Monday, February 6, 2023

This review provides a summary of non-pharmacological treatments for children and youth diagnosed with ADHD and related behavioral problems, and the scientific evidence regarding their effectiveness.

Background

Diagnosis

There is no biological test for ADHD. The diagnosis is made if a child is seen as having problems with being “inattentive,” “hyperactive,” or “impulsive,” and such behaviors “interfere” with “functioning and development.” As there is a subjective element to making the diagnosis, diagnostic standards vary greatly in different settings, and in different countries.

Efficacy of Drugs

While ADHD medications may be effective in ameliorating the symptoms of the disorder over the short term, studies have found that they do not provide a benefit on any functional domain, including academic performance, over the long term, while exposing the child or adolescent to a number of possible adverse effects.

Informed consent

Most clinical care guidelines for ADHD urge that decision-making include the health care professional, the parents/carers, and the child with ADHD. Health care professionals are reminded to provide full “informed consent” to the parents and child, which requires discussing the evidence of the risks and benefits of different approaches, including their long-term effects.

More on diagnosis and efficacy of drugs


Non-Drug Therapies

Many clinical care guidelines recommend combining behavioral therapies with stimulant medication. However, in making those recommendations, most of the guidelines focus on studies showing that drugs may ameliorate ADHD symptoms over the short-term, without assessing their long-term effects. The reviews here focus on scientific studies assessing the efficacy of behavioral therapies alone, and not in combination with ADHD medications.


1. Behavioral Classroom Management

This intervention involves teachers being trained (and sometimes having specialized aides) in order to provide behavioral conditioning responses to students with ADHD. This usually involves training teachers to provide a consistent, powerful system of rewards and punishments in order to control the behavior of children with ADHD in the classroom setting. The daily report card is a form of monitoring and goal-setting which enables tracking of progress in the classroom.

In general, teachers report these interventions are found to be helpful for managing behavior in the classroom. Evidence on overall effects indicates that the program is effective for maintaining behavioral control as long as the system is maintained at its most intense level. If teachers do not continue providing extreme rewards and punishments, or if they are not consistently supported with training and additional aides, the system appears to be much less effective.

For a detailed overview, see the book chapter available here.


2. Cognitive Behavioral Therapy (CBT)

In the context of ADHD and childhood behavioral problems, CBT involves directly teaching children or adolescents skills for managing their behaviors (which makes it different from other interventions that focus on teaching parenting skills). They are taught how to deal with distractibility and procrastination, and how to alter thought processes that may interfere with effective goal-pursuit.

In the literature it is usually framed as a treatment for residual ADHD symptoms (what is left over after children are using another treatment, usually medication). As such, it is considered an add-on treatment and has been tested only in children who are also on medication.

In preliminary studies (small initial trials), CBT as an add-on to medication has been shown to reduce ADHD symptoms and behaviors by both parent report and adolescent report. Overall improvement such as quality of life is minimal, however.

For information about a study of this intervention, click here.


3. Collaborative Problem Solving/Collaborative and Proactive Solutions (CPS)

Interventions of this design are based on the idea that children who exhibit problematic behaviors, such as those diagnosed with oppositional defiant disorder, conduct disorder, or ADHD, lack the skills to engage in more appropriate behaviors for the situation. Thus, this model involves working with the child to identify problematic areas and develop skills to overcome them. Essentially, the theory here is that children act out because they lack skills to respond to what’s being asked of them.

This intervention was developed by Ross Greene, author of numerous books on child behavior, such as The Explosive Child, Lost at School, Lost & Found, and Raising Human Beings. It resides at the website for Lives in the Balance, Greene’s non-profit organization.

The model, according to Greene is now known as “Collaborative and Proactive Solutions” after a long legal battle over intellectual property, ending with Massachusetts General Hospital putting forth its own version of the model, led by J. Stuart Ablon, which took the model’s original name of “Collaborative Problem Solving.” MGH’s version of the model resides at the website for Think:Kids.

What has research found?

One well-conducted study compared CPS to parent behavioral training, and found that outcomes were generally comparable—parents reported improvements in oppositional behaviors as well as in parent-child conflict. This was true in both the CPS group and in the parent behavioral training group.

Other studies have found similar outcomes: parents consistently report improvements in their children’s ADHD symptoms and oppositional behaviors.

