Clinical Child and Family Psychology Review, Vol. 3, No.

4, 2000

The Efficacy, Safety, and Practicality of Treatments for

Adolescents with Attention-Deficit/Hyperactivity Disorder
(ADHD)

Bradley H. Smith,1,5 Daniel A. Waschbusch,2 Michael T. Willoughby,3 and Steven Evans4

Studies examining interventions for adolescents diagnosed with attention-deficit/hyperactiv-

ity disorder (ADHD) were reviewed to evaluate their efficacy. These efficacy findings were
supplemented with a preliminary system for judging safety and practicality. Results suggest
that the stimulant drug methylphenidate (MPH) is safe and well-established empirically, but
has some problems with inconvenience and noncompliance. Preliminary research supports the
efficacy, safety, and practicality of some psychotherapeutic interventions, including behavioral
classroom interventions, note-taking training, and family therapy. Treatment with tricyclic
antidepressants was judged to have minimal empirical support and debatable safety. Very
little is known about long-term effectiveness of treatments, long-term compliance, or
multimodal treatments for adolescents such as stimulants plus behavior therapy.
KEY WORDS: ADHD; adolescent; hyperactive; inattentive; stimulant; teen; treatment.

Attention - deficit / hyperactivity disorder
(ADHD) is one of the most frequently diagnosed
and best-studied clinical syndromes in child and ado-
lescent psychology (Goldman, Genel, Bezman, &
Slanetz, 1998; Hinshaw, 1994). Nevertheless, myths,
misunderstandings, and misinformation continue to
interfere with optimal treatment of ADHD. For ex-
ample, until the 1980s there was a dearth of high-
quality research on adolescents with ADHD
(Brown & Borden, 1986; Clampit & Pirkle, 1983).
The lack of research was attributed to the hypothesis
that ADHD was a self-limiting disorder of childhood
with remission of symptoms after puberty. During
the 1970s and 1980s the results of several longitudinal
studies of children diagnosed with ADHD who were
1
Assistant Professor, Department of Psychology, University of
South Carolina.
2
Assistant Professor, Dalhouse University.
3
Department of Psychology, University of North Carolina.
4
Associate Professor, Department of Psychology, James Madi-
son University.
5
Correspondence regarding this article should be addressed to
Bradley H. Smith, Department of Psychology, University of South
Carolina, Columbia, SC 29206. Email: SMITHBRAD@SC.EDU.
followed into adolescence and adulthood challenged
the zeitgeist that ADHD could be diagnosed only in
children. The consensus of the longitudinal studies
was that at least half of children diagnosed with
ADHD continue to meet diagnostic criteria for
ADHD when they are adolescents (Mannuzza, Klein,
Konig, & Giampino, 1990; Weiss & Hechtman, 1993).
Although many adolescents who were diagnosed with
ADHD during childhood succeed despite the diagno-
sis, the majority of adolescents with a childhood his-
tory of ADHD suffer more problems than adolescent
controls. These problems include increased academic
and interpersonal problems, elevated risk for failing
to finish school, higher incidence of automobile acci-
dents, and higher rates of criminal offending and
psychoactive substance use.
It should be emphasized that many adolescents
with a childhood history of ADHD continue to ex-
hibit moderate to severe impairment in life function-
ing even when they have subclincal levels of ADHD
(Barkley, 1998). For this reason, some researchers
have recommended modification in the ADHD diag-
nostic criteria developed for children such that the
criteria are more appropriate for adolescents and

