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Is behavioral intervention an alternative medicine in childhood/adolescent ADHD?

Young, Miu-ning.; 楊妙寧. Young, M. [楊妙寧]. (2012). Is behavioral intervention an alternative medicine in childhood/adolescent ADHD?. (Thesis). University of Hong Kong, Pokfulam, Hong Kong SAR. Retrieved from http://dx.doi.org/10.5353/th_b4842720 2012

http://hdl.handle.net/10722/179950

The author retains all proprietary rights, (such as patent rights) and the right to use in future works.

IS BEHAVIORAL INTERVENTION AN ALTERNATIVE MEDICINE IN CHILDHOOD / ADOLESCENT ADHD

YOUNG MIU NING

A project submitted in partial fulfillment of the requirements for the Master of Public Health at the University of Hong Kong August 2012

Abstract of the project entitled: IS BEHAVIORAL INTERVENTION AN ALTERNATIVE MEDICAL THERAPY FOR ADHD CHILDREN/ ADOLESCENT

Submitted by YOUNG MIU NING For the degree of Master of Public Health at the University of Hong Kong in August 2012

Objectives: The objective of this project is to examine the effectiveness of nonpharmacological intervention - behavioral therapy for ADHD children so as to determine whether this is as an alternative medical therapy for ADHD children.

Background: Attention Deficit and Hyperactivity Disorder (ADHD) is the most common neurobehavioral disease in child. Symptoms can continue through adolescence and adulthood. Children suffering from ADHD disorders have symptoms of hyperactivity, failure to concentrate on activities and poor behavioral control. There are three sub-types of ADHD disorder, namely; hyperactive dominant type, inattentive dominant type and combined type. There are increasing numbers of children who are referred to child psychiatrists with an ADHD diagnosis internationally. In Hong Kong, ADHD contributes the majority of patients seen in child psychiatric clinics. The prevalence rate of ADHD in Hong Kong is 6.1% in primary school students and represents a ii

similar rate to that reported worldwide. Despite pharmacological treatment being effective in treating ADHD disorders, most children with ADHD have behavioural problems. Hence, improving daily functioning by improving behaviour, peer and family relationship by behavioural treatment is warranted. Moreover, drug use in treating ADHD is a concern. This project examines the evidence concerning non-pharmacological interventionsbehavioral therapy for children with ADHD.

Methods: A literature search was conducted via Medline, PubMed and Google, to find relevant studies reviewing the effectiveness of non-pharmacological interventions for ADHD children.

Result: Nine articles were identified that matched the inclusion criteria for this review. These studies concern behavioral interventions for ADHD children and include a range of behavioral and cognitive behavioral approaches. Two of these nine articles provided evidence that for pre-school children aged up to six years old, parent-training programs were effective in improving ADHD symptoms. Six of these nine articles provided evidence that for school aged children providing mixed Cognitive Behavioral Therapy (CBT) and Social Skills Training (SST) along with parallel group sessions for parents are beneficial to ADHD children. One of these nine articles provided evidence that CBT is beneficial in adopting appropriate coping skills in ADHD children. iii

Conclusions: In views of the concerns about use of drug therapy for ADHD, behavioral intervention appears to be feasible and potentially effective as an alternative medicine for children with ADHD.

Keywords: ADHD, children, adolescent, behavioral intervention, cognitive behavioral intervention and psychological intervention

-An abstract of exactly 365 words-

iv

Declaration

I declare that this project represents my own work, except due acknowledgement is made, and that it has not been previously included in a thesis, dissertation or report submitted to this University or to other institution for a degree, diploma or other qualification.

Signed ………………………………………………………………………………….. YOUNG MIU NING

v

Acknowledgements I would like to express my whole heated gratitude to my beloved family members for giving me endlessness support, encouragement and tolerance throughout the years of my MPH study. I would also like to thanks my supervisor Professor C. Mary Schooling in giving me guidance and advice on my project. Last but not least, great thanks would go to my friends for their great encouragement in my endeavor.