Studies of CPS in locked, inpatient hospital units found that this intervention reduced the use of restraints, seclusion, and injuries to staff and patients.

Anecdotal data from residential units using this intervention support its efficacy in reducing aggressive behavior and outbursts in adolescents, as well as improving parent’s ratings of other emotional problems in children.

CPS has as yet rarely been tested in a systematic manner against other approaches or using randomized group methods.

For more information about the research on this intervention, see the review article available here.


4. Environmental Management/Environmental Modification

Usually focused on the classroom and/or the home, this intervention involves making adjustments to the space and/or accommodating the child’s needs. For instance, removing distractions, changing seating arrangements, and incorporating movement breaks are common adjustments to be made. Increased exercise has been suggested to be beneficial; some studies have suggested that exposure to “green spaces,” such as taking a 20-minute nature walk, is beneficial as well.

These are time-honored strategies for dealing with concerns around attention and focus. Some guidelines (e.g. NICE) urge that they be used before any other interventions are tried. However, there is little research on the intervention as a whole. Studies generally address differing individual aspects of this overall broad intervention, or focus on similar interventions such as behavioral classroom management (which uses behavioral conditioning to alter behavior in the classroom).

For more detailed information about what modifications are typically used in this intervention, see the article available here.


5. Intensive Behavioral Intervention

This intervention involves behavioral skills-building therapy delivered in an intensive, systematic fashion to children and adolescents; sometimes it includes their parents. The Summer Treatment Program, which involves a long, intensive summer camp peer-group component, is one primary example. After-school programs such as Challenging Horizons also fall under this label, and outpatient mental health settings are also common places for intensive behavioral therapy.

In general, this approach first identifies problematic areas of functioning—often in collaboration with the child/adolescent—and then targets these areas for change, using cognitive behavioral strategies. These areas usually include academics and family functioning.

The Summer Treatment Program specifically has been rated as very helpful by parents, and has been extensively used.

The research on this intervention is composed of a great deal of individual case studies, with few comparisons between groups receiving control interventions. However, the research consistently demonstrates positive changes in family relationships. Parents also generally see improvements in hyperactivity measures of their children’s behavior. There appears to be minimal impact on academics, with GPA showing minimal improvement and teachers reporting minimal improvement.

For more information about the Summer Treatment Program, see the book chapter available here. For the abstract of an article summarizing effectiveness of the Challenging Horizons After-School Program, click here.


6. 
Positive Behavioral Intervention

Positive behavioral intervention is a term for any home- or school-based behavioral intervention based on the principles of applied (or functional) behavioral analysis (often abbreviated ABA). This intervention involves determining the function of the child’s behavior (i.e. why the child behaves this way) in order to change the behavior.

Positive behavioral intervention can include approaches such as providing children with choices, teaching children self-management of behavior, and teaching children communication skills. It can also include systems of reinforcement based on conditioning principles (e.g. rewards and reward withholding).

Teacher and parent reports indicate that this intervention is successful at reducing problematic behaviors, especially in people with autism and developmental disabilities. However, very little research has been conducted on children with ADHD.

Studies on this intervention are widespread but very few use groups or a randomized design (most follow a single subject through an intervention). Most of the studies on this intervention have been conducted on children with autism, developmental disabilities, and intellectual disability. However, some research has been done on children with ADHD or with no diagnosed disorder in very young children.

For more information about the research on this intervention, see the review papers available here and here.


7. Psychoeducation

Psychoeducation means teaching parents (and sometimes teachers) about current understandings of the ADHD diagnosis and what it means for them and their children, in order to reduce stigma associated with the diagnosis and promote adherence to other treatments, usually medication. As such, it is considered an add-on treatment and its main goal is to support medication use.

Psychoeducation can be carried out in a structured (manualized and led by a professional) or unstructured (support group) manner.

Structured support groups are led by a trained professional who provides information about the diagnosis as well as some parenting skills training. These have been demonstrated to increase parents’ knowledge about current medical theory about ADHD. Few studies have assessed whether psychoeducation actually impacts ADHD behaviors or other problems of childhood, and none as a stand-alone intervention. When compared to unstructured support groups as an add-on treatment to medication and behavioral intervention, structured groups have been shown in at least one study to improve inattention and social functioning.