243
1096-4037/00/1200-0243$18.00/0  2000 Plenum Publishing Corporation
244
adults. For example, Barkley (1998) recommends
lowering the number of symptoms necessary for a
diagnosis in childhood (i.e., six) to four or five for
adolescents. Clinical trials are currently underway to
test the validity of changing cutoffs and making other
modifications in the diagnostic criteria for adoles-
cents and adults being evaluated for ADHD. Despite
the continued work on age-appropriate diagnostic
criteria, there is strong evidence that ADHD tends to
be a chronic disorder that persists well past childhood
and into adolescence and adulthood.
Given the multitude of problems typically exhib-
ited by adolescents with ADHD, it may be surprising
that only a minority of adolescents with ADHD re-
ceive treatment. For example, Kazdin (1990) re-
ported that only 10–30% of adolescents with clinically
significant dysfunction receive any mental health
care. Similar rates of treatment for youth with
ADHD were recently reported (Jensen et al., 1999).
These investigators found that only one in eight youth
with ADHD receive medication, and one-third of
these youth receive some form of psychosocial or
educational intervention. Although these data in-
cluded young children as well as adolescents, it is
unlikely that rates of treatment for adolescents would
be significantly higher. Indeed, Kazdin’s (1990) data
suggest that treatment rates for adolescents with
ADHD may be lower than with children.
The reasons for low rates of treatment of adoles-
cents with ADHD are unclear. One possibility is that
the treatment that parents desire for their adolescent
with ADHD is not readily available. For example,
in a recent survey, most parents said that although
they preferred psychosocial intervention to medica-
tion for treating their adolescent’s ADHD, they were
more likely to have access to medication than psy-
chosocial treatments (Jensen et al., 1999). Also of
note are the results of a major randomized trial in
which parent satisfaction ratings were higher when
parents received psychosocial treatment than when
they received medication alone (MTA Collaborative
Group, 1999). The reasons for this preference of psy-
chosocial treatment over pharmacologic treatment
are poorly understood, and research on the palatabil-
ity of treatment may have important practical impli-
cations. For instance, it is currently unclear if access
to relatively desirable treatments actually lead to bet-
ter compliance and outcomes.
Another practical issue is family economic re-
sources, including but not limited to money. The
treatment economy of ADHD should consider time,
limited resources of parental influence, and money.
Smith, Waschbusch, Willoughby, and Evans
Treatment for ADHD, especially in the early stages,
is expected to be time consuming and usually requires
a lot of parental guidance to encourage reluctant
teens to participate in treatment (Robin, 1998). These
expenses must be quantified and considered as practi-
cal issues along with the more obvious monetary costs
to families. Nevertheless, money is an important con-
straint on access to treatment. For example, Robin
(1998) recommends 20 sessions with a qualified men-
tal health professional. This can easily cost more than
$3,000. Many managed care programs may not pay
for all recommended treatments of ADHD because it
tends to be lengthy and often deviates from standard
office visit psychotherapy to involve nonreimbursed
services, such as school visits.
Still another reason for lack of treatment of ado-
lescents is ignorance or low motivation. Little is
known about treating adolescents with ADHD, and
parents and professionals may not know what consti-
tutes appropriate diagnosis or treatment. Some par-
ents might not be aware that ADHD is at the root
of the problems exhibited by their adolescent. Con-
tinued outreach programs through schools and parent
support organizations may be necessary to get help
for adolescents with ADHD. This is not to imply that
all adolescents with ADHD necessarily need some
sort of extensive treatment. There are many adoles-
cents who may thrive with the guidance of supportive
families and organized schools. However, the major-
ity of adolescents with ADHD are presumed to have
problems that would improve with treatment. The
majority of these troubled adolescents apparently do
not receive the services they need.
Despite the many barriers to treatment, there
have been tremendous increases in the number of
adolescents diagnosed with and treated for ADHD
since the early 1980s. This is part of a general boom in
the diagnosis and treatment of ADHD. For example,
surveys comparing physician practices in 1986 and
1999 found a three-fold increase in diagnoses of
ADHD and a 10-fold increase treatment services for
ADHD (Hoagwood, Kelleher, Feil, & Comer, 2000).
Similarly, the U.S. Department of Education com-
pared data from 1987 through 1988 with data from
1997 through 1998 and reported a 315% increase in
the number of children identified as having an ‘‘other
health impairment’’ (the large majority of which are
attributable to ADHD diagnosis). Research from
Safer and colleagues (1994, 1996) provides some in-
formation specific to adolescents with ADHD. Most
notably, adolescents with ADHD are being treated
with stimulants at a rapidly growing rate. For exam-
Treatment for Adolescents with ADHD
ple, the percentage of students taking medication for
ADHD in secondary school more than tripled from
0.22% in 1983 to 0.70% in 1993 (Safer & Krager,
1994). Subsequent surveys indicate that the propor-
tion of adolescents in public schools who are treated
with medication for ADHD continues to double
about every 5 years (Safer, Zito, & Fine, 1996). Simi-
lar figures on increased use of psychosocial or educa-
tional interventions with adolescents were not avail-
able; however, an increase in educational services is
likely due to the clarification of schools’ obligations
to youth with ADHD by the Department of Educa-
tion in 1991 (Barkley, 1998; Robin, 1998). This clari-
fication to the education regulations increased the
obligations of schools to provide services for ADHD
youth who are classified as having an ‘‘other health
impairment.’’
In stark contrast to the number of adolescents
receiving treatment is the small number of studies
reporting treatment results specific to adolescents
with ADHD. The most frequently recommended
treatments for ADHD are stimulant medications and
behavioral therapy, such as parent training and class-
room behavior contingencies. There are several
dozen studies of stimulant treatment for children with
ADHD (see reviews by Swanson, McBurnett, Chris-
tian, & Wigal, 1995; Spencer et al., 1996b). However,
we found only eight controlled studies of stimulant
treatment for adolescents with ADHD. A similar
disparity was found with behavioral treatment. Previ-
ous reviews found dozens of studies of psychosocial
treatments for ADHD (e.g., Pelham, Wheeler, &
Chronis, 1998), but we found only a handful of pub-
lished studies of psychosocial treatments with adoles-
cents with ADHD. The dearth of data specific to
adolescents is a serious limitation to the understand-
ing of the treatment of ADHD because the presenta-
tion and treatment of psychopathology often differs
as a function of age.
As developmental psychopathologists point out,
examining how psychopathology does or does not
change across development can lead to important
advances in understanding psychopathology in both
younger and older children (Sroufe, 1990; Sroufe &
Rutter, 1984). Nevertheless, researchers and clini-
cians often extrapolate results from research on
nonadolescent samples with ADHD (i.e., adults or
children with ADHD) to clinical practice with adoles-
cents with ADHD. Indeed, most reviews of treat-
ments for adolescents with ADHD have made up-
ward extrapolations from studies on children (e.g.,
Swanson et al., 1995). Although there are several
245
published studies of pharmacologic treatment for
adults, no controlled trials of psychosocial treatments
for adults with ADHD have been published (Barkley,
1998). In sum, the vast bulk of the literature on treat-
ment of ADHD is on elementary school-age children.
Consequently, there is a great temptation to base
treatments for adolescents with ADHD on studies
of children.
The tendency to treat adolescents with ADHD
as if they were large children discounts the fact that
there are many differences between children and ad-
olescents, and these differences may be clinically rele-
vant to the treatment of ADHD. Some of these differ-
ences are related to changes within the adolescent,
such as the possibility that medication effects may
be different before and after puberty. Other changes
are within the adolescent but interact with the envi-
ronment. These developmental considerations have
been discussed at length in other reviews (Barkley,
1998; Robin, 1998; Teeter, 1998). Elaboration of de-
velopmental considerations as they interact with
ADHD is in its early stages and has not been sub-
jected to focused research. Thus, most of the develop-
mental considerations are generic, or when specific
to ADHD, theoretical. Future research and clinical
practice should be informed by the interaction of
developmental theory and various theories related
to subtypes of ADHD.
Although full consideration of the host of devel-
opmental changes that arise during the transition
from childhood to adolescence is beyond the scope
of this article, we consider five issues that are salient
to adolescence that deserve consideration with re-
spect to treatment. First, adolescence is typically
marked by greater cognitive capacities that are char-
acteristic of formal operations. These new capacities
involve the ability to think more abstractly and the
increased ability to solve problems in a more system-
atic manner. Consequently, adolescents as compared
to children are more self-conscious, better able to
analyze their own performance, better able to predict
their own behavior ahead of time, and better able
to evaluate critically possible available strategies to
achieve a goal (Teeter, 1998). These improved cogni-
tive abilities and new social expectations might have
an impact on the effectiveness of available treatments
for adolescents as compared to children. Second, ado-
lescence is marked by a focus on identity formation
and the establishment of greater independence. Re-
lated to this is the notion of adolescent ‘‘storm and
stress,’’ which is often manifested as increased oppo-
sitionality toward authority figures. Third, the diffi-
246
culties associated with this increased independence
and autonomy are typically met by a greater reliance
on peers as intimate partners rather than simply
friends with similar interests. Fourth, the transition
to middle and high school results in a different daily
routine. Adolescents routinely interact with up to six
different teachers across the course of the day and
are expected to have greater responsibility in keeping
up with their materials, staying on time, and so on.
Finally, physiological changes, such as growth and
the development of secondary sexual characteristics,
have major influences on social behavior and its con-
sequences (Teeter, 1998). For example, aggression
and defiance, which often accompany ADHD, are
more problematic with a 6-ft, 180-lb individual as
compared to a 4-ft, 80-lb individual!
Consideration of these five issues related to ado-
lescence may result in a number of modifications to
standard methods of treatment. Parents, teachers,
and treatment providers should capitalize on the ado-
lescent’s cognitive abilities and striving for indepen-
dence. For example, the adolescent can become in-
creasingly involved in their own treatment planning
meetings. This would allow adolescents to have input
into the types of treatment that are considered. It
would also serve to provide them with a broader
appreciation for why treatment is necessary. This may
increase their investment and serve to increase com-
pliance. At a minimum, this practice conveys a sense
of treatment ownership to the adolescent that may
not be relevant for children with ADHD. Also, when
treatments involve daily report cards or other behav-
ior-based interventions, clinicians should consider
having adolescents attempt to self-monitor their own
progress. Rather than simply informing the adoles-
cent of their success at meeting certain behavioral
goals, clinicians should encourage adolescents to
gauge their own performance prior to giving them
feedback.
Another developmental consideration is that re-
wards provided to adolescents who meet behavioral
goals should be ecologically valid. Rather than pro-
viding tangible rewards, parents and clinicians might
consider granting adolescents who meet their behav-
ior goals greater opportunities to interact with peers
(e.g., a later curfew, more phone time) or to exert
their independence (e.g., driving privileges). Given
the developmental importance of peer relationships
during adolescence, treatment providers should work
diligently with parents and teachers to facilitate posi-
tive peer relationships. This may involve exposing
adolescents to a broad set of activities that involve
Smith, Waschbusch, Willoughby, and Evans
other peers who may be of interest. Another realm
of therapeutic opportunity for adolescents is expo-
sure to structured vocational experiences such as a
part-time job or volunteer work. Positive experiences
with responsibility may serve to improve adolescents’
sense of self and individuation.
Given the changes in the structure of the school
environment in going from elementary to middle and
high schools, parents and treatment providers should
be conscious of the fact that coordination among
teachers both in the implementation and evaluation
of interventions will be increasingly difficult. How-
ever, development may also improve the opportunity
for successful treatment by creating new opportuni-
ties for interventions. For example, one of the pub-
lished intervention studies with adolescents with
ADHD involved the instruction and practice of note
taking in lecture format classes (Evans, Pelham, &
Grudburg, 1994a). This intervention improved be-
havior and academic performance for a group of
young adolescents, but would have almost certainly
met with failure with a group of second- and third-
grade students with ADHD because the note-taking
task would not be developmentally appropriate for
elementary school children.
Finally, due to the physical maturation of the
adolescent, some disciplinary practices (e.g., physical
confrontation or corporal punishment) may need to
be abandoned. Indeed, such disciplinary practices are
not recommended with children with ADHD (Pel-
ham, 1993).
To summarize, adolescents with ADHD are a
high-risk population that includes many individuals
who should benefit from treatment. We believe this
population has unique treatment needs relative to
children and is grossly understudied relative to chil-
dren with ADHD. There are many reasons why ado-
lescents with ADHD have received so little attention
from clinical researchers, and many of these reasons
have been repudiated by recent research. Treatment
for adolescents with ADHD is growing at an enor-
mous rate. Along with the growing numbers of ado-
lescents being treated for ADHD, there is a growing
interest in developing a body of literature that will
