Does Poverty Moderate Psychosocial Treatment Efficacy for ADHD? A Systematic Review

Objective: To determine the extent to which children in poverty show differential benefit versus non-impoverished peers when undergoing behavioral treatment for ADHD. Method: Multiple readers conducted a systematic review using four research databases, one national treatment database, and multiple recent reviews and meta-analyses to identify appropriate studies. Results: Of 1192 initial search results, only five studies met inclusion criteria and were fully abstracted. Conclusion: Results suggest mixed evidence that low-income children may benefit less, compared with peers from higher income families, from psychosocial treatment for ADHD. Findings point to the need for more consistent, more precise, and higher quality reporting of income information.

Practitioner Review: Current best practice in the use of parent training and other behavioural interventions in the treatment of children and adolescents with attention deficit hyperactivity disorder

BACKGROUND

Behavioural interventions are recommended for use with children and young people with attention deficit hyperactivity disorder (ADHD); however, specific guidance for their implementation based on the best available evidence is currently lacking.

METHODS

This review used an explicit question and answer format to address issues of clinical concern, based on expert interpretation of the evidence with precedence given to meta-analyses of randomised controlled trials.

RESULTS

On the basis of current evidence that takes into account whether outcomes are blinded, behavioural intervention cannot be supported as a front-line treatment for core ADHD symptoms. There is, however, evidence from measures that are probably blinded that these interventions benefit parenting practices and improve conduct problems which commonly co-occur with ADHD, and are often the main reason for referral. Initial positive results have also been found in relation to parental knowledge, children's emotional, social and academic functioning - although most studies have not used blinded outcomes. Generic and specialised ADHD parent training approaches - delivered either individually or in groups - have reported beneficial effects. High-quality training, supervision of therapists and practice with the child, may improve outcomes but further evidence is required. Evidence for who benefits the most from behavioural interventions is scant. There is no evidence to limit behavioural treatments to parents with parenting difficulties or children with conduct problems. There are positive effects of additive school-based intervention for the inattentive subtype. Targeting parental depression may enhance the effects of behavioural interventions.

CONCLUSIONS

Parent training is an important part of the multimodal treatment of children with ADHD, which improves parenting, reduces levels of oppositional and noncompliant behaviours and may improve other aspects of functioning. However, blinded evidence does not support it as a specific treatment for core ADHD symptoms. More research is required to understand how to optimise treatment effectiveness either in general or for individual patients and explore potential barriers to treatment uptake and engagement. In terms of selecting which intervention formats to use, it seems important to acknowledge and respond to parental treatment preferences.

Factor Structure of the Conners' Teacher Rating Scale-Short Form in a Low-Income Preschool Sample

The Conners' Teacher Rating Scale (CTRS) is among the most commonly used rating scales for the evaluation of childhood behavior disorders. This study examined the structural characteristics of the CTRS in a sample of 235 low-income, primarily African American, preschool children. Children were rated on the CTRS by an assessment research assistant, an intervention research assistant, and a classroom teacher. Multiple exploratory factor analyses converged on the same basic three-factor solution. The three factors could be labeled Hyperactivity/Impulsivity, Inattention, and Oppositional Behavior. This three-factor solution did not correspond to the published factor structure of the CTRS. Instead, it more closely paralleled consensus ratings of experts in the field of child psychology and the criteria for behavior disorders according to the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV; American Psychiatric Association, 1994).

Conduct Problems and Treatment across Home and School: A Review of the Literature

Treatment of conduct problems in the home setting has received much attention in the literature, and there are well established, empirically derived treatment programs that have been demonstrated to be effective. However, treatment for conduct problems in the classroom has not received a comparable amount of attention, and the intervention programs are diverse, occasionally lacking empirical support, and often not consistent with strategies used in the home setting. As past research has demonstrated that conduct problems in multiple settings is related to poorer prognosis, it is logical to suggest that interventions should focus on as many of the settings as possible in which a child displays the behaviour problems. This paper reviews the literature on the effects of conduct problems in the classroom, on teacher managerial skills, and on interventions across the home and school settings. It is concluded that classroom management of conduct problems could be improved by providing a hierarchical system of intervention strategies.

