The experiences of and attitudes toward non-pharmacological interventions for attention-deficit/hyperactivity disorder used in school settings: a systematic review and synthesis of qualitative research

When ADHD knocks on the door - discourse theory as a frame to explore subject positions and mental wellbeing before diagnosis

PURPOSE

Attention deficit hyperactivity disorder (ADHD) is currently the most prevalent childhood psychiatric diagnosis. This article reports how 10 young adults in Norway positioned themselves before they were diagnosed with ADHD either during early childhood or adolescence. A central theme is how these subject-positions relate to societal norms and mental well-being.

METHOD

Individual interviews were conducted, and the transcriptions of the interviews were analysed according to discourse theory.

RESULT

Six central subject positions were identified which in turn related to two major positions: 1) failure with schoolwork and 2) struggle in social interaction. The findings indicated specific emotional and environmental needs and that individuals were confronted with societal norms related to the criteria for ADHD prior to and regardless of whether one had received a formal diagnosis.

CONCLUSION

We argue that analysing subject positions provides important knowledge regarding ADHD that is useful for individuals, parents, teachers, practitioners, policymakers, and helping professionals in the field of mental health and education when it comes to interventions that support children who possess different temperaments.

A systematic meta-review of systematic reviews on attention deficit hyperactivity disorder

BACKGROUND

There are now hundreds of systematic reviews on attention deficit hyperactivity disorder (ADHD) of variable quality. To help navigate this literature, we have reviewed systematic reviews on any topic on ADHD.

METHODS

We searched MEDLINE, PubMed, PsycINFO, Cochrane Library, and Web of Science and performed quality assessment according to the Joanna Briggs Institute Manual for Evidence Synthesis. A total of 231 systematic reviews and meta-analyses met the eligibility criteria.

RESULTS

The prevalence of ADHD was 7.2% for children and adolescents and 2.5% for adults, though with major uncertainty due to methodological variation in the existing literature. There is evidence for both biological and social risk factors for ADHD, but this evidence is mostly correlational rather than causal due to confounding and reverse causality. There is strong evidence for the efficacy of pharmacological treatment on symptom reduction in the short-term, particularly for stimulants. However, there is limited evidence for the efficacy of pharmacotherapy in mitigating adverse life trajectories such as educational attainment, employment, substance abuse, injuries, suicides, crime, and comorbid mental and somatic conditions. Pharmacotherapy is linked with side effects like disturbed sleep, reduced appetite, and increased blood pressure, but less is known about potential adverse effects after long-term use. Evidence of the efficacy of nonpharmacological treatments is mixed.

CONCLUSIONS

Despite hundreds of systematic reviews on ADHD, key questions are still unanswered. Evidence gaps remain as to a more accurate prevalence of ADHD, whether documented risk factors are causal, the efficacy of nonpharmacological treatments on any outcomes, and pharmacotherapy in mitigating the adverse outcomes associated with ADHD.

Collaboration Between Occupational Therapy Practitioners and Elementary School Educators to Support Students with Attention Deficit Hyperactivity Disorder

AIMS

This study compares experiences of occupational therapy practitioners (OTPs) and other elementary school educators when supporting students with attention deficit hyperactivity disorder (ADHD). The aim is to establish collaborative methods for OTPs and other educators to support students with ADHD. Recommendations to overcome barriers to supporting students with ADHD are made based on study findings and current research.

METHODS

An online survey of OTPs and other educators was conducted. The survey asked about the barriers to supporting elementary students with ADHD, and the training resources that would improve the ability to support students with ADHD.

RESULTS

Responses from 147 OTPs and 35 other educators were compared using two-sample proportion tests. The groups shared common barriers and preferences for training resources, however, statistically significant (p < 0.05) differences were found in; 1) the barrier of limited knowledge and training about ADHD, with other educators being more limited by this barrier; and, 2) the preference for video formatted training, with other educators identifying a higher preference for this option.

