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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5267_Библиотеки_им_академика_М_И_Перельмана
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with comparable contact times but lacking the active therapeutic components of the
experimental intervention. Studies were excluded if the comparison group received an
active and potentially therapeutic intervention. The included studies varied in relation
to two key characteristics of the sample populations that might impact on the effec-
tiveness of a psychological intervention – the medication status and age of the chil-
dren with ADHD.
Ten trials met the eligibility criteria set by the GDG, providing data on 549 partic-
ipants. All were published in peer-reviewed journals between 1997 and 2007. In addi-
tion, 71 studies were excluded from the analysis. The most common reasons for
exclusion were related to study design or because there was no appropriate interven-
tion. One study of a parent-training intervention was excluded from the analysis as
the level of attendance was poor to the extent that any difference between the inter-
vention and control groups might not be attributable to the intervention
(BARKLEY2000). In this trial only 13% of parents assigned to parent training
attended a minimum of nine out of 14 sessions, and while the majority did attend at
least one session (67%) under half (42%) attended a minimum of five sessions. The
children in this study also differed somewhat from others as they were younger (mean
age 4.8 years) and were included on the basis of a parent measure of disruptive behav-
iour (14 symptom items for ADHD and eight symptom items for oppositional defiant
disorder). Further information about both included and excluded studies can be found
in Appendix 17.
In trials where participants continued to receive usual care medication for ADHD,
the type and dose of medication participants received might vary. This contrasts with
trials of combination treatment for ADHD, where both the pharmacological and
psychological interventions are determined by the study protocol. As discussed
above, the GDG concluded that trials of combination treatment for ADHD should
be excluded from the analysis of the effectiveness of psychological interventions
for children with ADHD, even where they had a group on medication only that could
be compared with a group receiving medication plus a psychological intervention
(studies of combination treatment for ADHD are reviewed in Chapter 11). Studies
were also excluded if the intervention and comparison groups differed in terms of
their receipt of medication for ADHD. The Multimodal Treatment Study of Children
with ADHD (MTA) (MTA Co-operative Group, 1999a) was therefore excluded as
two-thirds of the community care comparison group received medication for ADHD
whereas the group receiving the intensive MTA behavioural intervention did not
receive medication.
In all included studies, the psychological interventions were broadly based on CBT
principles, with the different approaches used reflecting clinical practice for the age
range of the study population. The studies involving only pre-school children with
ADHD looked at parent-training interventions (BOR2002; SONUGA-BARKE2001),
as did the studies involving school-age children with ADHD where the mean age of
participants was under 8 years (HOATH2002; HOOFDAKKER2007). Studies involv-
ing participants with a mean age of 8 or 9 looked at the effects of work with both
the child and the parents or family (BLOOMQUIST1991; FEHLINGS1991;
PFIFFNER1997; TUTTY2003) or just the child (ANTSHEL2003; GONZALEZ2002).
Psychological interventions and parent training
159
Psychological interventions and parent training
160
Five of the included studies were three-arm trials. For the purposes of this review,
only two arms of each trial were included in the analysis. For BLOOMQUIST1991
and PFIFFNER1997, Group 1 and 3 were included; for BOR2002 and GONZALEZ
2002, Group 2 and 3 were included; for SONUGA-BARKE2001, Group 1 and 2 were
included (further information about each group can be found in Appendix 17).
No RCTs of family therapy interventions for ADHD were identified that allowed
a comparison between the family therapy intervention and a control condition.
7.2.5 Clinical evidence for psychological interventions
for children with ADHD
Important study population characteristics and a summary of the evidence are
presented in Table 6. The associated forest plots can be found in Appendix 18.