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.

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.

Cognitive Processes Underlying the Behavior Change in Cognitive Behavior Therapy with Childhood Disorders: A Review of Experimental Evidence

While Cognitive Behavior Therapy (CBT) has been widely used for treatment of childhood disorders, the process underlying the success of CBT in this area is still unclear. This paper attempts to examine empirically the above issue, using the literature from 1974 to 1989 to see whether there is support for the underlying changes in cognitive processes that are assumed to mediate the therapy. The results show that while CBT is relatively effective in treating some childhood disorders, there is little empirical evidence to support the underlying cognitive models of childhood disorders.

[Effectiveness of parent training for children with ADHD in routine clinical practice]

Studies on the effectiveness of parent trainings, especially for children treated with stimulants, yielded conflicting results. This study investigated the effectiveness of parent training (PT) as a part of routine clinical care. Compared to a waitlist control (n=16) PT-mothers (n=16) reported significantly fewer ADHD-symptoms, better acceptance of their children and a trend to better relationship satisfaction. No differences were found between children treated with or without stimulants. Contrary to the high level of consumer satisfaction fathers didn't report any improvements on all outcome domains.

Direct comparisons of treatment modalities for youth disorders: a meta-analysis

A meta-analysis was conducted to determine whether differences in efficacy exist among treatment approaches applied to youth. Included were all studies published between 1980 and 2005 involving participants 18 years of age or younger with diagnoses of depression, anxiety, conduct disorder, and attention-deficit/hyperactivity disorder that contained direct comparisons among two or more treatment methods intended to be therapeutic. Effect sizes were found to vary significantly, providing some evidence that differences in efficacy exist among treatments for these disorders in youth. However, the upper bound of the true difference in effects among treatments was small. Furthermore, researcher allegiance was found to be strongly associated with the difference in effect sizes so that when allegiance was controlled there was no evidence of any differences among treatments.

A pilot study of the feasibility and efficacy of the Strategies to Enhance Positive Parenting (STEPP) program for single mothers of children with ADHD

OBJECTIVE

The Strategies to Enhance Positive Parenting (STEPP) program was developed to address putative factors related to poor engagement in and outcomes following traditional behavioral parent training (BPT) for single mothers of children diagnosed with ADHD.

METHOD

Twelve single mothers of children with ADHD were enrolled in an initial investigation of the feasibility and preliminary efficacy of the 9-week STEPP program.

RESULTS

Results indicated that the STEPP program was effective in reducing problematic child behavior and improving parental stress and psychopathology at posttreatment. The STEPP program resulted in high rates of treatment attendance and completion and consumer satisfaction with the program. However, results also indicated that the STEPP program did not improve childrens' overall psychosocial impairment and resulted in small effect size findings across measures.

CONCLUSION

The results of the pilot study are encouraging but indicate a need to improve the potency and delivery of certain aspects of the STEPP program.

Efficacy of methylphenidate, psychosocial treatments and their combination in school-aged children with ADHD: a meta-analysis

INTRODUCTION

This meta-analysis compares effect-sizes of methylphenidate and psychosocial treatments and their combination on ADHD, concurrent oppositional, conduct symptoms, social behaviors and academic functioning.

METHOD

Several databases (PubMed, PsycInfo, ISI Web of Science) were searched for articles published between 1985 and September 2006. Inclusion criteria were: a diagnosis of ADHD; age from 6-12 years; a randomized controlled treatment design; efficacy established with parent and teacher rating scales; psychosocial treatments used were described as behavioral or cognitive-behavioral; the methylphenidate treatment was short-acting; and finally, treatment was conducted in a clinical setting.

RESULTS

ADHD outcomes showed large mean weighted effect-sizes for both methylphenidate and combined treatments, psychosocial treatments had a moderate mean weighted effect-size; a similar pattern emerged for oppositional and conducted behavior symptoms. Social behavior outcomes showed comparable moderate mean weighted effect-sizes for all treatments, while on academic functioning, all treatments had low mean weighted effect-sizes. There was no correlation between duration of psychosocial treatment and effect-size.