vi

List of tables and diagrams

Diagram 1: Flow chart of search result………………………………………………..9

Abbreviations ADHD

Attention Deficit and Hyperactivity Disorder

BFI

Behavioural Family Intervention

BPT

Behavioural Parent Training

BSS

Behavioural and Social Skills

CBCL

Children Behaviour Checklist

CBT

Cognitive Behavioral Therapy

CDC

Centre for Disease Control and Prevention

CLAS

Child Life and Attention Skills Program

DSM

Diagnostic Statistical Manual of Mental Disorder

EBFI

Enhanced Behavioural family intervention

NICE

National Institute for Health and Clinical Excellence

RCC

Routine Clinical Care

RCT

Randomized Control Trails

SCRS

Self Control Rating Scale

SSRS

Social Skills Rating System

SST

Social Skills Training

SST-PG

Social Skills Training –parent mediated generalization

vii

Table of Contents Abstracts………………………………………………………………………………ii Declaration…………………………………………………………………………….v Acknowledgements…………………………………………………………………...vi List of Tables and Diagrams………………………………………………………….vii Abbreviations………………………………………………………………………...vii Chapter 1- Introduction 1.1

The ADHD Disorder…………………………………………………..1

1.2

Causes of ADHD ……………………………………………………...1

1.3

Prevalence of ADHD in Hong Kong…………………………………. 2

1.4

Impact of ADHD………………………………………………………3

1.5

Treatment of ADHD 1.5.1 Drug treatment…………………………………………………3 1.5.2 Behavioural intervention for children with ADHD…………....4

1.6

Behavioral intervention as a non-pharmacological treatment of ADHD…………………………………………………………………4

1.7

Aims and Objectives…………………………………………………..6

Chapter 2 – Method……………………………………………………………………7 Chapter 3 – Results 3.1

Descriptions of the selected studies……………………………………8

3.2

Clinical Evidence of BT for children with ADHD…………………….9

3.3

Effective behavioural intervention for ADHD 3.3.1 Characteristic of Behavioral intervention for Pre-school children ………………………………………………………10 viii

3.3.2 Behavioral intervention for School aged children by using CBT and Social Skills Training……………………………………10 Chapter 4 – Discussion 4.1

Issues of implementing behavioral intervention as an alternative medicine to children with ADHD 4.1.1 Applicability and feasibility………………………………….13 4.1.2 Cost…………………………………………………………...13 4.1.3 Certain Group may not be Benefit for BT……………………14 4.1.4 Others………………………………………………………...15

4.2

Limitations 4.2.1 Studies with uneven quality and different outcomes…………15 4.2.2 Potential bias…………………………………………………17 4.2.3 Generalizability ……………………………………………...17

4.3

Further Research 4.3.1 Effectiveness of group-based training for young children…...18 4.3.2 Effectiveness of non-pharmacological treatment for adult with ADHD ……………………………………………………………….18 4.3.3 Effectiveness of environmental manipulation and recreational activity ……………………………………………………………….18 4.3.4 Effect of provide training to teacher for behavioral management of children with ADHD…………………………………....................19 4.3.5 Identification of children with ADHD and early referral.........19

Chapter 5

Conclusion……………………………………………………………20

Appendix……………………………………………………………………………..22 References……………………………………………………………………………32 ix

Chapter 1 Introduction

1.1 The ADHD disorder Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common childhood chronic neurobehavioral disorders1, 5. This disorder can continue through adolescence and adulthood

1-2

. As the name implies, over-activity, difficulty paying

attention and difficulty controlling behavior are the core symptoms of ADHD. By definition, there are three types of ADHD, including hyperactive and impulsive dominate type, inattentive dominate type and combined type3. Generally, ADHD symptoms appear between the ages of 3 to 6 years1. ADHD affects children in different ways depending on which disorder is dominant. For children with predominately the inattention type of ADHD, they experience difficulty in organizing work, easily get distracted, have short attention span and have difficulty following rules, completing task and organizing activities 3-5. For the predominately hyperactive and impulsive type, children have symptoms of difficulty waiting for their turn, difficulty staying seated as required, interrupting others and talking excessively. For the combined type, children may experience most of the above symptoms and it represents the most common type among children with ADHD 3-5. The Diagnostic and Statistical of Mental Disorder (DSM) is a tool to define ADHD internationally2.

1.2

What causes ADHD Up until now, the causes of ADHD are not known. Although genes may play a

part in ADHD, like many other illnesses, ADHD is caused by a combination of other factors. Beside genetics, researchers are looking for other factors, such as brain injury, 1

environmental factors, nutrition and social environment that might be associated with ADHD 6-15. As regards genetic factors6-8 children with ADHD have thinner brain tissues responsible for attention, however, when they grow older, symptoms may improve. Moreover, if parents or close relatives have ADHD; their children will have a 30% chance of ADHD5. Many lifestyle and environmental attributes have been suggested as related to ADHD. Cigarette smoking and alcoholic consumption during pregnancy have potential links with ADHD.9-10 The idea that sugar consumption or refined sugar may cause ADHD or make ADHD symptoms worse is popular. 11-13 However, studies suggest that there are no behavior difference for those consuming more or less sugar or sugar substitutes. Some studies have suggested a link between food additives and ADHD, such as artificial colorings and preservatives.

