Effects of an educational intervention on mothers of male children with attention deficit hyperactivity disorder

Effectiveness and cost-effectiveness of interventions to increase knowledge and awareness of attention deficit hyperactivity disorder: a systematic review

Various interventions, including caregiver education, psychoeducation, teacher and clinician training and behavioral management embedded with education, are available to enhance awareness and knowledge among caregivers, teachers, and clinicians. This review synthesizes evidence on the effectiveness and cost-effectiveness of interventions to increase ADHD awareness and knowledge for caregivers, clinicians, and teachers. Peer-reviewed literature was identified through the systematic searches of six databases: MEDLINE Complete, APA PsycInfo, CINAHL Complete, ERIC, Global Health and EconLit. Two independent reviewers completed a two-stage screening process and quality assessment. Results are presented as a narrative synthesis. Economic evaluation study cost data were converted for comparability. Of the 5963 results, 28 studies were included. Most interventions were found to be effective in increasing the awareness and knowledge of ADHD among caregivers, clinicians, and teachers. Clinician knowledge and capacity to assess, diagnose and treat ADHD were improved. Of the economic evaluation studies, interventions were promising in parent education, and behavioral management and psychosocial therapy interventions were found to be cost-effective. The review provides important insights about effective and cost-effective interventions to increase ADHD awareness and knowledge. These insights are critical to effectively plan services/interventions for families and children with ADHD. Further research in economic evaluation of interventions is needed to assist policy-decision making.

Interventions to promote health literacy among working-age populations experiencing socioeconomic disadvantage: systematic review

Background

Experiencing financial insecurity and being underserved is often associated with low health literacy, i.e., the ability to identify, obtain, interpret and act upon health information, which may result in poor health outcomes. Little is known about effective interventions for promoting health literacy among underserved populations. The objective of this systematic review is to summarize the literature on such interventions and identify characteristics that differentiate more effective interventions.

Methods

Following PRISMA guidelines we searched the databases SCOPUS, Pubmed, Web of Science core collection and CINAHL. We included primary studies with a quantitative study design and control groups testing interventions to increase health literacy or health knowledge in underserved populations between 18 and 65 years. Where possible, we converted effect sizes into Cohen's d and compared mean differences of intervention and control groups. Albatross plots were created to summarize the results according to different health literacy and health knowledge outcomes.

Results

We screened 3,696 titles and abstracts and 206 full texts. In total, 86 articles were analyzed, of which 55 were summarized in seven albatross plots. The majority of the studies (n = 55) were conducted in the United States and had a randomized controlled study design (n = 44). More effective intervention approaches assessed needs of participants through focus group discussions prior to conducting the intervention, used bilingual educational materials, and included professionals fluent in the first languages of the study population as intervention deliverers. Additionally, the use of educational materials in video and text form, fotonovelas and interactive group education sessions with role playing exercises were observed to be effective.

Discussion

Although the outcomes addressed in the included studies were heterogeneous, effective intervention approaches were often culturally sensitive and developed tailored educational materials. Interventions aiming to promote health literacy in underserved populations should hence consider applying similar approaches.Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=323801, PROSPERO registration ID: CRD42022323801.

Behavioral Parent Training for School-Aged Children With ADHD: A Systematic Review of Randomized Control Trials

BACKGROUND

All guidelines for the treatment of ADHD in children include behavioral parent training in combination with other strategies. In the past, several systematic reviews have been carried out that were either outdated or not sufficiently specific to ADHD. We wanted to conduct a new review focusing on a specific ADHD population of school age (4-12 years) and on behavioral and cognitive programs. We aimed to test our hypothesis that behavioral parent training would improve parents' difficulties, children's symptomatology, and the quality of life of families with ADHD.

METHODS

PUBMED, PsychInfo, Web of Science, ERIC, and Cochrane databases were searched for original articles on randomized control trials on behavioral parent training group for children with ADHD aged from 4 to 12 years until July 2023.

RESULTS

A total of 20 studies were included in the systematic review. The results were divided into four categories: parent data, child data collected by parents, teachers, or researchers. A qualitative analysis revealed for parents, effects on parental stress, feelings of parental efficacy, and negative parental educational behavior. As regard children, only effects are noted for parental assessment, on ADHD symptomatology, externalized disorders, and social skills.

