View in EDS HTML Full Text PDF Full Text

ROAR-Early Childhood: Pilot Testing a Brief Telemedicine Parent Training Program for Rural Children Diagnosed with ADHD

Saved in:
Bibliographic Details
Title: ROAR-Early Childhood: Pilot Testing a Brief Telemedicine Parent Training Program for Rural Children Diagnosed with ADHD
Language: English
Authors: James T. Craig, Michael T. Sanders, Christina C. Moore, Erin Barnett, Kady F. Sternberg (ORCID 0009-0008-1262-1222), Nicole L. Breslend, Lauren C. Vazquez, Nina Sand-Loud, Mary K. Jankowski
Source: Journal of Attention Disorders. 2026 30(7):857-871.
Availability: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: https://sagepub.com
Peer Reviewed: Y
Page Count: 15
Publication Date: 2026
Sponsoring Agency: Substance Abuse and Mental Health Services Administration (SAMHSA) (DHHS/PHS)
Contract Number: H79SM082302
Document Type: Journal Articles
Reports - Research
Education Level: Adult Education
Descriptors: Attention Deficit Hyperactivity Disorder, Rural Areas, Teleconferencing, Parent Education, Outreach Programs, Program Effectiveness, Young Children, Empowerment, Behavior Problems, Symptoms (Individual Disorders), Feasibility Studies, Telecommunications, Educational Technology, Access to Education
Geographic Terms: New Hampshire
Assessment and Survey Identifiers: Eyberg Child Behavior Inventory
DOI: 10.1177/10870547251415434
ISSN: 1087-0547
1557-1246
Abstract: Objective: Attention Deficit/Hyperactivity Disorder (ADHD) is a chronic and impairing neurodevelopmental disorder diagnosed in approximately 2% to 4% of preschool-age children and 9% of all children. Behavioral parent training (BPT) and high-quality education are effective treatments for young children with ADHD; however, poor rates of treatment access and participation limit the reach of BPTs to rural and underserved communities. In this study, we tested the newly developed Rural Outreach and ADHD Research-Early Childhood (ROAR-EC) program, a clinician-led, 7-session education and parent training program designed for delivery over telemedicine. Method: We conducted a pilot RCT to assess the feasibility, acceptability, engagement of mechanism, and exploratory group × time effects of the ROAR-EC program compared to a control group in a sample of 44 children diagnosed with ADHD from a predominantly rural area (ages 3-7; Mage = 4.8; 62% male; 96% White; 89% non-Hispanic/Latinx). Families were randomized into either ROAR-EC or treatment as usual through developmental pediatrics and followed for 24 weeks. Assessed were metrics of feasibility, acceptability, parenting practices, caregiver empowerment, disruptive behaviors, and ADHD symptoms. Results: Results indicated that ROAR-EC was feasible to implement and acceptable to caregivers. Repeated measures ANOVAs found significant group × time interaction effects in favor of the treatment group compared to control for family empowerment, parenting practices, total behavior problems, impairment, and inattentive symptoms. Conclusions: This study demonstrated the promise of brief telemedicine programs as feasible, acceptable, and likely beneficial alternatives to traditional BPTs for young children with ADHD in rural and low-resource areas.
Abstractor: As Provided
Entry Date: 2026
Accession Number: EJ1507677
Database: ERIC
Full text is not displayed to guests.
FullText Links:
  – Type: pdflink
    Url: https://content.ebscohost.com/cds/retrieve?content=AQICAHj0k_4E0hTGH8RJwT4gCJyBsGNe_WN95AvKlDbXJGqwxwEFw9MT7LTAywAAgE3SBlW6AAAA4jCB3wYJKoZIhvcNAQcGoIHRMIHOAgEAMIHIBgkqhkiG9w0BBwEwHgYJYIZIAWUDBAEuMBEEDLlzry1yFth6Xb2BIgIBEICBmhRu73epv40af_ALbBbA_lt1B0aqrhGr6E4k8o4Pg4A9FzzfbXTQT8C_ctHFSsOLgTkY9ixCDV6DinesEWfILIsgT6X4WUqbSnhOM7sp4zT3MLid0yaJKaSqtOt3_GmEoMjnYyYNdiO7cq8pMkgUVOGuURp54a71o9N427Ena8C9Am86YWvJo6nqK0SZtHSRU1bVXMbWOSOl-hE=
Text:
  Availability: 1
  Value: <anid>AN0194258087;gs001jul.26;2026Jun05.02:55;v2.2.500</anid> <title id="AN0194258087-1">ROAR-Early Childhood: Pilot Testing a Brief Telemedicine Parent Training Program for Rural Children Diagnosed with ADHD </title> <p>Objective: Attention Deficit/Hyperactivity Disorder (ADHD) is a chronic and impairing neurodevelopmental disorder diagnosed in approximately 2% to 4% of preschool-age children and 9% of all children. Behavioral parent training (BPT) and high-quality education are effective treatments for young children with ADHD; however, poor rates of treatment access and participation limit the reach of BPTs to rural and underserved communities. In this study, we tested the newly developed Rural Outreach and ADHD Research-Early Childhood (ROAR-EC) program, a clinician-led, 7-session education and parent training program designed for delivery over telemedicine. Method: We conducted a pilot RCT to assess the feasibility, acceptability, engagement of mechanism, and exploratory group × time effects of the ROAR-EC program compared to a control group in a sample of 44 children diagnosed with ADHD from a predominantly rural area (ages 3–7; M <sub>age</sub> = 4.8; 62% male; 96% White; 89% non-Hispanic/Latinx). Families were randomized into either ROAR-EC or treatment as usual through developmental pediatrics and followed for 24 weeks. Assessed were metrics of feasibility, acceptability, parenting practices, caregiver empowerment, disruptive behaviors, and ADHD symptoms. Results: Results indicated that ROAR-EC was feasible to implement and acceptable to caregivers. Repeated measures ANOVAs found significant group × time interaction effects in favor of the treatment group compared to control for family empowerment, parenting practices, total behavior problems, impairment, and inattentive symptoms. Conclusions: This study demonstrated the promise of brief telemedicine programs as feasible, acceptable, and likely beneficial alternatives to traditional BPTs for young children with ADHD in rural and low-resource areas.</p> <p>Keywords: ADHD; behavioral parent training; telemedicine</p> <hd id="AN0194258087-2">Introduction</hd> <p>Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that occurs in 7% to 10% of youth globally ([<reflink idref="bib4" id="ref1">4</reflink>]; [<reflink idref="bib58" id="ref2">58</reflink>]) and approximately 3% of preschool-age children (ages 2–5 years; [<reflink idref="bib21" id="ref3">21</reflink>]). Children are diagnosed with ADHD when they demonstrate persistent symptoms of inattentiveness, hyperactivity, and/or difficulties inhibiting impulses that are beyond what is typical for their chronological age and result in significant distress and/or impairment ([<reflink idref="bib4" id="ref4">4</reflink>]). ADHD is presumed to be a life-course disorder with symptoms first appearing in early childhood and persisting into adulthood for 70% of individuals ([<reflink idref="bib18" id="ref5">18</reflink>]). During preschool and early childhood, individuals with ADHD experience more accidental injuries, show poorer pre-academic skills entering grade school ([<reflink idref="bib53" id="ref6">53</reflink>]; [<reflink idref="bib57" id="ref7">57</reflink>]), and approximately 50% will be diagnosed with Oppositional Defiant Disorder ([<reflink idref="bib4" id="ref8">4</reflink>]). During adolescence and adulthood, individuals with ADHD are at higher risk for conduct and impulse-control disorders, problematic substance use, anxiety, depression, suicidality, low academic achievement, and underemployment compared to individuals without ADHD ([<reflink idref="bib4" id="ref9">4</reflink>]; [<reflink idref="bib19" id="ref10">19</reflink>]; [<reflink idref="bib31" id="ref11">31</reflink>]; [<reflink idref="bib36" id="ref12">36</reflink>]; [<reflink idref="bib40" id="ref13">40</reflink>]). Given the complicated risks associated with ADHD, it is one of the costliest mental health conditions in the United States with estimated costs over $260 billion per year ([<reflink idref="bib60" id="ref14">60</reflink>]).</p> <p>The trajectory from early neurodevelopmental delays to worsening problems later in life is presumed to be at least partially mediated by the quality of children's parent-child relationships ([<reflink idref="bib48" id="ref15">48</reflink>]). Starting in early childhood, symptoms of ADHD can manifest in over reactivity to stress, difficulties with compliance, and aggressive behaviors, all which strain parent-child relationships. As children manifest these challenging behaviors, caregivers may respond with more harsh, coercive, and inconsistent parenting practices that threaten the quality of the relationship ([<reflink idref="bib17" id="ref16">17</reflink>]). Indeed, caregivers of children with ADHD self-report using less positive reinforcement and engaging in more frequent emotionally abusive parent-child interactions compared to caregivers of children without ADHD ([<reflink idref="bib12" id="ref17">12</reflink>]; [<reflink idref="bib46" id="ref18">46</reflink>]). This negative parent-child dynamic can begin to take root in the preschool years, prior to a diagnosis of ADHD and before parents understand their children's neurodevelopmental delays, specific needs for support, or the strategies for how to respond effectively to ADHD-specific challenges.</p> <hd id="AN0194258087-3">Behavioral Parent Training and High-Quality Education</hd> <p>The recommended treatments for children between ages two and seven with ADHD are behavioral parent training (BPT) and high-quality education aimed at empowering caregivers to advocate for their child and become informed consumers of evidence-based treatment ([<reflink idref="bib47" id="ref19">47</reflink>]; [<reflink idref="bib65" id="ref20">65</reflink>]). Although originally designed to treat oppositional behaviors in children, BPTs reduce symptoms and related impairments of ADHD for children ([<reflink idref="bib23" id="ref21">23</reflink>]; [<reflink idref="bib49" id="ref22">49</reflink>]). A recent meta-analysis found that BPTs (e.g., Parent-Child Interaction Therapy) used with preschool children with ADHD reduced disruptive behaviors, ADHD symptoms, and caregiver stress ([<reflink idref="bib50" id="ref23">50</reflink>]). BPTs also reduce the risk for further negative sequelae such as harsh or abusive parenting ([<reflink idref="bib39" id="ref24">39</reflink>]) and worsening conduct problems ([<reflink idref="bib10" id="ref25">10</reflink>]). BPTs are rooted in Social Learning Theory, which posits that parenting practices that meet children's needs for warmth while setting consistent limits on behavior lead to greater emotional and behavioral regulation, thereby reducing symptoms and impairment related to ADHD ([<reflink idref="bib25" id="ref26">25</reflink>]; [<reflink idref="bib43" id="ref27">43</reflink>]). Enhanced parenting practices are particularly important for children with ADHD as they do not inherently lack knowledge, inclination, or propensity for enacting prosocial behaviors (e.g., acting with kindness, following rules) but rather have difficulty consistently performing on-task and prosocial behaviors due to deficits in executive function and impulsivity ([<reflink idref="bib1" id="ref28">1</reflink>]).</p> <p>An emerging literature also supports the use of brief high-quality psychoeducation for caregivers of children with ADHD with a focus on knowledge and empowerment. Typically, psychoeducation programs include information on underlying neurological causes, symptoms, and evidence-based treatments for ADHD ([<reflink idref="bib16" id="ref29">16</reflink>]). Some programs for school-age children with ADHD have included components focused on helping caregivers navigate barriers to care and become effective advocates for their children in medical and educational settings ([<reflink idref="bib45" id="ref30">45</reflink>]). The Theory of Planned Behavior (see [<reflink idref="bib8" id="ref31">8</reflink>]) explains how psychoeducation for caregivers indirectly benefits children's ADHD symptoms. This theory posits that by preparing caregivers to act in ways that support healthy development in their children with ADHD and seek out the most effective treatments, caregiver knowledge and confidence translates into engagement in effective intervention, in turn, resulting in decreased symptoms. Further, [<reflink idref="bib47" id="ref32">47</reflink>] found that caregivers who received a psychoeducation-only intervention reported immediate changes in their feelings of empowerment, their self-rated confidence and ability to manage their children' s needs, and that caregivers who received the program were more likely to engage in both behavioral and pharmacological treatments 6 months later. In terms of behavioral outcomes, research on the impact of psychoeducation is somewhat mixed. A small number of studies reported reduced ADHD symptoms when education is provided either alongside BPT or as a monotherapy ([<reflink idref="bib16" id="ref33">16</reflink>]; [<reflink idref="bib61" id="ref34">61</reflink>]); however, a recent meta-analysis found that programs with a greater focus on ADHD education had smaller effects on behavior when compared to programs that spent more time focused on teaching behavior management skills ([<reflink idref="bib32" id="ref35">32</reflink>]). Together, this suggests that education may be important to preparing caregivers to manage ADHD symptoms, but that behavioral parent training skills may be a more potent component of intervention for young children with ADHD.