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Psychological interventions and parent training
179
Index, which was considered appropriate by the GDG. For the base-case analysis, it
was decided to synthesise data from BOR2002, HOATH2002, SONUGA-
BARKE2001; inclusion of data from PFIFFNER1997 in the meta-analysis of clinical
studies was considered in a sensitivity analysis. Analysis of efficacy data was based
on intention-to-treat. Details of the studies in terms of interventions examined, mode
of delivery, medication status of children, and definition of response are presented in
Table 8. Full details of the studies are provided in Appendix 17.
Utility data and estimation of QALYs In order to express clinical outcomes in
the form of QALYs, utility scores for health states of children with ADHD were
required. Utility scores represent the HRQoL associated with specific health states;
they are estimated using preference-based measures capturing people’s preferences
and perceptions on HRQoL characterising the health states under consideration. The
systematic review of the literature identified four studies providing utility scores for
health states of children with ADHD (Coghill et al., 2004; Gilmore & Milne, 2001;
Matza et al., 2005; Secnik et al., 2005b).
Gilmore and Milne (2001) estimated utility scores for children with ADHD before
and after treatment, using the Index of Health Related Quality of Life (IHRQL). This
index measures three dimensions of HRQoL: pain, social or physical disability and
emotional distress. The authors estimated that, before treatment, children with ADHD
experienced no pain, slight social disability and moderate emotional distress; after
treatment, responders experienced no pain, no physical or social disability, and slight
emotional distress. These health states of the IHRQL translated into utility scores of
0.884 (before treatment) and 0.970 (after treatment – responders).
The study by Coghill and colleagues (2004) was available as a poster presentation;
it reported utility scores for children with ADHD that either responded or did
not respond to treatment, generated from Euro-Qol 5-Dimension (EQ-5D) scores.
The study asked parents of 151 children with ADHD in the UK to fill in EQ-5D
Study Intervention examined Mode of Medication
delivery status
BOR2002 Enhanced and standard positive Individual None
parenting programme
HOATH2002 Enhanced positive parenting Group Some
programme
PFIFFNER1997 Social skills training with parent Group Some
generalisation
SONUGA- Parent training Individual None
BARKE2001
Table 8: Characteristics of the studies examining parent-based therapies for
children with ADHD included in the guideline systematic literature review
Psychological interventions and parent training
180
questionnaires, and then linked the responses with symptom severity or symptom
improvement following treatment, as determined by physicians. EQ-5D is a generic
measure of HRQoL, covering five dimensions of health: mobility, self-care, usual
activities, pain/discomfort and anxiety/depression. Health states defined by the five-
dimensional descriptive system can be converted into utility scores by using existing
value sets for EQ-5D health states, elicited from general population samples. Such
value sets for the general UK population have been developed using the Visual
Analogue Scale (Gudex et al., 1996) and the Time Trade-Off (TTO) method (Dolan,
1997). The utility values generated for children with ADHD as reported by Coghill and
colleagues (2004) were 0.837 for responders (symptom improvement) and 0.773 for
non-responders (no symptom improvement). Since the methodology used to obtain
these values was not described in detail, it is not known whether the authors made use
of any of the existing value sets produced from the general UK population, or followed
a different methodology in order to convert EQ-5D scores into utility scores.
Matza and colleagues (2005) evaluated parent preferences for health states of chil-
dren with ADHD in the US. Using the Standard Gamble (SG) technique, the authors
asked 43 parents to value their child’s current health and 11 hypothetical health states,
presented to parents as vignettes describing untreated ADHD, as well as ADHD
treated with a stimulant or non-stimulant, covering aspects such as response to treat-
ment and presence of intolerable side effects. The health states were defined accord-
ing to parent and clinical opinion, supported by a literature review. The resulting
utility scores, adjusted on a scale from 0 (death) to 1 (perfect health), ranged from
0.90 (severe untreated ADHD) to 0.98 (treatment with non-stimulant, response to
treatment, tolerable side effects).
