Parent Training Interventions for Attention Deficit Hyperactivity Disorder

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Parent Training Interventions for Attention
Deficit Hyperactivity Disorder

• Morris Zwi Jane Dennis
• Hannah Jones, Camilla Thorgaard , Ann York

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Context

• Started Oct 1999 _at_ SRTU, ICH
• ADHD still controversial overuse of stimulants?
  
• Interested in non-drug interventions in ADHD
• Key ADHD Systematic Reviews (Jadad Miller)
• Biggest RCT in ADHD treatments (MTA)

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Slowest ever Systematic Review?!

• NHS job with no designated research time
• Secretary for Health drive on waiting lists
• Searches needed repeated updating

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Searches

• Inception to 2004 6671
• 2004 to 2006 1542
• 2006 to 2008 1579
• 2008 to 2009 1280
• 2009 to 2010 1889

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Included Studies

• 12,691 records (minus duplicates) identified in
  searches
• Full texts of 112 papers examined
• Many investigators had to be contacted to supply
  further data before decisions on inclusion could
  be made.
• Included 5 unique studies (cited in six papers)
  
• Excluded 74 unique studies (reported in 89
  documents)

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Included Studies

• 5 trials, 284 participants, compared PT vs
  Treatment as usual
• Four trials assessed childrens ADHD
  symptom-related behavioural problems
• Two focused on childrens behaviour at home
• Two focused on behaviour at school

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Included Studies

• Blakemore 1993
• Fallone 1998
• Lehner-Dua 2001
• Van den Hoofdakker 2007
• Mikami 2010

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Results

• Four studies targeted childrens behaviour
  problems and one assessed changes in parenting
  skills
• Two focused on behaviour at home
• Two focused on behaviour at school

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Results

• Behaviour at home
• One found no difference between parent training
  and treatment as usual
• The other reported statistically significant
  results for parent training versus control

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Results

• Behaviour at school
• One found no difference between groups
• The other reported positive results for parent
  training when ADHD was not co-morbid with
  oppositional defiant disorder
• Better for girls for children on medication

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Results

• Only able to conduct meta-analysis for two
  outcomes
• Externalising Behaviour
• Internalising Behaviour

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Externalising behaviour

• conflict with others
• aggression
• rule-breaking
• oppositional behaviour

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Internalising behaviour

• Behaviours where stress appears to be directed
  against the self
• anxiety
• depression
• somatic problems
• social withdrawal

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Results
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Parenting Stress Index domains

• Child Domain

• Parent Domain

• Distractibility/Hyperactivity
• Adaptability
• Reinforces Parent
• Demandingness
• Mood
• Acceptability

• Competence
• Social Isolation
• Attachment to Child
• Health
• Role Restriction
• Depression
• Spouse

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Key methodological challenges

• Poor methodological quality of the included
  studies and consequent risk of bias
• Inclusion criteria limited to parent training
  only, excluding trials where parent and child
  interventions occurred simultaneously
• Heterogeneity within ADHD Parent Training
• Missing data e.g. ADHD-specific behaviour, school
  achievement adverse effects

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Campbell/Cochrane reviews too restrictive?

• Protocol editors requested exclusion of trials
  where parent and child interventions occurred
  simultaneously
• Seminal ADHD trials excluded e.g. MTA
• Age limit Excluded trials involving
  predominantly preschool children, though this
  group are possibly the most receptive to PT
• Co-morbidity an issue with trials cohorts
  assembled with focus on ADHD or Conduct Disorder
  etc.

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LaForrett comments in EBMH 2012

• Focus narrowed to RCTs
• Raises questions about how PT effectiveness is
  evaluated and implications for practice
• Conclusions differ from other syntheses with
  expanded review criteria that include non-RCTs
• Improving childrens academic achievement was
  investigated as an important outcome, potentially
  creating misconceptions about the role of parent
  training in ADHD

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LaForrett comments in EBMH 2012

• Experimental studies examining parent training in
  isolation
• Should be weighed against currently recommended
  multimodal treatment approaches
• Including direct involvement of the child,
  particularly as the child gets older

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Conclusions

• Parent Training may have a positive effect on the
  behaviour of children with ADHD
• Poor methodological quality of the included
  studies increases the risk of bias in the results
• Data concerning ADHD-specific behaviour are
  ambiguous

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Conclusions

• Parent Training may reduce parental stress and
  enhance parental confidence
• Data lacking for many important outcomes,
  including school achievement and adverse effects
• We need to consider expanding the inclusion
  criteria to reflect clinical practice and include
  multi-modal trials

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