</p> <hd id="AN0194258087-4">Barriers to Access and Engagement to Behavioral Parent Trainings</hd> <p>There are several barriers that complicate implementation of parent-focused programs and make them difficult to scale (see [<reflink idref="bib63" id="ref36">63</reflink>]). First, it can be challenging to evaluate for ADHD in children under 6 years due to limited validated assessment tools, a lack of collateral information available for children not yet in school, and limited treatment resources to provide following diagnosis ([<reflink idref="bib65" id="ref37">65</reflink>]). Nonetheless, The American Academy of Pediatrics (AAP) Clinical Practice Guidelines specifically recommend that pediatricians evaluate all children aged children ages four to six for ADHD and provide referrals to BPTs before starting a medication ([<reflink idref="bib65" id="ref38">65</reflink>]). However, discomfort with early diagnosis and low access to treatments other than medication management results in less than half of pediatricians following these guidelines ([<reflink idref="bib44" id="ref39">44</reflink>]).</p> <p>Second, families face both <emph>tangible</emph> barriers to participation in evidence-based treatments including cost, availability of providers in their community, and missed work and wages due to session attendance, as well as <emph>intangible</emph> barriers, such as stigma and lack of confidence in the potential benefits of psychosocial interventions ([<reflink idref="bib38" id="ref40">38</reflink>]; [<reflink idref="bib52" id="ref41">52</reflink>]). These barriers result in less than half of families who are recommended BPTs attending treatment past the third session ([<reflink idref="bib11" id="ref42">11</reflink>]; [<reflink idref="bib60" id="ref43">60</reflink>]). Furthermore, BPT clinicians are not evenly distributed geographically, and services are often severely limited in rural and low resource communities ([<reflink idref="bib5" id="ref44">5</reflink>]; [<reflink idref="bib51" id="ref45">51</reflink>]). As a result, youth in rural areas utilize more psychiatric medication and less behavioral treatment compared to urban and suburban areas ([<reflink idref="bib9" id="ref46">9</reflink>]). Given the size of the current care gap and geographic disparities, leaders have concluded that workforce expansion alone is not a viable solution and have called for the adaptation of traditional treatments into brief, scalable, culturally adaptive, and technology-driven programs ([<reflink idref="bib34" id="ref47">34</reflink>]; [<reflink idref="bib41" id="ref48">41</reflink>]; [<reflink idref="bib54" id="ref49">54</reflink>]).</p> <p>Brief behavioral interventions, defined as those with a planned course of treatment lasting one to eight sessions ([<reflink idref="bib59" id="ref50">59</reflink>]), are highly acceptable to consumers ([<reflink idref="bib33" id="ref51">33</reflink>]) and less burdensome and time intensive for caregivers and clinicians. A systematic analysis of brief BPTs found that participation in even two-session interventions had positive effects on parenting skills and children's disruptive behaviors ([<reflink idref="bib59" id="ref52">59</reflink>]). BPTs delivered via telemedicine have been found to be acceptable to caregivers, provide equal therapeutic benefits, reduce the burden of participation for caregivers ([<reflink idref="bib14" id="ref53">14</reflink>]), and may encourage participation from second caregivers ([<reflink idref="bib15" id="ref54">15</reflink>]). Two rigorous studies have examined the use of telemedicine parent trainings with school-age children with ADHD in rural areas ([<reflink idref="bib45" id="ref55">45</reflink>]; [<reflink idref="bib67" id="ref56">67</reflink>]). Families that received brief telemedicine programs reported fewer symptoms of inattention, hyperactivity, and impairment when compared to children that were provided with medication management alone ([<reflink idref="bib45" id="ref57">45</reflink>]). Furthermore, in a direct comparison of in-person versus telemedicine delivered BPTs in a sample of school-age children with ADHD, [<reflink idref="bib67" id="ref58">67</reflink>] found no differences between the groups in terms of outcomes.</p> <hd id="AN0194258087-5">Current Study</hd> <p>The primary objective of this study was to test the feasibility and acceptability of the Rural Outreach and ADHD Research—Early Childhood program (ROAR-EC) along with the chosen study procedures. The second objective was to provide a preliminary test of the target mechanism engagement and efficacy of the intervention. We designed ROAR-EC to engage two treatment mechanisms. The first hypothesized mechanism is enhanced parenting practices (e.g., positive reinforcement, limit-setting) to facilitate greater emotional and behavioral regulation in children ([<reflink idref="bib43" id="ref59">43</reflink>]). The second mechanism is caregiver empowerment, through which high quality psychoeducation and support from providers increases self-efficacy related to managing ADHD.</p> <p>We hypothesized that our research procedures and the ROAR-EC program would meet our <emph>a priori</emph> benchmarks for feasibility and treatment acceptability supporting the use of our program in future trials (See Table 1). No existing studies examine the feasibility and acceptability of brief telemedicine programs for children diagnosed with ADHD during early childhood, and establishing acceptability and feasibility is an important step in developing this model of care. Analyses assessing group × time differences for this pilot study are underpowered, exploratory, and not intended to assess efficacy. We hypothesized the ROAR-EC group would demonstrate improvements in parenting practices, and empowerment, compared to caregivers receiving standard care. Finally, we conducted analyses comparing our two groups (ROAR-EC vs. standard care) on ADHD symptoms, and disruptive behaviors at both 14- and 24-week follow-up.</p> <p>Table 1. Benchmarks for Feasibility and Acceptability.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th align="left">Domain of feasibility</th><th align="center">Benchmark</th><th align="center">Results (8-month recruitment)</th></tr></thead><tbody><tr><td>Recruitment</td><td>Receive 10 referrals/month</td><td>69 families were referred (8.6/month)</td></tr><tr><td>Enrollment</td><td>Enroll 4–5 eligible families/month</td><td>47 families were enrolled (5.8/month)</td></tr><tr><td>Treatment retention</td><td>80% of families will attended the full 7 sessions within a 14-week period of treatment</td><td>17/22 families (77% of randomized; 94% of those who attended session 1) completed all 7 sessions</td></tr><tr><td>Measurement completion</td><td>Retain 80% of families through all study time points (i.e., from study enrollment through 24-week follow-up)</td><td>35/47 families (74.5%) who enrolled in the study completed surveys at all time points</td></tr><tr><td>Acceptability</td><td>80% of families score >26 on TEI-SF</td><td>17/17 (100%) treatment families met TEI-SF threshold for acceptability</td></tr></tbody></table> </ephtml> </p> <hd id="AN0194258087-6">Methods</hd> <p></p> <hd id="AN0194258087-7">Setting and Procedures</hd> <p>All study procedures were approved by the Dartmouth Health Institutional Review Board. The study was completed in coordination with a developmental and behavioral pediatrics clinic in a large, rural academic medical center in New Hampshire2. The clinic was staffed by one developmental pediatrician and an advanced practice nurse and serves approximately 1,500 children annually. Children referred to the clinic received a full diagnostic assessment, including a comprehensive diagnostic interview and validated parent and teacher/care provider neurodevelopmental measures. Following evaluation by the developmental pediatrician, the clinic referred all children ages 3 to 7 years with a full or suspected diagnosis of ADHD to the study. Children were not referred if they met the following exclusion criteria: (a) diagnosis of autism spectrum disorder, schizophrenia, or other psychotic disorder, (b) previous psychiatric hospitalization, (c) exhibited serious self-injurious behaviors, or d) were actively participating in psychotherapy. Children were not excluded if they were prescribed medication as part of standard care. A research study coordinator contacted referred families by phone to confirm eligibility, and interested families were given the ADHD-5 ([<reflink idref="bib20" id="ref60">20</reflink>]) to ensure that families included in the study were continuing to report ADHD symptoms following referral from the developmental pediatrician. Families of children with scores greater than the 85<sups>th</sups> percentile on the total problems scale progressed to the consent process and enrolled in the study. Participants completed baseline assessment and were then block-randomized (to ensure equal distribution of gender) to either ROAR-EC or standard care and followed for 24 weeks.</p> <hd id="AN0194258087-8">Intervention</hd> <p>ROAR-EC was designed for children 3 to 7 years old with significant symptoms of ADHD living in rural or low resource communities. Prior to the current project, the study team adapted Helping the Noncompliant Child ([<reflink idref="bib42" id="ref61">42</reflink>]) into a four-session, made-for-telemedicine intervention called Managing Challenging Behaviors—telehealth (MCB-t) ([<reflink idref="bib15" id="ref62">15</reflink>]). In the original adaptation, the authors reduced Helping the Noncompliant Child to four sessions and constructed "digital session guides" to optimize content for delivery over telehealth. Digital session guides were visible to the clinician and family during sessions and included animated videos explaining skills, videos of live models using the skills with children, discussion questions, role-play activities, and links to resources to share with other caregivers in the home and educators. During sessions, caregivers practiced the skills of attending, praise, ignoring, and time-out with their children while being observed by the clinician and were given strengths-focused feedback and a homework assignment. MCB-t was designed for use with children 2 to 8 years presenting to primary care with disruptive behaviors, including ADHD. The program was tested in an open trial and demonstrated strong consumer acceptability and feasibility within the primary care setting. ROAR-EC is an expanded version of this protocol. Based on participant feedback, a fifth core behavioral management session was added to ROAR-EC to allow families to "trouble-shoot" and further practice time-out with their clinician. We also added two newly developed ADHD-specific education and advocacy sessions. In ROAR-EC, clinicians met with individual families virtually for seven sessions spaced 1 to 2 weeks apart, depending on scheduling availability. Sessions were 45 to 60 min long with some flexibility to meet the needs of the family. Parenting skills included in the program were attending (i.e., giving attention to "OK" behaviors), specific praise, active ignoring, clear instructions, and time-out (See Figure 1 for content included in each session). Education and advocacy content was designed to increase knowledge about ADHD, improve knowledge and attitudes toward evidence-based treatment, and support collaborative interactions among caregivers, medical providers, and educators.</p> <p>Graph: Figure 1. Participant flow through study procedures. Note. Families randomized to treatment included n = 8 female and n = 14 male participants; families randomized to control included n = 9 female and n = 13 male participants. One participant each in the treatment and control groups (two participants total) completed half of the measures at the 24-week assessment and were counted as retained.</p> <p>Clinicians for the current study included one post-doctoral fellow (female), one predoctoral psychology intern (male), and one applied behavioral analysis technical assistant (Bachelor's level; female). All three identified as White and non-Hispanic. Training in ROAR-EC consisted of one full-day, face-to-face learning session that included didactic teaching and hands-on role-play activities. After training, clinicians met with a licensed clinical psychologist (first author or third author) every week during program delivery for ongoing supervision.