provide information to guide treatment decisions and
future treatment research related to adolescents with
ADHD. A logical way to decide what information is
lacking is to summarize what is currently known from
existing research.
In an effort to pull together information relevant
to clinicians and researchers, we conducted a compre-
hensive literature review that focused on the results
Treatment for Adolescents with ADHD
of treatments delivered to adolescents diagnosed with
ADHD. In the process of locating pertinent publica-
tions, we found that the number of review papers
about treatments for adolescents with ADHD ex-
ceeded the number of empirical clinical studies spe-
cific to this population (some examples include
Baren, 1994; Biederman & Steingard, 1989; Brown &
Borden, 1986; Cantwell, 1986; Conners, 1985; Dendy,
1996; Evans, Vallano, & Pelham, 1995; Faigel,
Sznajderman, Tishby, Turel, & Pinus, 1995; Garland,
1998; Goldman et al., 1998; Robin, 1998; Spencer et
al., 1996b; Teeter, 1998; Tosyali & Greenhill, 1998;
Weiss & Hechtman, 1993; Wender, 1995).
Given the abundance of review articles related
to treatment of adolescents with ADHD, emphasis
must be made on how the current review is different
from its predecessors. First, in most previous reviews,
discussion of quantitative findings have focused on
statistically significant differences. In this review, we
use meta-analytic techniques to summarize treatment
effect sizes in the controlled studies. This quantitative
approach to summarizing research results should fa-
cilitate judgments of the relative efficacy of empiri-
cally evaluated treatments. Second, we attempt to be
as comprehensive as possible. Compared to previous
reviews, we examine at least twice as many empirical
studies of treatments for adolescents with ADHD.
Third, because efficacy alone does not determine the
utility of a treatment, we use an organizational frame-
work that emphasizes not only efficacy, but also
safety and practicality of treatment. Finally, in addi-
tion to providing clinically relevant information, we
summarize important methodologic features of the
current literature. These findings put the current liter-
ature in perspective (i.e., we do not know a lot about
treating adolescents with ADHD). Discussion of the
efficacy, safety, practicality, and methodologic fea-
tures of the current research culminates in recom-
mendations for research objectives and methodologic
standards that, if adopted in future research, should
help to fill some of the critical gaps in knowledge
about treatments for adolescents with ADHD.
JUDGING EFFICACY, SAFETY, AND
PRACTICALITY
Treatments for ADHD in adolescence are typi-
cally evaluated in terms of their efficacy. However,
safety and practicality of treatments are equally im-
portant considerations and are therefore highlighted
in this review. Introductory comments regarding the
247
efficacy, safety, and practicality of treatments are pre-
sented prior to applying these concepts to treatments
for adolescents with ADHD.
Efficacy
The criteria we use for evaluating efficacy are
similar to those adapted by a recent task force on
child psychopathology treatment commissioned by
the American Psychological Association (Lonigan,
Elbert, & Johnson, 1998). These criteria have two
levels of empirical support: well established and prob-
ably efficacious. We added two additional levels:
promising but not validated and probably ineffective.
The criteria for well-established interventions for
childhood disorders require that either (i) there are
two or more well-conducted group-design studies
completed by different research teams, or (ii) there
are several well-conducted single-case study designs
completed by independent investigators showing that
the treatment is either superior to placebo or is at
least as good as an existing well-established treatment
in a study with sufficient statistical power. The criteria
for probably efficacious interventions require either
(i) two studies that demonstrate that the intervention
is more effective than a no-treatment control group,
or (ii) there are two well-conducted group-design
studies, but they are by the same investigators or
group of investigators. For well-established and prob-
ably efficacious interventions, it is important to have
clearly specified sample characteristics. Furthermore,
use of sufficiently detailed treatment manuals that
allows for rapid treatment dissemination, and proce-
dures to measure the effect of adherence to the manu-
als is highly desirable. Our criteria for promising, but
not validated treatments were that there was at least
one well-controlled study or a limited number of
high-quality case studies that suggested that the treat-
ment was effective. Our criteria for probably ineffec-
tive treatments was that there was at least one study
showing null or negative results and no studies show-
ing positive results.
To help summarize our results and compile an
overall treatment quality score that included efficacy,
safety, and practicality, we created a quantitative
score for each of these three dimensions. With regard
to efficacy, well-established treatments were given a
3; probably efficacious treatments were given a 2;
promising but not validated treatments were given a
1; and probably ineffective treatments were given a
0. We were tempted to give the probably ineffective
248
treatments a negative score, but we thought that it
would be necessary to have at least a couple of well-
controlled studies with adequate statistical power
showing null or negative results.
Safety
There are debates in the public and professional
literature regarding the safety of medications for
treating adolescents with ADHD (Barkley, 1998).
Although all of these drugs meet the minimum safety
standards of the Food and Drug Administration
(FDA), not all of the drugs are equally safe and many
have been tested on adults only. Furthermore, once
a drug has been approved for any purpose, it can
be used at the physician’s discretion. Consequently,
drugs that are FDA approved to treat one problem
(e.g., depression in adults) might be used to treat
another problem (e.g., ADHD in adolescents), even
though there were no specific data on (i) the safety
of the drug to treat that problem, and (ii) the efficacy
of the drug for that problem. This practice, sometimes
called off-label prescribing, is very common in child
and adolescent psychiatry. Thus, data are often lack-
ing regarding the specific safety constraints for using
a given drug with a certain population for a specific
disorder. Given the lack of consistency in safety data,
it may not be surprising that opinions regarding the
safety of drugs vary depending on which criteria are
selected. In this review, we focus on reports of sudden
or premature death associated with doses in the ther-
apeutic range, the risk of a fatal overdose, and the
risk of acute and long-term impairment from doses
given in the normal therapeutic range.
We assigned scores for safety using the following
criteria. All treatments started with a safety score of
3. One point was subtracted if the drug had a rela-
tively high risk for fatal overdose, defined in this
review as likely to be fatal if 1 week’s supply of
medication was consumed at once. One point was
subtracted if there were occasionally life-threatening
or health-impairing side effects at therapeutic doses
(e.g., cardiac arrythmias, seizures). One point was
subtracted if there was the possibility of long-term
negative consequences from the treatment (e.g., ele-
vated rates of delinquent behavior).
It is important to note that safety considerations
are not limited to pharmacologic treatments. A com-
monly endorsed ethical principle is that the benefits
of treatment should far outweigh the costs incurred
in the treatment process (e.g., McFall, 2000). The
Smith, Waschbusch, Willoughby, and Evans
current APA criteria for evaluating the empirical
support of treatments do not include cost–benefit
considerations. More specifically, the current criteria
for evaluating psychosocial treatment are purely in-
clusive because they are based only on data that eval-
uate whether the treatment is associated with positive
outcomes. These standards for evaluating empirical
support do not have any systematic means of includ-
ing evidence of harmful effects. This limited perspec-
tive would clearly be inappropriate for medication
treatment, and seems inappropriate for psychosocial
treatment. For example, follow-up studies demon-
strate that some widely applied psychosocial inter-
ventions can have iatrogenic effects (Dishion,
McCord, & Poulin, 1999; McCord, 1978). Presum-
ably, these less than perfect first generation of evolv-
ing standards for evaluating treatment (see Weisz &
Hawley, 1998) will continue to be refined and will
soon include criteria for identifying treatments that
are inefficient, impractical, ineffective, or unsafe.
Practicality
The issues of practicality are germane to con-
trolled clinical studies (i.e., studies of treatment effi-
cacy), but have their most profound impact on utility
of treatments in natural settings (i.e., the treatment
effectiveness). Key issues defining treatment practi-
cality are (i) tolerability, which includes acceptability,
acute side effects, and factors affecting compliance;
(ii) dissemination of treatments from research to ap-
plied settings; and (iii) cost-effectiveness (Lonigan et
al., 1998). These three areas are discussed below.
Treatments are not going to be effective unless
families are willing to try them. Some treatments
may be completely unacceptable to families (e.g.,
electroconvulsive therapy for depression) even
though the treatment may be effective. As mentioned
previously, parents seem to prefer treatments for
ADHD that include a strong psychosocial compo-
nent. It is not known, however, if this initial prefer-
ence translates into better compliance and outcomes
for their children with ADHD.
Another factor affecting tolerability is whether
there are annoying side effects. Literature from sam-
ples of children suggests that side effects of medica-
tion treatments are usually reversible and often dose
dependent, but may make the treatment unpleasant
in the short run (Barkley, McMurray, Edelbrock, &
Robbins, 1990; Pelham, 1999; Pelham & Gnagy,
Treatment for Adolescents with ADHD
1999). Similar results have been found with adoles-
cents with ADHD (Smith et al., 1998a).
Another tolerability issue is the complexity of
demands made on adolescents and families for ad-
ministering the treatment. For example, once-a-day
dosing is more practical for clients than complicated
multiple-dose regimens. Practicality is also influenced
by access factors such as cost and service-delivery
models. Different service-delivery models, such as in-
office versus in-home treatments, are likely to be
associated with unique rates of compliance with treat-
ment, and treatments that have a higher cost may
diminish the effectiveness of treatment if the stake-
holder paying for the treatment (e.g., parent, HMO)
has not been persuaded that the treatment has a
favorable cost–benefit ratio (Henggeler, Schoen-
wald, Borduin, Rowland, & Cunningham, 1998).
Once the issue of tolerability has been ad-
dressed, the extent to which treatments generalize
from controlled efficacy studies must be considered.
A meta-analysis by Weisz, Weiss, Alicke, and Klotz
(1987) indicates that treatment provided in con-
trolled clinical studies is far more effective than treat-
ment delivered in the community. Some recent stud-
ies echo their results. For example, pharmacologic
treatment for ADHD was more effective in the con-
text of a research protocol than when received as
part of treatment as usual in the community (MTA
Collaborative Group, 1999). Similarly, multisystemic
family treatment was far more effective when pro-
vided by academic versus nonacademic service orga-
nizations (Huey, Henggeler, Brondino, & Pickrel,
2000). Understanding the reasons for this discrepancy
in efficacy between academic and nonacademic ser-
vice delivery models should be a high research prior-
ity and should be a cautionary note for the interpreta-
tion of the studies in this review because all were
completed by researchers in universities or academic
medical centers.
To summarize, our criteria regarding practicality
of treatments are preliminary and reflect our judg-
ment rather than a summary of empirically supported
findings from the research literature. Nevertheless,
the proposed practicality scores are designed to call
attention to important issues affecting the impact of
treatment. The scoring for practicality was as follows.
As with safety, all treatments started with a score of
3. Thus, practicality, safety, and efficacy were equally
weighted in this review. One point was deducted for
practicality if the treatment was associated with acute
and annoying side effects; one point was deducted
if the treatment regimen was inconvenient, such as
249
requiring multiple daily dosing, or expensive, such as
requiring an hour or more of therapist contact each
week for several weeks; and one point was deducted
if there were known problems with noncompliance.
METHODOLOGIC OVERVIEW OF
STUDIES REVIEWED
The literature review began with a search of
major electronic databases (e.g., Medline, ERIC,
PsychLit) using various forms and combinations of
the key words: treatment, adolescent, teen, ADHD,
hyperactive, inattentive, and stimulant. There was no
date limit to the literature search. Several articles
of historical interest were found in review papers
uncovered in the literature search. This research lo-
cated more than 200 articles. Between the literature
review and the references in the review papers, 29
papers were classified as empirical studies of adoles-
cents. Studies were excluded if the age range of the
participants was younger than 12 or older then 18.
Furthermore, because our emphasis was students
who had not yet graduated from high school, litera-
ture related to college students was not reviewed.
In many cases the range of ages in the published
studies indicated that the sample included adoles-
cents as part of a larger sample. Unfortunately, in
most of these cases the authors did not provide data
specifically on adolescents. In one such case, we were
able to contact the authors and obtain the adolescent
specific data. Data presented in other reviews (e.g.,
Spencer et al., 1996b) suggest at least a dozen studies
could be added to a review of treatments for adoles-
cents with ADHD if data specific to adolescents were
reported or otherwise made available. Authors of
future treatment research are therefore strongly en-
couraged to provide separate analyses of treatment
effects for adolescents.
The studies reviewed are presented in Table I
along with some selected methodologic data. Meth-
odologic data collected on each study included the
number of subjects, mean age of subjects, the dura-
tion of treatment, and key characteristics of design.
Whenever possible, we calculated effect sizes for the
treatment studies. Because the methodologic data
have important implications for the interpretation of
the results, we begin by summarizing the methodo-
logic composition of the studies.
Studies were coded according to the methodol-
ogy they used as follows: (i) historical studies, (ii)
open trials, (iii) case studies, and (iv) controlled stud-
250 Smith, Waschbusch, Willoughby, and Evans

