Psychosocial Interventions for Attention-Deficit/Hyperactivity Disorder: Systematic Review with Evidence and Gap Maps

Diversity and representation in ADHD psychosocial treatment research: A comprehensive synthesis with data from over 10,000 participants

Demographic data from nearly 50 years of treatment research for children and adolescents with attention-deficit/hyperactivity disorder (ADHD) are synthesized. Comprehensive search identified ADHD treatment studies that were between-group designs, included a psychosocial, evidence-based treatment, and were conducted in the United States. One hundred and twenty-six studies that included 10,604 youth were examined. Reporting of demographics varied with 48% of studies (k = 61) reporting ethnicity, 73% (k = 92) reporting race, 80% (k = 101) reporting age (M age = 8.81, SD = 2.82), and 88% (k = 111) reporting gender. Most participants identified as non-Hispanic/Latine (15.99% Hispanic/Latine), White (62.54%), and boys (74.39%; 24.47% girls). Since the 1970s, zero youth in ADHD treatment studies identified as Middle Eastern/North African, 0.1% were American Indian/Alaskan Native or Native Hawaiian Pacific Islander, 1.77% were Asian, 15.10% were Black, and 3.14% were Multiracial. Based on publication year, the proportions of girls, racially minoritized youth, and Hispanic/Latine youth included in ADHD treatment research have increased over time. Girls, non-binary and non-cisgender youth, young children, adolescents, Hispanic/Latine youth, and youth from all racial groups other than White are underrepresented in ADHD treatment research. Research gaps are discussed, and recommendations for comprehensive demographic reporting in child and adolescent psychological research are provided.

Behavior Management Training for Parents of Children with Preschool ADHD Based on Parent-Child Interactions: A Multicenter Randomized Controlled, Follow-Up Study

Objective

There is a need to develop optimized, evidence-based parent training programs tailored for preschoolers with attention deficit hyperactivity disorder (ADHD). The objective of this study was to explore a behavioral management training program aimed at the parents of preschool children with ADHD, which directly analyzes parent-child interaction from the perspective of system theory, and the intervention effect on ADHD in preschool children.

Methods

A multicenter randomized controlled study was conducted using system-based group therapy with 62 parents of preschool children with ADHD aged four to six years. ADHD symptoms, behavioral and emotional problems, and social functioning were compared with 61 control children whose parents did not receive training by applying the ADHD Rating Scale (ADHD-RS), Strengths and Difficulties Questionnaire (SDQ), and Questionnaire-Children with Difficulties (QCD) at the time of subject entry and at two and six months of entry, respectively.

Results

The results of the ADHD-RS assessment showed that children in the intervention group had significantly lower factor scores for attention deficit, hyperactivity, and impulsivity than the children in the control group after parental training and at follow-up (P < 0.05). Total scores on the SDQ scale, as well as character problems, hyperactivity, and peer interaction scores, significantly decreased with statistically significant differences (all P < 0.05), and emotional symptoms and prosocial behavior did not notable decline (P > 0.05). Compared with the control group, the total scores of the QCD scale and the scores of each factor in the intervention group remained significantly higher at the follow-up (P < 0.05).

Conclusion

After continuous intervention for eight weeks, parents were able to help the children with preschool ADHD to improve their ADHD symptoms and emotional behavioral and social functioning significantly, and the efficacy was maintained at the four-month follow-up; the systemic-based parent training in behavior management (PTBM) is applicable to the treatment of preschool ADHD and is worth promoting.

Components of Behavioral Parent Training for Children With Attention-Deficit/Hyperactivity Disorder: A Series of Replicated Single-Case Experiments

Behavioral parent training (BPT) is an evidence-based treatment for children with attention-deficit/hyperactivity disorder (ADHD). Stimulus control techniques (antecedent-based techniques, e.g., clear rules, instructions) and contingency management techniques (consequent-based techniques, e.g., praise, ignore) are the most common ones that are being taught to parents in BPT. However, research into the additive effects of these techniques is scarce. In this replicated single-case experimental ABC phase design, including six children on stable medication for ADHD (8-11 years) and their parents, the added efficacy of consequent-based techniques on top of antecedent-based techniques was evaluated. After a baseline period (phase A), we randomized the commencement time of two sessions parent training in antecedent-based techniques and two sessions parent training in consequent-based techniques for each child. Children's behaviors were assessed by daily parent ratings of selected problem behaviors and an overall behavior rating. Although visual inspection showed that behavior improved for most children in both phases, randomization tests did not demonstrate the added efficacy of the consequent-based techniques on top of the antecedent-based techniques. Limitations of the study and recommendations for future single-case experiments in this population are discussed.