CONCLUSIONS

Both methylphenidate and psychosocial treatments are effective in reducing ADHD symptoms. However, psychosocial treatment yields smaller effects than both other treatment conditions. Psychosocial treatment has no additional value to methylphenidate for the reduction of ADHD and teacher rated ODD symptoms. However, for social behavior and parent rated ODD the three treatments were equally effective. For improvement of academic functioning no treatment was effective.

Empirically tested psychotherapies for youth internalizing and externalizing problems and disorders

This article is a review of specific psychotherapies that have been supported in clinical trials. Treatments that showed significant effects in studies published over a period of 4 decades were identified, with the goal of complementing the overall picture of treatment benefit provided in narrative reviews and meta-analyses with a detailing of the specific interventions that have shown significant effects. The article focuses on treatments for four broad clusters of problems and disorders that account for a very large proportion of youth mental health referrals: anxiety, depression, attention-deficit/hyperactivity, and conduct.

Children with ADHD treated with long-term methylphenidate and multimodal psychosocial treatment: impact on parental practices

OBJECTIVE

To test the hypothesis that multimodal psychosocial intervention, which includes parent training, combined with methylphenidate significantly enhances the behavior of parents of children with attention-deficit/hyperactivity disorder (ADHD), compared with methylphenidate alone and compared with methylphenidate and nonspecific psychosocial treatment (attention control).

METHOD

One hundred three children with ADHD (ages 7-9), free of conduct and learning disorders, who responded to short-term methylphenidate therapy were randomized for 2 years to receive either (1) methylphenidate treatment alone; (2) methylphenidate plus psychosocial treatment that included parent training and counseling, social skills training, academic assistance, and psychotherapy; or (3) methylphenidate plus attention control treatment. Parents rated their knowledge of parenting principles and negative and positive parenting behavior. Children rated their parents' behavior.

RESULTS

Psychosocial treatment led to significantly better knowledge of parenting principles but did not enhance parenting practices, as rated by parents and children. Significant improvement in mothers' negative parenting occurred across all treatments and was maintained.

CONCLUSIONS

In nonconduct-disordered, stimulant-treated children with ADHD, parent training does not improve self-rated parental behavior. The benefits of brief stimulant treatment for negative parental behavior are sustained with extended treatment.

Achieving the goal of evidence-based psychiatric rehabilitation practices for mothers with mental illnesses

There is a growing commitment to evidence-based practices in mental health. There is no well-articulated evidence base for interventions for mothers with mental illnesses. Parenthood is common among women with mental illnesses. Women themselves report motherhood is an important role. The risks of parental mental illness to children have been demonstrated; the challenges that motherhood brings to people with mental illnesses have been described. Because outcomes for both children and adults are multiply determined, there are many intervention opportunities. Recommendations for intervention are drawn from a focus group study and from the existing literature on parent training and support, exemplary programs for mothers with mental illnesses, and other evidence-based psychosocial interventions. The value of a psychiatric rehabilitation approach is highlighted. Challenges in documenting and testing interventions for mothers with mental illness include resource allocation and research innovation.

The Conners' Parent Rating Scales: a critical review of the literature

The Conners' Parent Rating Scales (CPRS) have undergone a considerable amount of scrutiny--and subsequent refining, reshaping, and revising--since their development in 1970. While such longitudinal scrutiny has ultimately led to a more reliable, valid assessment tool, it has left behind a wake of literature filled with misinformation and ambiguity. Multiple versions of the Conners' Rating Scales (CRS), their misuse, and inaccurate reporting by researchers have created a body of literature that is difficult to interpret and misleading to both researchers and clinicians. This review is aimed at clarifying issues regarding the proper use of the CPRS as both a diagnostic instrument and a research tool.

Evaluation of a short-term group therapy program for children with behavior problems and their parents

The current study investigated the effectiveness of a short-term, cognitive behavioral program for 106 primary school-aged children referred with externalizing behavior problems and their parents, compared with 39 children and their parents on a waiting-list to be treated. Exploring Together' comprised a children's group (anger management, problem-solving and social skills training), a parents' group (parenting skills training and dealing with parents' own issues), and a combined children's and parents' group (to target parent-child interactions). The program reduced children's behavior problems and improved their social skills at home. Changes in children's behaviors and social skills at home were generally maintained at 6- and 12-month follow-up. Implications of the findings for improving interventions for childhood externalizing behavior problems are discussed.