CONCLUSION

Despite the heterogeneity or small number of studies in some categories, BPTs have positive effects on both parents and children. There are no convincing results to support the generalization of progress. This would seem to indicate that it remains essential to consider actions specific to each problematic environment for the child.

Behavioral interventions in attention-deficit/hyperactivity disorder: a meta-analysis of randomized controlled trials across multiple outcome domains

OBJECTIVE

Behavioral interventions are recommended as attention-deficit/hyperactivity disorder (ADHD) treatments. However, a recent meta-analysis found no effects on core ADHD symptoms when raters were probably blind to treatment allocation. The present analysis is extended to a broader range of child and parent outcomes.

METHOD

A systematic search in PubMed, Ovid, Web of Knowledge, ERIC, and CINAHAL databases (up to February 5, 2013) identified published randomized controlled trials measuring a range of patient and parent outcomes for children and adolescents diagnosed with ADHD (or who met validated cutoffs on rating scales).

RESULTS

Thirty-two of 2,057 nonduplicate screened records were analyzed. For assessments made by individuals closest to the treatment setting (usually unblinded), there were significant improvements in parenting quality (standardized mean difference [SMD] for positive parenting 0.68; SMD for negative parenting 0.57), parenting self-concept (SMD 0.37), and child ADHD (SMD 0.35), conduct problems (SMD 0.26), social skills (SMD 0.47), and academic performance (SMD 0.28). With probably blinded assessments, significant effects persisted for parenting (SMD for positive parenting 0.63; SMD for negative parenting 0.43) and conduct problems (SMD 0.31).

CONCLUSION

In contrast to the lack of blinded evidence of ADHD symptom decrease, behavioral interventions have positive effects on a range of other outcomes when used with patients with ADHD. There is blinded evidence that they improve parenting and decrease childhood conduct problems. These effects also may feed through into a more positive parenting self-concept but not improved parent mental well-being.

Group-based parent training programmes for improving parental psychosocial health

BACKGROUND

Parental psychosocial health can have a significant effect on the parent-child relationship, with consequences for the later psychological health of the child. Parenting programmes have been shown to have an impact on the emotional and behavioural adjustment of children, but there have been no reviews to date of their impact on parental psychosocial wellbeing.

OBJECTIVES

To address whether group-based parenting programmes are effective in improving parental psychosocial wellbeing (for example, anxiety, depression, guilt, confidence).

SEARCH METHODS

We searched the following databases on 5 December 2011: CENTRAL (2011, Issue 4), MEDLINE (1950 to November 2011), EMBASE (1980 to week 48, 2011), BIOSIS (1970 to 2 December 2011), CINAHL (1982 to November 2011), PsycINFO (1970 to November week 5, 2011), ERIC (1966 to November 2011), Sociological Abstracts (1952 to November 2011), Social Science Citation Index (1970 to 2 December 2011), metaRegister of Controlled Trials (5 December 2011), NSPCC Library (5 December 2011). We searched ASSIA (1980 to current) on 10 November 2012 and the National Research Register was last searched in 2005.

SELECTION CRITERIA

We included randomised controlled trials that compared a group-based parenting programme with a control condition and used at least one standardised measure of parental psychosocial health. Control conditions could be waiting-list, no treatment, treatment as usual or a placebo.

DATA COLLECTION AND ANALYSIS

At least two review authors extracted data independently and assessed the risk of bias in each study. We examined the studies for any information on adverse effects. We contacted authors where information was missing from trial reports. We standardised the treatment effect for each outcome in each study by dividing the mean difference in post-intervention scores between the intervention and control groups by the pooled standard deviation.

