In addition to the core components listed above, some key considerations in the CHP development process include a focus on provider acceptability, finding new approaches to service-delivery (e.g., after-school programs staffed by service-learning students), and an emphasis on continued innovation and testing (B. H. Smith, McQuillin, & Shapiro, 2008). This summary is designed to support our application for including the CHP in the National Registry of Evidence-based Programs and Practices. The summary describes the need for developing interventions such as the CHP, the accumulated CHP evidence-base (so far), and deployment considerations that have guided the development of the CHP.

There is an abundance of research on elementary-aged children with Attention-Deficit/Hyperactivity Disorder (AD/HD), but relatively little research on middle- or high-school aged youth. Whereas some reviews of children reported finding hundreds of studies, a review of treatment studies published prior to 1999 found only 29 studies that provided efficacy data on adolescents with AD/HD (B.H. Smith, Waschbusch, Willoughby, & Evans, 2000). Almost all of these studies of adolescents focused on pharmacological treatments, with 17 studies of stimulant medication, 3 studies of tricyclic antidepressants, and 3 studies of other medications. Only 6 studies examined non-pharmacological interventions. These studies showed promising preliminary support for note taking training, behavioral interventions in the classroom, and family-based interventions. Mean effect sizes of these interventions were in the medium to large range (i.e., .66 to .74); however, when using the APA criteria for evidence-based treatments (Chambless, et al., 1996), the only well-established intervention based on the literature published prior to 1999 was stimulant treatment with methylphenidate (B.H. Smith, et al., 2000).

Stimulant treatment is controversial and suffers from problems with acceptability and feasibility, especially with adolescents (B.H. Smith, et al., 2000). Even when there is clear evidence to document a child’s positive response to medication through controlled clinical experimentation, there is a steady decline in medication use as children get older (Jensen, et al., 2007). Furthermore, there is a major deterioration of adjustment when students with ADHD enter middle school (J. M. Langberg, et al., 2008).

The age-related decline in stimulant medication use among adolescents is just one of several reasons why there needs to be non-pharmacological options for treating adolescents who have ADHD (Pelham, Wheeler, & Chronis, 1998). First, it is generally accepted that about 30% of youth do not benefit from stimulant medication or can not tolerate this treatment (B.H. Smith, Barkley, & Shapiro, 2006). Second, stimulants interfere with sleep and therefore cannot be taken in the evening. This creates daily gaps in stimulant treatment during high stress periods (e.g., getting ready for school or for bed). These gaps need to be addressed by other interventions. Third, although there is some debate on this issue, there is growing consensus that pharmacological treatments most effective when combined with psychosocial or educational interventions ((Pelham, et al., 1998; B.H. Smith, et al., 2006). For these and other reasons, it is extremely important to develop effective, safe, and practical psychosocial interventions for middle and high school aged youth with AD/HD.

Unfortunately, progress on identifying well-established treatments for adolescents with ADHD has been slow and continues to lag behind treatments for children with ADHD. For instance, in an update of a comprehensive review of

evidence-based psychosocial treatments for children with ADHD (Pelham, et al., 1998), reviewers found 46 new studies (Pelham & Fabiano, 2008). Only 5 of these studies (11%) focus on treatment of adolescents. Two of these studies provide support for the effects of parenting interventions, but the authors of both of these studies identify limitations of parenting and state that the best approach to dealing with ADHD involves using multimodal interventions, such as after-school programs (Pelham & Fabiano, 2008).

Efficacy of the CHP

Two of the studies on adolescents reviewed by Pelham and Fabiano (2008) provide support for the CHP (Evans, Axelrod, & Langberg, 2004; Evans, Langberg, Raggi, Allen, & Buvinger, 2005). Furthermore, there are two randomized studies that were not included in the Pelham and Fabiano review. One is a randomized trial that was just recently accepted for publication (Molina, et al., in press). The other is the largest randomized study of the CHP, which shows that the CHP can be effective with youth who do not have ADHD (J.M. Langberg, et al., 2006). These studies are reviewed below.

Evans, Axelrod, and Langberg (2004) report treatment group only pre- and post-test pilot data on seven white youth aged 11 to 13 (5 males, 2 females) diagnosed with ADHD. These youth attended the CHP two hours and 15 minutes a day, three days a week for at least three months. During the program, students met with primary counselors to work on goals and participated in interpersonal skills training, therapeutic recreation, and academic skills groups. Primary counselors met weekly with teachers. Parent participated in monthly groups, plus received frequent reports home from the program. Outcomes were measured using school grades and ratings on ADHD rating scale and the Impairment Scale completed by parents and teachers. Significant pre- to post-test (p < .05) improvements were found for teachers’ ratings of inattentive behavior. Large effect sizes (i.e., Cohen’s d > .80) were noted for parent and teacher ratings of academic functioning and teacher ratings of classroom behavior. Medium effect sizes were found for parent and teacher ratings of behaviors with siblings and peers, respectively. Small effect sizes were noted for grades, parent and teacher ratings of adult-child relationships, and parent ratings of ADHD symptoms. It noteworthy that the slope of grades shifted from negative to positive while students were participating in the CHP (Evans, et al., 2004).