14

However, more studies need

to be conducted before confirmation. Some children with ADHD have a history of brain injuries; however, not many children with ADHD suffered from previous brain injury. 2Discordant family relations could also be associated with ADHD. 15

1.3

Prevalence of ADHD in Hong Kong ADHD is an increasingly familiar term in Hong Kong. It is exhibited by the

majority of patients seen in child psychiatry Out Patient Departments 16-17. According to a local study, 6.1% of Chinese schoolboys suffered from ADHD and 3.9% in early adolescence. Boys are more frequently affected than girls to reports from other countries worldwide 18-21.

2

16-17

. These data are similar

1.4

Impact of ADHD Learning disorders, oppositional defiant disorders, conduct disorder, anxiety

and depression are coexisting disorders in ADHD. Studies suggest that seeking help early gives a better outcome for children and their families

22

. As core symptoms of

ADHD continue into adolescence for 80% and into adulthood for 65%, this impairs development23. Hyperactivity and impulsivity can cause several kinds of adolescent maladjustment, such as lack of friends, work, leisure activities and lower quality of life

24-25

. As the major ADHD symptoms continue, other problems may become

obvious, such as antisocial problems, substance abuse, poor academic performance as well as social maladjustment 25. Furthermore, other studies also suggest that ADHD affects the quality of life of parents with an ADHD child 26. It is not only incurs intangible cost to family, such as productivity losses due to absenteeism from work and school, but also an emotional burden with family relationship strained due to parenting distress and marital discord 26-29

1.5

.

Treatment of ADHD

1.5.1 Drug treatment Treatment can help ADHD children with daily activities as well as learning. However, medication only works to improve ADHD symptoms but it is not a curative measure. The most commonly used medications are stimulants, such as, methylphenidate and amphetamine30. About 75% of patients found them effective31. Medication increases concentration, improves academic performance and behavior control, but is not a curative measure for ADHD 3

30-31

. On the other hand,

there are side effects that cause somatic complaints, such as stomach aches and headaches. From a psychological perspective, children may feel they are less sociable and have a sense of not feeling effective. Stigma issues also raise concerns, for example, children may be afraid of laughing by others and might hide the fact that they are on medication31. Furthermore, other psychological concerns, such as frustration, anger and embarrassment that made them leave the classroom have been documented31.

1.5.2 Behavioral Intervention for children with ADHD According to the National Resource Centre on ADHD32, psychological intervention is a crucial element of treatment for ADHD in children and adolescents. ‘Behaviorally oriented psychosocial treatments, also called behavior therapy32’ (BT) for ADHD is important because children with ADHD have to face day to day challenges with impairment 33-35, including poor academic achievement and poor relationships with parents and siblings. Factors that predict how children with ADHD will do in adulthood include how he or she gets along with other children, any effective parenting skills and success in school performance36-37. In addition, by using behavioral therapy, it teaches parents and teachers skills to assist them in dealing with ADHD children35, thus, it is possible that BT should be started as soon as a child is diagnosed.

1.6

Behavioral Intervention as a non-pharmacological treatment of ADHD There are several reasons to study non-pharmacological interventions for

ADHD children as there are limitations and objections to medications. Using stimulants to treat ADHD symptoms are the predominant pharmacological 4

management. Although this kind of treatment can reduce ADHD core symptoms, the long term effects are in question. The effect may not last long term or be maintained into adolescent 38. In addition, some studies suggest that the effect of medication only lasts as long as the clients are on medication. When medication was stopped, the effect was lost 39. Researchers are investigating other non-pharmacological interventions so as to lengthen drug effects. Children suffering from ADHD also experience other problems besides ADHD symptoms40. These problems affect the children, such as low self esteem and poor peer relationships. On family aspects, problems such as maternal stress and depression as well as alcohol misuse by fathers have been found 40. Furthermore, by using stimulants in ADHD, effects on academic performance and learning are in doubt38. There are significant numbers of ADHD children, who are not responding to medical treatment 41. These groups of clients warrant alternative intervention for their needs. On the other hand, there are children responding to medicine but the effects do not meet the clinical need42. Other interventions which can enhance drug effects would be valuable. There are significant numbers of children who are intolerant of the side effects of the medicine which causes them to terminate treatment. Studies found that 15% of children treated with stimulant-methylphenidate stopped their treatment at 4 months due to side effects43. Some young children who suffer from ADHD may need medicine as treatment. However,

by the

recommendation of the

pharmacological

manufacturers,

methylphenidate is not recommended for children under the age of six years. As such other alternative treatment is needed 38. 5

