child-focused psychosocial interventions … · 2 literature review ... comorbidity with other...
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CHILD-FOCUSED PSYCHOSOCIAL INTERVENTIONS FOR CHILDREN AND
ADOLESCENTS WITH ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD): A
SYSTEMATIC REVIEW AND META-ANALYSIS
by
Clarisa Markel
A thesis submitted in conformity with the requirements
for the degree of Doctor of Philosophy
Applied Psychology & Human Development Department
Ontario Institute for Studies in Education
University of Toronto
© Copyright by Clarisa Markel 2016
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CHILD-FOCUSED PSYCHOSOCIAL INTERVENTIONS FOR CHILDREN AND
ADOLESCENTS WITH ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD): A
SYSTEMATIC REVIEW AND META-ANALYSIS
Doctor of Philosophy, 2016
Clarisa Markel
Applied Psychology & Human Development Department
Ontario Institute for Studies in Education
University of Toronto
ABSTRACTABSTRACTABSTRACTABSTRACT
The purpose of this dissertation was to conduct a systematic review and meta-analysis of
previous studies that assess the efficaciousness of child-focused psychosocial interventions for
children and adolescents with Attention-Deficit/Hyperactivity Disorder (ADHD). The specific
outcomes that were examined were internalizing and externalizing symptoms and behaviours,
social skills, peer relationships, and family functioning. Although studies solely evaluating core
ADHD symptom outcomes were not eligible, when provided in an eligible study, data for core
ADHD symptoms (inattention, hyperactivity, and impulsivity) were extracted and analyzed. The
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aim was to provide clinicians with guidelines for treatment for children and adolescents with
ADHD with specific associated symptoms, functional impairments, and comorbid disorders. In
spite of identifying 26 studies that met criteria for this review, the data are insufficient to
recommend, with confidence, any specific child-focused intervention to treat specific child
problems. Results indicated that cognitive behavioural therapy (CBT), mindfulness training, and
social skills training (SST) interventions do not meet the criteria outlined by the American
Psychological Association for an intervention to be considered as a well-established or probably
efficacious intervention (APA Presidential Task Force on Evidence-Based Practice, 2006).
Nevertheless, there is some evidence that some of the child-focused psychosocial interventions
described in this systematic review and meta-analysis are promising and, as a result, that future
research with high quality studies is needed to investigate whether these interventions are
efficacious. Individual CBT with simultaneous parent treatment might be promising for
improving externalizing and internalizing symptoms, parent-child relationships, and core ADHD
symptoms in adolescents concurrently on medication. Furthermore, mindfulness training shows
promise in reducing peer relationship problems, internalizing symptoms, and ADHD symptoms
of adolescents, and might foster better parent-child relationships. Finally, there is evidence from
strong and moderate quality studies that SST interventions are associated with improvements in
social skills knowledge and assertion in school-age children. In addition, when SST is offered
with concurrent medications, parent treatment and teacher consultation, lower doses of
medication are required to achieve the same effect on internalizing symptoms, ODD symptoms,
social skills, and personal closeness in parent-child relations.
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ACKNOWLEDGEMENTSACKNOWLEDGEMENTSACKNOWLEDGEMENTSACKNOWLEDGEMENTS
Thank you Alejandro Dario Aguado for your unconditional support. Thank you for always
allowing me to pursue my dreams and making me feel so loved. Thank you for encouraging and
believing in me. Almost twelve years ago we immigrated to Canada as two young professionals
with one suitcase full of dreams. With you, I feel anything is possible.
Thank you Mackenzie Markel-Aguado for your warmth, love and laughter that makes me
stronger every day. I am proud to be your mother. Thank you for putting up with my moods and
along with your sister-to-be Riley, for reminding me what is truly important in this world.
To my thesis supervisor, Dr. Judy Wiener: Thank you for your mentorship and guidance over the
past eight years. Thank you for taking the chance on me; the Argentinean psychologist who
wanted to find her path in a new country. You changed my life!
To Dr. Olesya Falenchuk: Thank you for your insightful expertise, thoughtful guidance and
kindness. You were instrumental in this dissertation from day one. I have felt very supported
having the wisest stats consultant around!
To my thesis committee, Dr. Alice Charach, Dr. Eunice Jang, Dr. Maggie Toplak, and Dr. Anne-
Claude Bedard: Thank you for your time, guidance, expertise, curiosity, interest, stimulating
discussions, and your contributions through this process. Your feedback was invaluable.
To Dr. Ashley Major: Thank you for doing the time-consuming and detailed task of second
coding of my studies! Thank you for being an amazing dependable friend during this program;
the ride would have been very different without you.
Thank you to my mentors in Vancouver, where I started this process of re-training in Canada.
Special thanks to the people who trusted in me from the very beginning, even when I did not
trust in myself: Dr. Janet Werker and Dr. Charlotte Johnston.
To my psychology best pals for their unconditional support, words of wisdom, words of support
and much more: Dr. Jen Theule, Dr. Vicky Timmermanis, Dr. Sol Pound, and doctor-to-be
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Ashley Brunsek: I am so grateful to have had you along with me on this roller coaster ride.
To my friends, who I am so blessed to have in my life; and prepare meals, help me with school
pick-ups and drop-offs; leave surprises on my doorstep to cheer me up after long working days.