Psychological intervention versus control
Total number of studies (number 10 (549)
of participants)
Study ID ANTSHEL2003
BLOOMQUIST1991
BOR2002
FEHLINGS1991
GONZALEZ2002
HOATH2002
HOOFDAKKER2007
PFIFFNER1997
SONUGA-BARKE2001
TUTTY2003
Study population characteristics
Pre-school children with ADHD BOR2002
SONUGA-BARKE2001
School-age children with ADHD ANTSHEL2003
BLOOMQUIST1991
FEHLINGS1991
GONZALEZ2002
Table 6: Study information and evidence summary table
for trials of psychological interventions
Psychological intervention versus control
HOATH2002
HOOFDAKKER2007
PFIFFNER1997
TUTTY2003
Not on medication for ADHD BOR2002
FEHLINGS1991
SONUGA-BARKE2001
Some on treatment-as-usual HOATH2002
medication for ADHD HOOFDAKKER2007
PFIFFNER1997
All on treatment-as-usual ANTSHEL2003
medication for ADHD GONZALEZ2002
TUTTY2003
Medication status unclear BLOOMQUIST1991
Benefits (end of treatment)
Core ADHD symptoms at end of SMD 0.25 (0.56 to 0.07)
treatment (teacher-rated) Quality: High
K 4, N 163
Core ADHD symptoms at end of SMD 0.57 (1.00 to 0.14)
treatment (parent-rated) Quality: Moderate
K 5, N 288
Conduct at end of treatment SMD 0.12 (0.61 to 0.38)
(teacher-rated) Quality: Moderate
K 3, N 63
Conduct at end of treatment SMD 0.54 (1.05 to 0.04)
(parent-rated) Quality: Moderate
K 5, N 231
Social skills at end of treatment SMD 0.40 (1.33 to 0.54)
(teacher-rated) Quality: Moderate
K 1, N 18
Social skills at end of treatment SMD 0.59 (1.80 to 0.61)
(parent-rated) Quality: Low
K 2, N 138
Social skills at end of treatment SMD 0.23 (0.61 to 0.15)
(child-rated) Quality: High
K 1, N 120
Table 6: (Continued)
Continued
Psychological interventions and parent training
161
Psychological interventions and parent training
162
Psychological intervention versus control
Emotional outcomes at end of SMD 0.20 (1.12 to 0.73)
treatment (teacher-rated) Quality: Moderate
K 1, N 18
Emotional outcomes end of SMD 0.36 (0.73 to 0.01)
treatment (parent-rated) Quality: High
K 2, N 112
Self-efficacy at end of treatment SMD 0.03 (0.48 to 0.42)
(child-rated) Quality: High
K 3, N 78
Benefits (3–6 months post-treatment)
Core ADHD symptoms at SMD 0.05 (0.44 to 0.35)
5–6 months post-treatment Quality: High
(teacher-rated) K 2, N 101
Core ADHD symptoms at SMD 0.91 (1.23 to 0.59)
5–6 months post-treatment Quality: High
(parent-rated) K 3, N 174
Conduct at 3–4 months SMD 0.13 (1.05 to 0.80)
post-treatment (teacher-rated) Quality: Moderate
K 1, N 18
Conduct at 3–5 months SMD 0.51 (1.01 to 0.01)
post-treatment (parent-rated) Quality: High
K 2, N 68
Social skills at 3–4 months SMD 0.06 (0.98 to 0.86)
post-treatment (teacher-rated) Quality: Moderate
K 1, N 18
Social skills at 3–4 months SMD 0.06 (0.29 to 0.42)
post-treatment (parent-rated) Quality: High
K 2, N 138
Social skills at 3 months SMD 0.04 (0.34 to 0.42)
post-treatment (child-rated) Quality: High
K 1, N 120
Emotional outcomes at SMD 0.19 (1.11 to 0.74)
3–4 months post-treatment Quality: Moderate
(teacher-rated) K 1, N 18
Table 6: (Continued)
7.2.6 Clinical evidence summary for psychological interventions
for children with ADHD
For individual outcomes, the quality of the evidence was generally moderate to high.
Overall, the evidence shows that compared with control conditions psychological
interventions for children with ADHD have moderate beneficial effects on parent
ratings of ADHD symptoms and conduct problems at the end of treatment. These
beneficial effects are sustained at follow-up 3 to 6 months after the end of treatment.