ies. Studies were coded historical when the diagnostic
status of the subjects was uncertain. Studies were
coded open trial when there were no within-subject
or between-subject controls (i.e., no placebo controls
or no treatment control group). Case studies were
controlled studies with only one or two subjects. Stud-
ies were coded as controlled when they used more
stringent design features, such as double-blinds, pla-
cebo-controls, and randomization of treatment con-
ditions either in the context of a between-subjects
study or crossover design in which the subjects served
as their own controls.
Sample of Subjects
As shown in Table II, combining across 29
studies, a sample of 550 adolescents was evaluated.
Among these adolescents, about 92% of the subjects
were male and, although not shown on Table II,
more than 90% were Caucasian, with the remaining
10% classified as African American. The age range
in the studies spanned 12 to 20 years old, but the
mean age was in the young adolescent range (i.e.,
about 13 years old). Problems with reporting subject
characteristics made it difficult to calculate a precise
mean age. About two-thirds of the subjects were
described as having comorbid behavioral pro-
blems, usually in the form of high levels of ag-
gression. These individuals were expected to
meet diagnostic criteria for either Oppositional
Defiant Disorder (ODD) or Conduct Disorder
(CD). In sum, the research reviewed is most re-
levant to poorly behaved, young, white, male adoles-
cents.

Table I. Selected Methodologic Features of Studies that Examined Treatments for Adolescents Diagnosed with ADHD
Sample Duration
Study Treatment type size Category (weeks) Research design
Historical
Eisenberg et al., 1962 Stimulants 42 Historical 9 Between subjects
Maletzky, 1974 Stimulants 28 Historical 12 Between subjects
Korey, 1944 Stimulants 21 Historical 6 Between subjects
Brown et al., 1983 Stimulants 1 Historical 10 Case study
Lerer & Lerer, 1977 Stimulants 27 Historical 8 Pre-post group
Safer & Allen, 1975 Stimulants 11 Historical 104 Pre-post within subject
MacKay et al., 1973 Stimulants 10 Historical ? Pre-post within subject
Kaplan et al., 1990 Stimulants 9 Historical 7 Mix of between and within
Varley, 1983 Stimulants 22 Historical 3 Crossover within subjects
Controlled Studies of Methylphenidate (MPH)
Brown & Sexson, 1988 MPH 11 Controlled 8 Crossover within subjects
Brown et al., 1991 MPH ⫹ inpatienta 22 Controlled 1 Crossover within subjects
Evans & Pelham, 1991 MPH ⫹ STPb 9 Controlled 6 Crossover within subjects
Fischer & Newby, 1991 MPH 27 Controlled 3 Crossover within subjects
Klorman et al., 1987 MPH 19 Controlled 6 Crossover within subjects
Klorman et al., 1990 MPH 48 Controlled 6 Crossover within subjects
Pelham et al., 1991 MPH ⫹ STPb 17 Controlled 6 Crossover within subjects
Smith et al., 1998 MPH ⫹ STPb 46 Controlled 6 Crossover within subjects
Psychosocial Treatments
Evans et al., 1994–1995 (#1) Note taking ⫹ STP 16 Controlled 8 Crossover within subjects
Evans et al., 1994–1995 (#2) Note taking ⫹ STP 14 Controlled 8 Crossover within subjects
Ervin et al., 1998 Behavior modificatin 1 Case study 72 A-B-C
Stewart et al., 1992 Behavior modification 1 Case study 3 ABAB
Morris, 1993 Rational emotive therapy 12 Controlled 12 Between subjects
Barkley et al., 1992 Family therapy 61 Controlled 9 Between subjects
Tricyclic antidepressants (TCAs)
Biederman et al., 1989 Desipramine 20 Controlled 6 Between subjects
Wilens et al., 1993 Nortriptyline 21 Open 122 Pre post within subjects
Spencer et al., 1993 Desipramine 16 Open 120 Pre post within subjects
Other treatments
Chappell et al., 1995 Guanfacine 3 Open 14 Pre post within subjects
Riggs et al., 1996 Pemoline 3 Open 7 Pre post within subjects
Riggs et al., 1998 Bupropion 13 Open 5 Pre post within subjects
MPH ⫹ inpatient indicates that the trial of medication was completed on an inpatient psychiatric unit.
a

MPH ⫹ STP indicates that the trial of medication was completed in the context of a Summer Treatment Program.
b
Treatment for Adolescents with ADHD 251

Table II. Summary of Sample and Design Characteristics of Studies that Examined Treatments for Adolescents Diagnosed with ADHD
Percentage
of subjects Percentage Mean
with comorbid of studies duration of
Number Number Percentage disruptive classified controlled
of of of male behavior as well studies
Type of study studies subjects subjects disorders controlled (weeks)
Stimulants (historical) 9 171 98 95 0 NA
Stimulants (modern) 8 214 92 69 100 6
Psychosocial 6 105 89 69 67 9
Antidepressants 3 57 94 69 33 6
Other medications 3 18 50 40 0 NA
Summary 29 565 92 77 40 7