In an extension and replication of their pilot work, Evans and colleagues conducted a quasi-experimental evaluation of the CHP in which 13 Caucasian youth aged 11 to 14 (2 female, 9 on stimulant medication) participated in the CHP using very similar procedures and measures that were used in the pilot study (Evans, et al., 2005). Pre- to post-changes in the treatment group were compared to 14 "community control" youth aged 11 to 14 (4 female, 13 on stimulant medication) who attended a school where the CHP was not offered. Within group effect sizes were in the large range for parent ratings of peer interactions, academic performance, and overall functioning in the treatment group. This compares to small to negative effect sizes for parent ratings of youth in the control group. Effect-size comparisons of teacher ratings was inconclusive. There was a trend for beneficial effects of the CHP on grades (p = .071). However, rather than improving grades in the CHP group, the CHP appears to have stopped a decline in grades illustrated by the fact that grades in the community comparison group declined while those in the CHP group were unchanged. The authors note that low statistical power, missing data, and concern about the validity of teacher reports hampered the interpretation of these data.

Molina and colleagues (in press) conducted a small, randomized study of the CHP. A total of 23 youth were recruited to the study, with 12 randomized to the CHP and 11 to control. Half of the youth were from ethnic minorities, most were from two parent households. The groups were similar on most characteristics, but more parents in the control group had earned a bachelor’s degree (44% vs 27%) and more youth in the control group were taking medication (36% vs. 25%). Subsequent attrition after a 10-week, two hour a day, twice a week program resulted in pre- and post-test data from 11 and 9 youth, respectively. CHP procedures were similar to the Evans et al. studies with the exception that a behavioral level system was introduced and parents attended three, two-hour parent meetings designed to review CHP content and improve management of behavior at home. The authors stated emphasis of this study was to demonstrate that is was feasible to replicate the CHP in the context of a randomized study. Nevertheless, the study did generate some effect size data indicative of efficacy.

Molina et al. (2008) reported treatment in the CHP was associated with medium-sized improvements (d = .55 to .59) in parent-rated internalizing problems and adolescent-rated school maladjustment and emotional symptoms. This compares to no change on these measures in the control group. Similar to the findings of Evans et al. (2005), there was no change in grades in the CHP group, but there was a decline in grades in the control group (d = .34 to .46). Despite the very low statistical power, there were some significant group by time interactions indicative of positive effects of the CHP on parent-rated internalizing symptoms (p < .05), delinquency or conduct problems (p <.10), and school maladjustment (p < .10).

Langberg et al. (2006) conducted the largest study of the CHP to date. However, the version of the CHP tested by Langberg et al. was modified to fit the needs of a school district supported after-school program for youth who had performed poorly on state standardized tests(J.M. Langberg & Smith, 2006). Key differences from Evans et al. and Molina et al. were that the CHP did not focus exclusively on youth with ADHD, the program was provided four days a week for two hours per day, and staff were trained in a specialist or "small group" model (e.g., leading small specialty groups such as organization and goals) as opposed to the generalist "primary counselor" in which staff provided many services to the youth individually. Also, the Langberg et al. study did not have a social skills group but social skills were emphasized throughout the program and specifically reinforced by counselors’ praise and the behavioral level system.

Youth in the Langberg et al study were recruited if they had scored "below basic" on the state standardized test but were excluded if their Full Scale IQ was lower than 70. A total of 48 youth were randomly assigned and t-tests found no differences on key variables such as age, socioeconomic status, grade, or Full Scale IQ. Randomization was conducted at the beginning of the fall semester and youth in the CHP group started the program immediately. Those assigned to the wait-list control group were scheduled to begin the CHP in the spring. Importantly, 85% of the youth in the control group participated in the after-school program that met 1 to 3 days a week to provide academic remediation.

Results of the Langberg et al. study demonstrate the flexibility and efficacy of the CHP. There were large effects on parent ratings of academic progress, in this case the group by time interaction was significant (p < .05). The within subject d was .74 for the CHP group and -.24 for the control group. There were also statistically significant (p < .05) changes favoring the CHP group in terms of parent-rated self-esteem, overall severity of problems, organization and homework completion, and the Conners Global Index (CGI). The latter is noteworthy because the CGI is a measure of ADHD symptoms (REF), thus suggesting the modified CHP is still effective in reducing ADHD related problems. Teacher ratings were limited by missing data in this study and none of the teacher ratings on the IRS showed a statistically significant group by time interaction. However, there was a significant effect of the CHP on mean grades for science and trend toward improvement with small to moderate effect sizes in history, math, and English language arts. Finally, youth in the control group were served detention or were suspended almost twice as often as those in the CHP (i.e., 10 vs. 6 detentions and 10 vs. 5 suspensions).

To summarize, the studies on the general efficacy of the CHP have spanned a broad range of research designs and populations in three US cities. Parents of youth in the CHP have consistently reported positive effects of the program, and many of these findings reached statistical significance (p < .05) despite low statistical power. Another finding across the studies was the tendency for the control group to show deteriorating academic performance, while youth in the CHP maintained steady performance or showed improvement. There were few instances of teacher ratings showing significant change related to the CHP; however, this may be due to limitations of teacher ratings rather than a lack of efficacy of the CHP. Overall, it appears that 10 to 12 weeks in the CHP is sufficient to achieve benefits that are noticeable to parents and impact ecologically valid measures like grades.