If the small study by Pfiffner and McBurnett (PFIFFNER1997) is excluded from the
analysis the effect of psychological interventions on conduct problems at the end of
treatment remains positive, but beneficial effects do not reach statistical significance
at the later follow-up. The meta-analysis therefore cannot be regarded as establishing
that psychological interventions have sustained effects on conduct problems in chil-
dren with ADHD. There is no evidence that psychological interventions for children
with ADHD have positive effects on teacher ratings of either ADHD symptoms or
Psychological intervention versus control
Emotional outcomes at SMD 0.04 (0.89 to 0.96)
3–4 months post-treatment Quality: Moderate
(parent-rated) K 1, N 18
Self-efficacy at 5 months SMD 0.89 (1.70 to 0.08)
post-treatment (child-rated) Quality: Moderate
K 1, N 26
Dichotomous outcomes
Leaving study for any reason Data not pooled
ANTSHEL2003: 0% (psychological inter-
view) versus 0% (control)
BLOOMQUIST1991: 31% versus 0%
BOR2002: 31% versus 16%
FEHLINGS1991: 0% versus 0%
GONZALEZ2002: not reported
HOATH2002: 10% versus 0%
HOOFDAKKER2007: 2% versus 2%
PFIFFNER1997: 0% versus 0%
SONUGA-BARKE2001: 7% total
TUTTY2003: 9% versus 0%
Non-responders RR 0.49 (0.27 to 0.88)
Quality: High
K 1, N 48
Table 6: (Continued)
Psychological interventions and parent training
163
Psychological interventions and parent training
164
conduct-related behaviours. Beneficial effects of psychological interventions for
ADHD therefore do not appear to transfer to the classroom environment.
In the absence of evidence that psychological interventions have a positive effect
on teacher ratings of ADHD symptoms and conduct behaviour, the evidence of bene-
ficial effects based on ratings by parents should be interpreted with some caution.
Parent ratings may be potentially subject to bias because in trials of psychological
interventions for children with ADHD that do not use a control intervention, parents
will know whether they and/or their child has received the intervention. Even where
teachers are also aware which children are receiving the intervention it is possible that
there is a greater risk of bias in parents’ ratings as they have more invested in the child
and may therefore be less objective. However, it is impossible to determine whether
bias has contributed to the findings on parent outcomes; indeed an alternative expla-
nation for the discrepancy between parent and teacher ratings is that behavioural
symptoms are less severe in the more structured classroom environment. There is
therefore less scope for a psychological intervention to deliver measurable benefits.
A further consideration is that the primary focus of psychological interventions,
particularly parent-training interventions and other interventions that involve the
parents or family as a whole, may be to improve behaviour in the home environment,
in which case greater improvements might be expected in parent ratings of behaviour.
With respect to the other outcomes that it was considered might be targeted by
psychological interventions, or on which psychological interventions might have a
greater impact (social skills, emotional state as represented by internalising symp-
toms and anxiety, self-efficacy and academic performance), beneficial effects were
not generally in evidence. Positive effects were detected for self-efficacy at follow-up
3 to 6 months after the end of treatment, but this finding comes from only one small
study that reported a self-efficacy outcome at this follow-up time point
(FEHLINGS1991). At the end of treatment neither this trial nor the overall meta-
analysis pointed to positive effects of psychological interventions on self-efficacy,
and the one finding at follow-up therefore cannot be taken as establishing an effect of
psychological interventions on self-efficacy in children with ADHD.
Unfortunately, owing to the limited number of RCTs meeting inclusion criteria,
there was insufficient data to allow robust sub-analyses to be performed to look at the
circumstances in which psychological interventions might be effective for children
with ADHD. Questions of particular interest are whether:
● psychological interventions are effective in the subgroup of children with ADHD
not on medication for ADHD
● psychological interventions are effective in the subgroup of children with ADHD
continuing to receive medication for ADHD as part of their usual care
● psychological interventions are effective in pre-school children with ADHD
● psychological interventions are effective in school-age children with ADHD
● psychological interventions targeting parents are effective for children with ADHD
● psychological interventions targeting children with ADHD are effective
● psychological interventions targeting both children and parents, and family inter-
ventions, are effective for children with ADHD
● psychological interventions delivered to groups are effective for children with ADHD
Psychological interventions and parent training
165
● psychological interventions delivered individually are effective for children with
ADHD.
However, it is notable that when separate analyses were undertaken for trials
where participants were not on medication (BOR2002; FEHLINGS1991; SONUGA-
BARKE2001) and for trials where some or all of the participants were on continuing
medication for ADHD or where no details of the medication status of participants were
given (ANTSHEL2003; BLOOMQUIST1991; GONZALEZ2002; HOATH2002;
HOOFDAKKER2007; PFIFFNER1997; TUTTY2003), similar effects or trends were
found to those reported in the overall analysis. While only tentative inferences can be
drawn from these sub-analyses, they tend to support the validity of analysing trials
with participants not on medication and trials with participants on usual care medica-
tion together. The analysis conducted here therefore suggests that CBT interventions
for ADHD can have beneficial effects whether delivered in the absence of medication
or as an adjunct to continued routine medication for ADHD.