The outcome of parent training using the behavior management flow chart with mothers and their children with oppositional defiant disorder and attention-deficit hyperactivity disorder

The effects of parent training, using parameters established in the Behavior Management Flow Chart, on mother behavior and on the disruptive behavior of eight children who emitted behavior consistent with the diagnoses of both Oppositional Defiant Disorder and Attention-Deficit Hyperactivity Disorder were evaluated. There are important differences between the Behavior Management Flow Chart and well-known parent-training programs that are based on the Hanf model. Parent training was conducted within a multiple baseline design across children. Direct observation of mother and child behavior, phone interviews, and standardized rating scales showed that training improved parenting behavior, reduced maternal stress, and reduced oppositional child behavior. A 6-month follow-up revealed that parenting and child behavior remained stable. The results are comparable with prior research on behavioral parent training for families that have children with oppositional/hyperactive behavior.

Empirically supported psychosocial treatments for attention deficit hyperactivity disorder

Reviews and evaluates psychosocial treatments for attention deficit hyperactivity disorder (ADHD) in children and adolescents according to Task Force Criteria (Lonigan, Elbert, & Johnson, this issue). It is concluded that behavioral parent training and behavioral interventions in the classroom meet criteria for well-established treatments. Cognitive interventions do not meet criteria for well-established or probably efficacious treatments. Issues regarding the evaluative process are discussed and future directions for psychosocial treatment for ADHD are outlined.

Mother-child interactions and noncompliance in hyperactive boys with and without conduct problems

Mother-child interaction, and parent ratings of child noncompliance and defiance among hyperactive boys with conduct problems (H/CP), hyperactive boys without conduct problems (H), and normal boys (N) were compared. Results indicated more negative mother-child interactions and more noncompliance in the H/CP group than in the other two groups. The H group was more noncompliant than normal children, but these groups showed no differences in defiance, nor in the behaviour of mothers. The implications of these findings in relation to the development of conduct problems in hyperactive children, treatment and research are discussed.

Parent training for attention-deficit hyperactivity disorder: its impact on parent functioning

This study examined changes in parent functioning resulting from parental participation in a behavioral parent training (PT) program specifically designed for school-aged children with attention-deficit hyperactivity disorder (ADHD). Relative to wait list controls, subjects who completed the nine-session PT program showed significant posttreatment gains in both child and parent functioning, which were maintained 2 months after treatment. In particular, there were PT-induced reductions in parenting stress and increases in parenting self-esteem, which accompanied parent-reported improvements in the overall severity of their child's ADHD symptoms. In addition to their statistical importance, these findings are discussed in terms of their clinical significance, utilizing methods developed by Jacobson and Truax (1991).

Attention deficit disorders in children and adolescents

Children and adolescents who present with inattention, impulsivity, and hyperactivity constitute a large portion of the behavior problems seen in pediatric patients. Attention deficit disorders are associated with various other childhood conditions that need to be investigated systematically. Multimodality treatment includes psychoeducational counseling, pharmacotherapy, behavior management, school interventions, family therapy, and social skills training. This article summarizes recent scientific and clinical research into this complex biopsychosocial disorder and presents a comprehensive guide to its evaluation and management.

Sex differences in school-aged children with pervasive attention deficit hyperactivity disorder

This study investigated 54 children (37 boys and 17 girls) with cross-situational attention deficit hyperactivity disorder (ADHD) to determine whether there are sex differences in the expression of either the primary or secondary symptomatology of ADHD. Results indicated that the male and female ADHD groups were strikingly similar on all measures of primary (impulsivity, inattention, and overactivity) and secondary (learning problems, externalizing symptoms, internalizing symptoms, peer relationship difficulties, and self-perceptions) symptomatology included in this study. The lack of significant sex differences conflicts with prior reports in the literature, and these conflicting results are discussed in terms of differences in inclusion criteria. Implications for understanding the long-term outcome of ADHD in girls are also discussed.