MAIN RESULTS

We included 48 studies that involved 4937 participants and covered three types of programme: behavioural, cognitive-behavioural and multimodal. Overall, we found that group-based parenting programmes led to statistically significant short-term improvements in depression (standardised mean difference (SMD) -0.17, 95% confidence interval (CI) -0.28 to -0.07), anxiety (SMD -0.22, 95% CI -0.43 to -0.01), stress (SMD -0.29, 95% CI -0.42 to -0.15), anger (SMD -0.60, 95% CI -1.00 to -0.20), guilt (SMD -0.79, 95% CI -1.18 to -0.41), confidence (SMD -0.34, 95% CI -0.51 to -0.17) and satisfaction with the partner relationship (SMD -0.28, 95% CI -0.47 to -0.09). However, only stress and confidence continued to be statistically significant at six month follow-up, and none were significant at one year. There was no evidence of any effect on self-esteem (SMD -0.01, 95% CI -0.45 to 0.42). None of the trials reported on aggression or adverse effects.The limited data that explicitly focused on outcomes for fathers showed a statistically significant short-term improvement in paternal stress (SMD -0.43, 95% CI -0.79 to -0.06). We were unable to combine data for other outcomes and individual study results were inconclusive in terms of any effect on depressive symptoms, confidence or partner satisfaction.

AUTHORS' CONCLUSIONS

The findings of this review support the use of parenting programmes to improve the short-term psychosocial wellbeing of parents. Further input may be required to ensure that these results are maintained. More research is needed that explicitly addresses the benefits for fathers, and that examines the comparative effectiveness of different types of programme along with the mechanisms by which such programmes bring about improvements in parental psychosocial functioning.

Effectiveness of occupational performance coaching in improving children's and mothers' performance and mothers' self-competence

OBJECTIVE

This study examined the effectiveness of occupational performance coaching in improving children's and mothers' occupational performance and mothers' parenting self-competence.

METHOD

A one-group time-series design was used to evaluate changes in children's (n = 29) and mothers' (n = 8) occupational performance at four time points: (1) pre-wait list, (2) preintervention, (3) postintervention, and (4) follow-up.

RESULTS

Significant improvements in occupational performance occurred postintervention for children, F(1, 78) = 153.72, p < .001, η² = .86, and mothers, F(1, 78) = 153.72, p < .001, η² = .86, that were maintained 6 wk after intervention. Mothers' self-competence in parenting also improved, F(1, 72) = 17.36, p < .001, η² = .42.

CONCLUSION

Findings provide preliminary evidence supporting the effectiveness of occupational performance coaching in improving children's and mothers' occupational performance and mothers' parenting self-competence. Improvements were sustained and appeared to generalize to other areas of performance.

A meta-analysis of behavioral parent training for children with attention deficit hyperactivity disorder

This meta-analysis examined the effect of behavioral parent training on child and parental outcomes for children with attention deficit hyperactivity disorder. Meta-analytic procedures were used to estimate the effect of behavioral parent training on children with attention deficit hyperactivity disorder. Variables moderating the intervention effect were examined. Forty studies were included and generated an overall moderate effect size at post-treatment and a small effect size at follow-up. The majority of outcome categories were associated with a moderate effect size at post-treatment that decreased to a small effect size at follow-up. Parenting competence was the only outcome that had a large effect, which decreased to moderate at follow-up. The strength of the effect differed between questionnaire and observation measures. Behavioral parent training is an effective intervention for children with attention deficit hyperactivity disorder. Sustainability of the effects over time is a problem that awaits further scrutiny. Recommendations for further research and clinical practices are provided.

Group-based parent training programmes for improving parental psychosocial health

BACKGROUND

Parental psychosocial health can have a significant effect on the parent-child relationship, with consequences for the later psychological health of the child. Parenting programmes have been shown to have an impact on the emotional and behavioural adjustment of children, but there have been no reviews to date of their impact on parental psychosocial wellbeing.

OBJECTIVES

To address whether group-based parenting programmes are effective in improving parental psychosocial wellbeing (for example, anxiety, depression, guilt, confidence).

SEARCH METHODS

We searched the following databases on 5 December 2012: CENTRAL (2011, Issue 4), MEDLINE (1950 to November 2011), EMBASE (1980 to week 48, 2011), BIOSIS (1970 to 2 December 2011), CINAHL (1982 to November 2011), PsycINFO (1970 to November week 5, 2011), ERIC (1966 to November 2011), Sociological Abstracts (1952 to November 2011), Social Science Citation Index (1970 to 2 December 2011), metaRegister of Controlled Trials (5 December 2011), NSPCC Library (5 December 2011). We searched ASSIA (1980 to current) on 10 November 2012 and the National Research Register was last searched in 2005.

SELECTION CRITERIA

We included randomised controlled trials that compared a group-based parenting programme with a control condition and used at least one standardised measure of parental psychosocial health. Control conditions could be waiting-list, no treatment, treatment as usual or a placebo.