The evidence for the benefits of CBT for children with ADHD is based on stud-
ies including children between 3 and 13 years. In all the studies that included children
up to 12 or 13 years the mean age was 9 or under and children aged 12 or over were
more than one standard deviation above the mean age for the sample (ANTSHEL2003;
FEHLINGS1991; GONZALEZ2002; HOOFDAKKER2007; TUTTY2003). One
other study of CBT for school-age children with ADHD did not specify the age
range, but participants were drawn from a US ‘elementary school’ population
(BLOOMQUIST1991). The RCT evidence on the effects of CBT for children there-
fore does not apply to adolescent populations with ADHD.
7.2.7 Clinical evidence for other interventions with parents/carers
for children with ADHD
For the review of other interventions with parents/carers for children with ADHD,
important study characteristics and a summary of the evidence are presented in Table 7.
The forest plots can be found in Appendix 18.
Parent training is included in the review of the effectiveness of psychological inter-
ventions for ADHD (see 7.2.5) because it is to all intents and purposes a behavioural
intervention in that the parents are taught to use behavioural training techniques with
their child. Other types of intervention targeting the parents or main carer may also aim
to address the child’s ADHD symptoms. Studies were included where they were RCTs
that compared a group receiving an intervention for parents or carers of children with
ADHD (other than parent training) with a control group not receiving the intervention.
Only studies giving outcome data for the child with ADHD were included (outcomes
for parents were not included in the analysis). Studies were only included if the medica-
tion status of the children in the intervention and control groups was comparable.
7.2.8 Clinical evidence summary for other interventions
with parents/carers for children with ADHD
One small trial (32 families) of psychoeducation for parents of children with ADHD
(LONG1993) met the inclusion criteria for this review. In this study, parents were
Psychological interventions and parent training
166
given a manual outlining various behavioural techniques for managing oppositional
child behaviour. The findings suggest that children with ADHD may benefit from
their parents being given written material on behavioural management techniques
(see Table 7). Outcomes measured around 2 months after the material was given to
parents point to a significant benefit of the intervention on teacher ratings of conduct
problems. While parent ratings of ADHD symptoms and conduct problems favoured
the intervention, neither reached significance (teacher ratings of ADHD symptoms
were not reported). Given the focus of the intervention on the management of oppo-
sitional behaviour an effect on conduct problems might be expected. These findings
indicate that a larger-scale RCT of a similar psychoeducation intervention might be
of value to clarify whether written materials on behavioural management are an effec-
tive intervention for ADHD symptoms and other behavioural problems associated
with ADHD.
While there are other interventions for parents and carers of children with ADHD,
including counselling, CBT and peer support groups, these are more directed at
improving the parents’ or carers’ well-being and helping them cope, for example by
teaching stress management techniques or providing mutual support. Such interven-
tions would have been included in the review if there were RCTs that reported
outcomes for the child with ADHD. Studies of support for parents and/or carers that
only reported outcomes for the parents were excluded, however, because they were
outside the scope of the guideline.
Psychological intervention versus control
Total number of studies 1 (32)
(number of participants)
Study ID LONG1993
Benefits
Core ADHD symptoms SMD 0.69 (1.41 to 0.03)
(parent-rated) Quality: Moderate
K 1, N 32
Conduct (parent-rated) SMD 0.71 (1.43 to 0.01)
Quality: Moderate
K 1, N 32
Conduct (teacher-rated) SMD 1.01 (1.75 to 0.27)
Quality: Moderate
K 1, N 32
Table 7: Study information and evidence summary table for trials of other
interventions with parents or carers for children with ADHD
RCTs of approaches currently used to support parents and carers of children with
ADHD would be valuable. In order to determine whether those interventions are
effective for ADHD, study protocols would need to include measures of outcomes for
the child, particularly measures of ADHD symptoms and conduct problems.