You bring so much joy in my life that I would be forever thankful. Thank you for your
unconditional support. Irena, Val, Nella, Maya, Lola, Jen, Amy, and Joyti. Thank you for putting
up with my moods and always finding a way to cheer me up. You are my rocks and I could not
have done this without you!
Thank you to my “lab-partner” Sifon, who made me company for the past three years in the long
hours of thinking and writing. You will not be able to read this, but I hope you know that you
make my days better with your sweet naiveté.
And finally, thank you to the Social Science and Humanities Research Council of Canada and to
OISE/ University of Toronto for helping to fund this work and support my re-training in Canada.
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TABLE OF CONTENTS
ABSTRACT ................................................................................................................................... ii
ACKNOWLEDGEMENTS ........................................................................................................ iv
LIST OF TABLES ....................................................................................................................... xi
LIST OF FIGURES ................................................................................................................... xiii
LIST OF APPENDICES ........................................................................................................... xiv
LIST OF ABBREVIATIONS .....................................................................................................xv
1 INTRODUCTION....................................................................................................................1
2 LITERATURE REVIEW .......................................................................................................5
2.1 Definition and Prevalence of ADHD ................................................................................5
2.2 Pharmacological Interventions..........................................................................................8
2.3 Psychosocial Interventions for ADHD ...........................................................................12
2.3.1 Parent-Focused Interventions.................................................................................13
2.3.2 Teacher-Focused Interventions ..............................................................................16
2.3.3 Child-Focused Interventions ..................................................................................19
2.3.3.1 Cognitive Behavioural Therapy ..............................................................20
2.3.3.2 Mindfulness Training Therapies .............................................................21
2.3.3.3 Social Skills Training ..............................................................................22
2.3.3.4 Family Therapy .......................................................................................23
2.4 Moderating Variables That May Contribute to Child-Focused Psychosocial Treatment Outcome .......................................................................................................................25
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2.4.1 Child Characteristics ..............................................................................................25
Age……… .............................................................................................................25
Gender…… ............................................................................................................26
Medication Status...................................................................................................28
ADHD Subtype ......................................................................................................28
Comorbidity with Other Disorders ........................................................................29
Family Characteristics ...........................................................................................30
2.4.2 Intervention Characteristics ...................................................................................30
2.4.3 Outcome Measure Characteristics .........................................................................31
2.4.4 Study Level Characteristics ...................................................................................31
2.5 Advantages and Disadvantages of Systematic Reviews and Meta-analyses ..................32
2.6 Measurement of Child Outcomes ...................................................................................33
2.7 Conclusions From Previous Meta-analyses of Psychosocial Treatments for Children and Adolescents With ADHD ......................................................................................35
2.8 Summary .........................................................................................................................39
2.9 Objectives of the Systematic Review and Meta-analysis ...............................................41
3 METHODS .............................................................................................................................48
3.1 Criteria for Study Selection ............................................................................................48
3.2 Search and Retrieval of Studies ......................................................................................48
3.2.1 Data Extraction ......................................................................................................50
3.2.2 Variable Coding .....................................................................................................51
3.2.3 Data management...................................................................................................53
3.3 Statistical Approach for Meta-analyses ..........................................................................53
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4 RESULTS ...............................................................................................................................60
Part A: Description of Studies ....................................................................................................60
4.1 Studies’ Publication Status and Country of Origin .........................................................60
4.2 Pooled Sample of Participants ........................................................................................62
4.3 Description of Included Studies by Intervention Type ...................................................64
4.3.1 Cognitive Behavioural Treatment Studies .............................................................65
4.3.1.1 Individual CBT .......................................................................................65
4.3.1.2 Group CBT..............................................................................................66
4.3.2 Mindfulness Training Intervention Studies ...........................................................68
4.3.3 Social Skills Training Intervention Studies ...........................................................71
4.3.3.1 SST as a stand-alone treatment ...............................................................73
4.3.3.2 SST plus concurrent parent treatment .....................................................74
4.3.3.3 SST plus concurrent parent treatment and teacher consultation .............74
4.3.3.4 SST plus concurrent medication and parent treatment and teacher consultation ..........................................................................................76
4.3.3.5 Summary of SST intervention studies ....................................................77
4.3.4 Summary of Study Descriptions ...............................................................................80
Part B: Systematic Review and Meta-Analyses Results ...........................................................83
4.4 Cognitive Behavioural Treatment Interventions .............................................................84
4.4.1 Individual Cognitive Behavioural Therapy ...........................................................85
4.4.1.1 Internalizing symptoms and behaviours .................................................85
4.4.1.2 Externalizing symptoms and behaviours ................................................85
4.4.1.3 Social skills, peer relationships, and family functioning ........................85
4.4.1.4 Core ADHD symptoms ...........................................................................86
4.4.2 Group Cognitive Behavioural Therapy ..................................................................86
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4.4.2.1 Internalizing symptoms and behaviours .................................................86
4.4.2.2 Externalizing symptoms and behaviours ................................................86
4.4.2.3 Social skills, peer relationships, and family functioning ........................87
4.4.2.4 Core ADHD symptoms ...........................................................................87
4.4.3 Potential Variables That May Moderate Response to Cognitive Behavioural Therapy Interventions ............................................................................................88
4.4.3.1 Age ..........................................................................................................88
4.4.3.2 Comorbidity with other disorders ...........................................................89
4.4.4 Summary of CBT Interventions .............................................................................90