For ethical reasons, religious reasons or other unexplained reason, there are some professionals, parents; ADHD children who have objections to medicine 44

.There might have a wide range of concerns that affect the acceptance of medicine,

such as stigmatization of ADHD, fear of side effects and long term harms.

1.7

Aims and Objectives In order to address the question whether behavioral intervention is an

alternative medical treatment for ADHD children/adolescents, this project aims to summarize and examine the effectiveness of behavioral interventions as a treatment for ADHD children, and the potential of applying behavioral interventions as an alternative to pharmacological management of ADHD symptoms. Moreover, we explored the issues regarding the application of behavioral intervention in ADHD children, and the areas for further research.

6

Chapter 2 - Method

A systematic approach was implemented to identify, analysis and reach a conclusion from studies which examined the effect of behavioral interventions as a treatment for ADHD children and adolescents. Searches of Medline, PubMed as well as Google were used to identify research from 1990 to 2012. Relevant references in identified papers were used to conduct a manual search as well. However, the researcher did not seek agreement from other researchers for the selection. The whole process was conducted by the researcher alone. The search terms: (behavioral intervention OR cognitive behavioral intervention OR psychological Intervention) AND (ADHD*) AND (children OR adolescent) were used throughout. The inclusion criteria were RCTs that compared a behavioral intervention with a control group which had control conditions including without treatment, treatment as usual and assignments to waiting lists. However, articles of combination treatment for ADHD were excluded. Furthermore, studies other than research articles, For example, review, editorial, comments were excluded. Articles written in languages other than English or without full text available were also excluded. After screening according to the inclusion criteria, the content of each study was studied in detail for applicability of the study to the research questions. Furthermore, Jadad Score was used to assess the methodological quality of the studies. Methodical features

including

randomization, blinding and withdraw or dropout were assessed, and a quality grading given. In order to facilitate comparison of each study, important information was recorded in a table format. For example, sample size, study design; quality grading, outcome measure and main finding were recorded. Details are in appendix 1.

7

Chapter 3 – Result 3.1 Description of the selected studies The literature search generated 260 articles. After screening the titles and abstracts, there were 36 citations left. These articles were examined in-depth and 9 articles met all the inclusion criteria, therefore, these articles were included in this review. All the 9 selected articles45-53 were randomized controlled trails (RCTs). The sample size of these articles ranged from 26 to 120. Age of the subjects ranged from ages 3 to 12 years. Seven of the trials were carried out in the USA. One trial was from the Netherlands. The 9 randomized trials included a total of 664 participants. There were all of children aged between 3 and 12 years old. All participants included in this study were diagnosed with ADHD or ADHD with comobidity. Diagnostic criteria were using tools based on international DSM diagnostic systems. On medication aspect, among the 9 studies, there were 3 studies where participants were not on medication for ADHD

51-53

and 3 studies where some of the participants were on treatment as usual

medication for ADHD

46-47, 50

. For the other 3 studies, all participants were on usual

intervention as medication for ADHD 45, 48-49. In all included studies, the non-pharmacological interventions were based on Cognitive Behavioral Therapy (CBT) training or Education

52-53

51

, Behavioral Therapy (BT)

as well as Social Skills Training (SST)

45, 47, 50

46, 48, 49

, Parent

. There were

2 studies involving only pre-school children looking at parent training interventions5253

. There were 5 studies involving school-aged children with ADHD, to evaluate the

effects of work with the child and their families at just the effect of work with the child 45, 51. 8

46-50

. The remaining 2 studies looked

Three included studies were three-arm trials. In this project, 2 arms of each trial were included. Thus, For Pfiffner 1997

46

, the control group and social skills

training with parent mediated-generalized were included. For Bor 2002 52, the control group and Standard Behavioral Family Intervention group (SBFI) were included. For Gonzalez 2002

45

, only the control group and Parent teaching of Stress management

group were included.

