Parent Training Interventions for Attention Deficity Hyperactivity Disorder (ADHD) in Children Aged 5 to 18 years

Abstract

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder. For a child to be diagnosed with ADHD, adults such as parents, carers, healthcare workers or teachers must have noticed higher levels of inattention, hyperactivity and impulsivity in the child before the age of seven years compared to children of similar age. The inattention, hyperactivity and impulsivity must be observed in a range of situations, for a substantial period of time and cause impairment to the child's learning or social development. Parent training programmes aim to equip parents with techniques to manage their child's ‘difficult’ or ADHD‐related behaviour (that is their inattention and hyperactivity‐impulsivity). We found five randomised controlled studies that met our inclusion criteria. Four set out to improve children's general behaviour and one focused specifically on how parents could help their children make friends. All studies were small and their quality varied. Results from these studies were somewhat encouraging as far as parental stress and general child behaviour were concerned, but were uncertain with regard to other important outcomes including ADHD‐related behaviour. No study provided data on the key outcomes of achievement in school, harmful effects or parent knowledge of ADHD. There was no evidence to say whether parent training is better delivered in groups or individually. The evidence we found was limited in terms of the size of the trials and in their quality, and therefore we do not think it can be used as the basis for guidelines of treatment of ADHD in clinics or schools. We believe more research is needed and that it should ensure better reporting of the study procedures and results. Abstract 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 eighteen years with a diagnosis of ADHD, compared to controls with no parent training intervention. SEARCH STRATEGY 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. 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, I2 = 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, I2 = 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. PLAIN LANGUAGE SUMMARY Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder. For a child to be diagnosed with ADHD, adults such as parents, carers, healthcare workers or teachers must have noticed higher levels of inattention, hyperactivity and impulsivity in the child before the age of seven years compared to children of similar age. The inattention, hyperactivity and impulsivity must be observed in a range of situations, for a substantial period of time and cause impairment to the child's learning or social development. Parent training programmes aim to equip parents with techniques to manage their child's ‘difficult’ or ADHD‐related behaviour (that is their inattention and hyperactivity‐impulsivity). We found five randomised controlled studies that met our inclusion criteria. Four set out to improve children's general behaviour and one focused specifically on how parents could help their children make friends. All studies were small and their quality varied. Results from these studies were somewhat encouraging as far as parental stress and general child behaviour were concerned, but were uncertain with regard to other important outcomes including ADHD‐related behaviour. No study provided data on the key outcomes of achievement in school, harmful effects or parent knowledge of ADHD. There was no evidence to say whether parent training is better delivered in groups or individually. The evidence we found was limited in terms of the size of the trials and in their quality, and therefore we do not think it can be used as the basis for guidelines of treatment of ADHD in clinics or schools. We believe more research is needed and that it should ensure better reporting of the study procedures and results.