CONCLUSIONS

The data suggest that there is an opportunity for OTPs and other educators to collaboratively develop ADHD training videos for all educators to foster the success of elementary students with ADHD.

Synthesising the existing evidence for non-pharmacological interventions targeting outcomes relevant to young people with ADHD in the school setting: systematic review protocol

BACKGROUND

Children and adolescents with attention-deficit/hyperactivity disorder (ADHD) have impairing levels of difficulty paying attention, impulsive behaviour and/or hyperactivity. ADHD causes extensive difficulties for young people at school, and as a result these children are at high risk for a wide range of poor outcomes. We ultimately aim to develop a flexible, modular 'toolkit' of evidence-based strategies that can be delivered by primary school staff to improve the school environment and experience for children with ADHD; the purpose of this review is to identify and quantify the evidence-base for potential intervention components. This protocol sets out our plans to systematically identify non-pharmacological interventions that target outcomes that have been reported to be of importance to key stakeholders (ADHD symptoms, organisation skills, executive-global- and classroom-functioning, quality of life, self-esteem and conflict with teachers and peers). We plan to link promising individual intervention components to measured outcomes, and synthesise the evidence of effectiveness for each outcome.

METHODS

A systematic search for studies published from the year 2000 that target the outcomes of interest in children and young people aged 3-12 will be conducted. Titles and abstracts will be screened using prioritisation software, and then full texts of potentially eligible studies will be screened. Systematic reviews, RCTs, non-randomised and case-series studies are eligible designs. Synthesis will vary by the type of evidence available, potentially including a review of reviews, meta-analysis and narrative synthesis. Heterogeneity of studies meta-analysed will be assessed, along with publication bias. Intervention mapping will be applied to understand potential behaviour change mechanisms for promising intervention components.

DISCUSSION

This review will highlight interventions that appear to effectively ameliorate negative outcomes that are of importance for people with ADHD, parents, school staff and experts. Components of intervention design and features that are associated with effective change in the outcome will be delineated and used to inform the development of a 'toolkit' of non-pharmacological strategies that school staff can use to improve the primary school experience for children with ADHD.

TRIAL REGISTRATION

PROSPERO number CRD42021233924.

Facilitators and Barriers of Teachers’ Use of Effective Classroom Management Strategies for Students with ADHD: A Model Analysis Based on Teachers’ Perspectives

Students with attention-deficit/hyperactivity disorder (ADHD) often experience school-related difficulties. Although evidence-based classroom management strategies (CMS) are known to alleviate such problems, they are rarely implemented. The current study examined whether a path model including variables influencing the use of effective CMS developed by top-down methods can be replicated utilizing an open science method. An extended model including class size and experience with children with ADHD was also calculated. We further explored prominent implementation barriers. N = 336 in-service teachers completed an online survey. Perceived effectiveness, training on ADHD, perceived disruption, and affiliation with primary/special educational needs schools were important variables associated with the use of CMS. While class size was not correlated with the use of CMS, experience mediated by training revealed an indirect association with it. Class size, lack of time, and many students with disabilities were the most frequently reported implementation barriers. The implementation of effective CMS could thus be mainly enhanced by improving how effectiveness is perceived and by engaging teachers in ADHD-specialized training. Preparing teachers in how to cope with potential barriers should also be considered.

Interventions to improve the mental health of children and young people with long-term physical conditions: linked evidence syntheses

BACKGROUND

Although mental health difficulties can severely complicate the lives of children and young people (CYP) with long-term physical conditions (LTCs), there is a lack of evidence about the effectiveness of interventions to treat them.

OBJECTIVES

To evaluate the clinical effectiveness and cost-effectiveness of interventions aiming to improve the mental health of CYP with LTCs (review 1) and explore the factors that may enhance or limit their delivery (review 2).

DATA SOURCES

For review 1, 13 electronic databases were searched, including MEDLINE, EMBASE, PsycINFO, Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Science Citation Index. For review 2, MEDLINE, PsycINFO and CINAHL were searched. Supplementary searches, author contact and grey literature searches were also conducted.