DATA COLLECTION AND ANALYSIS

At least two review authors extracted data independently and assessed the risk of bias in each study. We examined the studies for any information on adverse effects. We contacted authors where information was missing from trial reports. We standardised the treatment effect for each outcome in each study by dividing the mean difference in post-intervention scores between the intervention and control groups by the pooled standard deviation.

MAIN RESULTS

We included 48 studies that involved 4937 participants and covered three types of programme: behavioural, cognitive-behavioural and multimodal. Overall, we found that group-based parenting programmes led to statistically significant short-term improvements in depression (standardised mean difference (SMD) -0.17, 95% confidence interval (CI) -0.28 to -0.07), anxiety (SMD -0.22, 95% CI -0.43 to -0.01), stress (SMD -0.29, 95% CI -0.42 to -0.15), anger (SMD -0.60, 95% CI -1.00 to -0.20), guilt (SMD -0.79, 95% CI -1.18 to -0.41), confidence (SMD -0.34, 95% CI -0.51 to -0.17) and satisfaction with the partner relationship (SMD -0.28, 95% CI -0.47 to -0.09). However, only stress and confidence continued to be statistically significant at six month follow-up, and none were significant at one year. There was no evidence of any effect on self-esteem (SMD -0.01, 95% CI -0.45 to 0.42). None of the trials reported on aggression or adverse effects.The limited data that explicitly focused on outcomes for fathers showed a statistically significant short-term improvement in paternal stress (SMD -0.43, 95% CI -0.79 to -0.06). We were unable to combine data for other outcomes and individual study results were inconclusive in terms of any effect on depressive symptoms, confidence or partner satisfaction.

AUTHORS' CONCLUSIONS

The findings of this review support the use of parenting programmes to improve the short-term psychosocial wellbeing of parents. Further input may be required to ensure that these results are maintained. More research is needed that explicitly addresses the benefits for fathers, and that examines the comparative effectiveness of different types of programme along with the mechanisms by which such programmes bring about improvements in parental psychosocial functioning.

Parent training interventions for Attention Deficit Hyperactivity Disorder (ADHD) in children aged 5 to 18 years

BACKGROUND

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterised by high levels of inattention, hyperactivity and impulsivity that are present before the age of seven years, seen in a range of situations, inconsistent with the child's developmental level and causing social or academic impairment. Parent training programmes are psychosocial interventions aimed at training parents in techniques to enable them to manage their children's challenging behaviour.

OBJECTIVES

To determine whether parent training interventions are effective in reducing ADHD symptoms and associated problems in children aged between five and eigtheen years with a diagnosis of ADHD, compared to controls with no parent training intervention.

SEARCH METHODS

We searched the following electronic databases (for all available years until September 2010): CENTRAL (2010, Issue 3), MEDLINE (1950 to 10 September 2010), EMBASE (1980 to 2010 Week 36), CINAHL (1937 to 13 September 2010), PsycINFO (1806 to September Week 1 2010), Dissertation Abstracts International (14 September 2010) and the metaRegister of Controlled Trials (14 September 2010). We contacted experts in the field to ask for details of unpublished or ongoing research.

SELECTION CRITERIA

Randomised (including quasi-randomised) studies comparing parent training with no treatment, a waiting list or treatment as usual (adjunctive or otherwise). We included studies if ADHD was the main focus of the trial and participants were over five years old and had a clinical diagnosis of ADHD or hyperkinetic disorder that was made by a specialist using the operationalised diagnostic criteria of the DSM-III/DSM-IV or ICD-10. We only included trials that reported at least one child outcome.

DATA COLLECTION AND ANALYSIS

Four authors were involved in screening abstracts and at least 2 authors looked independently at each one. We reviewed a total of 12,691 studies and assessed five as eligible for inclusion. We extracted data and assessed the risk of bias in the five included trials. Opportunities for meta-analysis were limited and most data that we have reported are based on single studies.