Secnik and colleagues (2005b), using a similar methodology to Matza and
colleagues (2005), produced utility scores by interviewing 83 parents of children with
ADHD in England. Parents were asked to value their child’s current health plus 14
hypothetical health states, also using the SG technique. The 14 health states were
comparable with those described in Matza and colleagues (2005), but distinguished
between IR and MR stimulants. The utility scores resulting from this exercise, adjusted
on a scale from 0 (death) to 1 (perfect health), ranged from 0.88 (treatment with IR
or MR stimulant, no response, presence of side effects) to 0.95 (no medication, symp-
tom improvement).
NICE recommends a standardised and validated generic instrument for the meas-
urement of HRQoL in cost-utility analyses, with utility scores generated according to
public preferences using a choice-based method, that is, TTO or SG technique. EQ-
5D is suggested as the most appropriate choice in the UK; at the same time, it is
acknowledged that under certain circumstances EQ-5D may not be suitable to use in
the estimation of QALYs (NICE, 2004). Following NICE guidance, the utility scores
reported in Coghill and colleagues (2004), which were generated from EQ-5D, were
used in the base-case analysis of all economic evaluations of interventions for chil-
dren with ADHD in this guideline, also taking into account that they were used in the
recent NICE TA on the use of pharmacological treatments for the management of
children and adolescents with ADHD (NICE, 2006b). The GDG expressed concern
that the EQ-5D, as a generic measure, was not sensitive enough to capture all aspects
of HRQoL in children with ADHD. As an alternative option, the utility values
reported by Secnik and colleagues (2005b), which were produced by SG technique
using vignettes describing health states of children with ADHD in the UK, were
tested in a sensitivity analysis; for the current analysis of parent training versus no
treatment, utility scores for health states characterised by no medication/untreated
ADHD described in Secnik and colleagues (2005b) were assumed to describe the
HRQoL of all children in the model, despite the fact that in the clinical studies a
number of children were reported to receive some medication during the intervention
period. This was necessary as no details on the type of medication and the rate of side
effects were reported for those children; however, this is unlikely to have affected the
results of the analysis, as the overall use of medication was similar between the two
arms of the model.
It was assumed that HRQoL in children initially responding to treatment
improved linearly over 10 weeks starting from the utility score of non-responders and
reaching the utility score for responders (10 weeks was the average duration of inter-
ventions in the clinical trials considered in the economic analysis), and remained at
this value for the remaining time of the analysis.
Resource utilisation and cost data Owing to lack of patient-level cost data,
deterministic costing of the treatment options assessed was undertaken. Relevant
healthcare resource use was estimated and subsequently combined with unit prices to
provide total costs associated with parent training or no treatment. Costs of children
receiving medication, as described in some clinical studies that provided the effec-
tiveness data, were not estimated, but these were likely to be similar in the two arms
of the model. Resource use estimates associated with parent training were based on
average resource use reported in the clinical studies that provided effectiveness data.
The GDG confirmed that these estimates reflected optimal resource use and were
consistent with clinical practice in the UK. In addition, booster sessions for respon-
ders were modelled according to optimal practice required to retain a positive
outcome (GDG expert opinion).
Two of the trials of parent-based psychological therapies versus no treatment
described group-based interventions (HOATH2002 and PFIFFNER1997), while the
remaining two trials examined individually-delivered programmes (BOR2002 and
SONUGA-BARKE2001). The results of the meta-analysis showed that there was no
heterogeneity between group-based or individual programmes regarding clinical
effect size. Therefore, it was estimated that the clinical effectiveness of parent-
training/education programmes for children with ADHD did not depend on the mode
of delivery and was similar in individual and group-based interventions. Given that
the intervention costs of group-based therapies are spread over a number of families,
group-based parent training dominates individually delivered parent training, as it
produces the same clinical outcome at a lower cost. For this reason, group-based
parent training has been modelled in the base-case analysis; the cost effectiveness of
individual parent training, indicated under certain circumstances, has been explored
in a sensitivity analysis.