REVIEW METHODS

The first systematic review sought randomised controlled trials (RCTs) and economic evaluations of interventions to improve elevated symptoms of mental ill health in CYP with LTCs. Effect sizes for each outcome were calculated post intervention (Cohen's d). When appropriate, random-effects meta-analyses produced pooled effect sizes (d). Review 2 located primary qualitative studies exploring experiences of CYP with LTCs, their families and/or practitioners, regarding interventions aiming to improve the mental health and well-being of CYP with LTCs. Synthesis followed the principles of metaethnography. An overarching synthesis integrated the findings from review 1 and review 2 using a deductive approach. End-user involvement, including topic experts and CYP with LTCs and their parents, was a feature throughout the project.

RESULTS

Review 1 synthesised 25 RCTs evaluating 11 types of intervention, sampling 12 different LTCs. Tentative evidence from seven studies suggests that cognitive-behavioural therapy interventions could improve the mental health of CYP with certain LTCs. Intervention-LTC dyads were diverse, with few opportunities to meta-analyse. No economic evaluations were located. Review 2 synthesised 57 studies evaluating 21 types of intervention. Most studies were of individuals with cancer, a human immunodeficiency virus (HIV) infection or mixed LTCs. Interventions often aimed to improve broader mental health and well-being, rather than symptoms of mental health disorder. The metaethnography identified five main constructs, described in an explanatory line of argument model of the experience of interventions. Nine overarching synthesis categories emerged from the integrated evidence, raising implications for future research.

LIMITATIONS

Review 1 conclusions were limited by the lack of evidence about intervention effectiveness. No relevant economic evaluations were located. There were no UK studies included in review 1, limiting the applicability of findings. The mental health status of participants in review 2 was usually unknown, limiting comparability with review 1. The different evidence identified by the two systematic reviews challenged the overarching synthesis.

CONCLUSIONS

There is a relatively small amount of comparable evidence for the effectiveness of interventions for the mental health of CYP with LTCs. Qualitative evidence provided insight into the experiences that intervention deliverers and recipients valued. Future research should evaluate potentially effective intervention components in high-quality RCTs integrating process evaluations. End-user involvement enriched the project.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42011001716.

FUNDING

The National Institute for Health Research (NIHR) Health Technology Assessment programme and the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.

Experiences of interventions aiming to improve the mental health and well-being of children and young people with a long-term physical condition: A systematic review and meta-ethnography

BACKGROUND

Children and young people with long-term physical health conditions are at increased risk of experiencing mental health and well-being difficulties. However, there is a lack of research that explores the experiences of and attitudes towards interventions aiming to improve their mental health and well-being. This systematic review seeks to address this gap in the literature by exploring what children and young people with long-term conditions, their caregivers, and health practitioners perceive to be important aspects of interventions aiming to improve their mental health and well-being.

METHODS

An information specialist searched five academic databases using predefined criteria for qualitative evaluations of interventions aiming to improve the mental health or well-being of children with long-term physical conditions. Reviewers also performed supplementary citation and grey literature searches. Two reviewers independently screened titles, abstracts, and full texts that met the inclusion criteria and conducted data extraction and quality assessment. Meta-ethnography was used to synthesize the findings.

RESULTS

Screening identified 60 relevant articles. We identified five overarching constructs through the synthesis: (a) Getting In and Staying In, (b) Therapeutic Foundation, (c) Social Support, (d) A Hopeful Alternative, and (e) Empowerment. The line of argument that links these constructs together indicates that when interventions can provide an environment that allows young people to share their experiences and build empathetic relationships, it can enable participants to access social support and increase feelings of hope and empowerment.

CONCLUSION

These findings may provide a framework to inform the development of mental health interventions for this population and evaluate existing interventions that already include some of the components or processes identified by this research. Further research is needed to establish which of the constructs identified by the line of argument are most effective in improving the mental well-being of young people living with long-term conditions.