7.2.9 NICE guidance on parent-training/education programmes
in the management of children with conduct disorders
NICE, in collaboration with the Social Care Institute for Excellence (SCIE), recently
published a technology appraisal (TA) on the use of parent-training/education pro-
grammes for the management of children with conduct disorders (NICE, 2006a). In
the context of this TA the term ‘conduct disorders’ is used to refer to conduct disor-
der and oppositional defiant disorder and the term ‘parent’ applies to the main carer
of the child. Conduct disorders are characterised by a repetitive and persistent pattern
of antisocial, aggressive or defiant conduct and are often seen in association with
ADHD. The high prevalence of comorbid conduct disorders in children with ADHD
– estimates suggest that somewhere between 43% and 93% of children with ADHD
will have a comorbid conduct disorder (Jensen et al., 1997) – supports the generali-
sation of this TA to children with ADHD, and in particular those who have conduct
problems in addition to core ADHD symptoms.
For children with ADHD, the relevance of the TA is further supported by the rela-
tively inclusive population sample and by the inclusion of populations with comor-
bidities including ADHD. The evidence on which the guidance is based comes from
studies that include a wider population than just those with diagnosed conduct disor-
ders. Studies were included where children were defined as having behavioural prob-
lems either by scales that measure aspects of child behaviour or by descriptive criteria
without any attempt to classify or grade behaviour.
In seven of the included studies some or all children had ADHD – indeed while
only 24% of the total sample had diagnosed conduct disorders, over 12% either had
a diagnosis of ADHD or were on stimulant medication (some of those with ADHD
had comorbid conduct disorders). Furthermore, though the actual level of ADHD in
the sample population on which the guidance is based is impossible to determine, it
is likely to be substantially higher than 12%. First, this estimate does not include stud-
ies where some participants with ADHD are included in the sample but there are no
details of the number of participants with coexisting conditions. Second, in studies
where participants have diagnosed conduct disorders, and in the absence of the exclu-
sion of comorbid populations or details on comorbidity, it might be assumed that the
proportion of participants who have comorbid ADHD would be consistent with the
estimates of the prevalence of ADHD in children with conduct disorders in
the general population. Third, studies that include children with behaviour problems,
whether defined by behavioural scales or descriptively, are likely to include children
with ADHD unless coexisting conditions are explicitly excluded. Conversely,
it should be noted that a number of the studies included in the analysis for the
TA excluded children receiving treatment – a criterion which would exclude some
Psychological interventions and parent training
167
children with ADHD but which might not necessarily exclude children with ADHD
who were not receiving treatment at the time of recruitment for the trial.
The TA along with a summary of the supporting background information in
the guidance document is given below (for more detailed information see
www.nice.org.uk/TA102/NICE, 2006).
Guidance from the NICE TA102
The TA guidance on parent-training/education programmes in the management of
children with conduct disorders only applies to the management of children aged
12 years or younger or with a developmental age of 12 years or younger. The
guidance states:
1. Group-based parent-training/education programmes are recommended in the
management of children with conduct disorders.
2. Individual-based parent-training/education programmes are recommended in the
management of children with conduct disorders only in situations where there are
particular difficulties in engaging with the parents or a family’s needs are too
complex to be met by group-based parent-training/education programmes.
3. It is recommended that all parent-training/education programmes, whether group-
or individual-based, should:
● be structured and have a curriculum informed by principles of social-learning
theory
● include relationship-enhancing strategies
● offer a sufficient number of sessions, with an optimum of 8–12, to maximise
the possible benefits for participants
● enable parents to identify their own parenting objectives
● incorporate role-play during sessions, as well as homework to be undertaken
between sessions, to achieve generalisation of newly rehearsed behaviours to
the home situation
● be delivered by appropriately trained and skilled facilitators who are super-
vised, have access to necessary ongoing professional development, and are
able to engage in a productive therapeutic alliance with parents
● adhere to the programme developer’s manual and employ all of the necessary
materials to ensure consistent implementation of the programme.
4. Programmes should demonstrate proven effectiveness. This should be based on
evidence from randomised controlled trials or other suitable rigorous evaluation
methods undertaken independently.
5. Programme providers should also ensure that support is available to enable the partici-
pation of parents who might otherwise find it difficult to access these programmes.
Parent-training/education programmes for conduct disorders
The main goals of parent-training/education programmes for conduct disorders are to
enable parents to improve their relationship with their child and to improve their
child’s behaviour. Interventions are structured, with the key components documented
so that programmes can be reliably applied by different workers with appropriate
training. Many programmes are conducted primarily with the parents and involve no
Psychological interventions and parent training
168
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