MAIN RESULTS

We found five studies including 284 participants that met the inclusion criteria, all of which compared parent training with de facto treatment as usual (TAU). One study included a nondirective parent support group as a second control arm.  Four studies targeted children's behaviour problems and one assessed changes in parenting skills. Of the four studies targeting children's behaviour, two focused on behaviour at home and two focused on behaviour at school. The two studies focusing on behaviour at home had different findings: one found no difference between parent training and treatment as usual, whilst the other reported statistically significant results for parent training versus control. The two studies of behaviour at school also had different findings: one study found no difference between groups, whilst the other reported positive results for parent training when ADHD was not comorbid with oppositional defiant disorder. In this latter study, outcomes were better for girls and for children on medication.We assessed the risk of bias in most of the studies as unclear at best and often as high. Information on randomisation and allocation concealment did not appear in any study report. Inevitably, blinding of participants or personnel was impossible for this intervention; likewise, blinding of outcome assessors (who were most often the parents who had delivered the intervention) was impossible.We were only able to conduct meta-analysis for two outcomes: child 'externalising' behaviour (a measure of rulebreaking, oppositional behaviour or aggression) and child 'internalising' behaviour (for example, withdrawal and anxiety). Meta-analysis of three studies (n = 190) providing data on externalising behaviour produced results that fell short of statistical significance (SMD -0.32; 95% CI -0.83 to 0.18, I(2) = 60%). A meta-analysis of two studies (n = 142) for internalising behaviour gave significant results in the parent training groups (SMD -0.48; 95% CI -0.84 to -0.13, I(2) = 9%). Data from a third study likely to have contributed to this outcome were missing, and we have some concerns about selective outcome reporting bias.Individual study results for child behaviour outcomes were mixed. Positive results on an inventory of child behaviour problems were reported for one small study (n = 24) with the caveat that results were only positive when parent training was delivered to individuals and not groups. In another study (n = 62), positive effects (once results were adjusted for demographic and baseline data) were reported for the intervention group on a social skills measure.The study (n = 48) that assessed parenting skill changes compared parent training with a nondirective parent support group. Statistically significant improvements were reported for the parent training group. Two studies (n = 142) provided data on parent stress indices that were suitable for combining in a meta-analysis. The results were significant for the 'child' domain (MD -10.52; 95% CI -20.55 to -0.48) but not the 'parent' domain (MD -7.54; 95% CI -24.38 to 9.30). Results for this outcome from a small study (n = 24) suggested a long-term benefit for mothers who received the intervention at an individual level; in contrast, fathers benefited from short-term group treatment. A fourth study reported change data for within group measures of parental stress and found significant benefits in only one of the two active parent training group arms (P ≤ 0.01).No study reported data for academic achievement, adverse events or parental understanding of ADHD.

AUTHORS' CONCLUSIONS

Parent training may have a positive effect on the behaviour of children with ADHD. It may also reduce parental stress and enhance parental confidence. However, the poor methodological quality of the included studies increases the risk of bias in the results. Data concerning ADHD-specific behaviour are ambiguous. For many important outcomes, including school achievement and adverse effects, data are lacking.Evidence from this review is not strong enough to form a basis for clinical practice guidelines. Future research should ensure better reporting of the study procedures and results.

Attention-deficit/hyperactivity disorder in African American youth

This article examines attention-deficit/hyperactivity disorder (ADHD) in African American youth. Tackling the myths and misinformation surrounding ADHD in the African American community can be one of the most difficult issues in mental illness circles. There is a lot of conflicting information about how African Americans are diagnosed, examined, and treated. This article clarifies some of the misconceptions and offers some comprehensibility to the issue of ADHD in African American youth. The incidence of ADHD is probably similar in African Americans and Caucasians. However, fewer African Americans are diagnosed with and treated for ADHD. That reality flies in the face of some perceptions in many African American communities. Reasons for this disparity have not been fully clarified and are most likely complex and numerous. Some barriers to treatment are driven by the beliefs of patients and their families, while others are the result of limitations in the health care system. Patient-driven obstacles to care include inadequate knowledge of symptoms, treatment, and consequences of untreated ADHD and fear of overdiagnosis and misdiagnosis. System-driven limitations include a lack of culturally competent health care providers, stereotyping or biases, and failure of clinicians to evaluate the child in multiple settings before diagnosis.

