The Campbell Collaborationwww.campbellcollaboration.org Parent Training Interventions for Attention Deficit Hyperactivity Disorder Morris Zwi & Jane Dennis Hannah Jones, Camilla Thorgaard, Ann York

The Campbell Collaborationwww.campbellcollaboration.org Context Started Oct 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)

The Campbell Collaborationwww.campbellcollaboration.org Slowest ever Systematic Review?! NHS job with no designated research time Secretary for Health drive on waiting lists Searches needed repeated updating

The Campbell Collaborationwww.campbellcollaboration.org

Searches Inception to 2004: to 2006: to 2008: to 2009: to 2010:1889

The Campbell Collaborationwww.campbellcollaboration.org 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)

The Campbell Collaborationwww.campbellcollaboration.org 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

The Campbell Collaborationwww.campbellcollaboration.org Included Studies Blakemore 1993 Fallone 1998 Lehner-Dua 2001 Van den Hoofdakker 2007 Mikami 2010

The Campbell Collaborationwww.campbellcollaboration.org 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

The Campbell Collaborationwww.campbellcollaboration.org 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

The Campbell Collaborationwww.campbellcollaboration.org 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

The Campbell Collaborationwww.campbellcollaboration.org Results Only able to conduct meta-analysis for two outcomes Externalising Behaviour Internalising Behaviour

The Campbell Collaborationwww.campbellcollaboration.org Externalising behaviour conflict with others aggression rule-breaking oppositional behaviour

The Campbell Collaborationwww.campbellcollaboration.org Internalising behaviour Behaviours where stress appears to be directed against the self anxiety depression somatic problems social withdrawal

The Campbell Collaborationwww.campbellcollaboration.org §

Results

The Campbell Collaborationwww.campbellcollaboration.org

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

The Campbell Collaborationwww.campbellcollaboration.org

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

The Campbell Collaborationwww.campbellcollaboration.org 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.

The Campbell Collaborationwww.campbellcollaboration.org

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

The Campbell Collaborationwww.campbellcollaboration.org 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

The Campbell Collaborationwww.campbellcollaboration.org 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

The Campbell Collaborationwww.campbellcollaboration.org 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