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Parent Training Interventions for Attention Deficit Hyperactivity Disorder

Parent Training Interventions for Attention Deficit Hyperactivity Disorder. Morris Zwi & Jane Dennis Hannah Jones, Camilla Thorgaard , Ann York. Context. Started Oct 1999 @ SRTU, ICH ADHD still controversial – overuse of stimulants? Interested in non-drug interventions in ADHD

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Parent Training Interventions for Attention Deficit Hyperactivity Disorder

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  1. Parent Training Interventions for Attention Deficit Hyperactivity Disorder Morris Zwi & Jane Dennis Hannah Jones, Camilla Thorgaard , Ann York

  2. Context • Started Oct 1999 @ 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)

  3. Slowest ever Systematic Review?! • NHS job with no designated research time • Secretary for Health drive on waiting lists • Searches needed repeated updating

  4. Searches • Inception to 2004: 6671 • 2004 to 2006: 1542 • 2006 to 2008: 1579 • 2008 to 2009: 1280 • 2009 to 2010: 1889

  5. 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)

  6. Included Studies • 5 trials, 284 participants, compared PT vs Treatment as usual • Four trials assessed children’s ADHD symptom-related behavioural problems • Two focused on children’s behaviour at home • Two focused on behaviour at school

  7. Included Studies • Blakemore 1993 • Fallone 1998 • Lehner-Dua 2001 • Van den Hoofdakker 2007 • Mikami 2010

  8. Results • Four studies targeted children’s behaviour problems and one assessed changes in parenting skills • Two focused on behaviour at home • Two focused on behaviour at school

  9. 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

  10. 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

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

  12. Externalising behaviour • conflict with others • aggression • rule-breaking • oppositional behaviour

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

  14. §

  15. Results

  16. Parenting Stress Index domains Child Domain Parent Domain Competence Social Isolation Attachment to Child Health Role Restriction Depression Spouse • Distractibility/Hyperactivity • Adaptability • Reinforces Parent • Demandingness • Mood • Acceptability

  17. 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

  18. 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.

  19. 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 children’s academic achievement was investigated as an important outcome, potentially creating misconceptions about the role of parent training in ADHD

  20. 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

  21. 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

  22. 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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