Review: Experiences of healthcare transitions for young people with attention deficit hyperactivity disorder: a systematic review of qualitative research

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterised by hyperactivity, inattention and impulsivity. Up to two thirds of young people with ADHD may experience symptoms into adulthood, yet the limited literature available suggests that many young people with ongoing needs do not transfer from child to adult healthcare services. Although worldwide and NICE guidelines recognise the importance of supported transition, evidence suggests for ADHD that this is poorly managed and variable. Little is known about how transition is experienced by those involved. We aimed to synthesise existing peer-reviewed literature to understand views and experiences of young people, carers and clinicians on transitioning between child and adult ADHD services.

METHOD

Five databases were searched and all articles published between 2000 and up until January 2017 considered. Four key search areas were targeted; ADHD, Transition, Age and Qualitative Research. Quality appraisal was conducted using Wallace criteria. Findings from included studies were synthesised using thematic analysis.

RESULTS

Eight papers, six from the UK and one each from Hong Kong and Italy, were included. Emerging themes centred on difficulties transitioning; hurdles that had to be negotiated, limitations of adult mental health services, inadequate care and the impact of transition difficulties.

CONCLUSIONS

Healthcare transition for this group is difficult in the United Kingdom because of multiple challenges in service provision. In addition to recommendations in NICE guidelines, respondents identified a need for better provision of information to young people about adult services and what to expect, greater flexibility around age boundaries and the value of support from specialist adult ADHD services. More research is needed into ADHD healthcare transition experiences, especially in countries outside the United Kingdom, including accounts from carers and clinicians.

Educators' experiences of managing students with ADHD: a qualitative study

BACKGROUND

The symptoms of attention-deficit/hyperactivity disorder are associated with difficulty coping with the social, behavioural and academic components of school. Compared with medication and other non-pharmacological treatment, there is less evidence relating to school-based interventions to support children with ADHD. There is additionally an absence of any research focused on the experiences and practices of educators in the UK around how they work with children who are inattentive, impulsive and hyperactive.

METHODS

Forty-two educational practitioners from primary, secondary and alternate provision schools in the UK participated in focus groups or individual interviews that explored (1) their experiences of managing students with ADHD in the classroom and (2) factors that helped and hindered them in this endeavour. Transcripts were analysed using thematic analysis.

RESULTS

Analysis identified six themes: broad strategies, student-centred, inclusive strategies, labelling, medication and relationships. Participants' experiences of managing students with ADHD drew upon a wide range of strategies that typically involved responding to individual needs in an inclusive manner, so individuals with ADHD could access the classroom with their peers. Participants spoke about three factors that helped and hindered managing students with ADHD. Labelling of students with ADHD was reported, with the negative aspects of labelling, such as stigmatization, affecting the classroom. Educators reported mixed experiences regarding the helpfulness of medication; where helpful, it allowed the use of strategies in the classroom. Although students with ADHD were described as having rollercoaster relationships, positive relationships were considered key to the support of children with these difficulties.

CONCLUSIONS

This study suggests that factors such as attitudes towards ADHD, relationships experienced by students with ADHD and other treatments being delivered need to be carefully considered before strategies are put in place in the classroom. This study supports the need for further work on the implementation of evidence-based school interventions for ADHD.

Asking More of Qualitative Synthesis: A Response to Sally Thorne

We continue the conversation initiated by Sally Thorne's observations about "metasynthetic madness." We note that the variety of labels used to describe qualitative syntheses often reflect authors' disciplines and geographical locations. The purpose of systematic literature searching is to redress authors' lack of citation of relevant earlier work and to reassure policy makers that qualitative syntheses are systematic and transparent. There is clearly a need to develop other methods of searching to supplement electronic searches. If searches produce large numbers of articles, sampling strategies may be needed to choose which articles to synthesize. The quality of any synthesis is dependent on the quality of the primary articles; both primary research and qualitative synthesis need to move beyond description and toward theory and explanation. Synthesizers need to pay attention to those articles which do not seem to fit their emerging analysis if they are to avoid stifling new ideas.