Group-based parent training consisted of ten meetings (lasting 1 hour each) of
clinical psychologists with groups of parents of children with ADHD. Every group
Psychological interventions and parent training
181
Input parameter Base-case Source/comments
value
Response rates
Parent training 0.522 Meta-analysis of BOR2002,
No treatment 0.206 HOATH2002 and SONUGA-
BARKE2001; analysis based on
intention-to-treat
Utility scores
Responder 0.837 Coghill et al., 2004; scores
Non-responder 0.773 based on EQ-5D; questionnaires
filled in by parents of children
with ADHD in the UK
Parent training cost
10 1 hour group sessions £660 Curtis & Netten, 2006; clinical
with clinical psychologist psychologist cost per hour: £29;
1 extra hour training and £29 cost per hour of client contact:
preparation £66; qualification costs excluded
Total intervention cost £689
Total cost per family, £69
assuming 10 families in
each group
3 0.5 hour individual £99
booster sessions for responders
Total cost for responders £168
over 1 year
Table 9: Input parameters utilised in the base-case economic analysis
of parent training versus no treatment for children with ADHD
Psychological interventions and parent training
182
comprised ten families. Clinical psychologists were assumed to spend an extra hour
for training and preparation. Following completion of the intervention, parents of
children responding to parent training attended three further individual booster
sessions with psychologists, lasting 30 minutes each, in order to maintain children’s
response for the remaining time of the analysis.
The unit cost of clinical psychologists was taken from the Unit Costs for Health
and Social Care 2006 (Curtis & Netten, 2006). This cost does not include qualifica-
tion costs, as the latter are not available for clinical psychologists. Discounting was
not applied, as costs and benefits were measured over a period of 1 year.
All input parameters, including effectiveness data, utility scores and cost data
utilised in the base-case economic analysis of parent training versus no treatment are
presented in Table 9.
Sensitivity analysis Sensitivity analysis was undertaken to investigate the
robustness of the results under the uncertainty characterising input parameters of the
model. The following scenarios were tested in one-way sensitivity analyses:
1. Changes in response rates to treatment
● Use of the upper and lower 95% CIs of the RR of parent training to no treat-
ment (mean RR 2.48; 95% CIs 1.46 to 4.23)
● Inclusion of data from PFIFFNER1997 in the meta-analysis of clinical studies.
2. Utility scores obtained from Secnik and colleagues (2005b) for the health state of
no medication/untreated ADHD. The scores for responders and no responders
were 0.95 and 0.90 respectively.
3. Changes in resource use estimates for parent training
● Group-based CBT, appropriate for school-age children, provided by clinical
psychologists, consisting of ten 1-hour sessions with parents and ten 1-hour
sessions with children (ten parents and ten children in each group, respectively),
plus 2 extra hours for training and preparation. In addition, three individual
booster sessions, lasting 30 minutes each, were offered to parents of children
responding to treatment, in order to maintain children’s response for the remain-
ing time of the analysis. The cost of this intervention was £237 per family.
● In addition to the above intervention, provision of two extra individual
sessions of clinical psychologists with the children’s teachers at school, last-
ing 30 minutes each. The additional cost of these extra sessions was £69,
including clinical psychologists’ travel costs.
● Individual parent training, consisting of ten weekly sessions with a clinical
psychologist, lasting 1 hour each, in cases where group-based programmes are
not a suitable option. This scenario explored the cost effectiveness of individ-
ual parent training under a number of alternative hypotheses, such as
use of the upper and lower 95% CIs of the RR of parent training to no treat-
ment, inclusion of data from PFIFFNER1997 in the meta-analysis of clinical
studies, use of utility scores obtained from Secnik and colleagues (2005b), as
well as provision of parent training by health visitors instead of clinical
psychologists (at a unit cost of £61 per clinic hour excluding qualification
costs, according to Curtis and Netten, 2006).
Results
Base-case analysis Group-based parent training incurred an incremental cost
of £6,608 per QALY compared with no treatment. This value is well below the
cost-effectiveness threshold of £20,000 per QALY set by NICE (NICE, 2006c); there-
fore, this finding indicates that group-based parent training is a cost-effective option for
children with ADHD. Full results of the base-case analysis are presented in Table 10.