A Family-Centered Approach to Planning and Measuring the Outcome of Interventions for Children with Attention-Deficit/Hyperactivity Disorder

This paper discusses a set of closely related parenting and family factors that should be considered when planning and measuring the outcome of interventions for children with attention-deficit/hyperactivity disorder (ADHD). These include parenting and parent-child relationships, parental cognitions, parental adjustment, marital interactions, general family relationships, and adaptive child functioning within the family. The measurement of each construct is discussed, and comparative, longitudinal, and treatment outcome studies using these measures are reviewed. It is concluded that measures of treatment outcome for children with ADHD could be improved by utilizing multiple informants, developing tools with greater content and contextual validity, relying more on observational methods, and identifying those measures which are of greatest importance to families. Given the multiple pathways via which both psychosocial and pharmacological interventions exert their influence, composite measures combining multi-informant, multimethod constructs may represent more useful measures of treatment outcome than measures of primary ADHD symptoms.

Pragmatic randomised controlled trials in parenting research: the issue of intention to treat

STUDY OBJECTIVE

To evaluate trials of parenting programmes, regarding their use of intention to treat (ITT).

DESIGN

Individual trials included in two relevant Cochrane systematic reviews were scrutinised by two independent reviewers. Data on country of origin, target audience, trial type, treatment violations, use of ITT, and the management of missing data were extracted.

MAIN RESULTS

Thirty trial reports were reviewed. Three reported the use of an ITT approach to data analysis. Nineteen reported losing subjects to follow up although the implications of this were rarely considered. Insufficient detail in reports meant it was difficult to identify study drop outs, the nature of treatment violations, and those failing to provide outcome assessments. In two trials, study drop outs were considered as additional control groups, violating the basic principle of ITT.

CONCLUSIONS

It is recommended that future trial reports adhere to CONSORT guidelines. In particular ITT should be used for the main analyses, with strategies for managing treatment violations and handling missing data being reported a priori. Those conducting trials need to acknowledge the social nature of these programmes can sometimes result in erratic parent attendance and participation, which would only increase the chances of missing data. The use of approaches that can limit the proportion of missing data is therefore recommended.

Effects of an education programme on family participation in the rehabilitation of children with developmental disability

The growth and development of children with developmental disability depend very much on the parents. The present study was designed to examine whether family-focused education could enhance parental skills, knowledge and competency. The enhancement would in turn result in greater parental participation in the rehabilitation process of these children. The parental needs of Chinese parents were reviewed for the formulation of the Family-Focused Education Programme, which was then implemented, and evaluated using a pre-test/post-test control group design. Forty parents were invited to participate in the study using a convenience sampling technique. The mean scores of these variables were in the direction of increasing after the programme, though repeated measures ANOVA did not indicate any statistically significant changes in parenting knowledge, attitude and stress. It was apparent that the Family-Focused Education Programme enhanced parental competence. Undoubtedly, the family-focused approach is crucial for enhancing parenting competency, and education is fundamental to enabling parents.

Help when it's needed first: a controlled evaluation of brief, preventive behavioral family intervention in a primary care setting

This study evaluated the effects of a brief 3- to 4-session behavioral family intervention program for parents of preschool-aged children in a primary care setting, compared to parents in a wait-list control condition. Parents receiving the Primary Care Triple P-Positive Parenting Program intervention reported significantly lower levels of targeted child behavior problems, dysfunctional parenting, and reduced parental anxiety and stress in comparison to wait-listed parents at postassessment. These short-term effects were largely maintained at 6-month follow-up assessment of the intervention group. Implications of these findings for the prevention of behavioral and emotional problems in children are discussed.

Parent-training programmes for improving maternal psychosocial health

BACKGROUND

Mental health problems are common and there is evidence to suggest that the origins of such problems lie in infancy and childhood. In particular, there is evidence from a range of studies to suggest that maternal psychosocial health can have a significant effect on the mother-infant relationship, and that this in turn can have consequences for both the short and long-term psychological health of the child. The use of parenting programmes is increasing in the UK and elsewhere and evidence of their effectiveness in improving outcomes for children has been provided. Evidence is now required of their effectiveness in improving outcomes for mothers.

OBJECTIVES

The objective of this review is to address whether group-based parenting programmes are effective in improving maternal psychosocial health including anxiety, depression, and self-esteem.