Review: Which components of behavioral parent and teacher training work for children with ADHD? - a metaregression analysis on child behavioral outcomes

BACKGROUND

This metaregression analysis examined which behavioral techniques that are commonly used in behavioral parent and teacher training programs for children with attention-deficit/hyperactivity disorder (ADHD) were related to program effectiveness on children's behavioral outcomes.

METHODS

We included 32 randomized controlled trials (N = 2594 children) investigating behavioral parent training, teacher training, or a combination, in children with ADHD under 18 years. Outcomes were symptom counts of total ADHD, inattention, and hyperactivity-impulsivity and behavioral problems. The dosage of techniques was extracted from the intervention manuals. Metaregression was used to assess which techniques and intervention characteristics (setting, delivery method, duration, and home-school collaboration) were associated with intervention effectiveness.

RESULTS

Higher dosage of psycho-education for parents was associated with smaller effects on behavioral problems and, only in case of parent training, also with smaller effects on ADHD symptoms. Higher dosage of teaching parents/teachers to use negative consequences was associated with larger effects on behavioral problems. Individual training compared with group training was associated with larger effects on ADHD and hyperactivity-impulsivity symptoms.

CONCLUSIONS

This study provides first insights into the specific techniques that are essential in behavioral parent and teacher training programs for children with ADHD. This knowledge can eventually be used to improve and tailor interventions.

Effectiveness of Specific Techniques in Behavioral Teacher Training for Childhood ADHD Behaviors: Secondary Analyses of a Randomized Controlled Microtrial

Behavioral teacher training is an effective intervention for children with attention-deficit/hyperactivity disorder (ADHD). Intervention effectiveness may be enhanced by including intervention components that carry the strongest evidence for their effectiveness. A previous article of this group showed that both antecedent- (i.e., stimulus-control) and consequent-based (i.e., contingency management) techniques were highly effective in reducing daily teacher-rated, individually selected problem behaviors in a specific situation of the child. Effects were observed up to three months post intervention. Here, we tested whether effects were also present in teacher-rated and masked DSM-based assessments that comprise the full range of ADHD and oppositional defiant disorder (ODD) symptoms, as well as on teacher-rated impairment. Teachers of 90 children with (subthreshold) ADHD (6–12 years) were randomly assigned to one of three conditions: a short (two sessions), individualized intervention consisting of either a) antecedent-based techniques or b) consequent-based techniques; or c) waitlist. Multilevel analyses showed that both sets of techniques were effective in reducing teacher-rated ADHD symptoms and impairment immediately after the intervention and up to three months later, as compared to waitlist. Masked observations of ADHD behavior were in line with teacher ratings, with effects being most pronounced for inattention. No effects on teacher-rated or masked ODD behavior were found. This study showed that antecedent- and consequent-based techniques were effective in improving classroom ADHD symptoms and impairment. Long-term changes in teacher-rated ADHD are promising. These results extend previous findings and show the potential of short individually tailored interventions in classroom settings as treatment of ADHD symptoms.

Mental Health Information Seeking Online: A Google Trends Analysis of ADHD

Health information influences consumer decision making to seek, select, and utilize services. Online searching for mental health information is increasingly common, especially by adolescents and parents. We examined historical trends and factors that may influence population-level patterns in information seeking for attention-deficit/hyperactivity disorder (ADHD). We extracted Google Trends data from January 2004 to February 2020. Keywords included "ADHD," "ADHD treatment," "ADHD medication," and "ADHD therapy." We examined trends (systematic change over time) and seasonality (repeating pattern of change) via time-series analyses and graphics. We also used interrupted time-series analyses to examine the impact of celebrity and pharmaceutical events. Queries of "ADHD medication" increase, while queries for "ADHD therapy" remain relatively low despite a positive linear trend. Searches for "ADHD treatment" displayed a downward trend in more recent years. Analyses on seasonality revealed that holiday breaks coincided with a decrease in search interest, while post-break periods illustrated a rise, and the ADHD Awareness Month (October) coincided with a rise of public interest in all four search terms. Celebrity effects were more prominent in earlier years; the "Own It" pharmaceutical campaign may have increased ADHD awareness and the specificity of searches for "ADHD medication." The anonymous, accessible, and low-cost nature of seeking information online makes search engines like Google important sources of mental health information. Changing search patterns in response to seasonal, advocacy, and media events highlight internet-based opportunities for raising awareness and disseminating empirically supported information.