4.5 Mindfulness Training Interventions ................................................................................90
4.5.1 Internalizing Symptoms and Behaviours ...............................................................91
4.5.2 Externalizing Symptoms and Behaviours ..............................................................92
4.5.3 Social Skills, Peer Relationships, and Family Functioning ...................................92
4.5.4 Core ADHD Symptoms .........................................................................................92
4.5.5 Potential Variables That May Moderate Response to Mindfulness Training Interventions ..........................................................................................................94
4.5.5.1 Age ..........................................................................................................94
4.5.5.2 Comorbidity with other disorders ...........................................................94
4.5.6 Summary of Mindfulness Training Interventions ..................................................95
4.6 Social Skills Training Interventions................................................................................95
4.6.1 Internalizing Symptoms and Behaviours ...............................................................96
4.6.2 Externalizing Symptoms and Behaviours ..............................................................98
4.6.3 Social Skills and Peer Relationships ....................................................................101
4.6.4 Family Functioning ..............................................................................................105
4.6.5 Core ADHD Symptoms .......................................................................................107
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4.6.6 Potential Variables That May Moderate Response to Social Skills Training Interventions ........................................................................................................108
4.6.6.1 Comorbidity with other disorders .........................................................109
4.6.6.2 Age ........................................................................................................111
4.6.6.3 Gender ...................................................................................................112
4.6.6.4 Medication status ..................................................................................112
4.6.6.5 ADHD subtype......................................................................................113
4.6.7 Summary of SST Interventions ............................................................................114
5 DISCUSSION .......................................................................................................................146
5.1 Cognitive Behavioural Therapy Interventions ..............................................................147
5.1.1 Individual Cognitive Behavioural Therapy .........................................................147
5.1.2 Group Cognitive Behavioural Therapy ................................................................150
5.2 Mindfulness Training Interventions ..............................................................................151
5.3 Social Skills Training Interventions..............................................................................155
5.4 Quality of the Included Studies.....................................................................................159
5.5 Limitations ....................................................................................................................161
5.6 Implications for Future Research ..................................................................................163
5.6.1 Cognitive Behavioural Therapy Interventions .....................................................167
5.6.1.1 Individual Cognitive Behavioural Therapy ..........................................167
5.6.1.2 Group Cognitive Behavioural Therapy .................................................169
5.6.1.3 Summary of Cognitive Behavioural Therapy Interventions .................171
5.6.2 Mindfulness Training Interventions .....................................................................171
5.6.2.1 Summary of Mindfulness Training Interventions .................................173
5.6.3 Social Skills Training Interventions.....................................................................174
5.6.3.1 Summary of Social Skills Training Interventions .................................185
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5.7 Conclusions ...................................................................................................................186
REFERENCES ...........................................................................................................................188
APPENDICES ............................................................................................................................218
LIST OF TABLESLIST OF TABLESLIST OF TABLESLIST OF TABLES
Table 1. Conclusions and Limitations of Previous Meta-analyses of Child-Focused
Psychosocial Interventions for Children or Adolescents with ADHD. (Chapter 2) .................... 43
Table 2. SPIO (Study Design, Population, Interventions, Outcomes) Framework. (Chapter 3) . 57
Table 3. Description of Included Studies. (Chapter 4)............................................................... 116
Table 4. Description of Sample Characteristics. (Chapter 4) .................................................... 124
Table 5. Description of the Interventions. (Chapter 4) .............................................................. 129
Table 6. Results of Child-Focused Psychosocial Intervention Studies by Intervention Type. (Chapter 4) ................................................................................................................................. 132
Table 7. Meta-analyses Results. Cognitive Behavioural Therapy Interventions, Between-Group
Design Studies, Teacher-Reported Conduct Disorder Symptoms. (Chapter 4) ......................... 139
Table 8. Meta-analyses Results. Mindfulness Training Interventions, Within-Subject Design
Studies, Self and Parent-Reported Inattention and Internalizing Symptoms. (Chapter 4) ........ 140
Table 9. Meta-analyses Results. Social Skills Training Interventions, Between-Group Design
Studies, Parent and Teacher-Reported Internalizing Symptoms. (Chapter 4) ........................... 141
Table 10. Meta-analyses Results. Social Skills Training Interventions, Between-Group Design
Studies, Parent and Teacher-Reported Externalizing Symptoms and Behavioural Problems. (Chapter 4) ................................................................................................................................. 142
Table 11. Meta-analyses Results. Social Skills Training Interventions, Within-Subject Design
Studies, Parent and Teacher-Reported Social Skills. (Chapter 4) ............................................. 143
Table 12. Meta-analyses Results. Social Skills Training Interventions, Between-Group Design
Studies, Parent, Teacher, and Self-Reported Social Skills and Peer Relations. (Chapter 4) .... 144
Table 13. Meta-analyses Results. Social Skills Training Interventions, Within-Subject Design
Studies, Parent and Teacher-Reported Inattention and Hyperactivity/Impulsivity Symptoms. (Chapter 4) ................................................................................................................................. 145
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LIST OF FIGURESLIST OF FIGURESLIST OF FIGURESLIST OF FIGURES
Figure 1. PRISMA Flow Diagram ............................................................................................... 59
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LIST OF LIST OF LIST OF LIST OF APPENDICESAPPENDICESAPPENDICESAPPENDICES
Appendix A. Description of Instruments Used for Outcome Measurement .............................. 215
Appendix B. Online Library Searches....................................................................................... 233
Appendix C. Coding Forms and Manual .................................................................................. 248
Appendix D. Results of t-tests for Between Groups Design Studies .......................................... 308
Appendix E. Hedge’s g Formulas ............................................................................................. 311
Appendix F. Excluded Studies ................................................................................................... 312
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LIST OF ABBREVIATIONSLIST OF ABBREVIATIONSLIST OF ABBREVIATIONSLIST OF ABBREVIATIONS
AAP American Academy of Paediatrics
ADHD Attention-deficit hyperactivity disorder
ANOVA Analysis of variance
APA American Psychological Association
BPT Behavioural parent training
CBT Cognitive behavioural therapy
CD Conduct disorder
CHP Challenging Horizons Program
CNS Central nervous system
COPE Community parent education
DSM Diagnostic and Statistical Manual of Mental Disorders
EESC Emotion Expression Scale for Children
EMT Emotion management training
EMT-SST Emotion management training combined with social skills training
EPHPP Effective public health practice project
ERIC Education Resources Information Center
GPA Grade point average
LD Learning disability
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MTA Multimodal treatment of attention deficit hyperactivity disorder
ODD Oppositional defiant disorder
OVID Ovid Technologies Inc.