SEARCH STRATEGY

A range of biomedical, social science, educational and general reference electronic databases were searched including MEDLINE, EMBASE CINAHL, PsychLIT, ERIC, ASSIA, Sociofile and the Social Science Citation Index. Other sources of information included the Cochrane Library (SPECTR, CENTRAL), and the National Research Register (NRR).

SELECTION CRITERIA

Only randomised controlled trials were included in which participants had been randomly allocated to an experimental and a control group, the latter being a waiting-list, no-treatment or a placebo control group. Studies had to include at least one group-based parenting programme, and one standardised instrument measuring maternal psychosocial health.

DATA COLLECTION AND ANALYSIS

A systematic critical appraisal of all included studies was undertaken using a modified version of the Journal of the American Medical Association (JAMA) published criteria. The treatment effect for each outcome in each study was standardised by dividing the mean difference in post-intervention scores for the intervention and treatment group, by the pooled standard deviation, to produce an effect size. Where appropriate the results were then combined in a meta-analysis using a fixed-effect model, and 95% confidence intervals were used to assess the significance of the findings.

MAIN RESULTS

A total of 23 studies were included in the original review which was increased to 26 at the first udate (2003). Of these 20 provided sufficient data to calculate effect sizes. The 20 studies provided a total of 64 assessments of outcome on a range of aspects of psychosocial functioning including depression, anxiety, stress, self-esteem, social competence, social support, guilt, mood, automatic thoughts, dyadic adjustment, psychiatric morbidity, irrationality, anger and aggression, mood, attitude, personality, and beliefs. Data sufficient to combine in a meta-analysis existed for only five outcomes (depression; anxiety/stress; self-esteem; social support; and relationship with spouse/marital adjustment). The results of the meta-analyses show statistically significant results favouring the intervention group for depression; anxiety/stress; self-esteem; and relationship with spouse/marital adjustment. The meta-analysis of the social support data showed no evidence of effectiveness. Of the remaining data that it was not possible to combine in a meta-analysis, approximately 22% of the outcomes measured, showed significant differences between the intervention group and the control group. A further 40% showed non-significant differences favouring the intervention group. Approximately one-third of outcomes showed no evidence of effectiveness.A meta-analysis of the follow-up data on three outcomes was also conducted - depression, self-esteem and relationship with spouse/marital adjustment. The results show that there was a continued improvement in self-esteem, depression, and marital adjustment at follow-up, although the latter two findings were not statistically significant. This review has been updated (2003) with the addition of 3 new included studies. A number of additional excluded studies have also been added. There is one additional study awaiting 03) with the addition of 3 new included studies. A number of additional excluded studies have also been added. There is one additional study awaiting assessment and 2 ongoing studies listed for inclusion at a future update of this review. The size of effect for the main outcomes has not been substantially altered by this update. Additional sensitivity analyses to assess the impact of quasi randomised studies on the result have also been added. Where the quasi randomised studies are excluded from the analysis, the result was found to be slightly more conservative.

REVIEWER'S CONCLUSIONS

It is suggested that parenting programmes can make a significant contribution to the short-term psychosocial health of mothers. However, there is currently a paucity of evidence concerning whether these results are maintained over time, and the limited follow-up data which are available show equivocal results. This points to the need for further evidence concerning the long-term effectiveness of parenting programmes on maternal mental health. Whilst the results of this review are positive overall, some studies showed no effect. Further research is needed to assess which factors contribute to successful outcomes in these programmes with particular attention being paid to the quality of delivery.These results suggest that parenting programmes have a potential role to play in the promotion of mental health.

Compliance with stimulants for attention-deficit/hyperactivity disorder: issues and approaches for improvement

Attention-deficit/hyperactivity disorder (ADHD) affects approximately 8-10% of school-aged children in the US and for many individuals persists into adolescence and adulthood. Both pharmacological and nonpharmacological (behavioural) therapies are used to treat individuals with ADHD. Treatment with stimulant medications, which include methylphenidate and amphetamine, typically requires multiple daily doses to maintain efficacy. The frequency of treatment, coupled with the importance of timing of doses and the long-term nature of treatment, make noncompliance a particular issue in the treatment of ADHD. Studies report noncompliance rates of 20-65% with stimulant treatment, although there are only limited published studies and these show considerable individual variation. Noncompliance can arise through inadequate supervision of those receiving medication, leading to delayed or missed doses, or through the reluctance of individuals to take medication, which is influenced by a number of factors (e.g. social attitudes, pressures or worries surrounding medication use and the inconvenience of multiple daily doses). Two approaches are likely to increase compliance with stimulant treatment: effective once-daily formulations of medication and improved treatment information. The development of effective once-daily formulations for stimulant treatments removes the need for multiple daily doses, with the associated problems of ensuring adequate treatment supervision and personal privacy. Improved provision of education and information for individuals with ADHD, as well as their families and teachers, should help them address the issues surrounding stimulant medication and allow full participation in the treatment process. Together, these strategies should improve treatment compliance for individuals with ADHD.

