADHD medication (3.9%) indicated that the parent had taken the adolescent's ADHD medication. Thus, a total of 6 participants (7.8%) reported any type of misuse or diversion of ADHD medication since their last assessment. Comorbidity profiles and racial or ethnic backgrounds could not be analyzed in misuse or diversion of ADHD medication due to low base rate of these events.

Nonpharmacological treatment utilization

Educational interventions (e.g., academic tutoring) were the most common nonpharmacological treatment utilized by the sample 53.4% (N = 94 of 176). The rate of participants who received psychosocial therapy in a mental health setting was 37.5% (N = 66 of 176). The most prevalent alternative treatment reported was ADHD coaching 13.6% (N = 24 of 176), followed by nutritional supplements 8.0% (N = 14 of 176), and herbal remedies 6.3% (N = 11 of 176; see Table 2). There was no significant difference in nonpharmacological treatment utilization by the three comorbidity profiles or based on racial/ethnic background, nor was there an association between family adversity and nonpharmacological treatment utilization within the Latinx subsample.

Table 2.

Nonpharmacological Attention-Deficit/Hyperactivity Disorder Treatment Utilization in the Sample

Form of treatment or method	%	n
Educational intervention	53.4	94
Psychotherapeutic intervention	37.5	66
ADHD coaching	13.6	24
Nutritional supplements	8.0	14
Herbal remedies	6.3	11
Computerized cognitive or memory training sessions	3.4	6
Meditating or yoga	3.4	6
Neurofeedback or biofeedback	2.3	4
Homeopathic medicine sessions	1.7	3
Massage therapy	1.7	3
Chiropractic adjustment	1.7	3
Acupuncture	1.1	2
Hypnotism	0	0

ADHD, attention-deficit/hyperactivity disorder.

Discussion

The current study provides information on ADHD medication and nonpharmacological treatment utilization and diversion in a primarily minority community sample of adolescents with ADHD. During a 3-year period of adolescence from approximately age 14 (age M = 13.94, SD = 1.63) to age 17 (4FU age M = 16.80, SD = 1.65), the primary findings were as follows: (1) the majority of the sample sought treatment for ADHD in their community, (2) rates of psychosocial treatment utilization were higher than medication utilization, (3) approximately half of the medicated sample discontinued community-administered ADHD medication during the follow-up period, citing negative attitudes toward medication, and (4) Latinx and Black adolescents with ADHD demonstrated very low medication misuse and diversion. Race/ethnicity did not predict treatment utilization patterns, but lower family adversity was a significant predictor of medication utilization within the Latinx subsample. In the full sample, comorbidity predicted persistence of medication use over time.

In the current sample, the rates of participants utilizing pharmacological ADHD medication during the adolescent age period (43.8%) differed from epidemiological data reflecting primarily nonminority youth. Danielson et al. (2018) reported medication utilization of 62.1% for adolescents with ADHD aged 12–17 years old. Although the age range lines up imperfectly with the current sample, and medication utilization is known to decline with age (Newlove-Delgado et al., 2018; Rao et al., 2021), it is possibly that lower rates of medication utilization reflect ethnic or other sociocultural differences in the primarily minority sample (Glasofer and Dingley, 2022; Glasofer et al., 2021). Compared to a similar clinical sample of study-treated youth with ADHD, the current sample had similar ADHD medication utilization rates (43.8%) as the MTA study at the 6-year follow-up (mean age of 14.9) with 42.0% of the MTA sample utilizing ADHD medication (Molina et al., 2009) and higher rates than the 8-year follow-up, with 31.0% of the MTA sample (mean age of 16.8) utilizing ADHD medication (Molina et al., 2009).

The rates of pharmacological treatment discontinuation also differed from the MTA. In the current study 45.5% of participants had discontinued ADHD medication treatment since their previous assessment (3 years prior) compared to the 61.5% in the MTA (Molina et al., 2009). In both the MTA and the current study, it is possible that successful response to study treatment reduced treatment seeking in the follow-up period. It should be noted that MTA data were collected ∼10 years before the current study, which may also influence between-study differences.

With respect to reasons for discontinuation (Table 1), the most common perceived reason endorsed for both parent and adolescent was “was tired of taking it.” The second most common reason endorsed for adolescents was “my parent decided to stop it” which was not endorsed by any parent. Parents also endorsed that adolescents discontinued medication because they felt “drugged.” In contrast, Brinkman et al., reported that no longer needing the medication was the most common reason for medication desistence, followed by the experience of adverse effects. Our current data suggest that top reasons for medication discontinuation may be sample specific.

Efforts to improve persistence of medication treatment in minority adolescents with ADHD might target the perceived value of medication for adolescents, as well as parent barriers to maintaining consistent treatment or parent negative attitudes toward medication (Glasofer et al., 2021). Managing side effects on the teen's sense of self may also be important (i.e., feeling socially blunted; see Table 1). Given parent roles in discontinuation and misuse of ADHD medication, family-based approaches to promoting adherence may be appropriate. Adolescents with simple ADHD, who may have lower levels of psychiatric need, are most at risk for discontinuation and might be prioritized for these efforts.