</p> <hd id="AN0194258087-9">Control Condition</hd> <p>Individuals in the control condition were provided with standard care through the developmental pediatric clinic. Standard care included access to medication, general guidance about behavior and development from the developmental pediatrician, social work support, and consultation with schools. We asked participants if they started a BPT at each time-point and excluded any participants that started a parenting program during the observation period. Because of the high needs of this population in our predominantly rural area, we determined that it was most ethical to offer the intervention to all participants following completion of the study. Thus, we refer to the control condition as standard care, with the caveat that participants were informed that they could access the program after 24 weeks.</p> <hd id="AN0194258087-10">Participants</hd> <p>Forty-four caregiver-child dyads were recruited between October 2022 and May 2023 (<emph>M</emph><subs>age</subs> at enrollment = 4.8 years; range 3–7 years). At study entry, caregivers completed a brief demographic questionnaire reporting on socioeconomic status, child gender, age, race/ethnicity, medication status, previous participation in therapy, and relationship to child.</p> <p>Children in the study were 62% male; 96% White, 2% Black; and 89% non-Hispanic/Latinx. Enrolled families had a median annual income of $90,000 (range = $0–$250,000). Of the families enrolled, 84.1% lived in an area designated as "rural" by the Federal Office of Rural Health Policy. Seven of the 44 families did not fall into this classification. For these seven families, RUCA codes (Rural Urban Commuting Area; based on address) were as follows: one resided in a code 10 (rural area), one resided in code 4 (micropolitan core), and two resided in code 3 (metropolitan low commuting), and three resided in code 1 (metropolitan core). On average, participating families lived 57.8 miles (<emph>SD</emph> = 30.0 miles) from the developmental pediatric clinic. The majority (78%) of participating caregivers identified themselves as biological mothers. About one-third (31%) reported their child was on any medication for ADHD at baseline and 27% reported that their child was taking a stimulant medication. No families in the control condition began therapy during the observation period.</p> <hd id="AN0194258087-11">Measures</hd> <p></p> <hd id="AN0194258087-12">Feasibility</hd> <p>Feasibility metrics were collected throughout the duration of the study and included: (a) recruitment rate (i.e., number of participants recruited per month); (b) number of families screened and rate of positive screens; (d) number of sessions attended; and (e) rate of completion of study measurements and procedures. To assess the feasibility of our program, we selected <emph>a priori</emph> benchmarks for each feasibility metric (see Table 1) based on previous literature ([<reflink idref="bib7" id="ref63">7</reflink>]; [<reflink idref="bib22" id="ref64">22</reflink>]) and the calculated rate of recruitment and enrollment needed to adequately test the intervention in a future fully powered efficacy trial (see "Plan of Analysis").</p> <hd id="AN0194258087-13">Acceptability</hd> <p></p> <hd id="AN0194258087-14">Intervention Acceptability</hd> <p>Participants in the intervention group completed the Treatment Evaluation Inventory Short Form (TEI-SF; [<reflink idref="bib35" id="ref65">35</reflink>]) post-treatment to assess their perceptions of the acceptability using a 5-point Likert scale. This 9-item measure (α =.74; all observed αs are from current study) assessed perspectives on different components of behavioral interventions (e.g., "I find this treatment to be an acceptable way of dealing with the child's problem behavior"; "I believe this treatment is likely to result in permanent improvement"). A score of 27 indicates <emph>Moderate Acceptability</emph>, per published guidelines.</p> <hd id="AN0194258087-15">Parenting Skill Usefulness and Difficulty</hd> <p>Participants that received ROAR-EC completed the Parent Consumer Satisfaction Questionnaire (PCSQ; [<reflink idref="bib26" id="ref66">26</reflink>]) adapted to reflect each skill in our protocol. The 14-item measure asked participants to rate the difficulty (seven items) and usefulness (seven items) of the various skills (e.g., attending, ignoring, time-out) using a 7-point Likert scale (1 = "extremely difficult/not useful" to 7 = "extremely easy/useful; α<subs>DifficultySkills</subs> =.63; α<subs>UsefulnessSkills</subs> =.86).</p> <hd id="AN0194258087-16">Measures of Mechanism</hd> <p></p> <hd id="AN0194258087-17">Parenting Practices</hd> <p>Participants completed [<reflink idref="bib6" id="ref67">6</reflink>] 30-item Parenting Scale (PS). The PS measures three parenting styles associated with ineffective parenting practices using a 7-point Likert scale. We used the subscales of laxness (e.g., "I am the kind of parent that... 1 = "Sets limits on what my child is allowed to do" to 7 = "Lets my child do whatever he/she wants"; α<subs>pre</subs> =.85; α<subs>post</subs> =.83), reactivity (α<subs>pre</subs> =.80; α<subs>post</subs> =.78), and verbosity α<subs>pre</subs> =.58; α<subs>post</subs> =.80). Four items are not included in any of the factor scores, one item is included in both laxness and verbosity domains, and one item is included in both over-reactivity and verbosity domains. Subscales were summed to create a total score (α<subs>pre</subs> =.89; α<subs>post</subs> =.91) representing overall parenting practices (lower scores indicated more effective parenting).</p> <hd id="AN0194258087-18">Family Empowerment</hd> <p>Participants completed the [<reflink idref="bib37" id="ref68">37</reflink>] Family Empowerment Scale (FES). The FES assesses a caregiver 's ability to advocate for their child in three domains using a 5-point Likert scale (1 = "not at all true" to 5 = "very true") the 12-item family domain (e.g., "I feel confident in my ability to help my child grow and develop"; αpre =.86; αpost =.91), the 12-item services domain (e.g., "I am able to work with agencies and professionals to decide what services my child needs"; α<subs>pre</subs> =.88; α<subs>post</subs> =.88), and the 10-item community domain (e.g., "I feel that my knowledge and experience as a parent can be used to improve services for children and families"; α<subs>pre</subs> =.87; α<subs>post</subs> =.91). Subscales were summed to create a total score representing general family empowerment (α<subs>pre</subs> =.94 α<subs>post</subs> =.96).</p> <hd id="AN0194258087-19">Measures of Outcomes</hd> <p></p> <hd id="AN0194258087-20">Disruptive Behaviors</hd> <p>Participants completed the Eyberg Child Behavior Inventory (ECBI; [<reflink idref="bib24" id="ref69">24</reflink>]) to assess general behavior problems at each time point in the study. Caregivers rated the frequency of different disruptive behavior problems (e.g., "Refuses to obey until threatened with punishment"; "Has temper tantrums"; "Hits parents") on a 7-point Likert scale (1 = "never" to 7 = "always"; α<subs>pre</subs> =.87; α<subs>post</subs> =.91; α<subs>follow-up</subs> =.93). Frequency items were summed to create a Total Severity score. Previous work ([<reflink idref="bib24" id="ref70">24</reflink>]) established a clinical cutoff score of 131 for total disruptive behaviors. The measure has been validated across diverse samples ([<reflink idref="bib27" id="ref71">27</reflink>]; [<reflink idref="bib29" id="ref72">29</reflink>]).</p> <hd id="AN0194258087-21">Symptoms of ADHD</hd> <p>Participants completed the ADHD Rating Scale-5 ([<reflink idref="bib20" id="ref73">20</reflink>]) to assess the severity of their child's inattentive (nine items; e.g., "Has difficulty sustaining attention in tasks or play activities"; α<subs>pre</subs> =.84; α<subs>post</subs> =.89; α<subs>follow-up</subs> =.87) and hyperactive (nine items; e.g., "On the go, acts as if driven by a motor"; α<subs>pre</subs> =.77; α<subs>post</subs> =.88; α<subs>follow-up</subs> =.89) symptoms on a 3-point Likert scale (0 = "never or rarely" to 2 = "often"). Both symptom domains were summed to create a total ADHD score (α<subs>pre</subs> =.85; α<subs>post</subs> =.92; α<subs>follow-up</subs> =.93) that was used to calculate ADHD clinical severity using the established 85<sups>th</sups> percentile cutoff score (18 for girls, 20 for boys; [<reflink idref="bib20" id="ref74">20</reflink>]). The ADHD-5 has also been validated in samples of school-aged children and adolescents across genders, races, and ethnicities, and shows good inter-rater reliability ([<reflink idref="bib3" id="ref75">3</reflink>]; [<reflink idref="bib20" id="ref76">20</reflink>]).</p> <hd id="AN0194258087-22">Plan of Analysis</hd> <p>At baseline, we completed preliminary independent sample t-tests to ensure participants were equally distributed across intervention and control groups based on age, family income, and all outcome measures. Chi-square tests were used to compare gender and medication status across groups. To ensure our sample reflected a clinical sample, we compared scores for parent-rated ADHD-5 total problems, and ECBI total problems to established clinical cutoff scores (85<sups>th</sups> percentile).</p> <p>To test the hypothesis that our study design and intervention protocols are appropriate for a large-scale efficacy RCT, we compared our obtained study feasibility metrics against the <emph>a priori</emph> benchmarks. To determine whether our study methods would be feasible to replicate on a large scale, we first conducted a power analysis to determine the minimum sample size necessary to test group × time interactions, including gender as a covariate, and a full mediation model ([<reflink idref="bib2" id="ref77">2</reflink>]; [<reflink idref="bib55" id="ref78">55</reflink>]) in a moderate-sized RCT (4-year study recruitment period). A sample size of <emph>n</emph> = 240 (assuming 80% study retention rate) would be required to detect a medium effect (Cohen's <emph>d</emph> =.25) in mediation analyses ([<reflink idref="bib13" id="ref79">13</reflink>]) similar to observed effects for other brief behavioral interventions ([<reflink idref="bib59" id="ref80">59</reflink>]). We then set benchmarks for recruitment and retention using these values for our pilot, using an 8-month recruitment period to test whether our methods would be feasible to replicate in a large-scale efficacy trial. Based on previous work on brief telemedicine interventions, we anticipated that at least 90% of participants ([<reflink idref="bib15" id="ref81">15</reflink>]) would rate ROAR-EC as at least "moderately acceptable" (using an established cut-off score of >26 on the TEI-SF).</p> <p>To test whether ROAR-EC engaged our proposed mechanisms of action, we conducted a series of 2 (group) × 2 (time) RM-ANOVAs for parenting practices and family empowerment measured at baseline and at 14 weeks post-baseline for both groups. We explored interaction effects on Parenting Practices and Family Empowerment total scores and individual subscales (see [<reflink idref="bib59" id="ref82">59</reflink>]).</p> <p>To test whether participation in the intervention would reduce parent-rated behavior problems and ADHD symptom severity significantly more than the control group, we conducted a series of 2 (group) × 3 (time) RM-ANOVAs for general behavior problems and ADHD-related hyperactivity, inattention, and total symptoms measured at baseline, 14 weeks, and 24 weeks post-baseline for both groups. Simple effects testing was conducted and reported for each interaction effect to determine direction of effects at each time point; however, only the simple effects for statistically significant interactions were interpreted. Given the exploratory nature of the analyses, models controlled for child age and gender; across analyses, <emph>p</emph> values < ⍺ =.05 indicated statistical significance.