An initial set of 260 potentially relevant articles were identified to be screened based on title and abstract

224 articles excluded because they do not meet the inclusion criteria or are not related to the research question

36 articles retrieved for full text evaluation After in-depth evaluation, 27 articles excluded as they do not meet inclusion criteria or are not related to the research question

9 articles used in this literature review

Diagram 1: Flow chart of search result

3.2

Clinical evidence for Behavioral Interventions for children with ADHD In general, according to the studies, there were positive effects according to

parents’ ratings of the reduction in ADHD symptoms and conduct problems when comparing the behavioral intervention with the control conditions. These effects were sustainable at 3 to 6 months after the end of treatment. However, these effects were 9

not found in teacher ratings. As such, the beneficial effects did not appear to transfer to the classroom. On the other hand, regarding other outcomes measures, such as social skills, emotional state, anxiety, academic achievement and self-efficacy that were targeted by psychological treatment, beneficial effects were not evident. An exception is a small study

47

where a positive effect of psychological interventions on self efficacy were

noted three to six months after the end of treatment.

3.3

Effective Behavioral Interventions for ADHD In this project of behavioral intervention treatment for ADHD children, eight

studies found that BT improved outcomes for children with ADHD. Details information can be found in the reference tables depicted at Appendix I.

3.3.1 Characteristic of Behavioral Intervention for pre-school children Parental training was an effective treatment in two studies. These two studies involved parents with pre-school children

52-53

. Parental training was effective in

structured interventions on an individual participant basis. The characteristics of these studies were structured interventions. Information about ADHD was given to parents and an active learning technique, such as role play, to give role modeling and active feedback, individual assignments, use of diaries and observations were used.

3.3.2 Behavioral Intervention for school aged children by using CBT and Social Skills Training Four studies showed beneficial effects of behavioral interventions on ADHD symptoms jointly with conduct rating, social skills rating and self-efficacy rating 10

46,47,48,51

.

In one study46, researchers used social skills training as the main intervention; it contained an element of parent training so as to reinforce skills acquired by child participants. In another study

48

social skills interventions were the main training for

children on top of parents learning parenting skills and behavioral management interventions in separate groups. In such case, no matter the target was social skills or behavior, the Behavioral Intervention exhibited positive effects on core ADHD symptoms. One study

51

used CBT as a teaching technique to teach ADHD children in

home settings, by teaching problem solving skills, which included problem identification, setting goals, initiating problem solving strategies, choosing a solution and making evaluations. Furthermore, studies also employed active learning techniques, which included role modeling, role play and homework assignments in keeping with the situation at home. Using tokens as a reward was used as reinforcement of learning gains. In addition, there were 2 studies 46, 48 where they held individual sessions for parents to learn what is ADHD and have training in CBT methods. They were encouraged to use reinforcement on behavior in homework given to each child participant. Two studies used mixed SST/CBT

46, 48

delivered in group sessions in one

study. 51 The CBT treatment was conducted in individual sessions. For one study 50, using separate child and parent groups, positive results were not found. Another study49 employed social skills training with parent training domain, but it only comprised three sessions of giving information of the programme and guideline on monitoring of homework assignments given to the child. There are significant and consistent findings among all BT programs 11

regardless of duration and this allows helpful inferences to be made. For pre-school children52, parent training was conducted by specifically trained therapists, of 8 and 10 sessions lasting for 1 to 1.5 hours. For school aged children, CBT or SST intervention consisted of eight and twelve sessions lasting fifty to ninety minutes. For parents training, eight sessions lasting fifty to hundred and twenty minutes were conducted by specially trained facilitators.

12

Chapter 4 – Discussion 4.1

Issues related to implementation of behavioral intervention as an

alternative medicine to children with ADHD

4.1.1 Adaptability and feasibility Although evidence on the relationship between waiting time to be diagnosed and outcome of ADHD children are not well established

54

, from the parents’

perspective, it is a key issue to be considered. In general, the journey from referral to the child diagnosis of ADHD, takes several months in Hong Kong. Parents naturally are keen on having the child’s disorders addressed soonest. For pharmacological treatment, the optimum dosage can be achieved in 6 weeks, and it is generally perceived as providing symptomatic relief rapidly. Behavioral intervention, no matter if it is parent education/ training, cognitive behavioral training or social skills training, takes 8-10 weeks. In this context, this may discourage or lower the incentive to some parents to agree to Behavior Therapy without medication. In addition, significant waiting time for psychological treatment may further discourage parents; hence, it may affect recruitment, adherence and skills acquisition. On the contrary, for parents who have concerns about the use of drug treatment for ADHD, behavioral interventions appear to exhibit an applicable and potentially effective alternative treatment method for ADHD children54.