Sensitivity analysis The ICER of group-based parent training versus no treat-
ment remained below the cost-effectiveness threshold set by NICE (NICE, 2006c)
under any scenario tested in sensitivity analysis. In contrast, individual parent train-
ing was clearly not a cost-effective option: its ICER versus no treatment was £39,007
per QALY gained in the basic sensitivity analysis, and remained above £20,000 per
QALY in the vast majority of the alternative hypotheses examined. The only case
Psychological interventions and parent training
183
Psychological interventions and parent training
184
where the ICER of individual parent training versus no treatment fell below the cost-
effectiveness threshold of £20,000 per QALY was when the upper 95% CI of the RR
of parent training versus no treatment was used (that is, when effect size was
maximised); in this case the ICER fell to £19,360 per QALY.
Full results of the one-way sensitivity analyses for group-based and individual
parent training are shown in Table 11 and Table 12.
Threshold analysis showed that individual parent training was cost effective (with
an ICER reaching £17,302/QALY) when it consisted of four 1-hour sessions only
(instead of ten, as modelled in the base-case analysis). It is unlikely, however, that
parent training can be as effective as demonstrated in the meta-analysis of clinical
studies with only 4 hours of contact.
Limitations of the economic analysis
The results of the economic analysis were based on a simple decision-analytic model
developed to estimate costs and health benefits associated with provision of parent train-
ing in children with ADHD over the period of 1 year. Clinical evidence was derived
Intervention Total QALYs/ Total cost/ ICER
child child
Parent training 0.803 £168 Parent training versus no
No treatment 0.785 0
treatment: £6,608/QALY
Table 10: Cost effectiveness of parent training versus no treatment
in children with ADHD: results of the base-case analysis over 1 year
Scenario ICER
Upper 95% CI of RR of parent training to no treatment £4,028/QALY
Lower 95% CI of RR of parent training to no treatment £17,980/QALY
Inclusion of PFIFFNER1997 £5,567/QALY
Utility scores from Secnik et al. (2005b) £8,458/QALY
Group-based CBT for school-age children – no extra sessions £10,384/QALY
with teachers
Group-based CBT for school-age children – including extra £14,144/QALY
sessions with teachers
Table 11: Results of one-way sensitivity analysis for group-based parent
training versus no treatment in children with ADHD
from three trials that reported outcomes in the form of response to treatment. The total
number of participants in these trials was small (N 132). Additional evidence coming
from studies reporting outcomes in the form of changes on scales measuring ADHD
symptoms that were included in the guideline systematic review and meta-analysis
suggested a moderate beneficial effect of parent training in children with ADHD.
Costs consisted of intervention costs only; potential cost savings to the healthcare,
social and education services resulting from improvement in ADHD symptoms of
children were not considered owing to lack of relevant data. It is therefore likely that
the cost effectiveness of parent-training/education programmes for children with
ADHD is greater than that suggested by the results of the analysis.
Estimates on healthcare resource use were based on descriptions of resource use
in the clinical studies utilised in the economic analysis. According to the GDG expert
opinion, these estimates reflected optimal resource use, and were consistent with clin-
ical practice in the UK. Nevertheless, the clinical studies described only vaguely
some aspects of resource use, and obviously they did not provide any relevant data for
resource use beyond the duration of the trials (that is, beyond 10 weeks of treatment).
It is unknown whether three booster sessions with parents are sufficient to retain a
positive outcome in children with ADHD over 1 year (as assumed in the economic
model), as no relevant follow-up data are available. Likewise, the long-term effective-
ness of parent-training/education programmes in children with ADHD is unknown.
Therefore, it is not possible to estimate the cost effectiveness of parent-
training/education programmes in the long-term.
Utility scores used in the base-case analysis were based on EQ-5D questionnaires
filled in by parents of children with ADHD in England. EQ-5D is a generic measure
of HRQoL and, as such, it has been recommended by NICE for use in economic
evaluation. However, the full methods used to convert EQ-5D scores into utility
scores were not reported in the study that provided the utility data for this economic
analysis. Furthermore, the GDG expressed concerns about the appropriateness of
using a generic measure to capture aspects of quality of life in children with ADHD.