</p> <p>To measure the number of families that reported clinically meaningful changes, we examined whether raw scores for the ECBI Total problems and ADHD-5 Total changed from above to below the clinical threshold over the course of the intervention and follow-up periods. This corresponded to T-score of 60 and raw score of 131 on the ECBI and the 85<sups>th</sups> percentile clinical cutoff and raw scores of 18 (girls) and 20 (boys) on the ADHD-5. We paired this metric with reliable change index scores, which describe whether an individual's change score is significantly greater than would be expected given measurement error in the sample, calculated as <ephtml> <math display="inline" xmlns="http://www.w3.org/1998/Math/MathML"><mrow><mi>R</mi><mi>C</mi><mi>I</mi><mo>=</mo><mfrac><mrow><mo stretchy="false">(</mo><mi>p</mi><mi>o</mi><mi>s</mi><mi>t</mi><mi>t</mi><mi>e</mi><mi>s</mi><mi>t</mi><mspace width="0.25em" /><mi>s</mi><mi>c</mi><mi>o</mi><mi>r</mi><mi>e</mi><mo>−</mo><mi>p</mi><mi>r</mi><mi>e</mi><mi>t</mi><mi>e</mi><mi>s</mi><mi>t</mi><mspace width="0.25em" /><mspace width="0.25em" /><mi>s</mi><mi>c</mi><mi>o</mi><mi>r</mi><mi>e</mi><mo stretchy="false">)</mo></mrow><mrow><mi>S</mi><mi>E</mi><mi>d</mi><mi>i</mi><mi>f</mi><mi>f</mi><mi>e</mi><mi>r</mi><mi>e</mi><mi>n</mi><mi>c</mi><mi>e</mi></mrow></mfrac></mrow></math> </ephtml> ; significant RCIs were above the critical value of 1.96 (see [<reflink idref="bib30" id="ref83">30</reflink>]). In our sample, SE<subs>difference</subs> for the ECBI was 12.00 for girls and 6.77 for boys; SE<subs>difference</subs> for the ADHD-5 was 4.09 for girls and 2.84 for boys.</p> <hd id="AN0194258087-23">Randomization and Clinical Representation</hd> <p>Results of randomization revealed no significant differences between the treatment and control groups at study entry in child age, child gender, family income, medication status, or on any outcome measures. At baseline, 37 of 44 (84%) met or exceeded the established ECBI total problems clinical cutoff scores; our ECBI total problems sample mean at baseline (160.57) was significantly higher than that of the ADHD group (138.67) reported in the re-standardization sample in [<reflink idref="bib24" id="ref84">24</reflink>] manual. ADHD-5 total scores for all children in the sample met or exceeded the established clinical cutoff of the 85<sups>th</sups> percentile.</p> <hd id="AN0194258087-24">Feasibility and Acceptability</hd> <p>Obtained feasibility and acceptability values met or exceeded all <emph>a priori</emph> benchmarks (see Table 1). Of the 52 eligible, 44 (84.6%) families reached randomization. We retained 17 of 22 (81.8%) treatment families and 19 of 22 (86.4%) control families through 14-week post-baseline/end of treatment follow-up (see Figure 1 for participant flow through the study). All families who received ROAR-EC (17/17) found the treatment to be at least "moderately" acceptable (TEI-SF > 27) and "agreed" or "strongly agreed" their child had "an overall positive reaction to treatment." See Supplemental 1 for all TEI-SF responses.</p> <p>Figure 2 Panel A presents caregiver perceptions of the usefulness of specific ROAR-EC parenting skills. A majority of caregivers found the skills taught in the program either "useful" or "extremely useful" with little variability in responses. Caregiver perceptions of the difficulty of each skill are presented in Figure 2 Panel B. Caregivers generally found the skills easy to implement, with praise (16/17) rated as "easy" or "extremely easy" and clear instructions (14/17) rated as "easy" or "extremely easy." There was significant variability in the perception of difficulty for the time-out skill. Seven of seventeen caregivers rated time-out as "difficult" or "extremely difficult" while 7/17 rated the skill as either "easy" or "extremely easy."</p> <p>Graph: Figure 2. Parent ratings of preschool ROAR-EC usefulness and difficulty of learning parenting skills on the PCSQ. (a) Parent rating of preschool ROAR-EC skills: acceptability. (b) Parent rating of preschool ROAR-EC skills: difficulty. Note. PCSQ = Parent Consumer Satisfaction Questionnaire.</p> <hd id="AN0194258087-25">Intervention Effects</hd> <p>Raw means, standard deviations, and mean differences between the treatment and control group for all outcome measures are presented in Table 2. Medication status at baseline and medication changes at post-intervention and follow-up assessments were not significantly associated with total behavior problems or symptoms of ADHD.</p> <p>Table 2. Timeline of Measures with Measure Raw Means, Standard Deviations, and Group Comparisons (Between Estimated Marginal Means).</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th align="left" rowspan="3">Measure</th><th align="center" colspan="3">Study entry</th><th align="center" colspan="3">14 weeks</th><th align="center" colspan="3">24 weeks</th></tr><tr><th align="center">Treatment (<italic>n</italic> = 22)</th><th align="center">Control (<italic>n</italic> = 22)</th><th align="center" rowspan="2">T–C</th><th align="center">Treatment (<italic>n</italic> = 17)</th><th align="center">Control (<italic>n</italic> = 19)</th><th align="center" rowspan="2">T–C</th><th align="center">Treatment (<italic>n</italic> = 16)</th><th align="center">Control (<italic>n</italic> = 19)</th><th align="center" rowspan="2">T–C</th></tr><tr><th align="center"><italic>M</italic> (<italic>SD</italic>)</th><th align="center"><italic>M</italic> (<italic>SD</italic>)</th><th align="center"><italic>M</italic> (<italic>SD</italic>)</th><th align="center"><italic>M</italic> (<italic>SD</italic>)</th><th align="center"><italic>M</italic> (<italic>SD</italic>)</th><th align="center"><italic>M</italic> (<italic>SD</italic>)</th></tr></thead><tbody><tr><th align="left" colspan="10">Measures of mechanism</th></tr><tr><td><italic>Parenting Scale</italic></td><td>84.72 (23.68)</td><td>95.55 (16.32)</td><td>−10.83</td><td>73.94 (22.63)</td><td>97.16 (15.14)</td><td>−23.22<xref ref-type="table-fn" rid="tfn2">**</xref></td><td align="center">—</td><td align="center">—</td><td align="center">—</td></tr><tr><td> Laxness</td><td>29.36 (9.69)</td><td>34.14 (9.37)</td><td>−4.78</td><td>27.29 (8.69)</td><td>33.74 (8.35)</td><td>−6.45</td><td align="center">—</td><td align="center">—</td><td align="center">—</td></tr><tr><td> Over-reactivity</td><td>24.45 (9.71)</td><td>27.86 (5.40)</td><td>−3.41</td><td>22.00 (7.07)</td><td>28.89 (6.43)</td><td>−6.89</td><td align="center">—</td><td align="center">—</td><td align="center">—</td></tr><tr><td><italic>Verbosity</italic></td><td>24.36 (6.90)</td><td>26.77 (5.12)</td><td>−2.41</td><td>19.29 (8.33)</td><td>26.53 (4.30)</td><td>−7.24<xref ref-type="table-fn" rid="tfn2">**</xref></td><td align="center">—</td><td align="center">—</td><td align="center">—</td></tr><tr><td><italic>Family empowerment</italic></td><td>119.55 (23.54)</td><td>117.91 (20.16)</td><td>1.64</td><td>138.41 (21.52)</td><td>118.58 (17.84)</td><td>19.83<xref ref-type="table-fn" rid="tfn2">**</xref></td><td align="center">—</td><td align="center">—</td><td align="center">—</td></tr><tr><td><italic>Family</italic></td><td>44.41 (8.71)</td><td>44.27 (5.74)</td><td>0.14^</td><td>51.00 (7.66)</td><td>45.00 (6.60)</td><td>6.00<xref ref-type="table-fn" rid="tfn2">*</xref></td><td align="center">—</td><td align="center">—</td><td align="center">—</td></tr><tr><td><italic>Service</italic></td><td>48.09 (8.36)</td><td>47.14 (7.81)</td><td>0.95</td><td>53.00 (7.12)</td><td>47.58 (5.98)</td><td>5.42<xref ref-type="table-fn" rid="tfn2">*</xref></td><td align="center">—</td><td align="center">—</td><td align="center">—</td></tr><tr><td><italic>Community</italic></td><td>27.05 (8.59)</td><td>26.50 (8.88)</td><td>0.55</td><td>34.41 (8.75)</td><td>26.00 (8.52)</td><td>8.41<xref ref-type="table-fn" rid="tfn2">**</xref></td><td align="center">—</td><td align="center">—</td><td align="center">—</td></tr><tr><th align="left" colspan="10">Measures of outcome</th></tr><tr><td><italic>ECBI total problems</italic></td><td>162.55 (24.59)</td><td>158.59 (25.45)</td><td>3.96</td><td>136.00 (28.30)</td><td>152.84 (26.34)</td><td>−16.84</td><td>131.06 (31.26)</td><td>153.58 (24.66)</td><td>−22.52<xref ref-type="table-fn" rid="tfn2">*</xref></td></tr><tr><td><italic>ADHD-5 total problems</italic></td><td>38.00 (9.80)</td><td>36.59 (7.39)</td><td>1.41</td><td>31.24 (12.15)</td><td>36.37 (10.20)</td><td>−5.13</td><td>28.27 (11.73)</td><td>35.72 (9.74)</td><td>−7.45</td></tr><tr><td> Hyperactivity</td><td>19.82 (4.98)</td><td>20.32 (4.75)</td><td>−0.50</td><td>15.94 (7.01)</td><td>19.58 (5.05)</td><td>−3.64</td><td>15.13 (6.92)</td><td>19.00 (5.34)</td><td>−3.87</td></tr><tr><td><italic>Inattention</italic></td><td>18.18 (6.21)</td><td>16.27 (4.39)</td><td>1.91</td><td>15.29 (6.34)</td><td>16.79 (5.80)</td><td>−1.50</td><td>13.13 (5.50)</td><td>16.72 (5.46)</td><td>−3.59</td></tr></tbody></table> </ephtml> </p> <p>1 <emph>Note</emph>. Scores are scale raw means and standard deviations at each time point. Lower scores represent better outcomes for all measures except for Family Empowerment, where higher scores represent better outcomes. Boldface and italicized text reflects a significant group × time interaction effect for that measure. Asterisks reflect significant differences in estimated marginal means (which control for child age and gender and are not equivalent to the raw means presented in this table) for each comparison. One participant each in the treatment and control group (two participants total) completed the EBCI but not the ADHD-5 at the 24-week mark; ADHD<subs>Treatment</subs><emph>n</emph> = 15, ADHD<subs>Control</subs><emph>n</emph> = 18. T = treatment; C = control; M = mean; SD = standard deviation; ECBI = Eyberg Child Behavior Inventory; ADHD-5 = Attention-Deficit/Hyperactivity Disorder rating</p> <p>2 <emph>p</emph> <.05. **<emph>p</emph> <.01.</p> <hd id="AN0194258087-26">Engagement of Mechanism</hd> <p>Significant interaction effects emerged for the Parenting Scale total score, <emph>F</emph>(<reflink idref="bib1" id="ref85">1</reflink>, 32) = 4.75, <emph>p</emph> <.05, η<sups>2</sups> =.13, and its Verbosity subscale, <emph>F</emph>(<reflink idref="bib1" id="ref86">1</reflink>, 32) = 6.38, <emph>p</emph> <.05, η<sups>2</sups> =.18. No significant interaction effects emerged for the Laxness or Over-reactivity subscales. The interaction effects were significant for the Family Empowerment total score, <emph>F</emph>(<reflink idref="bib1" id="ref87">1</reflink>, 32) = 17.20, <emph>p</emph> <.001, η<sups>2</sups> =.35, and each Family Empowerment subscale, including empowerment at the family, <emph>F</emph>(<reflink idref="bib1" id="ref88">1</reflink>, 32) = 17.83, <emph>p</emph> <.001, η<sups>2</sups> =.36, service, <emph>F</emph>(<reflink idref="bib1" id="ref89">1</reflink>, 32) = 8.96, <emph>p</emph> <.01, η<sups>2</sups> =.22, and community, <emph>F</emph>(<reflink idref="bib1" id="ref90">1</reflink>, 32) = 11.65, <emph>p</emph> <.01, η<sups>2</sups> =.27, levels.</p> <p>At posttreatment, tests of simple effects indicated that participants in the ROAR-EC group endorsed significantly fewer total problematic parenting practices (EMM = 73.95), <emph>F</emph>(<reflink idref="bib1" id="ref91">1</reflink>, 32) = 12.57, <emph>p</emph> <.01, and less verbosity (EMM = 19.35), <emph>F</emph>(<reflink idref="bib1" id="ref92">1</reflink>, 32) = 9.11, <emph>p</emph> <.01, than those in the control group (EMM<subs>TotalProblems</subs> = 97.16; EMM<subs>Verbosity</subs> = 26.48). They also rated their perceptions of family empowerment (EMM = 138.91) as significantly higher than those in the control group (EMM = 118.13), <emph>F</emph>(<reflink idref="bib1" id="ref93">1</reflink>, 32) = 10.04, <emph>p</emph> <.01, in addition to each of the family (EMM<subs>treatment</subs> = 51.19; EMM<subs>control</subs> = 44.83), <emph>F</emph>(<reflink idref="bib1" id="ref94">1</reflink>, 32) = 7.15, <emph>p</emph> <.05, service (EMM<subs>treatment</subs> = 53.15; EMM<subs>control</subs> = 47.44), <emph>F</emph>(<reflink idref="bib1" id="ref95">1</reflink>, 32) = 6.73, <emph>p</emph> <.05, and community (EMM<subs>treatment</subs> = 34.57; EMM<subs>control</subs> = 25.86), <emph>F</emph>(<reflink idref="bib1" id="ref96">1</reflink>, 32) = 9.12, <emph>p</emph> <.01, subscales.</p> <hd id="AN0194258087-27">Exploratory Analysis of Symptom-Specific Outcomes</hd> <p>Results of RM-ANOVAs controlling for child age and gender revealed significant group × time effects for ECBI total behavior problems, <emph>F</emph>(<reflink idref="bib2" id="ref97">2</reflink>, 60) = 7.13, <emph>p</emph> <.01, η<sups>2</sups> =.19. Interaction effects were also significant for the ADHD total score, <emph>F</emph>(<reflink idref="bib2" id="ref98">2</reflink>, 56) = 4.11, <emph>p</emph> <.05, η<sups>2</sups> =.13, and ratings of inattention, <emph>F</emph>(<reflink idref="bib2" id="ref99">2</reflink>, 56) = 4.59, <emph>p</emph> <.05, η<sups>2</sups> =.14. Interaction effects for ratings of hyperactivity were not significant.</p> <p>On the ECBI, follow-up ratings of children's total behavior problems (EMM = 130.05) were significantly lower in the ROAR-EC group compared to the control group (EMM = 154.44), <emph>F</emph>(<reflink idref="bib1" id="ref100">1</reflink>, 32) = 6.62, <emph>p</emph> <.05. Neither ratings of ADHD total score nor ratings of inattention were significantly different between the ROAR-EC and control groups at any specific time point.