Which Techniques Work in Behavioral Parent Training for Children with ADHD? A Randomized Controlled Microtrial

OBJECTIVE

Behavioral parent training (BPT) is an evidence-based intervention for children with attention-deficit/hyperactivity disorder (ADHD), but little is known about the effects of separate techniques parents learn in BPT.

METHOD

In a three-armed randomized controlled microtrial including parents of 92 children (4-12 years) with ADHD, we examined the efficacy of two sessions parent training involving either stimulus control techniques (antecedent-based condition (AC)) or contingency management techniques (consequent-based condition (CC)), compared to a waitlist. Primary outcome was daily parent-rated problem behaviors, secondary outcomes were parent-rated symptoms of ADHD and oppositional defiant disorder (ODD), and mental health-care consumption. Measures were completed at baseline (T0), immediately after the training (T1), at two weeks (T2) and three months (T3) follow-up. We also explored whether child and parent characteristics moderated treatment effects.

RESULTS

Compared to the waitlist, in the AC, daily rated problem behaviors improved at T1 (d= .56) and T2 (d= .65); in the CC, these behaviors only improved at T2 (d= .53). Daily rated problem behaviors within both conditions remained stable between T2 and T3. In the AC compared to the other conditions, inattention symptoms decreased at T1 and T2. For both active conditions compared to waitlist, hyperactivity-impulsivity symptoms decreased only at T2 and ODD symptoms did not decrease. No moderators were identified. Mental health-care consumption after training was low and did not differ between the active conditions.

CONCLUSIONS

Brief training of parents in antecedent- or consequent-based techniques improves problem behaviors of children with ADHD. Antecedent-based techniques appear to be especially important to target inattention.

Effectiveness of Specific Techniques in Behavioral Teacher Training for Childhood ADHD: A Randomized Controlled Microtrial

Objective: Behavioral teacher training is the most effective classroom-based intervention for children with attention-deficit/hyperactivity disorder (ADHD). However, it is currently unknown which components of this intervention add to its effectiveness and for whom these are effective.

Method: In this microtrial, teachers of 90 children with impairing levels of ADHD symptoms (6–12 years) were randomly assigned to one of three conditions: a short (2 sessions), individualized intervention consisting of either (A) antecedent-based techniques (stimulus control), (B) consequent-based techniques (contingency management) or (C) waitlist. Primary outcome was the average of five daily assessments of four individualized problem behaviors, assessed pre and post intervention and three months later. Moderation analyses were conducted to generate hypotheses on child, teacher and classroom factors that may contribute to technique effectiveness.

Results: Multilevel analyses showed that both antecedent- and consequent-based techniques were equally and highly effective in reducing problem behaviors compared to the control condition (Cohen’s d =.9); effects remained stable up to three months later. Child’s age and class size were moderators of technique effectiveness. For younger children, consequent-based techniques were more effective than antecedent-based techniques, whereas for older children the effect was in the opposite direction. Further, beneficial effects of antecedent-based techniques increased when the number of students per class decreased, whilst effectiveness of consequent-based techniques did not depend on class size.

Conclusions: This study shows that both antecedent- and consequent-based techniques are highly effective in reducing problem behavior of children with ADHD. Interventions may be adapted to the child’s age and class size.

Cognitive behavior therapy for externalizing disorders in children and adolescents in routine clinical care: A systematic review and meta-analysis

Various Cognitive Behavioral Therapy (CBT) programs for externalizing disorders in children and adolescents are supported by a substantial body of empirical evidence. Most of the research evidence comes from efficacy studies conducted in university settings, but there is less knowledge about the effect of these treatments in routine clinical care. The purpose of this meta-analysis was to investigate the effectiveness of CBT in non-university settings for Attention Deficit Hyperactivity Disorder (ADHD), Conduct Disorder (CD) and Oppositional Defiant Disorder (ODD). Embase OVID, Ovid MEDLINE and PsycINFO were systematically searched for eligible studies published up to May 2020. In total, 51 treatment effectiveness studies involving 5295 patients were included. The average within-group effect size at post-treatment was significant (g = 0.91), and there were large effect sizes for both ADHD (g = 0.80) and CD/ODD (g = 0.98). At post treatment, remission rates were 38% for ADHD and 48% for CD/ODD, and the overall attrition rate was 14%. Benchmarking against efficacy studies showed that CBT in routine clinical care yields remission rates, within-group effect sizes and attrition rates that are very similar to those found in university settings. The findings support the transportability of CBT for externalizing disorders from university settings to routine clinical care. PROSPERO registration: CRD42020147524.