These demographics suggest that very little is
known about treatments for ADHD provided to
older adolescents, female adolescents, or adolescents
from non-white racial groups. There have been nu-
merous suggestions that response to medication may
be affected by ADHD diagnostic type (Hinshaw,
1991). For example, inattentive adolescents might
benefit differently from impulsive adolescents. This
issue has yet to be addressed in the adolescent litera-
ture. Furthermore, some researchers have suggested
that children and adolescents with comorbid anxiety
disorders may respond to stimulants differently that
children or adolescents whose psychopathology is re-
stricted to the disruptive behavior disorders (Quay,
1997). As implied in Table II, little is known about
the effects of treatment for adolescents with ADHD
who do not have comorbid behavioral problems.
Another consideration in the sample characteris-
tics is the definition of the population. For the pur-
poses of this review, adolescent was defined opera-
tionally as any person between the age of 11 and 20
years of age at the start of a given study. This defini-
tion is arbitrary. It would be desirable to obtain more
precise definitions of adolescence either physically
(e.g., with Tanner stages), socially (e.g., grade in
school), or cognitively (e.g., on tasks that distinguish
between children and adolescents). Unfortunately,
other than reporting age, in almost all of the studies
there was no attempt to measure the construct of
adolescence. For this reason, the adolescent literature
could be criticized for failing to describe the sample
characteristics adequately (see Lonigan et al., 1998).
An example of the potential limitations of rely-
ing on age to define adolescence is found in a study
that suggests that response to stimulant medication
is stable from childhood to adolescence (Smith et
al., 1998a). In this longitudinal study, the effect of
methylphenidate (MPH) was assessed when the par-
ticipants were ‘‘children’’ and again when they were
‘‘adolescents.’’ Childhood was defined as under 12
years old, adolescence as older than 12. Thus, in Smith
et al. (1998), the only indication that the participants
might be adolescents was that they were over 12 years
of age, they were a few years older than when they
were children, and they were physically bigger. Our
experience with the sample was that the range of
maturity within the sample of adolescents was sub-
stantial. For example, some were preoccupied with
members of the opposite sex, and some showed abso-
lutely no interest in dating. We found no correlation
between age and medication effect size. It is possible,
however, that a more precise measure of maturity
than age, such as Tanner Stage, could have revealed
a correlation among maturation, behavior, and treat-
ment response. This is purely speculative, but it is
possible that direct measures of physical and cogni-
tive development could produce more clarity in re-
search addressing the difference among child, adoles-
cent, and adult populations.
Study Design
Generally speaking, the well-controlled studies
used randomization, blinding, and other experimen-
tal procedures intended to control threats to the inter-
nal validity of the intervention (see Cook & Camp-
bell, 1979). Owing to the emphasis on minimizing
threats to internal validity in clinical trials, these stud-
ies were ‘‘efficacy’’ studies that describe what is possi-
ble under controlled experimental conditions (see
Lonigan et al., 1998). These well-controlled studies
do not necessarily describe the probable impact or
‘‘effectiveness’’ of treatments in widespread clinical
practice.
An important design feature is the length of the
252
study. The average length of the controlled studies
was 7 weeks. This is a very short period of time,
considering that ADHD tends to be a chronic disor-
der that presumably requires uninterrupted and
developmentally appropriate treatment (Barkley,
1998). Furthermore, none of the studies addressed
the critical issue of compliance with treatment under
nonexperimental conditions. A follow-up study of a
subset of the sample in Smith et al. (1998) indicated
that compliance with pharmacologic and psychoso-
cial treatment recommendations was poor following
participation in a summer treatment program for ad-
olescents with ADHD. Thus, future studies need to
examine long-term compliance and how compliance
is related to long-term outcomes of treatment.
Another important design feature is to compare
treatments to a reasonable criterion. Given the
evidence that some treatments are effective for
ADHD, it is unethical to have no-treatment control
groups (see Barkley, Guevremont, Anastopoulos, &
Fletcher, 1992b). A potentially interesting control
group is the so-called treatment as usual community
comparison. However, as mentioned early in this re-
view, the typical treatment for ADHD in the commu-
nity is no treatment, and this may be an unethical
condition. Other comparison conditions may be more
ethical and more informative. The ultimate measure
of efficacy is how it compares with the current ‘‘gold
standard’’ treatment. For adolescents with ADHD,
all indicators, including prescription practices and
number of studies on adolescents, suggest that MPH
is the most popular treatment. The results of the
review presented below suggest that it is the best-
studied treatment. Therefore, we propose that future
studies should evaluate results relative to treatment
with MPH.
Another important design feature is the poten-
tial impact of interventions provided in combination
with other interventions. Some of the interventions
are best described as multimodal treatment in which
only one aspect of the treatment has been evaluated
systematically. For example, Pelham and colleagues
studied medication effects in the context of a thera-
peutic Summer Treatment Program (STP) that in-
cluded elaborate psychosocial treatment components
(see Table I). It is possible that the behavior modifi-
cation procedures of the STP influenced the effect
of the medication. This seems likely because in the
MTA study, the children who received psychosocial
treatment and medication required less medication
than the children who received medication alone
(MTA Collaborative Group, 1999). Thus, treatments
Smith, Waschbusch, Willoughby, and Evans
completed in the STP may underestimate medication
effects that might be apparent in relatively less struc-
tured settings.
Domains of Outcome
One of the areas of great uncertainty in evaluat-
ing the empirical support for treatments of individu-
als with ADHD is selecting appropriate domains of
outcome. ADHD is manifested differently across set-
tings, and adolescents with ADHD experience im-
pairment in numerous facets of their lives. Potential
domains of outcome for adolescents include aca-
demic performance, social behavior with peers, de-
portment in school, interactions with siblings and par-
ents, and symptoms of ADHD and comorbid
conditions. It is noteworthy that ADHD is expected
to be a chronic condition, and therefore treatment is
not expected to eliminate the fact that the adolescent
has a developmentally high level of inattention, im-
pulsivity, or hyperactivity. Thus, although it should
be informative to track changes in ADHD symptoms,
the main emphasis should be to reduce the functional
impairments associated with ADHD. Unfortunately,
the literature review found a heavy emphasis on mea-
suring ADHD symptoms, and much less attention to
functional impairments (Table III).
As shown in Table III, about 82% of the adoles-
cent treatment studies reported changes in ADHD
behaviors at outcome. Although academic problems
are the most frequent reason for referral for treat-
ment of ADHD (Barkley, 1998), only 29% of the
studies reported measures related to school perfor-
mance. Defiant behavior or school deportment prob-
lems is the number two reason adolescents with
ADHD are referred for treatment, but only 46% of
the studies assessed aggressive behavior. This is sur-
prising, given that 77% of adolescent research sub-
jects were identified as having exhibiting comorbid
defiance or aggression at baseline. Only 21% of the
studies reported changes in behavior related to peers
and only 12% of the studies reported changes in be-
havior with adults. Only 50% of the medication stud-
ies reported data regarding side effects, and none of
the psychosocial studies examined possible side ef-
fects.
Most experts on ADHD recommend collecting
data from home and school settings. Usually, this
is in the form of ratings completed by parents and
teachers. Some strongly emphasize the importance
of collecting objective data. According to the sum-
Treatment for Adolescents with ADHD 253

Table III. Summary of Domains of Outcome Measured in Studies that Examined Treatments for Adolescents Diagnosed with ADHD
ADHD Aggressive Global Academic Behavior Behavior Treatment
symptoms behavior functioning performance with with side
Type of study (%) (%) (%) (%) peers (%) adults (%) effects (%)
Stimulants (historical) 100 100 0 33 66 33 33
Stimulants (modern) 93 71 29 50 21 7 57
Psychosical treatment 100 60 0 60 20 20 0
Antidepressants 66 0 66 0 0 0 33
Other medication 50 0 0 0 0 0 50
Mean percentages 98 77 10 48 36 20 30

mary in Table IV, nearly half of the studies included
data from parents (48%) or teachers (49%). The least
commonly gathered information involved objective
data, which were found in only 25% of the studies.
Adolescent self-report was collected in about 30% of
the studies. The utility of self-report is questionable
(Smith, Pelham, Gnagy, Molina, & Evans, 2000), and
accurate self-monitoring relative to objective mea-
sures of performance is an important clinical need
for many adolescents with ADHD. Counselor or
other type of interactive observer data was found in
nearly 40% of the studies and might be treated as
objective data in some circumstances. Physician re-
ports focused primarily on medication side effects,
and was collected in 42% of the studies and none of
the psychosocial studies.
Summary of the Methodologic Review
changes in functioning. Almost no attention has been
given to the issue of clinically significant change (see
Barkley et al., 1992b, for an important exception).
In addition, the range of domains of functioning
and sources of information have been too narrow in
most studies. This is a concern because some treat-
ments may affect one area of functioning detrimen-
tally while benefiting another. For example, high
doses of stimulants may decrease negative social be-
havior at the potential expense of social withdrawal,
cognitive or affective blunting, and negative side ef-
fects. Thus, the most informative studies collect data
in multiple domains (e.g., ADHD symptoms, social
behavior, academic performance, negative side ef-
fects) in multiple settings (e.g., home, school), and
from multiple sources (e.g., parents, teachers, objec-
tive measures). This recommendation is pertinent to
both clinical practice and research studies.

The bulk of the available research is on poorly
behaved, young, white, male adolescents who were
treated with MPH in well-controlled drug trial stud-
ies. Most of the data in the studies come from ratings
by parents and teachers, with one-quarter to one-
third of the data coming from objective measures.
Researchers focused heavily on measuring changes
in ADHD symptoms, with much less attention to
CALCULATING TREATMENT EFFECT SIZES
An important supplement to the efficacy ratings
in this study is the calculation of treatment effect
sizes for the controlled studies found in the literature
review. More specifically, we calculated unweighted
effect sizes in the form of a modified Cohen’s d, which
is the difference between the treated and untreated