</p> <hd id="AN0194258087-28">Clinically Meaningful Change</hd> <p>The percentage of families in ROAR-EC with ECBI Total Problems at or above the clinical threshold (raw score = 131) fell from 91% (20/22) at baseline to 44% (7/16) at the 24-week follow-up (M<subs>decrease</subs> = 31.69, range = –11.00, 76.00) compared to 77% (17/22) and 79% (15/19) of families in the control group at baseline and the 24-week follow-up, respectively (M<subs>decrease</subs> = 6.74, range = –21.00, 50.00). All families (<emph>n</emph> = 44) rated their children at or above the ADHD-5 clinical threshold (raw score = 18 for boys and 20 for girls) at baseline. The percentage of families in ROAR-EC at or above the clinical threshold fell to 73% (11/15) at the 24-week follow-up (M<subs>decrease</subs> = 11.40, range = –4.00, 29.00) compared to 89% (16/18) of families in the control group (M<subs>decrease</subs> = 1.44, range = –18.00, 27.00).</p> <hd id="AN0194258087-29">Reliable Change</hd> <p>Sixty-three percent (10/16) of families in ROAR-EC demonstrated a reliable decrease (i.e., RCI > 1.96) in ECBI Total Problems from baseline to the 24-week follow-up compared to 26% (5/19) of families in the control group. Similarly, 67% (10/15) of ROAR-EC families demonstrated a reliable decrease in ADHD-5 Total Problems from baseline to the 24-week follow-up compared to 17% (3/18) of families in the control group.</p> <hd id="AN0194258087-30">Discussion</hd> <p>The primary goal of the current study was to conduct a pilot RCT to evaluate the feasibility and acceptability of the ROAR-EC program and our methods in a sample of families primarily living in a predominantly rural area. Results provided promising evidence that ROAR-EC was feasible to implement within the medical clinic and highly acceptable to participating caregivers. The second objective of this study was to test whether our intervention engaged target mechanisms of parenting practices and caregiver empowerment. Our findings suggested that ROAR-EC partially engaged the target mechanism of parenting practices, with observed changes in total parenting practices, and verbosity. Results suggested that ROAR-EC engaged the family empowerment mechanism with caregivers in the ROAR-EC program showing increased empowerment over caregivers receiving standard care. Exploratory analyses of group × time differences indicated that both disruptive behaviors and ADHD symptoms improved beyond controls and that about a third of children moved from above to below clinical cut-off scores on measures of symptom severity. Overall, changes in disruptive behaviors were larger compared to changes in ADHD symptoms with limited changes in hyperactivity. We view these results as promising, but these analyses are exploratory and should not be considered as evidence for efficacy. The current study was underpowered, lacked an active control group, and group difference may result from expectancy effects rather than intervention induced changes. Thus, any strong conclusions about the efficacy of treatment will be left to a future fully powered RCT.</p> <p>ROAR-EC demonstrated excellent feasibility and acceptability outcomes in the current study. Enrollment procedures met all <emph>a priori</emph> benchmarks for referral rate, treatment attendance, and treatment and study retention. All participating caregivers had an overall positive view of ROAR-EC and a strong majority agreed with statements reflecting benefits to their child (e.g.,"I believe this treatment will result in permanent improvement.") These findings add to a literature which suggests that BPTs can be successfully adapted for telehealth delivery ([<reflink idref="bib14" id="ref101">14</reflink>]) and that brief, telemedicine BPTs are desirable to pediatric providers and caregivers of children diagnosed with ADHD and other disruptive behavior problems living in rural areas ([<reflink idref="bib15" id="ref102">15</reflink>]). This study is the first to support the acceptability of this modality for children diagnosed with ADHD under age seven and the first to support acceptability among a sample of predominantly rural families.</p> <p>Results from the current study also provide important insights into how caregivers perceive various skills taught in brief telemedicine programs. Overall, caregivers viewed BPT skills as useful and found that antecedent (i.e., clear instructions) and positive reinforcement (i.e., attending and praise) strategies were both useful and easy to implement. This aligned closely with our previous work ([<reflink idref="bib15" id="ref103">15</reflink>]) and leads to the conclusion that these skills can be taught and learned quickly via telemedicine. In contrast, results also highlighted the challenges associated with teaching disciplinary skills, particularly time-out, in a brief telemedicine model. In this study, over one-third of caregivers found time-out to be difficult or extremely difficult, which aligns closely to previous qualitative work that speaks to discomfort among caregivers when first learning time-out ([<reflink idref="bib66" id="ref104">66</reflink>]). This is an important barrier to address within brief intervention models given the robust evidence base supporting the benefits of time-out to improve behaviors and reduce risk for caregivers using harsh and inconsistent forms of discipline ([<reflink idref="bib28" id="ref105">28</reflink>]; [<reflink idref="bib62" id="ref106">62</reflink>]). We reasoned that, for a significant portion of caregivers, attending to cultural (e.g., media messages that time-out is harmful) and logistical (e.g., adapting time-out to the specific home environment) concerns may require both more time and a deeper rapport with clinician than brief intervention can provide. This is an important finding, given that some brief BPTs do not introduce time-out until the final session (e.g., FAST-B, [<reflink idref="bib56" id="ref107">56</reflink>]) and although parents may have an overall positive reaction to treatment, they may be hesitant to use specific disciplinary skills without a lengthier relationship with a trusted provider.</p> <p>Caregivers that participated in ROAR-EC evidenced statistically significant reductions in total parenting problems and improvement in verbose parenting style compared to controls. Interaction effects were not significant for the laxness or over-reactivity subscales, though scores trended in the anticipated direction. It is likely that the less robust findings may be explained by low power. It may also be that the behavioral skills included more directly influenced the mechanism of verbosity as praise and clear instructions that are emphasized in ROAR-EC, while more global traits of laxness and reactivity are more loosely related to the skills taught. Future evaluations of ROAR-EC would also benefit from more objective measurements of parenting skills such as behavioral observations of parent-child interactions that do not rely on caregiver self-report alone and longer follow-up related to parenting practices ([<reflink idref="bib64" id="ref108">64</reflink>]).</p> <p>We found a significant effect for engaging the mechanism of family empowerment. Caregivers in the treatment condition reported significantly greater self-efficacy in their ability to meet their children's ADHD needs at home, with service providers, and in the community compared to caregivers in the control group. We reason that participating in ROAR-EC had a positive impact on caregiver's overall self-efficacy in managing the diagnosis of ADHD and that education focused on navigating the school and healthcare systems improved caregivers' confidence in advocating for their children. The literature suggests that education alone can increase empowerment ([<reflink idref="bib47" id="ref109">47</reflink>]); however, we surmise that the combination of BPT skills training, brief education on ADHD, and recurring interactions with a trusted provider may be particularly helpful to caregivers of young children with ADHD. Research is still emerging on the link between empowerment and child outcomes, and it remains unclear whether empowerment translates to clinically meaningful and lasting change. In future studies of ROAR-EC, and other programs focused on empowerment, it will be important to include long-term follow-up and test whether empowerment <emph>mediates</emph> changes in behavior. One encouraging finding is that empowerment-focused programs can lead to caregivers initiating evidence-based treatment ([<reflink idref="bib47" id="ref110">47</reflink>]), an important step between empowerment and symptom reduction.</p> <hd id="AN0194258087-31">Clinical Implications</hd> <p>Results from the current study speak to the promise of brief and transportable versions of evidence-based treatments to increase access to behavioral healthcare. Increasing the efficiency and geographic reach of these parent-mediated interventions with telemedicine and digital tools may help pediatricians provide care more congruent with best practice guidelines ([<reflink idref="bib65" id="ref111">65</reflink>]) and ease concerns about making an ADHD diagnosis in early childhood, before a child has started primary school. Given the limitations of the current study, we cannot comment on the clinical impact of ROAR-EC relative to in-clinic or long-duration programs such as Parent-Child Interaction Therapy, which has demonstrated positive impacts on young children with ADHD ([<reflink idref="bib50" id="ref112">50</reflink>]). More research is needed to assess the relative cost-benefit advantages of offering brief telemedicine programs instead of dedicating resources to long-duration, in-person care models like PCIT. Past qualitative work suggests that brief telehealth programs help parents navigate barriers to care ([<reflink idref="bib15" id="ref113">15</reflink>]) and that telehealth programs reduce the burden of care ([<reflink idref="bib14" id="ref114">14</reflink>]). However, more nuanced and quantitative studies are needed to compare costs and care burden between in-person versus brief telehealth care for rural families. It would seem that for some rural populations, if the choice is between cost-prohibitive and overly burdensome care and brief telemedicine program, the latter holds significant appeal in terms of increasing feasibility. In our sample, we worked with a group of families that had to travel over an hour on average to have an ADHD assessment for their young children. They were eager to participate in telemedicine and 94% completed treatment, allowing their children access to evidence-based care that was not available in their home communities. For rural, treatment-seeking families, a "telemedicine first" approach may make the most sense when considering the needs of this population and strength of the emerging evidence supporting the acceptability, feasibility, and efficacy of brief telemedicine models.</p> <hd id="AN0194258087-32">Limitations and Future Directions</hd> <p>Several limitations must be considered when interpreting our findings. First, the relatively small sample size reduced power to detect significant effects, which limited our ability to make firm conclusions about the proposed mechanisms and efficacy of ROAR-EC. Future research should strive to test these mechanisms in a fully-powered mediation model and compare models of care directly to understand the cost-benefit trade-offs associated with long-duration, in-clinic care versus brief telemedicine models. Second, we were not able independently employ gold-standard, multi-informant assessments of ADHD for inclusion in the current study, instead relying on provider diagnosis. This limitation may impact the internal validity of our findings in that the intervention benefits young children <emph>specifically</emph> with ADHD. Our study also did not employ more objective measurements of inattention, hyperactivity, or parenting skills; however, parent-reported ADHD symptoms registered in the clinical range for each participant in the study, lending credence to our referral procedures and sample composition. Future research should include more rigorous and multi-informant diagnostic assessment procedures. Third, we used limited measurements when assessing treatment mechanisms of parenting practices and empowerment. Future studies may consider using more molar and proximal measures to assess whether parents improved on specific ADHD-related knowledge. Similarly, we assessed more distal changes in caregivers' management of misbehaviors and did not assess changes in parenting skills directly. Future research could include direct observation of parenting skills in parent-child interactions or a daily report of skills used with children. Fourth, our homogenous sample consisted of predominantly White families with middle- or high-income levels seeking care for their children in a specialty medical clinic. The ethnic and geographic demographics of our sample were generally representative of the rural region in which the study was conducted; however, our sample was skewed toward higher income families. Study results may not generalize to more ethnically and economically diverse families and non-treatment seeking populations. Future studies should incorporate more diverse recruitment settings including schools and community organizations with higher ethnic and economic diversity to further establish the acceptability and feasibility. Finally, there are inherent limitations to using a wait-list design due to expectancy effects. For this study, we felt that offering care after the study to the control group was the most ethical decision given the severely limited access participants had to mental health care; however, future studies using an active control could provide stronger methods of testing efficacy.