Scenario ICER
Main scenario of individual parent training £39,007/QALY
Upper 95% CI of RR of parent training to no treatment £19,360/QALY
Lower 95% CI of RR of parent training to no treatment £125,663/QALY
Inclusion of PFIFFNER1997 £31,831/QALY
Utility scores from Secnik et al. (2005b) £49,929/QALY
Individual parent training delivered by health visitor £36,052/QALY
Table 12: Results of one-way sensitivity analysis for individual
parent training versus no treatment in children with ADHD
Psychological interventions and parent training
185
For this reason, utility scores developed using vignettes describing health states
specific to ADHD were used in the sensitivity analysis. Utility scores used both in the
base-case and sensitivity analysis were generated using parents of children with
ADHD as proxy reporters of their children’s perceptions of their own HRQoL. There
are concerns about using parents’ ratings as proxies to children’s experience;
however, for some groups of children who are unable to report their own perceptions
and preferences reliably, parent proxies may be appropriate (Wallander et al., 2001;
De Civita et al., 2005). In the area of ADHD, no data on HRQoL preferences directly
reported by children rather than by their parents are currently available.
The findings of the base-case analysis regarding the cost effectiveness of group-
based programmes rely on the hypothesis of equivalent efficacy between group-based
and individually delivered programmes; such equivalence has not been established
in head-to-head comparisons, but existing indirect clinical evidence suggests that
the mode of delivery does not affect the clinical effectiveness of parent-training/
education programmes. In fact, HOATH2002, which described group-based parent
training, reported a larger effect size than that reported in BOR2002 and SONUGA-
BARKE2001, both examining individually delivered interventions. The ICER of
£6,608 per QALY, characterising parent training delivered in groups, was based on
intension-to-treat analysis. This means that estimated clinical effectiveness took
into account the fact that some children/families might drop out of treatment. On the
other hand, full intervention costs were estimated, assuming that all children
completed treatment. This assumption has probably overestimated the total cost of
parent training.
Overall conclusions from the economic analysis
The results of the economic analysis indicate that group-based parent-training/
education programmes (or CBT for school-age children) are likely to be cost effec-
tive for children with ADHD, if the mode of delivery of such programmes does not
affect their clinical effectiveness. Individual parent training is unlikely to be a cost-
effective option. Further research is needed to explore the long-term benefits and cost
savings associated with parent-training/education programmes for children with
ADHD, as well as to investigate in depth the perceptions of children and their carers
on aspects of HRQoL associated with ADHD. Moreover, future head-to-head
comparisons need to confirm the equivalence of efficacy between group-based and
individually delivered parent-training/education programmes, so that the cost effec-
tiveness of group-based parent training can be effectively established.
7.2.14 From evidence to recommendations: psychological interventions
for children and young people with ADHD
Overall, the evidence indicates that psychological interventions for children with
ADHD have moderate beneficial effects on parent ratings of ADHD symptoms and
conduct problems, both for children not on medication and as an adjunct to continued
Psychological interventions and parent training
186
routine medication for ADHD. However, the evidence suggests that slightly different
approaches are necessary for pre-school and older children.
For the pre-school group there is good evidence that individual parent training is
helpful for core ADHD symptoms and conduct problems. The characteristics of effec-
tive interventions are that they: are structured, are based on social learning and behav-
ioural learning principles, include provision of information on ADHD and involve
active learning strategies such as role play, modelling and active feedback, individu-
alised homework assignments, diaries and observation.
Further evidence on the use of parent-training/education programmes as an inter-
vention for ADHD comes from the findings of the NICE TA of parent training as an
intervention for children up to 12 with conduct disorders (NICE, 2006a). The GDG
concluded that the TA was broadly generalisable to children with ADHD given the
overlap between the population included in the TA and the population with ADHD.
The TA indicates that both group and individual programmes are likely to be effective.
Taken as a whole the available clinical evidence indicates that referring parents of
children with ADHD to established parent-training programmes, such as Triple P, is
likely to result in beneficial effects for the child. However, it may be important to
incorporate information about ADHD and the behavioural and emotional sequelae
that arise from the condition into a generic programme attended by parents of chil-
dren with ADHD.