Parent-training programmes for improving maternal psychosocial health

BACKGROUND

Mental health problems are common, and there is evidence from a range of studies to suggest that a number of factors relating to maternal psychosocial health can have a significant effect on the mother-infant relationship, and that this can have consequences for both the short and long-term psychological health of the child. The use of parenting programmes is increasing in the UK and evidence of their effectiveness in improving outcomes for mothers is now required.

OBJECTIVES

The objective of this review is to address whether group-based parenting programmes are effective in improving maternal psychosocial health including anxiety, depression, and self-esteem.

SEARCH STRATEGY

A range of biomedical, social science, educational and general reference electronic databases were searched including MEDLINE, EMBASE CINAHL, PsychLIT, ERIC, ASSIA, Sociofile and the Social Science Citation Index. Other sources of information included the Cochrane Library (SPECTR, CENTRAL), and the National Research Register (NRR).

SELECTION CRITERIA

Only randomised controlled trials were included in which participants had been randomly allocated to an experimental and a control group, the latter being either a waiting-list, no-treatment or a placebo control group. Studies had to include at least one group-based parenting programme, and one standardised instrument measuring maternal psychosocial health.

DATA COLLECTION AND ANALYSIS

A systematic critical appraisal of all included studies was undertaken using a modified version of the Journal of the American Medical Association (JAMA) published criteria. The treatment effect for each outcome in each study was standardised by dividing the mean difference in post-intervention scores for the intervention and treatment group, by the pooled standard deviation, to produce an effect size. Where appropriate the results were then combined in a meta-analysis using a fixed-effect model, and 95% confidence intervals were used to assess the significance of the findings.

MAIN RESULTS

A total of 23 studies were included in the review but only 17 provided sufficient data to calculate effect sizes. The 17 studies provided a total of 59 assessments of outcome on a range of aspects of psychosocial functioning including depression, anxiety, stress, self-esteem, social competence, social support, guilt, mood, automatic thoughts, dyadic adjustment, psychiatric morbidity, irrationality, anger and aggression, mood, attitude, personality, and beliefs. There was only sufficient data, however, on five outcomes (depression; anxiety/stress; self-esteem; social support; and relationship with spouse/marital adjustment) to combine the results in a meta-analysis. The meta-analyses show statistically significant results favouring the intervention group as regards depression; anxiety/stress; self-esteem; and relationship with spouse/marital adjustment. The meta-analysis of the social support data, however, showed no evidence of effectiveness. These results suggest that parenting programmes, irrespective of the type (or content) of programme, can be effective in improving important aspects of maternal psycho-social functioning. Of the data summarising the effectiveness of the different types of parenting programmes, which it was not possible to combine in a meta-analysis, approximately 22% of the outcomes measured, showed significant differences between the intervention group and the control group. A further 40% showed medium to large non-significant differences favouring the intervention group. Approximately one-third of outcomes showed small non-significant differences or no evidence of effectiveness. A meta-analysis of the follow-up data on three outcomes was also conducted - depression, self-esteem and relationship with spouse/marital adjustment. The results show that there was a continued improvement in self-esteem, depression and marital adjustment at follow-up, although the latter two findings were not statistically significant.

REVIEWER'S CONCLUSIONS

It is suggested that parenting programmes can make a significant contribution to short-term psychosocial health in mothers, and that the limited follow-up data available suggest that these are maintained over time. However, the overall paucity of long-term follow-up data points to the need for further evidence concerning the long-term effectiveness of parenting programmes on maternal mental health. Furthermore, it is suggested that some caution should be exercised before the results are generalised to parents irrespective of the level of pathology present, and that further research is still required.