</p> <hd id="AN0194258087-33">Conclusion</hd> <p>Results from this pilot RCT showed support for the viability of delivering brief telemedicine BPT to predominantly rural caregivers of young children diagnosed with ADHD. This study will serve as the basis for future large-scale research to test the efficacy of ROAR-EC. Future studies will be able to evaluate whether brief telemedicine programs can provide benefits similar to those of higher-cost, long-duration, and in-clinic models of care, leading to a significant change in the approach to caring for young children in rural areas.</p> <hd id="AN0194258087-34">Supplemental Material</hd> <p>Graph: Supplemental material, sj-jpg-1-jad-10.1177_10870547251415434 for ROAR-Early Childhood: Pilot Testing a Brief Telemedicine Parent Training Program for Rural Children Diagnosed with ADHD by James T. Craig, Michael T. Sanders, Christina C. Moore, Erin Barnett, Kady F. Sternberg, Nicole L. Breslend, Lauren C. Vazquez, Nina Sand-Loud and Mary K. Jankowski in Journal of Attention Disorders</p> <ref id="AN0194258087-35"> <title> References </title> <blist> <bibl id="bib1" idref="ref28" type="bt">1</bibl> <bibtext> Aduen P. A., Day T. N., Kofler M. J., Harmon S. L., Wells E. L., Sarver D. E. (2018). Social problems in ADHD: Is it a skills acquisition or performance problem? Journal of psychopathology and behavioral assessment, 40, 440–451. https://doi.org/10.1007/s10862-018-9649-7</bibtext> </blist> <blist> <bibl id="bib2" idref="ref77" type="bt">2</bibl> <bibtext> Ahn C., Heo M., Zhang S. (2014). Sample size calculations for clustered and longitudinal outcomes in clinical research. CRC Press.</bibtext> </blist> <blist> <bibl id="bib3" idref="ref75" type="bt">3</bibl> <bibtext> Alhossein A., Abaoud A. A., Becker D., Aldabas R., Bakhiet S. F., Al Jaffal M., Alsufyani M., Abdu Elrahim N. M., Alzrayer N. (2022). Psychometric properties of ADHD Rating Scale-5 for children and adolescents in Sudan-school version. Frontiers in Psychology, 13, Article 883578. https://doi.org/10.3389/fpsyg.2022.883578</bibtext> </blist> <blist> <bibl id="bib4" idref="ref1" type="bt">4</bibl> <bibtext> American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787</bibtext> </blist> <blist> <bibl id="bib5" idref="ref44" type="bt">5</bibl> <bibtext> Andrilla C. H. A., Patterson D. G., Garberson L. A., Coulthard C., Larson E. H. (2018). Geographic variation in the supply of selected behavioral health providers. American Journal of Preventive Medicine, 54(6), S199–S207. https://doi.org/10.1016/j.amepre.2018.01.004</bibtext> </blist> <blist> <bibl id="bib6" idref="ref67" type="bt">6</bibl> <bibtext> Arnold D. S., O'Leary S. G., Wolff L. S., Acker M. M. (1993). The Parenting Scale: A measure of dysfunctional parenting in discipline situations. Psychological Assessment, 5(2), 137–144. https://doi.org/10.1037/1040-3590.5.2.137</bibtext> </blist> <blist> <bibl id="bib7" idref="ref63" type="bt">7</bibl> <bibtext> Aschbrenner K. A., Kruse G., Gallo J. J., Plano Clark V. L. (2022). Applying mixed methods to pilot feasibility studies to inform intervention trials. Pilot and Feasibility Studies, 8, Article 217. https://doi.org/10.1186/s40814-022-01178-x</bibtext> </blist> <blist> <bibl id="bib8" idref="ref31" type="bt">8</bibl> <bibtext> Bai G. N., Wang Y. F., Yang L., Niu W. Y. (2015). Effectiveness of a focused, brief psychoeducation program for parents of ADHD children: Improvement of medication adherence and symptoms. Neuropsychiatric Disease and Treatment, 11, 2721–2735. https://doi.org/10.2147%2FNDT.S88625</bibtext> </blist> <blist> <bibl id="bib9" idref="ref46" type="bt">9</bibl> <bibtext> Bitsko R. H., Claussen A. H., Lichsein J., Black L. I., Everett Jones S., Danielson M. L., Hoenig J. M., Davis Jack S. P., Brody D. J., Gyawali S., Maenner M. J., Warner M., Holland K. M., Perou R., Crosby A. E., Blumberg S. J., Avenevoli S., Kaminski J. W., Ghandour R. M. (2022). Mental health surveillance among children—United States,2013–2019. MMWR Supplements 2022, 71(Suppl. 2), 1–42. https://doi.org/10.15585/mmwr.su7102a1</bibtext> </blist> <blist> <bibtext> Bjørnebekk G., Kjøbli J., Ogden T. (2015). Children with conduct problems and co-occurring ADHD: Behavioral improvements following parent management training. Child & Family Behavior Therapy, 37(1), 1–19. https://doi.org/10.1080%2F07317107.2015.1000227</bibtext> </blist> <blist> <bibtext> Chacko A., Jensen S. A., Lowry L. S., Cornwell M., Chimklis A., Chan E., Lee D., Pulgarin B. (2016). Engagement in behavioral parent training: Review of the literature and implications for practice. Clinical Child and Family Psychology Review, 19, 204–215. https://doi.org/10.1007/s10567-016-0205-2</bibtext> </blist> <blist> <bibtext> Clerkin S. M., Halperin J. M., Marks D. J., Policaro K. L. (2007). Psychometric properties of the Alabama parenting questionnaire–preschool revision. Journal of Clinical Child and Adolescent Psychology, 36(1), 19–28. https://doi.org/10.1080/15374410709336565</bibtext> </blist> <blist> <bibtext> Cohen J. (1988). Statistical power analysis for the behavioral sciences. Erlbaum.</bibtext> </blist> <blist> <bibtext> Comer J. S., Furr J. M., Miguel E. M., Cooper-Vince C. E., Carpenter A. L., Elkins R. M., Kerns C. E., Cornacchio D., Chou T., Coxe S., DeSerisy M., Sanchez A. L., Golik A., Martin J., Myers K. M., Chase R. (2017). Remotely delivering real-time parent training to the home: An initial randomized trial of Internet-delivered parent-child interaction therapy (I-PCIT). Journal of Consulting and Clinical Psychology, 85(9), 909–917. https://doi.org/10.1037/ccp0000230</bibtext> </blist> <blist> <bibtext> Craig J. T., Moore C. C., Barnett E. R., Knight E., Sanders M. T., Lafko Breslend N., Haskell H. G., Jankowski M. K. (2025). The feasibility and acceptability of delivering brief telehealth behavioral parent training in pediatric primary care. Journal of Child and Family Studies, 45, Article 101491. https://doi.org/10.1007/s10826-024-02860-9</bibtext> </blist> <blist> <bibtext> Dahl V., Ramakrishnan A., Spears A. P., Jorge A., Lu J., Bigio N. A., Chacko A. (2020). Psychoeducation interventions for parents and teachers of children and adolescents with ADHD: A systematic review of the literature. Journal of Developmental and Physical Disabilities, 32, 257–292. https://doi.org/10.1007/s10882-019-09691-3</bibtext> </blist> <blist> <bibtext> Danforth J. S., Diller J. W. (2020). Chapter 6—The adaptive nature of coercive interactions between parents and their children with defiant attention deficit hyperactivity disorder: Implications for treatment. In Sturmey P. (Ed.), Functional analysis in clinical treatment (2nd ed., pp. 123–149). Academic Press.</bibtext> </blist> <blist> <bibtext> Danielson M. L., Bitsko R. H., Ghandour R. M., Holbrook J. R., Kogan M. D., Blumberg S. J. (2018). Prevalence of parent-reported ADHD diagnosis and associated treatment among U.S. children and adolescents, 2016. Journal of Clinical Child and Adolescent Psychology, 47(2), 199–212. https://doi.org/10.1080/15374416.2017.1417860</bibtext> </blist> <blist> <bibtext> DuPaul G. J., Evans S. W., Mautone J. A., Owens J. S., Power T. J. (2020). Future directions for psychosocial interventions for children and adolescents with ADHD. Journal of Clinical Child & Adolescent Psychology, 49(1), 134–145. https://doi.org/10.1080/15374416.2019.1689825</bibtext> </blist> <blist> <bibtext> DuPaul G. J., Reid R., Anastopoulos A. D., Lambert M. C., Watkins M. W., Power T. J. (2016). Parent and teacher ratings of attention-deficit/hyperactivity disorder symptoms: Factor structure and normative data. Psychological Assessment, 28(2), 214–225. https://doi.org/10.1037/pas0000166</bibtext> </blist> <blist> <bibtext> Egger H. L., Kondo D., Angold A. (2006). The epidemiology and diagnostic issues in preschool attention-deficit/hyperactivity disorder: A review. Infants & Young Children, 19(2), 109–122. https://doi.org/10.1097/00001163-200604000-00004</bibtext> </blist> <blist> <bibtext> Eldridge S. M., Lancaster G. A., Campbell M. J., Thabane L., Hopewell S., Coleman C. L., Bond C. M. (2016). Defining feasibility and pilot studies in preparation for randomised controlled trials: Development of a conceptual framework. PLoS ONE, 11(3), e0150205. https://doi.org/10.1371/journal.pone.0150205</bibtext> </blist> <blist> <bibtext> Evans S. W., Owens J. S., Wymbs B. T., Ray A. R. (2018). Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder. Journal of Clinical Child & Adolescent Psychology, 47(2), 157–198. https://doi.org/10.1080/15374416.2017.1390757</bibtext> </blist> <blist> <bibtext> Eyberg S., Pincus D. (1999). Eyberg child behavior inventory & sutter-eyberg student behavior inventory-revised: Professional manual. Psychological Assessment Resources.</bibtext> </blist> <blist> <bibtext> Fabiano G. A., Pelham W. E. Jr. Coles E. K., Gnagy E. M., Chronis-Tuscano A., O'Connor B. C. (2009). A meta-analysis of behavioral treatments for attention-deficit/hyperactivity disorder. Clinical Psychology Review, 29(2), 129–140. https://doi.org/10.1016/j.cpr.2008.11.001</bibtext> </blist> <blist> <bibtext> Forehand R. L., McMahon R. J. (2005). Helping the noncompliant child (2nd ed.). The Guilford Press.</bibtext> </blist> <blist> <bibtext> Funderburk B. W., Eyberg S. M., Rich B. A., Behar L. (2003). Further psychometric evaluation of the Eyberg and Behar rating scales for parents and teachers of preschoolers. Early Education and Development, 14(1), 67–82. https://doi.org/10.1207/s15566935eed1401_5</bibtext> </blist> <blist> <bibtext> Graziano P. A., Bagner D. M., Sheinkopf S. J., Vohr B. R., Lester B. M. (2012). Evidence-based intervention for young children born premature: Preliminary evidence for associated changes in physiological regulation. Infant Behavioral Development, 35(3), 417–428. https://doi.org/10.1016/j.infbeh.2012.04.001</bibtext> </blist> <blist> <bibtext> Gross D., Fogg L., Young M., Ridge A., Cowell J., Sivan A., Richardson R. (2007). Reliability and validity of the Eyberg Child Behavior Inventory with African-American and Latino parents of young children. Research in Nursing & Health, 30(2), 213–223. https://doi.org/10.1002/nur.20181</bibtext> </blist> <blist> <bibtext> Guhn M., Forer B., Zumbo B. D. (2014). Reliable change index. In Michalos A. C. (Ed.), Encyclopedia of quality of life and well-being research (pp. 5459–5462). Springer. https://doi.org/10.1007/978-94-007-0753-5_2465</bibtext> </blist> <blist> <bibtext> Harvey E. A., Breaux R. P., Lugo-Candelas C. I. (2016). Early development of comorbidity between symptoms of attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). Journal of Abnormal Psychology, 125(2), 154–156. https://doi.org/10.1037/abn0000090</bibtext> </blist> <blist> <bibtext> Hornstra R., Groenman A. P., Van der Oord S., Luman M., Dekkers T. J., van der Veen-Mulders L., Hoekstra P. J., van den Hoofdakker B. J. (2023). Which components of behavioral parent and teacher training work for children with ADHD? A metaregression analysis on child behavioral outcomes. Child and Adolescent Mental Health, 28(2), 258–268. https://doi.org/10.1111/camh.12561</bibtext> </blist> <blist> <bibtext> Jewell C., Wittkowski A., Collinge S., Pratt D. (2023). A brief cognitive behavioural intervention for parents of anxious children: Feasibility and Acceptability Study. Child & Youth Care Forum, 52, 661–681. https://doi.org/10.1007/s10566-022-09704-x</bibtext> </blist> <blist> <bibtext> Kazdin A. E., Blase S. L. (2011). Rebooting psychotherapy research and practice to reduce the burden of mental illness. Perspectives on Psychological Science, 6(1), 21–37. https://doi.org/10.1177/1745691610393527</bibtext> </blist> <blist> <bibtext> Kelley M. L., Heffer R. W., Gresham F. M., Elliott S. N. (1989). Development of a modified treatment evaluation inventory. Journal of Psychopathology and Behavioral Assessment, 11, 235–247. https://doi.org/10.1007/BF00960495</bibtext> </blist> <blist> <bibtext> Kessler R. C., Adler L., Barkley R., Biederman J., Conners C. K., Demler O., Faraone S. V., Greenhill L. L., Howes M. J., Secnik K., Spencer T., Berdirhan Ustun T., Walters E. E., Zaslavsky A. M. (2006). The prevalence and correlates of adult ADHD in the United States: Results from the National Comorbidity Survey Replication. American Journal of Psychiatry, 163(4), 716–723. https://doi.org/10.1176/ajp.2006.163.4.716</bibtext> </blist> <blist> <bibtext> Koren P., DeChillo N., Friesen B. (1993). Family Empowerment Scale (FES). Research and Training Center on Family Support and Children's Mental Health, Portland State University.