4.1.2 Cost Economic analysis54 suggests that group-based parent training or education programmes as well as CBT for school aged children are probably cost effective for ADHD children. On the contrary, parent training in individual session is not a cost 13

effective. Thus, research on examining the long term benefits and cost savings related to parent training or education programmes for ADHD children is needed in the future. Furthermore, to confirm the similarity and efficacy between group and individual interventions, head to head comparisons are needed. As such, it may further establish the evidence of cost effectiveness of group based parent training.

4.1.3 Certain group may not be benefit from behavioral therapy Regarding the delivery of treatment, behavioral intervention may be beneficial for ADHD children both in group delivery and individual contexts 52. Adherence is also an important element in treatment effectiveness

52, 53

. If the programmes are not

attractive or seen as pertinent, it may be difficult to recruit adequate numbers to facilitate the programme getting started. If the drop - out rate is high, it may incur adverse effects on functioning of the remaining group members, such as cohesiveness of the group and mutual support. Likely, participants are strongly convinced to be involved especially given the commitment of time and inconvenience involved. Parents as well as children may need to commit themselves for 1 to 1.5 hours per week over a 8 to 12 week period. Child care arrangements and leave from work pose problems for many parents who have other children and have to work. To involve the father or parents, sounds desirable, but may pose problems for many families as they need to take time off from work in Hong Kong. Furthermore, studies in this review mainly examined the effect of behavioral interventions on children with ADHD, all participants were from age 3 to age 12 years52,

53

. The effects for children of age 13 and older of using psychological

intervention need to be further explored. CBT and social skills interventions may be 14

more applicable to young children. Whether, this can be transferred to adult populations with ADHD again needs further research.

4.1.4 Others A growing number of physicians believe that drug treatment alone is not as effective as combined with parent training and classroom behavioral intervention. The combination of treatment of medication with behavioral intervention may yield best results in children with ADHD

55

. It seems that the moderate beneficial effect of

psychological intervention alone evidence is not strong enough to change the psychiatrist’s practice 32.

4.2

Limitation

4.2.1 Studies with uneven quality and different outcomes Even though all the studies in this review were RCTs, the nature of the experimental behavioral treatments for ADHD children was heterogeneous. It is difficult to identify which specific interventions are the major contributors to the beneficial effects of intervention. In general, investigation of the effectiveness of treatment of ADHD involved not only children, but also their parents as well as teachers. Meta analysis is a significant statistical tool to offer a synthesis of data in a rigorous systematic review. Thus, in further update, researcher should consider to conduct meta analysis to help in assessment of the clinical effectiveness of healthcare intervention and look for presence of heterogeneity so as to have a more precise quantitative estimate in review. However, meta-analysis is difficult to implement with the heterogeneous outcomes found here. In one study, although the focus of treatment was on the ADHD child, parents 15

were also involved

50

. The involvement included information on treatment content as

it was aimed at encouraging parents to reinforce what the children learnt in the treatment sessions.

In some studies, with similar reasons, there were teachers’

involvements as well47. Studies with parent training interventions may also include the child. In the experimental treatment, the interventions consisted of several sessions with a therapist or trainer. The techniques or approach might have therapeutic value; it included CBT, social skills training. The result of effectiveness of intervention might not be specified. Blinding to participants or personnel involved likely was not possible, however, it is possible to practice blinding of raters to the participants. The majority of the selected studies did not report blinded rating except one

48

. This might

contributed to bias as well. There were two studies

46-47

where the teachers and families were paid for the

trials at follow up; which might lead to selection of participation and completion from those who are inclined to this incentive. The other study did not state the number of medicated children in the intervention and control group. Uneven distribution of subjects could not be excluded. In some studies 52-53, children had comorbid disorders, co-medication were not reported in these studies. This might contribute to bias. Studies only rating by participants may contribute to biased reporting of improvement after intervention49, also in that study, free treatment for those participants meeting the inclusion criteria for the study, this secondary gain may have contributed to bias in the rating.