Table IV. Summary of Sources of Outcome Data in Studies that Examined Treatments for Adolescents Diagnosed with ADHD
Objective
Number behavioral
of Parent Teacher Physician Self Observer/ measures
Type of study studies (%) (%) (%) (%) conselor (%) (%)
Simulants (historical) 9 66 66 66 33 66 0
Stimulants (modern) 9 50 86 29 21 21 57
Psychosocial 6 33 0 0 50 66 33
Tricyclic antidepressants 3 33 33 100 33 0 0
Other medication 3 33 0 33 0 0 33
Mean Percentages 48 49 42 30 39 27
254
means divided by the standard deviation in the un-
treated condition. We used the standard deviation in
the untreated condition instead of the pooled stan-
dard deviation, which is more commonly used (Co-
hen, 1992), because treatment tends to reduce the
variability in behavior in adolescents with ADHD.
Thus, compared to the pooled standard deviation,
the standard deviation in the untreated condition
tends to provide a more conservative effect size.
Effect sizes were calculated across three do-
mains: ADHD symptoms, social behavior, and aca-
demic performance. As discussed in detail in the
methodologic overview of the studies, reporting on
domains other than ADHD symptoms tended to be
scant, and we frequently had missing data. Further-
more, although it would have been nice to divide
social behavior into behavior toward peers, behavior
with parents, and behavior with teachers, the research
reports did not allow such an analysis.
Although the range of domains was narrow, the
studies tended to report a host of overlapping mea-
sures. We selected a single measure from each study
(Table V). For ADHD symptoms, we strove for a
composite measure such as the IOWA Conners
Inattention/Overactivity Scale (Loney & Milich,
1982). The studies that reported social behavior
tended to report scales indicative of ODD or CD,
such as the IOWA Conners Oppositional/Defiant
scale. If no such scale was available, the measure
was listed as ‘‘not available.’’ The most commonly
reported measure of academic performance in the
studies of MPH was related to arithmetic, such as
the percentage of correct math problems. If there
was no measure of mathematical performance for
the MPH studies, that domain was treated as having
missing data. The math measures were not available
for the psychosocial treatments and other measures
are used in this section. The results of the meta-
analysis are reported in Table V and are discussed
in detail in the sections discussing specific treatments
and in the final summary section.
Studies of Methylphenidate
Methylphenidate (MPH) is the most commonly
prescribed and best studied treatment for ADHD.
Recent estimates suggest that there are more than
127 published research studies on MPH treatment
for ADHD (Spencer et al., 1996b) and more than
8000 separate source articles listed in more than 300
review articles (Swanson et al., 1995). However, there
Smith, Waschbusch, Willoughby, and Evans
are relatively few studies that have examined MPH
in adolescents. We identified 9 historical studies of
stimulants, but due to the methodologic limitations
of these studies they are not reviewed in detail in
this section, even though a few of these studies used
MPH. We located 8 well-controlled studies that pro-
vided data on treatment of ADHD in adolescence,
including unpublished data specific to adolescents
provided by one author (Fischer, personal communi-
cation, 1996). Information on these studies is pre-
sented in Table I and sample characteristics are sum-
marized in Table II.
Efficacy
Each of the 8 well-controlled studies of MPH
resulted in statistically significant improvements from
treatment. Only 3 of these studies reported the pro-
portion of subjects who made clinically significant
improvements (see Table V), and the modal result
was that about half of the adolescents with ADHD
exhibited clinically significant improvements when
treated with stimulants. This is lower than the puta-
tive response rate of 70% reported in studies of chil-
dren (Barkley, 1990). However, the average effect
size on ADHD symptoms in the adolescent studies
(0.94) is at the top of the range reported in studies
with children (e.g., 0.47–0.96; Lipsey & Wilson, 1993).
The effect size was slightly larger for negative social
behavior (1.06) and even larger for math (1.25).
A few investigators have looked for dosage ef-
fects (see Smith et al., 1998b, for a review). Briefly,
of those studies with adolescents that have assessed
different dosage levels, less than 50% of them found
mean differences between low and high doses that
were statistically significant, but more than 90% of
the studies have found mean differences between
placebo and low doses that were statistically signifi-
cant. Moreover, once a therapeutic effect was
reached, higher doses of MPH typically failed to pro-
duce continued therapeutic gains but were instead
associated with progressively higher risk of negative
side effects. Thus, the current data suggest that MPH
has demonstrated efficacy for treating ADHD in ado-
lescence. The few available dosage studies found
nearly equal effects of MPH emerge for low and
high doses, suggesting that adolescents with ADHD
should be given generally low doses of MPH rather
than the highest dose they can tolerate.
Although the group-level studies have found
nearly equal effects for low doses as higher doses,
 Table V. Selected Effect Sizes from Well-Controlled Studies that Examined Treatments for Adolescents Diagnosed with ADHD
Effect Effect
size size for Effect
Treatment ADHD for Social social Academic size for
Study type/dose measure ADHD measure behavior measure academics
Controlled Studies of methylphenidate
Brown & Sexson, 1988 0.15 mg/kg Parent Conners 3.00
0.30 mg/kg Parent Conners 2.26
0.50 mg/kg Parent Conners 0.88
0.15 mg/kg Teacher Conners 0.83 ACTeRS social skills 0.70 Math (% correct) 0.13
0.30 mg/kg Teacher Conners 2.20 ACTeRS social skills 0.25 Math (% correct) 2.37
0.50 mg/kg Teacher Conners 2.55 ACTeRS social skills 1.09 Math (% correct) 2.56
Brown et al., 1991 10 mg CTRS–conduct factor 0.50 Math efficiency 0.71
15 mg CTRS–conduct factor 0.71 Math efficiency 3.36
20 mg CTRS–conduct factor 0.21 Math efficiency 3.22
Evans & Pelham, 1991 0.3 mg/kg Parent I/O Scale 0.41 Disruptive behavior (%) 0.52
0.6 mg/kg Teacher I/O Scale 0.48 Disrutpive behavior (%) 0.68
Fischer & Newby, 1991 0.2 mg/kg Parent Conners 0.21 CPRS-R Conduct 0.03 Math (% correct) ⫺0.50
0.4 mg/kg Parent Conners 0.33 CPRS-R Conduct 0.24 Math (% correct) ⫺0.38
0.2 mg/kg Teacher Conners 0.13 CTRS-R Conduct 0.24
0.4 mg/kg Teacher Conners 0.31 CTRS-R Conduct 0.12
Klorman et al., 1987 Low (25 mg/day) Parent Conners 0.65 CPRS Aggression 0.49
Medium (40 mg/day) Parent Conners 0.62 0.43
Klorman et al., 1990 MPH (0.22–0.28 mg/kg) Parent Conners 1.13 ACTeRS Aggression 0.88
Teacher Conners 1.22 ACTeRS Aggression 1.09
Pelham et al., 1991 0.3 mg/kg Teacher Conners 0.41 Math (% correct) 0.31
Counselor Conners 0.39
Smith et al., 1998 MPH 10 mg Teacher I/O Scale 0.37 Teacher O/D 0.35
MPH 20 mg Teacher I/O Scale 0.56 Teacher O/D 0.47
MPH 30 mg Teacher I/O Scale 0.74 Teacher O/D 0.65
Psychosocial treatments
Evans et al., 1994–1995 Note taking Classroom on-task (%) 0.74 Classroom disruptive (%) 0.09 Quiz scores 0.16
Barkley et al., 1992 BMT CBCL External 0.53 CBCL Social 0.20 CBCL Academic 0.33
PSCT CBCL External 0.74 CBCL Social 0.28 CBCL Academic 0.31
SFT CBCL External 0.63 CBCL Social 0.05 CBCL Academic ⫺0.01
Tricyclic antidepressants (TCAs)
Biederman et al., 1989 Desipramine Conners Parent 0.43
Conners Teacher 0.58
256
this finding is controversial and may be limited to
particular domains, such as symptoms of ADHD.
Response to stimulant medication is notoriously idio-
syncratic. Therefore, doses should be titrated based
on data from individual adolescents, preferably using
a double-blind, placebo-controlled, case study ap-
proach with crossover designs and measures of
multiple domains of functioning plus assessments of
self- and other-reported side effects and compliance
(Pelham & Smith, 1998).
Safety
There have been a number of concerns about
the safety of MPH. Among the more serious concerns
that have been expressed are that MPH can worsen
psychotic conditions (e.g., Robinson, Jody, & Lieber-
man, 1991), glaucoma, and hypertension, and that
MPH treatment can result in growth suppression,
increased rates of seizures, and increased rates of tic
disorders (PDR, 1988). However, studies of children
with ADHD provide little evidence supporting these
concerns (e.g., Gadow, Sverd, Sprafkin, Nolan, &
Ezor, 1995; Vincent, Varley, & Leger, 1990; Wro-
blewski, Leary, Phelan, Whyte, & Manning, 1992;
Roche, Lipman, & Overall, 1979; Spencer et al.,
1996a; Feldman, Crumrine, Handen, Alvin, & Teod-
ori, 1989).
Methylphenidate has a relatively large margin
of safety. This means that the ratio of the estimated
lethal dose for 1% of the population is much higher
than the minimum therapeutic dose for 99% of the
population (Levinthal, 1999). Because of the high
margin of safety, MPH is not considered a risky treat-
ment in terms of sudden death from accidental over-
dose. For the purposes of this discussion, we consid-
ered the effects of oral ingestion of 1 week’s worth
of medication. Although such overdoses of MPH may
cause hallucinations, tachycardia, and some other
acute symptoms, such overdoses are not expected to
be fatal if proper medical care is provided (Levin-
thal, 1999).
Other safety concerns with MPH include the
acute side effects. In child samples, the most fre-
quently reported adverse stimulant side effects are
loss of appetite and difficulty falling asleep, and less
common side effects include headaches, stomach-
aches, flattening of affect, and social withdrawal
(Barkley et al., 1990). Furthermore, there is some
evidence that side effects diminish and become com-
pletely insignificant with continued administration of
Smith, Waschbusch, Willoughby, and Evans
MPH (Pelham, 1999; Pelham & Gnagy, 1999). How-
ever, studies of the safety of MPH are based largely
on child samples, and as discussed earlier, it is not
necessarily valid to make conclusions about adoles-
cents based in childhood data. There were a few
sporadic reports of difficulty tolerating MPH in the
8 studies reviewed, but only Smith et al. (1998) pro-
vided a detailed assessment of side effects. In this
study, many putative side effects were not affected
by medication, and the side effects that were affected
by medication were dose dependent and virtually
nonexistent at the low (10 mg) dose. Indeed, one so-
called side effect, such a crabbiness, actually im-
proved as a function of medication.
Subjective side effects of MPH have not been
examined systematically; however, one study (Du-
paul, Anastopoulous, Kwasnik, Barkley, & McMur-
ray, 1996) suggests that adolescents may have a differ-
ent threshold for judging side effects than do parents.
Clinical lore posits that adolescents with ADHD re-
port that they feel ‘‘different’’ when the take stimu-
lants and their subjective reactions to being on stimu-
lants are unpleasant. This potential side effect
warrants investigation, but anecdotal reports abound
and are sometimes given as a reason by adolescents
for refusing to take medication. It is not clear if the
aversive state is due to changes in behavior (e.g.,
from being class clown to being one of the crowd),
subjective experiences, or biases against medication
that are unrelated to medication effects (e.g., fear of
being labeled a ‘‘head case’’). It would be helpful if
future studies of stimulant treatment for adolescents
gave closer attention to subjective effects of the medi-
cation.
It is worth emphasizing that one significant
safety consideration is the potential for interactions
between prescription stimulants and other drugs.
Several authors have cautioned against combining
stimulants and other medications (e.g., Greenhill,
1992). For example, there have been some reports
of fatal or near fatal cardiac incidents associated with
a regimen consisting of clonidine and MPH (Cant-
well, Swanson, & Connor, 1997; Swanson et al., 1995).
Similarly, combining fluoxetine and MPH can result
in elevated concentrations in the blood and may
therefore increase the risk of adverse side effects
(Gammon & Brown, 1993). These concerns are espe-
cially important when considering treatment of
ADHD in adolescence because depression is rela-
tively common in adolescence, and antidepressant
medication is a common treatment for this condition.
Depression may be especially common among ado-
Treatment for Adolescents with ADHD
lescents with ADHD, who are likely to have a history
of school failure and poor peer relationships
(Loeber & Keenan, 1994; Rey, 1994). Finally, the
interaction between prescription and nonprescription
agents is also not well understood. It may very well be
that MPH interacts in dangerous ways with common
drugs of abuse (e.g., alcohol, cannabis), and this must
also be considered when treating adolescents with
MPH. Research in this area is lacking and sorely
needed.
Practicality
In conducting our review, we found almost no
data on the practicality of MPH treatment in adoles-
cence. Given the lack of empirical data, it is necessary
to speculate on the potential practical limitations sur-
rounding stimulant treatment for adolescents with
ADHD.
One practical limitation of MPH is that the ther-
apeutic effects usuallylast only about 4 hours. Conse-
quently, medication is usually given multiple times a
day. This can complicate efforts to ensure compliance
with the treatment regimen, especially among adoles-
cents who are likely to be in middle or high school
settings where they interact with multiple adults
throughout the day and are often expected to take
responsibility for themselves. Low compliance to the
treatment regimen can produce a ‘‘rollercoaster’’ ride
of fluctuations in academic and social performance
(Pelham, 1993; Pelham et al., 1990). It may be possible
to counteract these fluctuations by using longer-
acting preparations of stimulants; however, there are
no published studies specific to adolescents that com-
pare short- and long-acting stimulants.
Another practical limitation is that stimulants
that are administered late in the day often cause
insomnia and/or loss of appetite (Greenhill, 1992).
As a result, stimulant treatment is often not an option
in the late evening. Consequently, treatments other
than MPH must be considered when problems (e.g.,
homework, family conflict) arise in the evening hours.
A potential practical limitation of MPH is the
potential for the adolescent to abuse MPH or divert
MPH to other adolescents. Systematic studies of the
prevalence and severity of MPH abuse are lacking,
but concerns about drug abuse often lead the parents
and schools administering MPH to adolescent to take
extra cautions. These extra efforts, along with the
constraints imposed by FDA regulations of prescrib-
ing only 1 month’s worth of medication at a time, adds
257
to the inconvenience of using MPH as a treatment of
ADHD.
Summary
Several short-duration clinical trials indicate that
MPH has beneficial effects on the functioning of ado-
lescents with ADHD. Responses to MPH vary widely
(i) between individuals and (ii) within individuals
across domains of functioning. This fact is well estab-
lished for children (Pelham & Milich, 1991; Wasch-
busch, Kipp, & Pelham, 1998) and seems to be true
for adolescents (Pelham & Smith, 1998). Neverthe-
less, there is limited information on individual re-
sponse rates in adolescents or the extent to which the
adolescents exhibited clinically meaningful change.
The results of our review also show virtually no major
problems with side effects from MPH in the clinical
trials. Moreover, as each of the major safety concerns
regarding MPH has been systematically investi-
gated, the evidence has supported the safety of this
treatment.
Although major advances have been made in the
understanding of the short-term efficacy and safety of
MPH, very little is known about the practicality (i.e.,
effectiveness) of MPH treatment in adolescents with
ADHD outside the context of a clinical trial. Studies
of long-term efficacy are badly needed. A crucial
issue in such studies is to document factors that sup-
port compliance or contribute to noncompliance. The
limited available information suggests that compli-
ance is poor and that only a fraction of adolescents
for whom MPH is effective actually take the medicine
as prescribed.
Based on the information, methylphenidate was
given a 3 for efficacy, a 2 for safety, and a 1 for
practicality (Table VI). The numerous replicated
studies, albeit over the short-term, make a strong
case that MPH is a well-established treatment. One
point was lost for safety due to the potential for
adverse interactions with other medications. One
point was lost to practicality due to the multiple daily
dosing and inconvenience of MPH prescription prac-
tices. Another point was lost for practicality due to
the preliminary indications of poor compliance due
to inconvenience, side effects, and stigma associated
with MPH.
Studies of Psychosocial Interventions
There are numerous behavioral, educational,
and psychological treatments that may be appro-
258
Table VI. Summary of Safety, Efficacy, and Practicality of Treatments
Type of treatment Efficacy
Methylphenidate Well-established (3)
Note-taking training Probably efficacious (2)