</bibtext> </blist> <blist> <bibtext> Larson J., dosReis S., Stewart M., Kushner R., Frosch E., Solomon B. (2013). Barriers to mental health care for urban, lower income families referred from pediatric primary care. Administration and Policy in Mental Health, 40(3), 159–167. https://doi.org/10.1007/s10488-011-0389-1</bibtext> </blist> <blist> <bibtext> Li H. C. W., Chan S. S., Mak Y. W., Lam T. H. (2013). Effectiveness of a parental training programme in enhancing the parent–child relationship and reducing harsh parenting practices and parental stress in preparing children for their transition to primary school: A randomised controlled trial. BMC Public Health, 13, Article 1079. https://doi.org/10.1186/1471-2458-13-1079</bibtext> </blist> <blist> <bibtext> Mayes S. D., Calhoun S. L., Baweja R., Feldman L., Syed E., Gorman A. A., Montaner J., Annapareddy J., Gupta N., Bello A., Siddiqui F. (2015). Suicide ideation and attempts are associated with co-occurring oppositional defiant disorder and sadness in children and adolescents with ADHD. Journal of Psychopathology and Behavioral Assessment, 37, 274–282. https://doi.org/10.1007/s10862-014-9451-0</bibtext> </blist> <blist> <bibtext> McCabe K. M., Yeh M., Zerr A. A. (2020). Personalizing behavioral parent training interventions to improve treatment engagement and outcomes for culturally diverse families. Psychology Research and Behavior Management, 13, 41–53. https://doi.org/10.2147/PRBM.S230005</bibtext> </blist> <blist> <bibtext> McMahon R. J., Forehand R. L. (2003). Helping the noncompliant child: Family-based treatment for oppositional behavior (2nd ed.). The Guilford Press.</bibtext> </blist> <blist> <bibtext> McNeil C. B., Hembree-Kigin T. L. (2011). Parent-child interaction therapy (2nd ed.). Springer. https://doi.org/10.1007/978-0-387-88639-8</bibtext> </blist> <blist> <bibtext> Moran A., Serban N., Danielson M. L., Grosse S. D., Cuffe S. P. (2019). Adherence to recommended care guidelines in the treatment of preschool-age medicaid-enrolled children with a diagnosis of ADHD. Psychiatric Services, 70, 26–34. https://doi.org/10.1176/appi.ps.201800204</bibtext> </blist> <blist> <bibtext> Myers K., Stoep A., Zhou C., McCarty C. A., Katon W. (2015). Effectiveness of a telehealth service delivery model for treating attention-deficit/hyperactivity disorder: A community-based randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 54(4), 263–274. https://doi.org/10.1016/j.jaac.2015.01.009</bibtext> </blist> <blist> <bibtext> Nemmezi Karaca S., Uzun Cicek A., Mercan Isik C., Kanak M., Demirel G. (2022). Evidence of the relationship between attention deficit/hyperactivity disorder (ADHD) and emotional abuse in a sample of preschool children. Children's Health Care, 51(3), 336–353. https://doi.org/10.1080/02739615.2022.2072311</bibtext> </blist> <blist> <bibtext> Normand S., Guiet J., LeBlanc V., Mautone J. A., Fogler J. M., Prud'homme-Maisonneuve A., Power T. J., Nissley-Tsiopinis J. (2024). An open trial of a brief engagement program for caregivers of children with ADHD. Evidence-Based Practice in Child and Adolescent Mental Health, 9(4), 528–543. https://doi.org/10.1080/23794925.2023.2261442</bibtext> </blist> <blist> <bibtext> Patterson G. R. (2016). Coercion theory: The study of change. In Dishion T. J., Snyder J. J. (Eds.), The Oxford handbook of coercive relationship dynamics (pp. 7–22). Oxford University Press.</bibtext> </blist> <blist> <bibtext> Pelham W. E., Fabiano G. A. (2008). Evidence-based psychosocial treatments for attention-deficit/hyperactivity disorder. Journal of Clinical Child & Adolescent Psychology, 37(1), 184–214. https://doi.org/10.1080/15374410701818681</bibtext> </blist> <blist> <bibtext> Phillips S. T., Druskin L. R., Mychailyszyn M. P., Victory E., Aman E., McNeil C. B. (2025). The Efficacy of Parent–Child Interaction Therapy (PCIT) for Youth with Attention-Deficit/Hyperactivity Disorder (ADHD): A meta-analysis. Child Psychiatry & Human Development, 56, 1757–1766. https://doi.org/10.1007/s10578-024-01678-2</bibtext> </blist> <blist> <bibtext> Prinz R. J., Sanders M. R. (2007). Adopting a population-level approach to parenting and family support interventions. Clinical Psychology Review, 27, 739–749. https://doi.org/10.1016/j.cpr.2007.01.005.</bibtext> </blist> <blist> <bibtext> Reardon T., Harvey K., Baranowska M., O'Brien D., Smith L., Creswell C. (2017). What do parents perceive are the barriers and facilitators to accessing psychological treatment for mental health problems in children and adolescents? A systematic review of qualitative and quantitative studies. European Child & Adolescent Psychiatry, 26(6), 623–647. https://doi.org/10.1007/s00787-016-0930-6</bibtext> </blist> <blist> <bibtext> Ruiz-Goikoetxea M., Cortese S., Aznarez-Sanado M., Magallon S., Zallo N. A., Luis E. O., de Castro-Manglano, P., Soutullo C., Arrondo G. (2018). Risk of unintentional injuries in children and adolescents with ADHD and the impact of ADHD medications: A systematic review and meta-analysis. Neuroscience & Biobehavioral Reviews, 84, 63–71. https://doi.org/10.1016/j.neubiorev.2017.11.007</bibtext> </blist> <blist> <bibtext> Schleider J. L., Dobias M., Sung J., Mumper E., Mullarkey M. C. (2020). Acceptability and utility of an open-access, online single-session intervention platform for adolescent mental health. JMIR Mental Health, 7(6), e20513. https://doi.org/10.2196/20513</bibtext> </blist> <blist> <bibtext> Schoemann A. M., Boulton A. J., Short S. D. (2017). Determining power and sample size for simple and complex mediation models. Social Psychological and Personality Science, 8(4), 379–386. https://doi.org/10.1177/1948550617715068</bibtext> </blist> <blist> <bibtext> Seattle Children's Hospital. (2017). First approach skills training- children behavior problems (FAST-B). https://<ulink href="http://www.seattlechildrens.org/globalassets/documents/healthcare-professionals/pal/fast/fast-b-guide.pdf">www.seattlechildrens.org/globalassets/documents/healthcare-professionals/pal/fast/fast-b-guide.pdf</ulink></bibtext> </blist> <blist> <bibtext> Thomaidis L., Choleva A., Janikian M., Bertou G., Tsitsika A., Giannakopoulos G., Anagnostopoulos D. C. (2017). Attention Deficit/Hyperactivity Disorder (ADHD) symptoms and cognitive skills of preschool children. Psychiatrike Psychiatriki, 28(1), 28–36. https://doi.org/10.22365/jpsych.2017.281.28</bibtext> </blist> <blist> <bibtext> Thomas R., Sanders S., Doust J., Beller E., Glasziou P. (2015). Prevalence of attention-deficit/hyperactivity disorder: A systematic review and meta-analysis. Pediatrics, 135(4), e994–e1001. https://doi.org/10.1542/peds.2014-3482</bibtext> </blist> <blist> <bibtext> Tully L. A., Hunt C. (2017). A randomized controlled trial of a brief versus standard group parenting program for toddler aggression. Aggressive behavior, 43(3), 291–303. https://doi.org/10.1002/ab.21689</bibtext> </blist> <blist> <bibtext> U.S. Department of Health and Human Services: Office of Inspector General. (2019). Many Medicaid enrolled children who were treated for ADHD did not receive recommended follow-up care. https://oig.hhs.gov/documents/evaluation/3083/OEI-07-17-00170-Complete%20Report.pdf</bibtext> </blist> <blist> <bibtext> Vander Stoep A., McCarty C. A., Zhou C., Rockhill C. M., Schoenfelder E. N., Myers K. (2017). The children's attention-deficit hyperactivity disorder telemental health treatment study: Caregiver outcomes. Journal of Abnormal Child Psychology, 45(1), 27–43. https://doi.org/10.1007/s10802-016-0155-7</bibtext> </blist> <blist> <bibtext> Webster-Stratton C., Reid M. J., Stool-Miller M. (2008). Preventing conduct problems and improving school readiness: Evaluation of the Incredible Years Teacher and Child Training Programs in high-risk schools. Journal of Child Psychology and Psychiatry, 49(5), 471–488. https://doi.org/10.1111%2Fj.1469-7610.2007.01861.x</bibtext> </blist> <blist> <bibtext> Weisenmuller C., Hilton D. (2021). Barriers to access, implementation, and utilization of parenting interventions: Considerations for research and clinical applications. American Psychologist, 76(1), 104–115. https://doi.org/10.1037/amp0000613</bibtext> </blist> <blist> <bibtext> Whalen D. J., Gilbert K. E., Luby J. L. (2021). Changes in self-reported and observed parenting following a randomized control trial of parent–child interaction therapy for the treatment of preschool depression. Journal of Child Psychology and Psychiatry, 62(1), 86–96. https://doi.org/10.1111%2Fjcpp.13263</bibtext> </blist> <blist> <bibtext> Wolraich M. L., Hagan J. F., Allan C., Chan E., Davison D., Earls M., Flinn S. K., Froehlich T., Frost J., Holbrook J. R., Ulrich Lehmann C., Robert Lessin H., Okechukwu K., Pierce K. L., Winner D. J., Zurhellen W. (2019). Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics, 144(4), e20192528. https://doi.org/10.1542/peds.2019-2528</bibtext> </blist> <blist> <bibtext> Woodfield M. J., Cartwright C. (2020). Parent-child interaction therapy from parents' perspective. Journal of Child and Family Studies, 29, 632–647. https://doi.org/10.1007/s10826-019-01611-5</bibtext> </blist> <blist> <bibtext> Xie Y., Dixon J. F., Yee O. M., Zhang J., Chen Y. A., DeAngelo S., Yellowlees P., Hendren R., Schweitzer J. B. (2013). A study on the effectiveness of videoconferencing in teaching parent training skills to parents of children with ADHD. Telemedicine Journal and E-health, 19(3), 192–199. https://doi.org/10.1089/tmj.2012.0108</bibtext> </blist> </ref> <ref id="AN0194258087-36"> <title> Footnotes </title> <blist> <bibtext> Kady F. Sternberg</bibtext> </blist> <blist> <bibtext>Graph https://orcid.org/0009-0008-1262-1222</bibtext> </blist> <blist> <bibtext> The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The research described in this manuscript was supported through a grant program of the federal Substance Abuse and Mental Health Services Administration (SAMHSA), Project LAUNCH (H79SM082302).</bibtext> </blist> <blist> <bibtext> The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.</bibtext> </blist> <blist> <bibtext> Supplemental material for this article is available online.</bibtext> </blist> </ref> <aug> <p>By James T. Craig; Michael T. Sanders; Christina C. Moore; Erin Barnett; Kady F. Sternberg; Nicole L. Breslend; Lauren C. Vazquez; Nina Sand-Loud and Mary K. Jankowski</p> <p>Reported by Author; Author; Author; Author; Author; Author; Author; Author; Author</p> <p></p> <p>James T. Craig, PhD is an Assistant Professor of Psychiatry at Geisel School of Medicine and Staff Psychologist at Dartmouth Health. Dr. Craig's research focuses on innovative treatments for children with aggressive and defiant behaviors that can be applied outside of traditional mental health care settings.</p> <p>Michael T. Sanders, PhD is an Assistant Professor in the Psychology Department at Colby College and an Adjunct Assistant Professor at the Geisel School of Medicine. His research focuses on designing and developing prevention and early intervention programming that leverages the reach and trust of public health systems (e.g., primary care, early childhood education, community organizations) to deliver social-emotional learning (SEL) skills and strategies to parents and young children.</p> <p>Christina C. Moore, PhD is an Assistant Professor of Psychiatry at Geisel School of Medicine and Staff Psychologist at Dartmouth Health. Her research focuses on increasing access to evidence-based interventions for youth living in rural settings at-risk of trauma and traumatic stress.</p> <p>Erin Barnett, PhD is an Associate Professor of Psychiatry at Geisel School of Medicine and The Dartmouth Institute for Health Policy and Clinical Practice, and a faculty member at the Dartmouth Trauma Interventions Research Center. Dr. Barnett is a clinical psychologist by training with expertise in child trauma and adversity, and the psychosocial and pharmacological services provided to this population.</p> <p>Kady F. Sternberg is a research coordinator in the Department of Psychiatry at Dartmouth Health. Her work focuses on increasing access and reducing barriers to evidence-based care for neurodivergent children and families.</p> <p>Nicole L. Breslend, PhD is a faculty member at the University of Vermont. Her primarily focus is program evaluation of child welfare and mental health agencies in addition to developing easy-to-access parenting resources.