16

4.2.2 Potential Bias There may be potential bias when identifying articles for this project. Simple methods were used to search two scientific databases. As such, it may under-represent some local journals. Citations bias may occur as references list often display articles which support their argument. In this project, only full text articles written in English were included, it might miss some qualitative articles and research, as such, some important information on psychological intervention of ADHD children might be missed. Publication bias is a kind of reporting bias in systematic reviews. Publication bias in this project could not be excluded, as it is difficult to identify missing or unreported studies. A search of a comprehensive trial registry would have identified recent trials but not older trials, if the outcomes had been more homogenous a funnel plot could have been used.

4.2.3 Generalizability All the nine studies included in this project were conducted in western countries. The generalization of findings to the local environment may not be satisfactory. As different culture norms of child rearing and different expectations from parents, teachers and children, such as of academic performance as well as most of the families having working parents, this might further impose problem practicing parent training or parent education. Moreover, the long commitment in taking classes may further impose problem. Furthermore, small sample sizes with limited participants might hinder generalize finding to our local community.

4.3

Further Research Despite the needs of more rigorous studies are crucial, more researches on 17

different areas are need. 4.3.1 Effectiveness of group based parent training for young children The evidence on parent-training or education is mainly based on studies of younger children and plays an important part in the management of ADHD, however, the effect and cost effectiveness is not well documented for school aged children and younger children. As such, head to head RCTs to evaluate the effect of group based parent training and drug treatment in school aged and young children with ADHD in terms of symptoms improvement, cost effectiveness and quality of life is warranted.

4.3.2 Effectiveness of non-pharmacological treatment for adults with ADHD Well established evidence suggests drug treatment of ADHD improves symptoms and other impairments35. ADHD in adults is strongly associated with drug misuse and personality disorders. However, evidence for non drug treatment specifically having benefits for these aspects of life is not well established. Thus, RCTs to evaluate whether non pharmacological treatments such as behavioral interventions are more effective than pharmacological treatments in reducing ADHD symptoms, improving quality of life and are cost effective is suggested.

4.3.3 Effectiveness of environmental manipulation and recreational activity During the search process other studies were found. A recent laboratory study suggested the significant of stimulation seeking and delay aversion in maintenance of ADHD symptomatology

56

. Hence, to evaluate the effectiveness of recreational

activities, such as music therapy, play therapy or exercise for symptom reduction in ADHD is suggested. If it demonstrated cost effectiveness for people with ADHD, the intervention could be carried out by wide range of professionals, carers or even 18

ADHD patients themselves.

4.3.4 Effect of providing training to teachers in behavioral management of children with ADHD Teachers are the personnel that children and young people have closest contact with. They have potential to play an active role in behavioral management in school for students with ADHD. RCTs to evaluate the effectiveness of training teachers in behavioral management and to look at academic attainment or improvement in ADHD is a possibility, but might conflict with the teacher’s other duties. Furthermore, students going from primary to secondary school might encounter negative impact, because they are expected to be independent and well organized. If teachers could take an active role in behavioral management in school, it might be effective. One study showed a promising result 57.

4.3.5

Identification of children with ADHD and early referral As there is no universal screening of ADHD, teachers may benefit by

receiving training on spotting children with ADHD symptoms, then the process of early referral can be initiated and intervention could start as early as possible. However, unless there is good evidence that early intervention is effective such screening would not be beneficial. Students spend a great proportion of time in school, further research to evaluate the effectiveness of raising the awareness of teachers in ADHD symptoms, could be beneficial if early identification leads to early referral and early effective intervention in terms of behavioral and academic improvement.

19

Chapter 5 – Conclusion

Implementation of behavioral intervention is an important intervention for students with ADHD so as to improve core ADHD symptoms and behavioral control. As a whole, the evidence demonstrates that behavioral treatments with ADHD have beneficial effects on parent ratings of improvement in ADHD symptoms and conduct problems. However, given it was less effective from the teacher’s perspective, when the teacher’s would have been unaware of the intervention, it is difficult to know whether this was a real improvement. The benefit was apparent both for children on medication and as an addition to routine medication for ADHD. Slightly different approaches are recommended for pre-school children and school aged children. For pre-school children, a well structured parent training intervention conducted by specially trained therapist with a duration of 8 to 10 sessions lasting for 1 to 1.5 hours based on behavioral learning and active learning principles is suggested. By providing information on ADHD, role play and role modeling it might be helpful for ADHD symptoms and conduct problems. For school age children, available evidence supports offering mixed CBT and social skills training along with parallel group sessions for parents of ADHD children. Similarly, regarding intervention duration, 8 to 12 sessions lasting 50 to 90 minutes conducted by specially trained facilitators for the child and 8 sessions lasting 1 to 2 hours for parent training are recommended. However, due to limited numbers of RCTs meeting the inclusions criteria, small sample sizes with a total number of 664 participants in these nine studies, potential publication bias as well as uneven quality of the studies selected. Due to single researcher to conduct articles selection, potential selection bias might also be generated. Then the overall quality of the evidence is not rigorous. Hence, there was 20