Classroom behavior modication Promising, but not validated (1)
Family therapy Promising, but not validated (1)
Tricyclic antidepressants Promising, but not validated (1)
Group cognitive–behavioral therapy Probably not effective (0)
priate for adolescents with ADHD. The scope of
these interventions ranges from very specific (e.g.,
training to take class notes) to very broad (e.g., be-
havioral family therapy to address multiple areas of
difficulty). Despite the range of possibilities, the re-
search on psychosocial interventions with children
and adolescents with ADHD is scant and has focused
primarily on behavioral interventions provided by
parents and teachers (Pelham et al., 1998). Some of
these treatments have been tested with samples that
include adolescents with ADHD; however, few stud-
ies have reported results specific to adolescents with
ADHD. More specifically, the literature search lo-
cated only 6 studies of psychosocial treatments, in-
cluding 2 case studies and 4 well-controlled studies
(see Table I). Only 105 adolescents are in the studies,
and 61 come from a single study (see Table I). Thus,
the results for psychosocial treatments are prelimi-
nary and unstable. Other sample characteristics for
these studies are summarized in Table II. Due to the
unique features of the studies and the complex nature
of psychosocial treatment relative to pharmacologic
treatment, we devoted more space to each of the
psychosocial treatment studies than we did for the
pharmacologic studies.
Efficacy
One line of psychosocial research with adoles-
cents with ADHD uses an educational intervention
to address learning and behavior problems. In one
study, adolescents were taught to take structured
notes (e.g., separate main ideas and supporting de-
tails) while they listened to a lecture-format Ameri-
can history class (Evans et al., 1994a). Following this
note-taking training, the ADHD adolescents showed
improvement on measures of comprehension, in-
creased levels of on-task behavior, and lower levels
Smith, Waschbusch, Willoughby, and Evans
Average
effect
size for
Overall ADHD
Safety Practicality score symptoms
Medium (2) Low (1) 6 0.94
Medium (2) Medium (2) 6 0.74
High (3) Medium (2) 6 NA
Medium (2) Low (1) 4 0.66
Low (1) Low (1) 3 0.5
Low (1) Low (1) 2 NA
of disruptive behavior compared to when they simply
listened to the lectures. The effect size for the note
taking intervention on symptoms of ADHD was 0.74,
which is a relatively large effect. For quiz scores, the
note-taking training effect size (0.16) is in the small
range, but compares favorably with other educational
interventions to improve test performance (Lipsey &
Wilson, 1993). When it comes to controlling disrup-
tive behavior in the classroom, the effect size was
small (0.09). This could be a confounded effect that
reflects the joint effects of note taking and the STP
program in reducing negative behavior.
Self-monitoring is another type of intervention
that has been investigated through a series of case
studies (Stewart & McLaughlin, 1992). In this case
study, the student received social and tangible rein-
forcement for on-task behavior. Moreover, the ado-
lescent engaged in self-monitoring, which is develop-
mentally and therapeutically important for this age
group (Evans, Vallano, & Pelham, 1994b). This treat-
ment resulted in a large improvement in on-task be-
haviors. Unfortunately, this was a single-subject case
study, and the efficacy with a group of adolescents
is unknown.
A third type of intervention tested was a func-
tional assessment followed by classroom-based inter-
ventions (Ervin, DuPaul, Kern, & Friman, 1998). The
authors in this study completed a functional assess-
ment of the target behaviors of two middle-school
age youth with problematic rates of off-task behavior.
Following the assessment procedure, functional
hypotheses were developed and a set of recommen-
dations was offered to the teachers. The classroom
teachers selected the strategies to be used based on
practicality and perceived effectiveness. Following
the implementation of these interventions the investi-
gators found large improvements in the on-task be-
havior of both boys in the targeted classrooms. For
both boys, the average percentage of on-task inter-
Treatment for Adolescents with ADHD
vals at baseline averaged between 54.2% and 78%.
Following these interventions, the classroom aver-
ages ranged from 88.2% to 95.4%. This study demon-
strates the potential utility of interventions based on
functional assessments with adolescents with a diag-
nosis of ADHD.
Family-based interventions are frequently rec-
ommended for adolescents with ADHD (Robin,
1998). However, only one study examined this inter-
vention with adolescents with ADHD (Barkley, An-
astopoulos, Guevremont, & Fletcher, 1992a). In this
study, the researchers compared three types of fam-
ily-based treatments: (i) behavioral parent training,
(ii) structural family therapy, and (iii) behavioral–
family systems treatments for adolescents with
ADHD. The three treatments performed about
equally well and produced statistically significant im-
provements on a variety of rating scales completed
by parents and adolescents. However, few subjects
exhibited clinically significant improvement and the
authors concluded that more potent treatments are
needed than 8–10 1-hour sessions with families. It is
noteworthy that the effect size for the treatments was
in the moderate to large range for ADHD symptoms
but in the relatively small range for social behavior
and academic performance (see Table V). Neverthe-
less, these effect sizes are on par with effect sizes for
behavioral family therapy (Lipsey & Wilson, 1993;
Shadish et al., 1993).
Consistent with data from children with ADHD,
cognitive–behavioral treatments do not appear to be
effective for adolescents with ADHD, in spite of the
fact that they appear to be effective for adolescents
with other disorders (Lipsey & Wilson, 1993). For
example, one study examined the effects of a 12-
week treatment program based on Rational–
Emotive Therapy with conduct disordered (CD) and
ADHD adolescents (Morris, 1993). The adolescents
who were diagnosed with CD but not ADHD exhib-
ited statistically significant improvement on several
rating scales, whereas the group of ADHD did not
show significant differences.
The presence of ADHD in adolescence also ap-
pears to play a role in psychosocial treatments for
problems other than ADHD. For example, adoles-
cents with ADHD do not seem to fare as well as
other adolescents in treatment for substance abuse
disorders. In a study of 225 adolescents receiving
treatment for substance abuse disorders, ADHD
made unique and clinically meaningful contributions
to predicting relapse to alcohol and illicit drugs (Lati-
mer, Winters, & Stinchfield, 1997). The most trou-
259
bling among the findings was that adolescents diag-
nosed with ADHD were more than twice as likely
to relapse in the first 6 months following treatment
than were non-ADHD peers. In other studies, re-
searchers found that the amount of time an adoles-
cent spends in treatment is positively prognostic of
outcome (DeLeon, 1988; Hubbard, Cavanaugh,
Craddock, & Rachal, 1985; Rush, 1979). It is notewor-
thy that another study (Adams & Wallace, 1994)
found that adolescents with ADHD exhibited a
higher rate of early termination from substance use
treatment than adolescents who do not have ADHD
(60% versus 30%, respectively). The potential effect
of ADHD on negative outcomes related to substance
use treatment is in the preliminary stages of research.
The point to be made is that adolescents with ADHD
may respond differently to treatment such that inter-
ventions that are helpful with the general population
might be ineffective or even harmful for adolescents
diagnosed with ADHD.
Safety
We did not find any studies that have systemati-
cally examined negative side effects produced by
nonpharmacologic treatments for adolescents with
ADHD. However, a few studies indicate that some
supposedly therapeutic practices may have iatrogenic
effects. For example, putting children and adoles-
cents with severe behavioral problems into groups or
classrooms filled with similarly behaviorally disor-
dered peers typically results in a worsening of behav-
ior (Carlberg & Kavale, 1980; Dishion et al., 1999).
Therefore, an important issue for clinical scientists
treating ADHD adolescents is to document that
‘‘possible negative side effects that might outweigh
any benefits must be ruled out empirically’’ (McFall,
2000, p. 11). This may require extended follow-up
because some evidence suggests iatrogenic effects
are not immediately apparent at the end of therapy
(Dishion et al., 1999).
Practicality
We did not find any studies that have systemati-
cally examined practicality of psychosocial treatments
for adolescents with ADHD. However, it is likely that
appropriate nonpharmacologic treatment for adoles-
cents with ADHD can be very expensive in terms of
professional resources and the amount of time,
260
money, and effort invested by parents and adoles-
cents. For example, some experts have recommend a
minimum of 20 initial office-based treatment sessions,
followed by regular checkups and, if necessary,
booster sessions (Robin, 1998). Furthermore, multiple
school visits are often necessary to establish produc-
tive school-to-home communication and appropriate
monitoring and structuring procedures at school. In
many cases it is necessary to establish psychoeduca-
tional interventions such as special programs at school
or after-school tutoring. Such intensive services can be
difficult practically because of their high cost. They can
also be difficult practically because few clinicians have
expertise to conduct such treatments with ADHD ad-
olescents. In addition, a comprehensive multimodal
approach, often required to treat ADHD adolescents
effectively, is not familiar to many health insurance
providers, and this may create problems with gaining
appropriate reimbursement for services. Finally, com-
pared to MPH, the rewards of psychosocial treatments
are not as immediate and the acute consequences of
noncompliance are usually not as pronounced. For
this reason and several others, we suspect that the
practicality of nonpharmacologic treatments tends to
be poor. In addition to the multiple barriers to getting
appropriate psychosocial services, little is known
about long-term compliance by parents, teachers, and
adolescents over extended periods of time. Compli-
ance and treatment success might be bolstered by
booster sessions (Robin, 1998). However, data back-
ing these assertions for treatment of adolescents with
ADHD are very limited.
A major consideration with respect to the practi-
cality of psychosocial treatments is if the treatment
is supposed to be brief and curative or enduring.
Antibiotics are supposed to cure pneumonia, which
is an acute condition. Insulin is supposed to sustain
the life of diabetics, who suffer from a chronic condi-
tion. Like diabetes, ADHD is expected to be a
chronic condition. When subjects served as their own
controls in crossover designs (e.g., Evans et al.,
1994a), their deterioration is akin to taking a diabetic
off of medication. This reveals the transient nature
of these psychosocial interventions and points to the
importance of promoting long-term compliance with
this treatment. When some treatments stop, so do
the benefits.
Summary
The scoring of the psychosocial treatments is
summarized in Table VI. Classroom-based interven-
Smith, Waschbusch, Willoughby, and Evans
tions using functional analysis and behavioral incen-
tives appear to be safe and probably efficacious treat-
ments for ADHD. These are not yet considered to
be well-established treatments because (i) all of the
note-taking studies come from a single research
group and (ii) support for the efficacy of classroom-
based behavioral interventions is based on a small
number of case studies. Ervin and colleagues (1998)
argue that their individualized classroom-based inter-
ventions are feasible, but Stewart and McLauglin
(1992) report some difficulties with fidelity. Practical
issues of generalizing note-taking training outside of
research settings have yet to be explored.
Three types of family therapy seemed to be help-
ful with adolescents with ADHD and were classified
as promising treatments. Replication of the efficacy
of these interventions and further exploration of clin-
ically significant change must be considered with
these approaches. Issues of safety and practicality
must be considered with group therapy for adoles-
cents with ADHD. Based on a single study, cogni-
tive–behavioral group therapy for adolescents with
ADHD was ineffective and is potentially unsafe. This
perplexing result underscores our assertion that treat-
ments for ADHD should not be assumed to work
with adolescents with ADHD even though the treat-
ment might work well with non-ADHD clients. It is
possible that well-established treatments with other
populations might cause more harm than good to
adolescents diagnosed with ADHD. Thus, special
precautions should be taken when providing psy-
chosocial treatment to adolescents with ADHD (see
McFall, 2000).
Studies of Tricyclic Antidepressants
Proponents of using tricyclic antidepressants
(TCAs) to treat adolescents with ADHD make three
main arguments (Popper, 1997). First, although MPH
is considered to be the treatment of choice for adoles-
cents with ADHD, not all adolescents benefit from
it or tolerate it (Barkley, 1998). Thus, TCAs have
been used primarily to treat the minority of adoles-
cents with ADHD who do not show a positive re-
sponse to stimulants. Second, whereas MPH is rela-
tively short acting, requiring multiple daily doses,
TCAs are long acting, requiring a single daily dose.
Finally, ADHD adolescents with comorbid inter-
nalizing problems tend to function worse in a number
of areas relative to ADHD adolescents without inter-
nalizing disorders (Russo & Beidel, 1994). Presum-
Treatment for Adolescents with ADHD
ably, TCAs directly address these comorbid inter-
nalizing problems such as anxiety and depressed
mood.
We found three studies examining TCAs as a
treatment for ADHD in adolescence (see Table III),
all of which come from the same research group and
only one of the studies was a controlled trail. Only
57 adolescents were included in these studies. Other
sample demographics are summarized in Table II.
Efficacy
These studies reported that 65% and 90% of ado-
lescents treated with TCAs were judged to be im-
proved on global measures of functioning. Although
the response rates are not directly comparable, it is
noteworthy that the response rate was about 50% in
the controlled studies of stimulant treatment. In the
only controlled trial of TCAs, the TCA effect size
for ADHD (0.50) was about half as big as for MPH
(0.94). It was noteworthy that the effect of desipra-
mine was statistically significant, but the effect size
was only 0.15, which is in the small range. An interest-
ing tangent in our literature review was a number
of reports that TCAs are not effective in treating
depressed non-ADHD adolescents (Brown & Iev-
ers, 1999).
Safety
Critics of using TCAs to treat children and ado-
lescents with ADHD assert that TCAs are associated
with severe side effects, including cardiac arrhyth-
mias, that make them an unacceptable treatment op-
tion. This issue has been hotly debated (Werry, 1995).
Direct evidence regarding the safety of TCAs to treat
ADHD is limited. Specifically, although electrocar-
diogram monitoring is considered to be an essential
part of treatment with TCAs, only one of the three
studies examining TCAs in adolescents with ADHD
provided electrocardiogram data (Spencer, Bieder-
man, Kerman, Steingard, & Wilens, 1993). In this
study, 24% of participants reportedly exhibited elec-
tocardiogram abnormalities and one subject report-
edly experienced heart palpitations. Most of the
arrhythmias were considered to be minor and pre-
sumably did not contraindicate continued administra-
tion of the TCA. Nevertheless, several incidents of
sudden deaths have been reported due to heart fail-
ure among children treated with TCAs. These inci-
261
dents do not show a causal link between TCA treat-
ments and sudden death, and the risk of sudden death
is apparently slight. There is limited evidence avail-
able about the side effects of TCAs. In the studies
listed in Table I, between 25% and 35% of the
adolescents experienced side effects from TCAs,
including lethargy, gastrointestinal distress, weight
gain, hypotension, insomnia, agitation, headaches,
dry mouth, decreased appetite. With the exception
of hypotension and weight gain, these side effects are
similar to those associated with stimulant medication.
Most of the TCA effects were thought to be minor,
but medication was discontinued due to serious side
effects for 3 of 57 adolescents treated (5.2%). In con-
trast, none of the studies of stimulant medication
reported side effects serious enough to withhold
treatment. The side effects of TCAs appear to be
more aversive than those of MPH, and therefore on
the basis of side effects, better compliance is expected
with MPH.
Although there are ongoing debates about risks
of TCAs at therapeutic doses, there is no doubt that
high doses of TCAs are much more toxic than many
of the medications commonly prescribed for adoles-