</p> <p>Lauren C. Vazquez, PhD is a Child Clinical Psychologist at Children's Hospital of Philadelphia's Young Child Program. Her work focuses on assessment and intervention in early childhood.</p> <p>Nina Sand-Loud, MD is a Developmental and Behavioral Pediatrician at Dartmouth Health Children's. She sees young children with a variety of neurodevelopmental and behavioral disorders including ADHD, autism, developmental delays and concerns about sleep.</p> <p>Mary K. Jankowski, PhD is an Associate Professor of Psychiatry at Geisel School of Medicine and Lead Psychologist at Dartmouth Health. Her research areas include child trauma and bringing best practices for child and adolescent mental health into real world settings.</p> </aug> <nolink nlid="nl1" bibid="bib58" firstref="ref2"></nolink> <nolink nlid="nl2" bibid="bib21" firstref="ref3"></nolink> <nolink nlid="nl3" bibid="bib18" firstref="ref5"></nolink> <nolink nlid="nl4" bibid="bib53" firstref="ref6"></nolink> <nolink nlid="nl5" bibid="bib57" firstref="ref7"></nolink> <nolink nlid="nl6" bibid="bib19" firstref="ref10"></nolink> <nolink nlid="nl7" bibid="bib31" firstref="ref11"></nolink> <nolink nlid="nl8" bibid="bib36" firstref="ref12"></nolink> <nolink nlid="nl9" bibid="bib40" firstref="ref13"></nolink> <nolink nlid="nl10" bibid="bib60" firstref="ref14"></nolink> <nolink nlid="nl11" bibid="bib48" firstref="ref15"></nolink> <nolink nlid="nl12" bibid="bib17" firstref="ref16"></nolink> <nolink nlid="nl13" bibid="bib12" firstref="ref17"></nolink> <nolink nlid="nl14" bibid="bib46" firstref="ref18"></nolink> <nolink nlid="nl15" bibid="bib47" firstref="ref19"></nolink> <nolink nlid="nl16" bibid="bib65" firstref="ref20"></nolink> <nolink nlid="nl17" bibid="bib23" firstref="ref21"></nolink> <nolink nlid="nl18" bibid="bib49" firstref="ref22"></nolink> <nolink nlid="nl19" bibid="bib50" firstref="ref23"></nolink> <nolink nlid="nl20" bibid="bib39" firstref="ref24"></nolink> <nolink nlid="nl21" bibid="bib10" firstref="ref25"></nolink> <nolink nlid="nl22" bibid="bib25" firstref="ref26"></nolink> <nolink nlid="nl23" bibid="bib43" firstref="ref27"></nolink> <nolink nlid="nl24" bibid="bib16" firstref="ref29"></nolink> <nolink nlid="nl25" bibid="bib45" firstref="ref30"></nolink> <nolink nlid="nl26" bibid="bib61" firstref="ref34"></nolink> <nolink nlid="nl27" bibid="bib32" firstref="ref35"></nolink> <nolink nlid="nl28" bibid="bib63" firstref="ref36"></nolink> <nolink nlid="nl29" bibid="bib44" firstref="ref39"></nolink> <nolink nlid="nl30" bibid="bib38" firstref="ref40"></nolink> <nolink nlid="nl31" bibid="bib52" firstref="ref41"></nolink> <nolink nlid="nl32" bibid="bib11" firstref="ref42"></nolink> <nolink nlid="nl33" bibid="bib51" firstref="ref45"></nolink> <nolink nlid="nl34" bibid="bib34" firstref="ref47"></nolink> <nolink nlid="nl35" bibid="bib41" firstref="ref48"></nolink> <nolink nlid="nl36" bibid="bib54" firstref="ref49"></nolink> <nolink nlid="nl37" bibid="bib59" firstref="ref50"></nolink> <nolink nlid="nl38" bibid="bib33" firstref="ref51"></nolink> <nolink nlid="nl39" bibid="bib14" firstref="ref53"></nolink> <nolink nlid="nl40" bibid="bib15" firstref="ref54"></nolink> <nolink nlid="nl41" bibid="bib67" firstref="ref56"></nolink> <nolink nlid="nl42" bibid="bib20" firstref="ref60"></nolink> <nolink nlid="nl43" bibid="bib42" firstref="ref61"></nolink> <nolink nlid="nl44" bibid="bib22" firstref="ref64"></nolink> <nolink nlid="nl45" bibid="bib35" firstref="ref65"></nolink> <nolink nlid="nl46" bibid="bib26" firstref="ref66"></nolink> <nolink nlid="nl47" bibid="bib37" firstref="ref68"></nolink> <nolink nlid="nl48" bibid="bib24" firstref="ref69"></nolink> <nolink nlid="nl49" bibid="bib27" firstref="ref71"></nolink> <nolink nlid="nl50" bibid="bib29" firstref="ref72"></nolink> <nolink nlid="nl51" bibid="bib55" firstref="ref78"></nolink> <nolink nlid="nl52" bibid="bib13" firstref="ref79"></nolink> <nolink nlid="nl53" bibid="bib30" firstref="ref83"></nolink> <nolink nlid="nl54" bibid="bib66" firstref="ref104"></nolink> <nolink nlid="nl55" bibid="bib28" firstref="ref105"></nolink> <nolink nlid="nl56" bibid="bib62" firstref="ref106"></nolink> <nolink nlid="nl57" bibid="bib56" firstref="ref107"></nolink> <nolink nlid="nl58" bibid="bib64" firstref="ref108"></nolink>
Header DbId: eric
DbLabel: ERIC
An: EJ1507677
AccessLevel: 3
PubType: Academic Journal
PubTypeId: academicJournal
PreciseRelevancyScore: 0
IllustrationInfo
Items – Name: Title
  Label: Title
  Group: Ti
  Data: ROAR-Early Childhood: Pilot Testing a Brief Telemedicine Parent Training Program for Rural Children Diagnosed with ADHD
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22James+T%2E+Craig%22">James T. Craig</searchLink><br /><searchLink fieldCode="AR" term="%22Michael+T%2E+Sanders%22">Michael T. Sanders</searchLink><br /><searchLink fieldCode="AR" term="%22Christina+C%2E+Moore%22">Christina C. Moore</searchLink><br /><searchLink fieldCode="AR" term="%22Erin+Barnett%22">Erin Barnett</searchLink><br /><searchLink fieldCode="AR" term="%22Kady+F%2E+Sternberg%22">Kady F. Sternberg</searchLink> (ORCID <externalLink term="https://orcid.org/0009-0008-1262-1222">0009-0008-1262-1222</externalLink>)<br /><searchLink fieldCode="AR" term="%22Nicole+L%2E+Breslend%22">Nicole L. Breslend</searchLink><br /><searchLink fieldCode="AR" term="%22Lauren+C%2E+Vazquez%22">Lauren C. Vazquez</searchLink><br /><searchLink fieldCode="AR" term="%22Nina+Sand-Loud%22">Nina Sand-Loud</searchLink><br /><searchLink fieldCode="AR" term="%22Mary+K%2E+Jankowski%22">Mary K. Jankowski</searchLink>
– Name: TitleSource
  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Journal+of+Attention+Disorders%22"><i>Journal of Attention Disorders</i></searchLink>. 2026 30(7):857-871.
– Name: Avail
  Label: Availability
  Group: Avail
  Data: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: https://sagepub.com
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 15
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2026
– Name: SourceSuprt
  Label: Sponsoring Agency
  Group: SrcSuprt
  Data: Substance Abuse and Mental Health Services Administration (SAMHSA) (DHHS/PHS)
– Name: NumberContract
  Label: Contract Number
  Group: NumCntrct
  Data: H79SM082302
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Audience
  Label: Education Level
  Group: Audnce
  Data: <searchLink fieldCode="EL" term="%22Adult+Education%22">Adult Education</searchLink>
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Attention+Deficit+Hyperactivity+Disorder%22">Attention Deficit Hyperactivity Disorder</searchLink><br /><searchLink fieldCode="DE" term="%22Rural+Areas%22">Rural Areas</searchLink><br /><searchLink fieldCode="DE" term="%22Teleconferencing%22">Teleconferencing</searchLink><br /><searchLink fieldCode="DE" term="%22Parent+Education%22">Parent Education</searchLink><br /><searchLink fieldCode="DE" term="%22Outreach+Programs%22">Outreach Programs</searchLink><br /><searchLink fieldCode="DE" term="%22Program+Effectiveness%22">Program Effectiveness</searchLink><br /><searchLink fieldCode="DE" term="%22Young+Children%22">Young Children</searchLink><br /><searchLink fieldCode="DE" term="%22Empowerment%22">Empowerment</searchLink><br /><searchLink fieldCode="DE" term="%22Behavior+Problems%22">Behavior Problems</searchLink><br /><searchLink fieldCode="DE" term="%22Symptoms+%28Individual+Disorders%29%22">Symptoms (Individual Disorders)</searchLink><br /><searchLink fieldCode="DE" term="%22Feasibility+Studies%22">Feasibility Studies</searchLink><br /><searchLink fieldCode="DE" term="%22Telecommunications%22">Telecommunications</searchLink><br /><searchLink fieldCode="DE" term="%22Educational+Technology%22">Educational Technology</searchLink><br /><searchLink fieldCode="DE" term="%22Access+to+Education%22">Access to Education</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22New+Hampshire%22">New Hampshire</searchLink>
– Name: SubjectThesaurus
  Label: Assessment and Survey Identifiers
  Group: Su
  Data: <searchLink fieldCode="SU" term="%22Eyberg+Child+Behavior+Inventory%22">Eyberg Child Behavior Inventory</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1177/10870547251415434
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1087-0547<br />1557-1246
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Objective: Attention Deficit/Hyperactivity Disorder (ADHD) is a chronic and impairing neurodevelopmental disorder diagnosed in approximately 2% to 4% of preschool-age children and 9% of all children. Behavioral parent training (BPT) and high-quality education are effective treatments for young children with ADHD; however, poor rates of treatment access and participation limit the reach of BPTs to rural and underserved communities. In this study, we tested the newly developed Rural Outreach and ADHD Research-Early Childhood (ROAR-EC) program, a clinician-led, 7-session education and parent training program designed for delivery over telemedicine. Method: We conducted a pilot RCT to assess the feasibility, acceptability, engagement of mechanism, and exploratory group × time effects of the ROAR-EC program compared to a control group in a sample of 44 children diagnosed with ADHD from a predominantly rural area (ages 3-7; Mage = 4.8; 62% male; 96% White; 89% non-Hispanic/Latinx). Families were randomized into either ROAR-EC or treatment as usual through developmental pediatrics and followed for 24 weeks. Assessed were metrics of feasibility, acceptability, parenting practices, caregiver empowerment, disruptive behaviors, and ADHD symptoms. Results: Results indicated that ROAR-EC was feasible to implement and acceptable to caregivers. Repeated measures ANOVAs found significant group × time interaction effects in favor of the treatment group compared to control for family empowerment, parenting practices, total behavior problems, impairment, and inattentive symptoms. Conclusions: This study demonstrated the promise of brief telemedicine programs as feasible, acceptable, and likely beneficial alternatives to traditional BPTs for young children with ADHD in rural and low-resource areas.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2026
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1507677
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1507677
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1177/10870547251415434
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 15
        StartPage: 857
    Subjects:
      – SubjectFull: Attention Deficit Hyperactivity Disorder
        Type: general
      – SubjectFull: Rural Areas
        Type: general
      – SubjectFull: Teleconferencing
        Type: general
      – SubjectFull: Parent Education
        Type: general
      – SubjectFull: Outreach Programs
        Type: general
      – SubjectFull: Program Effectiveness
        Type: general
      – SubjectFull: Young Children
        Type: general
      – SubjectFull: Empowerment
        Type: general
      – SubjectFull: Behavior Problems
        Type: general
      – SubjectFull: Symptoms (Individual Disorders)
        Type: general
      – SubjectFull: Feasibility Studies
        Type: general
      – SubjectFull: Telecommunications
        Type: general
      – SubjectFull: Educational Technology
        Type: general
      – SubjectFull: Access to Education
        Type: general
      – SubjectFull: New Hampshire
        Type: general
      – SubjectFull: Eyberg Child Behavior Inventory
        Type: general
    Titles:
      – TitleFull: ROAR-Early Childhood: Pilot Testing a Brief Telemedicine Parent Training Program for Rural Children Diagnosed with ADHD
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: James T. Craig
      – PersonEntity:
          Name:
            NameFull: Michael T. Sanders
      – PersonEntity:
          Name:
            NameFull: Christina C. Moore
      – PersonEntity:
          Name:
            NameFull: Erin Barnett
      – PersonEntity:
          Name:
            NameFull: Kady F. Sternberg
      – PersonEntity:
          Name:
            NameFull: Nicole L. Breslend
      – PersonEntity:
          Name:
            NameFull: Lauren C. Vazquez
      – PersonEntity:
          Name:
            NameFull: Nina Sand-Loud
      – PersonEntity:
          Name:
            NameFull: Mary K. Jankowski
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 07
              Type: published
              Y: 2026
          Identifiers:
            – Type: issn-print
              Value: 1087-0547
            – Type: issn-electronic
              Value: 1557-1246
          Numbering:
            – Type: volume
              Value: 30
            – Type: issue
              Value: 7
          Titles:
            – TitleFull: Journal of Attention Disorders
              Type: main
ResultId 1