Results

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Parent Training Interventions for Attention
Deficit Hyperactivity Disorder
Morris Zwi & Jane Dennis
Hannah Jones, Camilla Thorgaard , Ann York
The Campbell Collaboration
www.campbellcollaboration.org
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)
The Campbell Collaboration
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Slowest ever Systematic Review?!
• NHS job with no designated research time
• Secretary for Health drive on waiting lists
• Searches needed repeated updating
The Campbell Collaboration
www.campbellcollaboration.org
The Campbell Collaboration
www.campbellcollaboration.org
Searches
• Inception to 2004:
• 2004 to 2006:
• 2006 to 2008:
• 2008 to 2009:
• 2009 to 2010:
The Campbell Collaboration
6671
1542
1579
1280
1889
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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 Collaboration
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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 Collaboration
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Included Studies
• Blakemore
1993
• Fallone
1998
• Lehner-Dua
2001
• Van den Hoofdakker
2007
• Mikami
2010
The Campbell Collaboration
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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 Collaboration
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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 Collaboration
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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 Collaboration
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Results
• Only able to conduct meta-analysis for two outcomes
• Externalising Behaviour
• Internalising Behaviour
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Externalising behaviour
• conflict with others
• aggression
• rule-breaking
• oppositional behaviour
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Internalising behaviour
Behaviours where stress appears to be directed against the self
• anxiety
• depression
• somatic problems
• social withdrawal
The Campbell Collaboration
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§
The Campbell Collaboration
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The Campbell Collaboration
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Results
The Campbell Collaboration
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The Campbell Collaboration
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The Campbell Collaboration
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The Campbell Collaboration
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Parenting Stress Index domains
Child Domain
•
•
•
•
•
•
Distractibility/Hyperactivity
Adaptability
Reinforces Parent
Demandingness
Mood
Acceptability
Parent Domain
•
•
•
•
•
•
•
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Competence
Social Isolation
Attachment to Child
Health
Role Restriction
Depression
Spouse
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The Campbell Collaboration
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The Campbell Collaboration
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The Campbell Collaboration
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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 Collaboration
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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 Collaboration
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The Campbell Collaboration
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The Campbell Collaboration
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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 Collaboration
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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 Collaboration
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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 Collaboration
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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
The Campbell Collaboration
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