PICO Population, interventions, comparison, outcomes
PRISMA Preferred reporting items for systematic reviews and meta-analyses
PSCT Problem-solving communication therapy
RCT Randomized control trial
SES Socioeconomic status
SFT Structural family therapy
SST Social skills training
STP Summer treatment programs
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1111 INTRODUCTIONINTRODUCTIONINTRODUCTIONINTRODUCTION
Attention-deficit hyperactivity disorder (ADHD) is a chronic neurodevelopmental disorder
involving inattentiveness and/or hyperactive and impulsive behaviours that are evident before the
age of twelve years (American Psychiatric Association, 2013). These behaviour patterns
regularly lead to disruption in settings such as the individual’s home, school, work, and social
life (Barkley, 2015). ADHD affects millions of children, adolescents, and adults and has been
found to impact people across different cultures, ages and genders (APA, 2013). A diagnosis of
ADHD also conveys a significant risk for other associated symptoms and comorbid psychiatric
disorders. As many as 67% to 80% of clinic-referred children with ADHD have at least one other
disorder including oppositional defiant disorder, conduct disorder, depression, anxiety, and
learning disability (Barkley, Murphy, & Fisher, 2008).
The challenges associated with ADHD result in considerable impairment across multiple
domains for children and their families (Kent, Pelham, Molina, Sibley, Waschbusch, et al.,
2011), as well as economic consequences for society at large (Robb, Sibley, Pelham, Foster,
Molina, et al., 2011). This has resulted in efforts to develop effective treatments for children and
adolescents with ADHD. Two broad treatment modalities are commonly employed: medication
(Faraone, Biederman, Spencer, & Aleardi, 2006) and psychosocial interventions (broadly
defined) (Fabiano, Schatz, Aloe, Chacko, & Chronis-Tuscano, 2015). Medication is
recommended as a first-line treatment for ADHD symptoms for children 6 years or older and has
decades of efficaciousness and safety data beginning in the 1970’s (American Academic of
Paediatrics, 2011). Psychosocial interventions offer an alternative to medication management for
several important reasons. First, some children cannot tolerate medications because they
experience side effects (Pliszka, 2007; Vitiello et al., 2012). Second, pharmacological treatment
is not always effective, as there is a 20-30% non-response rate (Pliszka, 2007). Third, a major
barrier to the efficaciousness of stimulants is the tendency for adolescents to discontinue
medication (e.g., Charach, Yeung, Volpe, Goodale, & dosReis, 2014; Meaux, Hester, Smith, &
Shoptaw, 2006). Last, parents may reject pharmacological treatment altogether (Lerner & Wigal,
2008). Additionally, specific evidence-based psychosocial approaches may be better at targeting
the internalizing and externalizing behavioural symptoms and social impairments that are
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common in children with ADHD than medication (Chronis, Jones, & Raggi, 2006; Rapport,
Chung, Shore, & Isaacs, 2001).
Psychosocial treatments of children and adolescents with ADHD can be divided into three
overarching categories: 1) Parent-focused programs (e.g., Behavioural Parent Training); 2)
Teacher-focused programs (e.g., classroom behavioural management); and 3) Child-focused
interventions. In this systematic review I use the term child-focused psychosocial interventions to
refer to interventions wherein a trained therapist teaches children a set of skills aimed at reducing
internalizing or externalizing symptoms and behaviours, or improving maladaptive social skills,
peer relationships and family functioning. These interventions include cognitive behavioural
therapy (CBT), social skills training (SST), mindfulness training, and family therapy. Parent and
teacher intervention programs typically involve behavioural procedures where specific positive
and negative behaviours are targeted. As will be discussed in the next chapter, there are
sometimes barriers to implementing these interventions effectively (Carr, 2009). Similarly, as
previously mentioned, pharmacological treatments have their own concerns and limitations.
Therefore, it is worthwhile to examine child-focused psychosocial interventions and what they
can offer when other treatment modalities are not as effective as desired.
Child-focused psychosocial interventions are interventions that are provided directly to children
by trained therapists. These interventions involve teaching children skills aimed at improving
socialand family interactions (Pfiffner, 2008) and self-regulation (Carr, 2009) and reducing
internalizing symptoms such as anxiety and externalizing symptoms such as anger and
frustration (Hinshaw, Henker, & Whalen, 1984; Haydicky, Shecter, Wiener, & Ducharme,
2015). A child-focused psychosocial intervention may be part of a larger multimodal program
that offers a concurrent parent treatment and/or teacher consultation.