The present study's sample reported rates of misuse and diversion of ADHD medication at 7.8%. Similar to the current study (3.9%), a recent study by Molina et al. (2021) reported very low (1%) diversion in a sample of primary care ascertained adolescents. Recently published national survey data report 6.0% nonmedical use of stimulants by high school students (McCabe et al., 2023); it is not clear whether classmates without ADHD are receiving stimulants from peers with a valid ADHD prescription (few of whom appear to be diverting) or from another source such as the black market or peers without confirmed ADHD. Given that parents were also a source of medication misuse in this sample, family-based approaches to discussing responsible use of ADHD medications may be warranted. However, consistent with past work, practitioners treating minority youth should expect relatively low diversion of medication by youth with gold standard ADHD diagnoses.

Nonpharmacological treatments in the current study were pursued at higher rates than pharmacological treatments. The most commonly nonpharmacological treatment adolescents had engaged educational intervention (53.4%), followed by therapy received in a mental health context (37.5%), and ADHD coaching, a nonevidence-based approach (13.6%). The emergence of coaching as a utilized treatment in this sample requires further research to examine both its possible advantages (i.e., providing on demand executive function supports) and possible disadvantages (i.e., providing direct assistance rather than promoting self-management of ADHD symptoms, high involvement of the provider in the client's daily life). Our findings are in line with previous findings that minority families may prefer psychosocial to pharmacological treatment (Arcia et al., 2004; McLeod et al., 2007). It is also possible that this sample possesses particularly positive attitudes toward nonpharmacological treatments given previous experiences with them during the original research trial, which delivered state-of-the-art behavioral treatments (Sibley et al., 2018). To enhance treatment engagement in minority youth with ADHD, culturally appropriate evidence-based psychosocial treatments are necessary.

Despite this study's strengths (large school-recruited sample with gold standard ADHD diagnoses, cultural diversity, recent data collection, multi-informant design, use of validated measures), it possesses important limitations. The sample consisted of participants in a specific geographic location and may not generalize to a broader population. This study's goal was to provide information concerning a population that has been historically excluded from ADHD research (Latinx and Black participants); however, the results of the study may not generalize to racial/ethnic minority youth who were under-represented in our sample (Asian American and Native American adolescents). There were six participants that endorsed being both Latinx and Black; however, this subsample was not large enough to separately analyze. Although this was a community ascertained sample referred by their schools, parents had to consent to study treatment. Therefore, our findings may not generalize to families of youth who are uninterested in treatment. Although surveys were conducted privately, social desirability response biases are possible when reporting on illegal behaviors such as medication diversion.

Questions did not query the reason for psychosocial treatment so some reported services may have treated symptoms that were unrelated to ADHD. We also did not query the start and stop dates of psychosocial treatment, so we could not investigate whether initiation of pharmacological treatment was associated with initiation of psychosocial treatment. Provider characteristics and systemic barriers to care also may influence ADHD treatment utilization; the design of this study did not adequately collect information on these important variables. We also did not collect information on cultural beliefs, colorism, ethnocentricism, or other oppressive or discriminatory experiences held by participants. Therefore, we cannot draw inferences about how specific aspects of the minority experience influenced our findings. Future research should continue to examine how racial and ethnic factors influence response to medication and psychosocial treatments. Ultimately, it is critical to consider these factors to design culturally appropriate evidence-based treatment strategies for Latinx and Black youth with ADHD. Promising work on motivational interviewing in samples of Latinx and Black youth with ADHD might be incorporated into these efforts (Sibley et al., 2016).

Conclusion

In conclusion, this study suggests that most minority adolescents with ADHD received some treatment (medication or nonpharmacological) during the follow-up period, but the efficacy of these treatments are unknown and treatment discontinuation was high.

Clinical Significance

Efforts to improve persistence of ADHD medication treatment in ethnic minority samples should consider interventions that target the adolescent engagement, perhaps by enhancing their perceived value of treatment, addressing parent barriers to supporting medication adherence, and monitoring side effects that may be particularly important to adolescents (i.e., social blunting). These interventions may be particularly useful for minority adolescents without comorbidities, as they are most likely to underutilize ADHD medications. Because nonpharmacological treatments appear palatable, routine care settings that serve minority youth with ADHD should consider integration of evidence-based nonpharmacological treatments to increase care utilization (Sibley et al., 2022b). Combined treatment may be a promising approach for minority adolescents with ADHD, as previous studies suggest that psychosocial treatment utilization leads to increased medication adherence in primarily Latinx/African American community samples of youth with ADHD (Sibley et al., 2021).

Footnotes

Authors' Contributions

D.M.H.: conceptualization, methodology, formal analysis, writing—original draft preparation, writing—reviewing and editing, visualization. M.H.S.: investigation, validation, conceptualization, methodology, resources, formal analysis, writing—original draft preparation, writing—reviewing and editing. M.A.S.: writing—reviewing and editing. X.L.: writing—reviewing and editing.

Disclosures

In the past 12 months, Dr. Sibley has consulted with Supernus Pharmaceuticals and Tiefenbacher Pharmaceuticals. She also receives royalties from Guilford Press on a book about treating adolescent ADHD with behavioral intervention strategies. Dr. Stein has served as a consultant/advisor for Medici, Supernus, Genomind, Periap Health, and Maxist. No other authors report conflicts of interest.

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