For school-age children the available clinical evidence indicates that interventions
offering mixed CBT and social skills training group sessions for children along with
parallel group sessions for parents are beneficial. Effective interventions all followed
a structured curriculum. Areas that effective interventions addressed include: chal-
lenging and oppositional behaviour in the home; problem solving; listening skills;
recognising, dealing with and expressing feelings; anger management, self-control
and ignoring provocation; accepting consequences; assertiveness and conflict resolu-
tion; friendship skills; self-esteem and good sportsmanship. Successful programmes
tended to use active learning methods such as role play, modelling, observation
and feedback along with reward systems such as star boards and token rewards, with
similar rewards for home-based objectives. They also involved individualised
elements, often with homework assignments and diary keeping. The evidence indi-
cates that parent sessions should be designed to reinforce and support child learning
while also incorporating training in parenting skills and behavioural management
principles.
There is also some evidence that providing parents of school-age children with
written manuals on behavioural strategies to use at home may result in positive
improvements in child behaviour. While not a substitute for parent training this is an
intervention that can be delivered immediately.
No RCT evidence on interventions for young people of 13 years and older was
identified but it is likely that CBT/social skills therapy interventions as described for
older children would be applicable to young people with ADHD.
With respect to the delivery of interventions, the evidence indicates that psycho-
logical interventions may be beneficial for children with ADHD whether delivered
Psychological interventions and parent training
187
in group or individual contexts. For parent training the included studies involved
structured interventions delivered on an individual basis to parents of pre-school
children with ADHD. However, TA102 (NICE, 2006a) found that both group and
individual programmes were effective interventions for children with problem behav-
iours. Given the overlap between the population included in the TA and the ADHD
population, it is reasonable to extrapolate from the TA and conclude that group
parent-training programmes would also be effective for children with ADHD. For
school-age children with ADHD the evidence of benefits from psychological inter-
ventions comes from both group and individual approaches to delivering social skills
training and/or CBT for the child together with a parallel parental intervention.
The economic analysis undertaken for this guideline indicates that both group-based
parent-training programmes and group CBT for school-age children are likely to be
cost-effective interventions for children with ADHD. In contrast, individually delivered
parent training is probably not cost effective. These findings are supported by economic
evidence reported in the NICE TA. It must be noted that long-term benefits of parent
training and potential cost savings to the healthcare, social and education services
resulting from improvement in ADHD symptoms of children were not considered in the
analysis, owing to lack of relevant data. Therefore, the reported cost effectiveness of
parent training for children with ADHD is likely to be a conservative estimate.
In some special circumstances it may be necessary to deliver parent training and
other psychological interventions for ADHD on an individual basis. Such circum-
stances include situations where there are particular difficulties in engaging with the
parents or when a family’s needs are too complex to be met by group-based
programmes. On occasion factors such as parental ill health and diversity, disability
and accessibility issues may also necessitate intervention on an individual basis. For
older adolescents with ADHD and moderate impairment, individual psychological
interventions (such as CBT or social skills training) may be more acceptable than
group interventions. Additionally, in some services it may be necessary to deliver
interventions on an individual basis because participant numbers are low with the
result that viable group interventions are difficult to achieve or the need to recruit
a group would result in undue delays in commencing therapy.
In summary, the psychological interventions for ADHD that were evaluated are
well established and constitute a repertoire of interventions in current clinical practice
that are based on CBT principles and have beneficial effects for children with ADHD:
parent training, cognitive and behavioural therapy approaches, social skills training,
and self-instructional manuals. Generally therapist-led psychological interventions
were delivered in courses of between eight and 12 sessions lasting 1 to 2 hours.
Individual parent training that involves working with the child and parent together may
be favoured for pre-school children. However, the NICE TA of parent training as an
intervention for children with conduct disorders indicates that group interventions are
also likely to be effective for both pre-school and school-age children with ADHD. For
school-age children interventions that involve separate group sessions for parents and
children appear favoured. Given the concerns about the use of medication for ADHD,
psychological interventions therefore appear to present a deliverable and potentially
effective alternative therapeutic approach for children and young people with ADHD.
Psychological interventions and parent training
188
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