The purpose of this dissertation is to assess the efficaciousness of psychosocial interventions in
which treatment is delivered directly by a therapist (child-focused interventions) to children and
adolescents with ADHD that are purported to reduce their internalizing and externalizing
symptoms or behaviours, improve their social skills, and/or improve their peer relationships and
family functioning. The study includes a systematic review and meta-analysis. Decisions about
the utility of an intervention or the validity of a hypothesis should not be based on the results of a
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single (primary/independent) study, because results sometimes vary across studies. A systematic
review can be understood as a form of survey research in which primary studies, rather than
people, are surveyed. Typically, a systematic review involves several steps including (1)
developing one or more research questions for a certain sample or population, (2) identifying one
or more databases to search for relevant primary studies, (3) developing an explicit search
strategy, (4) developing a coding form (survey protocol) that guides the selection of titles,
abstracts, and manuscripts based on explicit inclusion and exclusion criteria, and (5) extracting
the data in a standardized format (Lipsey & Wilson, 2001). A systematic review identifies,
appraises, and synthesizes a body of literature following a rigorous and transparent protocol.
Consequently, this approach enables replication and ensures that all relevant evidence is
considered (Lipsey & Wilson, 2001). A meta-analysis is a statistical approach (that calculates an
effect size statistic) that combines the data derived from a systematic-review. A meta-analysis
represents the quantitative findings of a set of research studies in a standardized form that allows
for meaningful numerical comparison and analysis across the studies. Thus, every meta-analysis
is based on an underlying systematic review, but not every systematic review is a meta-analysis
(Borenstein, Hedges, Higgins, & Rothstein, 2009; Lipsey & Wilson, 2001).
Several meta-analyses have been conducted examining psychosocial interventions for children or
adolescents with ADHD; however, the majority have been devoted to examining the efficaciousness
of behavioural parent training (e.g., Charach, Carson, Fox, Ali, Beckett, et al., 2013; Lee, Niew,
Yang, Chen, & Link, 2012; Zwi, Jones, Thorgaard, York, & Dennis, 2011) or classroom
behavioural interventions (e.g., Du Paul, Eckert, & Vilardo, 2012; DuPaul & Eckert, 1997). Only a
few systematic reviews and meta-analyses conducted between 1999 to 2016 have included child-
focused psychosocial interventions (e.g., Evans, Owens, & Bunford, 2014; Pelham & Fabiano, 2008;
Majewicz-Hefley & Carlson, 2007; Pelham, Wheeler, & Chronis, 1998). Although several of these
systematic reviews are strong methodologically and meet the standards to be included in the
Cochrane database of systematic reviews, they each have one or more limitations (that will be
elaborated in the next chapter) that make it difficult to establish the efficaciousness of child-focused
psychosocial interventions in general, and specific types of child-focused psychosocial interventions
(i.e., CBT, mindfulness training, SST, family therapy) for children and adolescents with ADHD.
Although previous meta-analyses and systematic reviews have highlighted important findings
4
with regard to psychosocial treatments for children and adolescents with ADHD, none of these
reviews have specifically examined the effects of child-focused psychosocial treatments on their
internalizing and externalizing behaviours and disorders, social skills, peer relations, and family
relationships and functioning. Therefore, the purpose of the present dissertation is to provide a
systematic review and meta-analysis of child-focused psychosocial intervention studies for
children or adolescents with ADHD that have been published or prepared (in press, online, under
review, or dissertation) prior to November 2015. There were three primary objectives for this
systematic review and meta-analysis.
The first objective was to estimate efficaciousness of these psychosocial interventions for
improving externalizing behaviours and disorders (e.g., aggression, rule-breaking, oppositional
defiant disorder (ODD), conduct disorder (CD)), internalizing behaviours and disorders (e.g.,
anxiety, depression), social skills, peer relationships, and family functioning (e.g., parent-child
attachment, number and intensity of parent-child conflicts, sibling relationships), because these
outcomes reflect the social impairment associated with ADHD. Although studies solely
evaluating core ADHD symptom outcomes were not eligible, when provided in an eligible study,
data for core ADHD symptoms was extracted.
The second objective was to compare the efficaciousness of types of child-focused psychosocial
interventions and examine whether the addition of concurrent treatment components
(medication, parent treatment and/or teacher consultation) affects treatment outcomes.
The third objective was to identify possible moderators of treatment efficacy. Moderators
included sample/participant moderators (e.g., child age, gender, and previous experience with
psychosocial treatments), intervention moderators (e.g., intervention type, combined
pharmacological treatment, frequency and duration of intervention), outcome informant moderators
(i.e., self, parent, or teacher), and study level moderators (e.g., publication type, year of publication,
country of study, and quality of study).