For a detailed overview, see the article available here. For the abstract of an article comparing structured and unstructured groups, click here.


8. The Incredible Years

The parenting program known as The Incredible Years is an intervention that aims to reduce children’s behavioral problems by providing parenting skills training. It consists of 11-14 weeks of group therapy for parents, with video vignettes to introduce parenting skills topics and provide examples of healthy and unhealthy parenting styles. Parents then role-play parenting scenarios, and may rehearse with a therapist leading the session. There are also handouts and homework assignments.

This intervention was piloted by Carolyn Webster-Stratton and resides at the website http://www.incredibleyears.com. It was originally known as Parents and Children Series (PACS). It has been researched in numerous countries for several decades.

Mothers consistently respond favorably to the intervention. Mothers report that it reduces some negative parenting behaviors, increases some positive parenting behaviors, and improves the behavior of their children (including slight improvement to reported ADHD symptoms). The intervention does not appear to improve overall emotional health for either children or parents. Reports of whether it improves children’s social behaviors are mixed. Some research has found that the intervention is most successful for improving the behavior of children with severe conduct problems

Although most of the research is based on mothers’ reports of their parenting and their children’s behavior, some studies that included teachers’ reports and independent observation also detected improvements in parenting behaviors and children’s behavior. However, these effects were smaller than those represented in mothers’ self-reports.

For more information about the research on this intervention, see the studies available here and here.

 

9. New Forest Parenting Program (NFPP)

The New Forest Parenting Program (NFPP) is an intervention that aims to reduce ADHD symptoms in preschoolers by providing 8 sessions of in-home individual parent therapy. These sessions include information about ADHD, games parents can play with their children to improve attention and behavior, and therapist feedback after observing the game. It is a newer intervention that has been studied in the UK and the US for the past 15 years.

Parents report moderate to large improvements in children’s behavior, including ADHD symptoms and conduct problems. In this regard, it may be superior to alternative parent training programs that do not directly address ADHD.

However, NFPP suffers from the same limitations as other parent training research. Teacher ratings—and the clinical observations of researchers—do not show the improvements that parents report. Thus, the improvement appears to be in parents’ perception or expectations of their children’s behavior.

A UK overview of the NFPP can be found here. For more information about the research on this intervention, see the studies available here, here, and here.


10. The Nurtured Heart Approach (registered trademark)

This branded intervention held by the Children’s Success Foundation relies on the trademarked “3 Stands” of not reinforcing negative behavior, reinforcing positive behavior, and being clear about rules and boundaries.

According to their website, this approach “helps children (and adults) build their Inner Wealth (registered trademark). According to the anecdotes on the website, the NHA changes children’s entire personalities within 48 hours.

There has been no published research on this intervention, although the website refers to “anecdotal” data. Published studies referencing the NHA discuss its theoretical basis. The general conclusion is that its general theoretical basis is reasonable although some assumptions of NHA are not supported by evidence.

For the corporate website, click here. For the official abstract of a study on the theoretical basis of NHA, click here.


11. Triple-P (Positive Parenting Program)

Triple-P, or the Positive Parenting Program, is an intervention that aims to reduce children’s behavioral problems by providing parenting skills training. Triple-P has five levels, so that parents can receive the program intensity they need. It ranges from brief online self-help, to longer, therapist-led interventions to develop parenting skills.

Triple-P was developed by Matthew Sanders and colleagues at the University of Queensland in the 1990s, and was formalized as “Triple-P” around 2001. It has been extensively studied in Australia by this group.

Parents consistently respond favorably to the intervention. Parents report that it improves their parenting skills, the behavior of their children, and the emotional well-being of their children. The improvement appears to be in parents’ perception or expectations of their children’s behavior. This is because the behavior of the child—when observed by a researcher—does not appear to change significantly, and there is no significant improvement on ADHD symptoms.

The research is limited because the outcomes are almost entirely based on mothers’ reports of their children’s behavior. The researchers rarely conduct their own assessment of children’s behavior, and rarely use reports from others, such as fathers or teachers. The intervention appears to be best at improving the overall emotional well-being of children, rather than targeting specific symptoms or behaviors.

For more information about how this intervention works, the Triple-P website is available here For more information about the research on this intervention, see the studies available here and here.