insufficient and uneven quality data to allow robust investigation and analysis to look at the circumstances in which behavioral therapy might be effective for children or adolescents with ADHD. Furthermore, questions as to whether behavioral interventions are effective in children with ADHD not on medication for ADHD were not addressed. In sum, for some of the parents, given the concerns about the use of drug treatment for ADHD, behavioral interventions appear to be deliverable and from the parents’ perspective a potentially effective alternative approach for children with ADHD.

21

Appendix: Studies to evaluate the effectiveness of Behavioural Therapy for ADHD children *High Quality #Low Quality Reference # Gonzalez et al, 200245.

Medication Sample and Study Setting/Country Design All on Investigator’s RCT treatment research site or as usual subjects’ home; 3 arms medication for ADHD 42 children with ADHD, age 9-12,

Country: USA

Intervention or Condition

Outcomes

Major Findings

Behavioral Intervention

Pre and Post tested on self –concepts, locus of control and acquisition of coping skills

Acquisition of coping skills in all the three groups had no significant change. However, subjects led by child therapist group reported more appropriate coping

Subjects were randomly allocated to 1.Control group 2. experimental groups leaded by child therapist by teaching of stress management skills 3. experimental groups for teaching of stress management techniques by Parents Duration: 30-45 minutes per session It were held 2 times a week for totally 4 weeks

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Two-way analysis of variance (ANOVAs) was conducted for self-concept, locus of control, and coping strategies data. The ANOVAs did not reveal any significant effects.

Reference # Pfiffner et al, 199746.

Medication Sample and Setting/Country Some on University based treatment paediatric clinic as usual specialized in medication ADHD and for ADHD related disorder; 27 children with ADHD age 8-12

Study Design RCT 3 arms

Intervention or Condition

Outcomes

Major Findings

Social Skills Training

Social skills were rated by parents, teachers by using 30 items scale on a Likert scale: Social Skills Rating System (SSRS).

Parent reports of significant improvement in children’s social skills knowledge and disruptive behavior in experimental groups and these gain sustained at four months follow up.

Subjects were randomly allocated to Social Skills Training for the children (SST) group, Social Skills Training with parent mediated generalization (SST-PG) group or Wait list control group

There were also test of social skill knowledge by interviewers.

Country: USA Duration: Participants in the treatment groups attended 90 minutes group session each week in 8 consecutive weeks. There were per and post intervention assessment and follow up at 3 to 4 months post treatment

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Post Treatment 67 % and 63% of children showing clinically improvement in social skill and problem behavior.

Reference * Pfiffner et al, 200747.

Medication Sample and Setting/country Only 2 of Out Patient the Clinic; participants were taking 69 children in medication age 7-11 of ADHD children with ADHD-I

Study Design RCT

Intervention or Condition

Outcomes

Major Findings

Behavioral Therapy Subjects were randomly allocated to (CLAS) program or control group. There are 3 components in CLAS program including,, parent training, child skills training teacher consultation

Parent and teacher rating on child inattention, and functional impairment by using different inventory:

Duration of session:

The SCT scale

In intervention group, parents report significantly reducing in attention problem and lower severity of inattention symptom. This can be maintained after treatment was completed.

Child skills training: 1.5 hours group sessions in 12Weeks.

Organizational skills

Parent Training: Group session, each session is 1.5 hours, there were 4 to 5 family sessions. Teacher Consultation: Each session was half hour for over viewing of behavioral treatment and in classroom base. There were also 4to 5 times with half hour of teacher, therapist and child meeting over the 12 week period

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Child Symptom Inventory

Clinical Global impression

Children rated by Test of Life Skills knowledge Test for Consumer Satisfaction

Inattention symptoms decreased by >50% from pre to post treatment group and