5
2222 LITERATURE REVIEWLITERATURE REVIEWLITERATURE REVIEWLITERATURE REVIEW
The literature review provides a description of the characteristics of children and adolescents
with ADHD including core ADHD symptoms, and behavioural symptoms and social (peer and
family functioning) impairments commonly associated with ADHD. This is followed by a
summary of psychopharmacological interventions, which will indicate that in spite of the
efficaciousness of these interventions for many children and adolescents, there are also
limitations that may make medications inappropriate or insufficient for others. I then summarize
interventions that are delivered by parents, and where parents (but not their children) interact
with the therapist (i.e., parent-focused interventions such as behavioural parent training). This is
followed by a summary of interventions that are delivered by teachers where their students do
not interact with the therapist (e.g., classroom behavioural interventions). For both the parent-
focused and teacher-focused interventions I describe the most common interventions that have
been evaluated and discuss the evidence for these interventions. The main focus of this Literature
Review is a description of child-focused psychosocial interventions including individual and
group cognitive behavioural therapy (CBT), mindfulness training, social skills training (SST),
and family therapy (where both children and parents meet together with therapists). I then
discuss the potential moderators that may contribute to child-focused psychosocial treatment
outcome. This is followed by a discussion of the issue of measurement of child functioning
treatment outcomes addressing parent, teacher, and self-ratings. Previous meta-analyses of child-
focused psychosocial interventions (some of which include combinations of child-focused
interventions with psychopharmacological, parent treatment, and teacher consultation) are
discussed next in terms of their findings, the methodology used, and their limitations. This
chapter concludes with a summary and a statement of objectives and research questions.
2.12.12.12.1 Definition and Prevalence of ADHDDefinition and Prevalence of ADHDDefinition and Prevalence of ADHDDefinition and Prevalence of ADHD
ADHD is recognized as a chronic disorder that significantly impairs the functioning of children,
adolescents, and adults characterized by developmentally inappropriate levels of inattention,
overactivity, and impulsivity that result in impaired functioning across important domains in life
(APA, 2013). ADHD has been found to impact people across different cultures, ages and genders
6
(APA, 2013), although it is more common in males (Kessler, Adler, Barkley, Biederman,
Conners, et al., 2006). Currently, ADHD has a worldwide prevalence of approximately 5% for
children (Polanczyk, Willcutt, Salum, Kieling, & Rohde, 2014) and between 3 to 5 % for adults.
The disorder represents one of the most common reasons for referral to medical and mental
health practitioners in North America of children with behavioural problems (Barkley, 2015).
ADHD has a long history of clinical and scientific publications, with more than 10,000 since the
initial descriptions of clinical patients by Weikard in 1775 (Barkley, 2015). Current views of the
etiology of the disorder now emphasize its neurodevelopmental nature and the prominent roles
played by genetics and neurological factors (Mick & Faraone, 2008). The hereditary basis of
ADHD has become firmly established, and numerous candidate genes for the disorder have been
identified. There also have been immense advances in establishing the underlying neurological
nature and mechanisms involved in ADHD in the field of neuroimaging, along with findings
from developmental (longitudinal) neuroimaging studies documenting the delayed brain growth
and altered growth trajectories associated with the disorder (for review see Barkley, 2015). The
result has been an explosion in the size of the ADHD literature, which has nearly doubled in
2013 alone, along with the publication of numerous meta-analyses with various aspects of its
assessment and treatment.
The current official diagnostic criteria for ADHD are described in the fifth edition of the
Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013). DSM-5 criteria
mostly used in North America, are similar, although not identical to the definition of the disorder
in the 10th edition of the International Classification of Diseases (ICD-10; World Health
Organization, 2008).
DSM-5 criteria specify that individuals must have had their ADHD symptoms for at least 6
months, and that these symptoms must occur to a degree that is developmentally deviant, and
must have become evident by 12 years of age. The number of symptoms stipulated to meet
criteria vary according to the individual’s age. For children age 16 years or younger, six or more
(of the nine) symptoms from at least one cluster of symptoms (inattention or hyperactivity-
impulsivity) are required to be present. For adolescents age 17 years or older and adults, five or
more symptoms from at least one of the symptom clusters must be present. These symptoms are
7
required to interfere with the individual’s functioning in two or more settings. For children and
adolescents, the settings typically are the school and home environments. The presentation of
ADHD to be diagnosed depends on whether criteria are met for inattention (ADHD-I),
hyperactivity-impulsivity (ADHD-HI), or the combined presentation (ADHD-C). Severity
specifiers (mild, moderate, severe) can be used to further describe an individual’s diagnosis
based on his or her symptom profile and degree of functional impairment. According to Barkley
(2015), it is well established that deficits in executive functioning or self-regulation are central to
this diagnosis
ADHD symptomatology often leads to disruption in settings such as the individual’s home,
school, work, and social life (APA, 2013; Kent et al., 2011). ADHD symptomatology interferes
with social and family relationships; interrupting, talking excessively, and difficulty waiting for
their turn are likely to make children with ADHD appear intrusive and annoying (Pelham &
Bender, 1982). Children who have more difficult temperamental characteristics (i.e., difficulty
soothing, low positive affect) including ADHD symptomatology (i.e. impulsivity, difficulty
focusing and sustaining attention) may elicit negative or harsh parenting, as they struggle to cope
with the demanding interactions with their child (Johnston & Jassy, 2007). Parents of children
with ADHD often exhibit less warmth, less engagement, and poorer communication skills during
family interactions than parents of children without ADHD, particularly during a problem-
solving activity (Tripp Schaughency, Langlands Mouat, 2007). Adolescents with ADHD have
high levels of conflict with their parents (Markel & Wiener, 2014; see Johnston & Mash, 2001;
Deault, 2010, for review). Parents of children and adolescents with ADHD experience high
levels of parenting stress (Theule, Wiener, Tannock, & Jenkins, 2013; Wiener, Biondic,
Grimbos, & Herbert, 2016). Compared to children without ADHD, children with ADHD have
also greater likelihood of experiencing problematic interactions with peers including social skills
deficits, peer rejection (Hoza, 2007; Murray-Close, Hoza, Hinshaw, Arnold, Swanson, et al.,
2010) and fewer dyadic friendships (Normand, Schneider, Lee, Maisonneuve, Chupetlovska-
Anastasova, et al., 2013). Children (Wiener & Mak, 2009) and adolescents (Taylor, Saylor,
Twyman, & Macias, 2010; Timmermanis, & Wiener, 2011) with ADHD are also more likely to
report experiencing victimization by peers and participating in bullying others than typically
developing children and adolescents.
