Behavioral Interventions Effective for ADHD

Deborah Brauser

July 31, 2014

Using behavioral interventions to treat children and adolescents with attention-deficit/hyperactivity disorder (ADHD) can improve both child and parent functioning, new research suggests.

A meta-analysis conducted on behalf of the European ADHD Guidelines Group of 32 studies of young people with the disorder showed that families who received behavioral interventions had significant improvements in parenting and parental self-concept, as well as improvements in comorbid conduct problems in the children.

"The key message from our paper is that behavioral interventions such as parent training are an important component of multimodal treatments for ADHD," coinvestigator Edmund J. S. Sonuga-Barke, PhD, professor of developmental psychopathology at the University of Southampton in the United Kingdom and visiting professor at the University of Ghent, told Medscape Medical News.

He added that this is not necessarily because of their effects on ADHD symptoms "but rather because they can improve parenting, increase social functioning, and reduce oppositional and defiant behavior."

The study was published in the August issue of the Journal of the American Academy of Child and Adolescent Psychiatry.

Broader Outcomes

The investigators note that they wanted to build on a recent meta-analysis led by Dr. Sonuga-Barke to address a broader range of child and parent outcomes. They also wanted to determine answers to the following 3 questions:

  • Do behavioral interventions improve adult responses to children with ADHD?

  • For adults working with these children, do the interventions improve their sense of competence while also decreasing their own mental health problems?

  • Do these interventions decrease levels of child oppositional behavior and impairment in social skills and academic performance?

The researchers conducted a systematic review of randomized controlled trials (RCTs) published up to February 5, 2013, of individuals between the ages of 3 and 18 years who were diagnosed with ADHD. Of these, 32 trials were included in the current analysis.

The participants in the RCTs received either a "control condition" or behavioral interventions, which were defined as increasing desired behaviors and decreasing undesired behaviors through classic contingency management, cognitive-behavioral therapy, and behavioral therapy through parent or teacher mediators. All were implemented in a home or school setting.

The control conditions included treatment as usual (including medication) or wait listing.

Outcome measures included improvements in positive and negative parenting (assessed in 9 and 14 trials, respectively); anxiety, depression, or other mental health behavior in parents (assessed in 9 trials); and parenting self-concept/sense of competence (assessed in 7 trials).

Other measures focused specifically on the children and included improvements in ADHD symptoms (assessed in 19 of the studies), conduct problems (assessed in 15 trials), and academic achievement and social skills (assessed in 9 trials each).

Frontline Treatment?

Results from the "usually unblinded" assessment trials showed that the families who went through behavioral interventions had significantly improved scores in positive and negative parenting (standardized mean difference [SMD], 0.68 and 0.57, respectively) and parenting self-concept (SMD, 0.37), as well as in child ADHD symptoms (SMD, 0.35), conduct problems (SMD, 0.26), academic performance (SMD, 0.28), and social skills (SMD, 0.47).

Higher-quality trials measuring ADHD symptoms yielded larger effects. Plus, metaregression showed larger effect sizes in the studies with younger children for most positive parenting (P = .03), ADHD symptom (P = .05), and conduct problem (P = .03) measures.

In the "probably blinded" RCTs, significant improvements persisted for the behavioral interventions group in positive and negative parenting (SMD, 0.63 and 0.43, respectively) and in child conduct problems (SMD, 0.31).

None of the trials had a probably blinded measurement for ADHD symptoms. In addition, there were no significant effects of treatment in any of the studies in parental mental health measures.

"Although more evidence is required before behavioral interventions can be supported as a front-line treatment for core ADHD symptoms, [we] found evidence that they do have beneficial effects on parenting and parents' sense of empowerment and independently corroborated effects on conduct problems in children with ADHD," write the investigators.

They add that probably blinded analyses are also needed to confirm their findings of improved academic achievement and social skills. Plus, "greater exploration is needed on the moderating impact of child age on intervention outcome."

Clear Benefit

"Effective treatment for [ADHD] is crucial given the well-documented chronic and impairing nature of the disorder," Linda J. Pfiffner, PhD, professor of psychiatry at the University of California, San Francisco, writes in an accompanying editorial.

She notes that stimulant medications and behavioral interventions are 2 of the most studied treatments for ADHD.

"Professional practice guidelines usually recommend either treatment or both treatments for ADHD depending on age and severity of symptoms," she writes. "Owing to limitations of each treatment, multimodal approaches are often recommended."

Dr. Pfiffner adds that the current meta-analysis shows "clear benefits" of behavioral interventions on some parent and child outcomes. She notes that it also shows that "focusing on decreasing ADHD symptoms as an outcome underestimates the important and broader impact of behavioral interventions."

She reports that functional impairment or conduct problems are what often prompt families to seek treatment ― and that they are typically the key targets of behavioral interventions.

"As noted by the investigators, the findings on functional impairment are especially important given that medication generally has had limited effects on these domains," she writes.

She adds that treatment research still has several continuing challenges, especially when it comes to outcome measures.

"There is...a need for greater clarity and consensus about levels of evidence required for drawing conclusions about the efficacy of an intervention. In addition, there is no clear system for evaluating and interpreting mixed outcomes within and across studies," writes Dr. Pfiffner.

"A multi-method, multi-informant approach to evaluating treatments has the potential to provide a far more nuanced picture of treatment efficacy than single approaches and better matches the complexities inherent in treating ADHD and its associated impairments," she adds.

"Ultimately, these approaches seem best equipped to inform clinical decision-making and guidelines for practice."

Dr. Pfiffner has reported no relevant financial relationships. The study authors have noted several disclosures, which are listed in the original article.

J Am Acad Child Adolesc Psychiatry. 2014;53:830-832, 835-847.e5. Abstract, Editorial

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