Table 4.

Feasibility Issues and Changes for Full-Scale Sequential, Multiple Assignment, Randomized Trial

Feasibility dimension	Lessons learned in pilot SMART	Changes for full-scale SMART
Recruitment	Most mothers contacting study were seeking treatment for their child (recruited through psychiatric clinics) Most children diagnosed with ADHD before study	Recruit/screen in primary care (e.g., pediatrics, family medicine) Recruit younger children in “at risk” range for ADHD
Study assessments and protocol	Lengthy clinic visits High participant burden Low return of collateral report (i.e., teacher) measures Request further information and evaluation feedback on ADHD	Administer questionnaires digitally Streamline assessment measures; briefer battery Administer collateral report digitally Provide evaluation feedback session with psychoeducation on ADHD
Medication treatment	Weekly sessions not consistently needed for titration Minimal titration after 8 weeks Only a minority needed a booster for increased duration LDX was effective and well tolerated for the majority	Offer med titration visits through telehealth Switch to every-other week once optimized Abbreviate length of titration visits to be more feasible in real-world
Behavioral treatment	Clinician and family desire for more personalization and tailoring Diminishing acceptability and lower skill use for 16 weeks over 8 weeks BPT Some mother struggled to complete weekly home skills practice Clinician preference for on-sight supervision	Allow selection of supplemental modules based on family needs Tailor number of sessions to treatment response Increase clinician support for home skill practice Combined supervision through local supervisor plus expert/remote supervisor
Combination treatment	Drop out occurred only with monotherapy Generally, mother preference for meds before BPT	Consider tailoring of treatment sequence based on initial response (SMART design) Assess treatment preference and whether that moderates adherence and treatment response
Child monitoring	Procedure was adequate No children required medication during 16-week study period	It is feasible to treat mothers first

ADHD, attention-deficit/hyperactivity disorder; BPT, behavioral parent training; LDX, lisdexamphetamine; SMART, Sequential, Multiple Assignment, Randomized Trial.