8
A diagnosis of ADHD also conveys a significant risk for other associated symptoms and
comorbid psychiatric disorders. As many as 67-80% of clinic-referred children and 80% or more
of clinic-referred adults with ADHD have at least one other disorder, and up to half have two
additional disorders (Barkley, Murphy, & Fisher, 2008). For example, relative to the general
population, individuals with ADHD have greater than expected prevalence of ODD/CD (10
times), depression (5.5 times), and anxiety (3 times; Angold, Costello, & Erkanli, 1999).
2.22.22.22.2 Pharmacological InterventionsPharmacological InterventionsPharmacological InterventionsPharmacological Interventions
As summarized above, ADHD and associated behavioural symptomatology result in
considerable impairment across multiple domains for children and their families (Kent et al.,
2011), as well as economic consequences for the individuals involved and society at large (Robb,
Sibley, Pelham, Foster, Molina, et al., 2011). This has resulted in efforts to identify and
disseminate effective treatments for children and adolescents with ADHD. Two broad treatment
modalities are commonly employed: medication (Faraone, Biederman, Spencer, & Aleardi,
2006) and psychosocial interventions (broadly defined) (Fabiano, Schatz, Aloe, Chacko, &
Chronis-Tuscano, 2015). Professional guidelines recommend medication as a first-line
intervention for children 6 years or older (American Academy of Child and Adolescent
Psychiatry, 2007; American Academy of Paediatrics, 2011).
Although there are other psychotropic medications that are used in the treatment of ADHD
symptoms, Central Nervous System (CNS) stimulants are the most commonly used (Volkow,
Wang, Fowler, Logan, Franceschi, et al., 2002). Stimulants include both methylphenidate (e.g.,
trade names: Ritalin, Concerta) and dextroamphetamine (e.g., trade names: Dexedrine Spansule,
Vyvanse) compounds. These exert CNS actions that are known to enhance dopaminergic and
noradrenergic neurotransmission (Volkow et al., 2002). Stimulants have been found to be helpful
in treating age-inappropriate and impairing symptoms of inattention, impulsive behaviour, and
motor hyperactivity that are not due to another cause (e.g., substance use disorders, psychotic
disorder) and are persistent enough to cause impaired functioning at home, school, work, or in
the community. Stimulants as a treatment for ADHD symptoms in children who are at least 6
years of age, adolescents, and adults have decades of efficaciousness and safety data (Biederman
& Spencer, 2008; Vaughan & Kratochvil, 2012). Stimulants can have some continuing benefit in
9
long-term symptom management; as long as clients comply with treatment, benefits can be found
for as long as 5 years (Charach, Ickowicz, & Schachar, 2004; Charach, Yeung, Volpe, Goodale,
& dosReis, 2014). However, there is some debate around this issue.1 It is noteworthy that longer-
term effects on ADHD associated impairments such as academic or social functioning have not
been consistently documented to date (for review see Barkley, 2015).
Stimulant medications come in diverse formulations for different durations of action including
immediate-release, intermediate, and long-acting preparations. The current standard of care in
the treatment of childhood ADHD favours longer-acting formulations as a first-line intervention
for ease of use and more consistent ADHD symptom coverage (Faraone, 2009). Intermediate-
acting formulations are designed to cover the school hours with a once-daily dose preparation,
while long-acting formulations cover both the school and the afterschool hours with a single dose
given in the morning before school (Connor & Steingard, 2004).
Other medications that have been prescribed to treat ADHD include atomoxetine (trade name:
Strattera), and guanfacine (trade name: Intuniv) in Canada and also clonidine (trade name:
Kapvay), in the United States. Atomoxetine’s use, like stimulants, has also been approved for
children 6 years or older, adolescents and adults (Tanaka, Rohde, Jin, Feldman, & Upadhyaya,
2013). Although atomoxetine has fewer and milder side effects than stimulants (discussed below
in detail), treatment effects may take up to 12 weeks (Bushe & Savill, 2014), and have been
found to be less effective than long-acting stimulants (Newcorn, Kratochvil, Allen, Casat, Ruff,
et al., 2008). Clonidine extended release (Jain, Segal, Kollins, & Khayrallah, 2011) and
guanfacine extended release (Wilens, Bukstein, Brams, Cutler, Childress, et al., 2012) have been
respectively approved for the treatment of children and adolescents with ADHD ages 6-17 years,
each one as an adjunctive therapy in combination with stimulants. Clonidine and guanfacine
have been found to be less successful in managing symptoms of attention and concentration than
stimulants (Faraone, 2009; Jain et al., 2011; Wilens et al., 2012).
1 Stimulants are not recommended for use with children under 3 years of age as little is know about the medication
effects in this age group (Mash & Barkley, 2006).