cents. Consequently, a significant safety concern with
this medication is the relatively high probability of
fatalities from accidental or deliberate overdoses.
Such overdoses are rare, but parents and physicians
should be extremely vigilant to guard against over-
doses of TCAs.
Practicality
Like all of the other treatments covered in this
review, there is little information on the practicality
of TCAs used to treat adolescents with ADHD. As
stated previously, the dosing is relatively infrequent
compared to MPH, and there are no restrictions
against giving the drug in the evening. It is promising
that a couple of the TCA open trials were longer
than 2 years and that compliance was relatively high
for the adolescents in the open trial. Unfortunately,
there may have been selection bias in these open
trials that inflated the compliance rate over the 2-
year study period.
Summary
Tricyclic antidepressants got low scores for effi-
cacy, safety, and practicality. This treatment met cri-
262
teria for a promising but not validated treatment for
ADHD. Side-effect concerns limit the safety and
practicality of this treatment. Claims that TCAs help
with problems other than ADHD, such as depression,
have not been addressed in the literature. Although
the rate of serious problems in a controlled study was
reported to be minimal, some prominent psychiatrists
propose that the risks of using TCAs outweigh the
benefits (Werry, 1995). Nevertheless, there are some
staunch proponents of TCA treatment for ADHD.
Overall, the results suggesting that they are no more
effective than other treatments but are somewhat
more dangerous argue against the use of TCAs in
adolescents with ADHD.
Other Pharmacologic Treatments
Reviews of treatments for adolescents with
ADHD often mention a variety of treatments that
have no empirical support but are sometimes used
in clinical practice. Such treatments were not in-
cluded in this review and include interventions such
as EEG biofeedback and dietary restrictions. There
are many potentially effective treatments that are
essentially untested with adolescents with ADHD.
However, we did locate a few studies of adolescents
with ADHD that reported promising results from
weak research conditions. These studies consist of a
single open-label or otherwise minimally controlled
study (see Table I). These treatments include pemo-
line (Riggs et al., 1996), bupropion (Riggs, 1998),
and guanfacine (Chappell et al., 1995). None of these
treatments should be considered empirically vali-
dated for adolescents. Therefore, we did not review
the efficacy, safety, and practicality of these treat-
ments.
Comparison of Empirically Evaluated Treatments
Based on our review criteria, only six treatments
have received enough empirical scrutiny to be evalu-
ated for efficacy with ADHD adolescents. In Table
VI, the treatments are sorted to reflect the combined
scores for efficacy, safety, and practicality. We also
list effect sizes for reducing ADHD symptoms. Coin-
cidentally, these scores parallel the summary scores
for efficacy, safety, and practicality. Methylphenidate
was deemed to be the only treatment with well-estab-
lished treatment empirical support. Likewise, MPH
treatment resulted in the largest effect size compared
Smith, Waschbusch, Willoughby, and Evans
to the other treatments listed in Table VI. Thus, on
the basis of efficacy alone, MPH appears to be the
best treatment for adolescents with ADHD. How-
ever, problems with safety and practicality may limit
the clinical utility of MPH.
In the context of summary scores that consider
efficacy, safety, and practicality (see Table VI), we
concluded that MPH was tied with note-taking train-
ing and classroom behavioral interventions for the
status of best available treatment for adolescents with
ADHD. We should emphasize that it is not necessary
to select one of these treatments at the expense of
another. All three could be delivered simultaneously
and could have complimentary or synergistic effects,
but there are no multimodal treatment studies to
support this claim.
Following the top three treatments in Table VI
is family therapy. Although behavioral family ther-
apy and parent training are empirically validated for
use with children (Pelham et al., 1998), only one study
examined family therapy with adolescents with
ADHD. The results of this study showed statistically
significant change across three types of family ther-
apy, but disappointing results in terms of clinical sig-
nificance. Barkley and colleagues (1992) offered sev-
eral recommendations for modifications in the family
therapy, but these have yet to be examined empiri-
cally (although a study by Barkley and colleagues is
reportedly nearing completion). Given that (i) par-
ent–teenager conflict is one of the major presenting
problems of adolescents with ADHD and (ii)
Meichenbaum et al. (1999) found that MPH was inef-
fective in changing parent–teenager interactions, it
seems that further development of interventions to
treat parent–teenager conflict is an important fron-
tier in research with adolescents with ADHD. Solu-
tions to this problem are likely to come from improve-
ments in family-based interventions.
Tricyclic antidepressants are often referred to as
the second-line treatment for ADHD. This presumes
that the first-line treatment is MPH and that pharma-
cotherapy is the primary way of treating ADHD.
Our review suggests that there are some psychosocial
treatments that have better overall scores for efficacy,
safety, and practicality than some pharmacologic
treatments (e.g., TCAs) and therefore should be con-
sidered ahead of some pharmacotherapy options. For
example, in this review TCAs were, at best, a third-
line treatment.
Finally, we come to group-based cognitive ther-
apy for adolescents with ADHD. As with children
(Pelham et al., 1998), this treatment had little to no
Treatment for Adolescents with ADHD
positive effects in treating adolescents with ADHD.
Moreover, given the likelihood of negative effects
of putting high-risk adolescents together in a group
(Dishion et al., 1999), this treatment got a low score
for safety. Furthermore, groups can be difficult to
organize and lead, so we gave this treatment a low
score for practicality. In sum, we do not recommend
conducting cognitive therapy with groups of adoles-
cents. This does not preclude the potential for posi-
tive effects of cognitive therapies. Because this is
one of the most effective treatments psychotherapists
have to offer to the population in general (Lipsey &
Wilson, 1993), we would like to see studies of individ-
ual or family-based cognitive behavioral therapies for
adolescents with ADHD.
DISCUSSION
This review considers the efficacy, safety, and
practicality of treatments for adolescents with
ADHD. Since 1985, clinical researchers have begun
to fill what used to be a nearly complete void in
the understanding of treatments for adolescents with
ADHD. Generally speaking, the current literature
regarding MPH is positive, research on psychosocial
treatments is mixed, there are concerns regarding the
use of TCAs to treat adolescents with ADHD, and
other treatments are practically unstudied.
On the basis of contemporary criteria for judging
the efficacy of a treatment (Lonigan et al., 1998), the
only well-established treatment for adolescents with
ADHD is the stimulant drug MPH. However, it can-
not be emphasized strongly enough that MPH is not
necessary nor is it a sufficient treatment for adoles-
cents with ADHD. Although conservative doses of
MPH have positive effects at the group level, re-
sponses to this treatment vary widely for individuals
with ADHD (Smith et al., 1998b; Waschbusch et al.,
1998). In spite of this fact, most studies do not report
individual response rates, and those that do (i) do not
use standardized criteria and (ii) have not identified
individual characteristics that predict response to
MPH. Some have asserted that up to one-third of
children and adolescents do not respond positively
to MPH (Spencer et al., 1996b); however, this figure
lacks solid empirical support and could be quite a bit
higher or lower. Therefore, one of the most pressing
issues regarding MPH is to determine what percent-
age of individuals receiving this treatment exhibit
normalization, improvement, no change, or deterio-
ration in multiple domains of functioning.
263
Although there have been some provocative at-
tacks on the safety of MPH, the consensus is that
this is a relatively safe treatment. Apparently, the
major threats to the use of MPH are practical consid-
erations such as negative attitudes toward this drug,
long-term compliance, and efficacy that might be lim-
ited to when the drug is actually in the adolescent’s
system. The most respected guidelines for the treat-
ment of adolescents with ADHD state unequivocally
that MPH should only be given in the context of
appropriate psychosocial treatment (Goldman et al.,
1998). The results of the MTA study partially support
this recommendation (MTA Collaborative Group,
1999), but this further challenges the practicality of
treatment with MPH, especially with regard to the
cost of treatment.
Results from a well-controlled study of children
suggest that those receiving intensive psychosocial
treatment exhibited higher functioning and were able
to take lower doses of MPH (MTA Collaborative
Group, 1999). Because most side effects of MPH
disappear or considerably lessen in frequency or se-
verity at lower doses, concomitant psychosocial treat-
ment could make MPH much more tolerable than
when no psychosocial intervention is provided. Un-
fortunately, we are not aware of any studies that
examined the separate and combined effects of MPH
and psychosocial treatments with adolescents with
ADHD. This is an important line of future research
for all ages of individuals with ADHD.
Although psychosocial treatments are fre-
quently called for, very little is known about the effi-
cacy, safety, and practicality of psychosocial treat-
ments for adolescents with ADHD. On the basis of
the efficacy criteria, there are no well-established
treatments. Furthermore, some treatments such as
rational emotive therapy and substance abuse treat-
ment may be unsafe or, at the very least, may not as
effective with adolescents with ADHD as they are
with other adolescents with externalizing behavior
disorders.
Only a handful of psychosocial treatments were
deemed to have empirical support for treating adoles-
cents with ADHD. These promising treatments are
(i) highly structured academic activities (e.g., note
taking), (ii) classroom-based individualized behavior
management programs, and (iii) family-based inter-
ventions. We should note that the level of empirical
support for these treatments is only lukewarm and
is made even more tepid by the fact that we borrowed
some support for classroom-based behavioral inter-
ventions and family-based interventions from the lit-
264
erature on children with ADHD (see Pelham et al.,
1998). Although these treatments seem to be safe,
the data on the practicality of these treatments are
virtually nonexistent. We submit that the most impor-
tant research issue facing adolescents with ADHD
is the evaluation and development of appropriate
psychosocial treatments.
Commenting on the appropriateness of TCAs
to treat adolescents with ADHD is a delicate issue.
A single research group generated all of the empirical
support for this treatment. Members of this research
group are not alone in their endorsement of TCAs
as a second- or third-line treatment for adolescents
with ADHD (Pliszka, 1991). However, there are a
number of prominent opponents to the use of TCAs
to treat ADHD, and the opposition is based primarily
on safety considerations (Werry, 1995). We should
also note that the practicality of TCAs should also
be considered, and side effects of this drug that are
not life-threatening may affect long-term compliance
negatively. We expect that TCAs will fade from a
second-line treatment to gradually more obscure sta-
tus as some of the safer and more palatable alterna-
tives to TCAs gain empirical support.
We have deliberately understated the list of
treatments for adolescents with ADHD that have
been evaluated empirically. In some reviews, treat-
ments that have only minimal empirical support are
discussed as if they were on the same clinical founda-
tion as well-established or probably efficacious treat-
ments. We hope to discourage this leap of faith by
emphasizing the fact that many treatments for adoles-
cents with ADHD are virtually unstudied. With the
exception of required FDA approval studies con-
ducted with on adults, there is very little age-appro-
priate information on the efficacy, safety, and practi-
cally of many proposed pharmacologic treatments for
children with ADHD. We are especially concerned
about the practice of polypharmacy. For example,
there have been some disturbing reports about poten-
tial negative effects of mixing MPH with other drugs
(Cantwell et al., 1997).
We should reiterate briefly some of the meth-
odologic limitations to the handful of interventions
with empirical support. The current literature is al-
most exclusively focused on young, white, male ado-
lescents with comorbid behavior problems. More-
over, many of the changes observed in this narrow
sample are of indeterminate clinical significance.
Most of the studies have been relatively short term
and conducted in the context of a controlled clinical
trail. Future research must measure functioning in a
Smith, Waschbusch, Willoughby, and Evans
wide range of domains captured in natural or natural-
istic settings. This includes keeping a keen watch for
potential negative effects that might not be evident
until some time after treatment is terminated (see
Dishion et al., 1999). Studying potentially differential
response to treatment across ADHD subtypes and
comorbidity clusters would be interesting. Also, there
should be a strong emphasis on treating functional
problems, measuring multiple outcomes, and analyz-
ing for clinically significant changes.
Perhaps our most important recommendation
for future research is that studies should use treat-
ment with MPH as the benchmark against which
other treatments are judged. Methylphenidate is the
best understood and most commonly used treatment
for ADHD. Understanding effectiveness of treat-
ments relative to MPH is the appropriate clinical
reference point for a progressive science of treatment
for adolescents with ADHD because MPH is cur-
rently the only well-established treatment and the
most widely used treatment. In these future studies, a
major consideration should be evaluating compliance
with treatment and how compliance affects out-
comes. Even among the estimated 90% of children
and adolescents who receive a prescription for medi-
cation to treat ADHD, only 12% to 25% regularly
take medication for ADHD (Sherman & Hertzig,
1991; Sloan, Jensen, & Kettle, 1999; Szatmari, Of-
ford, & Boyle, 1989; Wolraich et al., 1990). The reason
why only a small fraction of those treated with medi-
cation continue to take it are unknown, but noncom-
pliance is a huge barrier to the effectiveness of phar-
macologic treatment of ADHD. Data on compliance
with psychosocial treatments are practically nonexis-
tent. Thus, it is unknown if parents would persist in
using a treatment perceived to be more desirable
(e.g., a behavioral intervention) than a treatment
thought to be less desirable (e.g., medication).
In addition to using MPH as a comparison treat-
ment, it is important to test multimodal treatments.
Psychosocial treatments may have synergistic effects
with MPH. For example, medication may not be help-
ful with academic performance if the adolescent does
not sit and study. Behavior therapy can increase rates
of sitting and studying, but without medication the
studying may be frustrating or even futile. The com-
bined effect of medication and behavioral modifica-
tion to promote studying may interact and be much
more effective than either intervention alone. A sec-
ond issue is potentially complementary effects. Medi-
cation may have unique effects on some domains of
functioning, such as academic performance, but may
Treatment for Adolescents with ADHD
have little effect on other domains, such as social
skills. Likewise, family therapy with an emphasis on
communication and social skills training may pro-
mote better interpersonal behavior, but may not nec-
essarily improve academic performance. Please note
that these comments about multimodal treatment are
speculative and have yet to be established empirically
with adolescents.
Finally, the ratings in Table VI are preliminary
and intended to broaden consideration of treatment
beyond efficacy into other clinically meaningful
realms. In this case, we highlight the areas of safety
and practicality. Some might define these broad cate-
gories differently. Others might question giving effi-
cacy, safety, and practicality equal weight in our sum-
mary scores. It is hoped that this discussion will
stimulate thought and action that will result in better
treatment and more meaningful treatment research
pertinent to adolescents diagnosed with ADHD.
ACKNOWLEDGMENTS
We would like to thank Georgeann Stamper and
A. D. Ingram for their assistance in preparing this
manuscript.
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