Advancing the science of adaptive interventions

When we struggle with depression, anxiety, substance use, or another health-related problem, we need healthcare professionals who treat us according to our unique circumstances and conditions. To treat us this way, healthcare professionals need protocols that help them turn information about us into decisions about when and how to intervene.

Adaptive interventions guide the delivery of the right type of treatment, in the right amount, at the right time.

We develop the tools scientists need to systematically construct adaptive interventions that respond appropriately and efficiently to people’s changing needs.

Adaptive Interventions

An adaptive intervention is an intervention design that guides the adaptation of treatments. Adaptation refers to the use of dynamic information about a person to decide whether and how to intervene. Adaptation is intended to address the unique and changing needs of individuals over time. In contrast with other types of adaptive interventions, standard adaptive interventions are typically motivated to address conditions that unfold relatively slowly. Thus, the adaptation takes place at a few decision points spaced weeks or months apart. Standard adaptive interventions typically guide the adaptation of human-delivered components.

EXAMPLE. A hypothetical adaptive intervention for ADHD in children.
  • Adaptive interventions increase the number of individuals who benefit from treatment by addressing conditions that represent risk for ultimate treatment non-response, such as insufficient progress or non-adherence.
  • Adaptive interventions enhance overall resource-efficiency of an intervention by delivering treatment only when it is needed and by avoiding delivering unnecessary or potentially harmful treatment.

The Sequential, Multiple Assignment, Randomized Trial

The SMART is an experimental design that researchers can use to efficiently answer multiple scientific questions concerning the selection and integration of the components that make up an adaptive intervention. A SMART involves multiple stages of randomizations, meaning that some or all individuals participating in a SMART are randomized more than once. This is the SMART’s defining feature.

EXAMPLE. A SMART designed to answer questions about the sequencing and adaptation of behavioral and pharmacological treatments for children with ADHD. Learn more about this study.

What types of questions can a SMART answer?

What intervention option should we offer first?

Among individuals who do not respond to first stage treatment, what is the effect of augmenting treatment compared to the effect of intensifying treatment?

Among individuals who respond to first stage treatment, what is the best frequency for continuing treatment?

Should the first-stage intervention differ based on comorbid health conditions, history of prior treatment, or other factors known prior to starting treatment?

How should changes in patients’ health metrics determine intervention options in stage 2 and beyond?

What should trigger the transition from stage one to stage two—adherence, therapeutic response, or some combination of the two?

Are there positive or negative interaction effects between the intervention options delivered sequentially?

Are there later-stage treatment options that compromise the benefits of earlier treatment options?

Which first-stage treatment yields insights that inform a more optimal second stage treatment decision?

What is the best way to define response and non-response to first-stage treatment?

How stringent or lenient should we make the cutoff that defines response and non-response to first-stage treatment?

How often should individuals be monitored in an adaptive intervention?

Featured Resources

Almirall, D., Nahum-Shani, I., Sherwood, N. E., & Murphy, S. A. (2014). Introduction to SMART designs for the development of adaptive interventions: with application to weight loss research. Translational behavioral medicine, 4(3), 260–274.

Collins, L. M., Murphy, S. A., & Bierman, K. L. (2004). A conceptual framework for adaptive preventive interventions. Prevention Science, 5(3), 185-196.

Kidwell, K. M., & Almirall, D. (2023). Sequential, Multiple Assignment, Randomized Trial Designs. JAMA, 329(4), 336–337.

Nahum-Shani, I., & Almirall, D. (2019). An Introduction to Adaptive Interventions and SMART Designs in Education. NCSER 2020-001. National Center for Special Education Research.

Nahum-Shani, I. & Militello, L.K. (2018). Promoting Military Family Well-Being with Digitally Supported Adaptive and Just-In-Time Adaptive Interventions: Opportunities and Challenges. The National Academies of Sciences, Engineering, and Medicine consensus study: The Well-Being of Military Families; Commissioned paper:

Pelham, W. E., Jr, Fabiano, G. A., Waxmonsky, J. G., Greiner, A. R., Gnagy, E. M., Pelham, W. E., 3rd, Coxe, S., Verley, J., Bhatia, I., Hart, K., Karch, K., Konijnendijk, E., Tresco, K., Nahum-Shani, I., & Murphy, S. A. (2016). Treatment Sequencing for Childhood ADHD: A Multiple-Randomization Study of Adaptive Medication and Behavioral Interventions. Journal of clinical child and adolescent psychology : the official journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53, 45(4), 396–415.

Pfammatter, A. F., Nahum-Shani, I., DeZelar, M., Scanlan, L., McFadden, H. G., Siddique, J., … & Spring, B. (2019). SMART: study protocol for a sequential multiple assignment randomized controlled trial to optimize weight loss management. Contemporary Clinical Trials, 82, 36-45.

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