10
The Multimodal treatment of attention deficit hyperactivity disorder (MTA) study is the basis for
current childhood ADHD standards for practice recommended by both the American Academy
of Child and Adolescent Psychiatry and the American Academy of Paediatrics (Barkley, 2015).
The MTA randomized 579 seven to nine-year-old children with ADHD to one of four treatment
arms: a) standardized pharmacotherapy with methylphenidate, b) intensive behavioural therapy,
c) combined therapy with a) and b) treatment types, and d) community care as usual (MTA
Study Group, 1999). At the 14-month post treatment, the pharmacotherapy and the combined
treatment arms showed significant reduction of ADHD symptoms, and both were superior to
community care as usual and behavioural therapy alone. The fact that the combined treatment
was not found to have a statistically significantly better outcome than the stimulant-alone arm
provided the basis for the current clinical practice of stimulant therapy as the first line
intervention for ADHD in school-age children (Greenhill, Pliska, Dulcan, Bernet, Arnold, et al.,
2002). However, further analyses documented that combined treatment was associated with the
use of lower methylphenidate doses, a reduction in comorbid anxiety, and an overall greater
parenting satisfaction (Jensen, Hinshaw, Kraemer, Lenora, Newcorn, et al., 2001; Swanson et al.,
2008).
In their review of reports on the MTA study published between 1995 and 2007, Hoza and
colleagues concluded that there are two general types of challenges associated with
pharmacological treatments: Challenges when medications are taken and challenges when
medications are not taken regularly (Hoza, Kaiser, & Hurt, 2007). Pharmacological treatment is
not always effective, as there is a 20-30% non-response rate (Pliszka, 2007) and medications are
often not sufficient to manage the associated impairments and comorbidities of ADHD
(depression, anxiety, social relationships problems, etc.) (Hoza, Owens, & Pelham, 1999;
Pliszka, 2007). This is important because fewer than 32% of the MTA study participants were
diagnosed with ADHD alone, suggesting that comorbidity is the rule rather than the exception
for children with ADHD (Jensen et al., 2001). Furthermore, some children cannot tolerate
stimulants and non-stimulant medications because they experience side effects, including
headaches, stomachaches, decreased appetite, abdominal discomfort, problems falling asleep,
irritability, fatigue, social withdrawal, or motor and vocal tics (Conners, 2002; Greenhill,
Kollins, Abikoff, McCracken, Riddle, et al., 2006; Pliszka, 2007; Vitiello, Elliot, Swanson,
11
Arnold, Hechtman, et al., 2012). Specifically related to clonidine and guanfacine extended
release, side effects also include feeling faint, dizzy, or light headed (Kollins, Jain, Brams, Segal,
Findling, et al., 2011). In terms of stimulants, other rare side effects include the exacerbation of
psychosis in individuals with a pre-existing psychotic disorder (e.g., schizophrenia or mania), or
with vulnerability to psychotic symptoms (McKetin, Lubman, Baker, Dawe, & Ali, 2013). In
respect to long-term side effects, stimulants might also reduce children’s growth for up to three
years (Swanson, Elliott, Greenhill, Wigal, Arnold, et al. 2007). More significant weight deficits
than height deficits are found, and these appear greater for taller and heavier children, and for
children ages 6 to 12 years compared with adolescents (Faraone, Biederman, Morley, & Spencer,
2008). Discontinuing medication appears to attenuate deficits in weight but not height (Swanson
et al. 2007). Similar concerns have been raised based on animal research regarding the long-term
effects of stimulant medications on the developing brain (Volkow & Insel, 2003).
A second set of limitations and concerns of the pharmacological treatments are that medications
need to be used frequently and consistently in order to have the desired effect. There are
qualitative (e.g., Charach et al., 2014; Meaux et al., 2006) and quantitative (e.g., Marcus, Wan,
Kemmer, & Olfson, 2005) studies suggesting high rates of underuse of ADHD medications. A
major barrier to the efficaciousness of stimulants is the tendency for adolescents to discontinue
medication. The number of children treated with medications appears to peak between the ages
of 9 and 12 before a steady decline (Centres for Disease Control and Prevention, 2005). Studies
indicate that fewer than one in five children who are prescribed stimulant medication for ADHD
continue taking the medications beyond one year (Marcus et al., 2005). For example, when
Meaux and colleagues (2006) interviewed 18-21 year old college male and female students who
had a diagnosis of ADHD that was received prior to school about their previous experiences with
stimulants they found that adolescents perceived a mix of positive and negative effects from the
medication, but that in general, it was reported that the negatives outweighed the positives and
teens ended up stopping taking the medications. Most participants in the Meaux et al. (2006)
study reported that they did not believe that taking stimulants affected their grades, but that the
medications did affect how hard they had to work to get those grades, being easier when on
medication. Other benefits reported were improved driving skills. However, the negatives
described by most participants were feeling frustration, anger, sadness and embarrassment about
12
being singled out in school. Other adolescents reported that medication affected their
personalities; particularly making them feel somber and socially withdrawn. Most college
students agreed that despite telling their parents they were on medication, they had stopped
taking it abruptly. The most common pattern was to take the medication before a test or big
project at school, and being on and off the medications without any professional monitoring.
Charach and colleagues (2014) reported similar findings when interviewing twelve adolescents
with a current or past diagnosis of ADHD (and their parents) ages 12 to 15 years. About half of
their sample voiced concerns regarding the medication changing who they are, feeling less
sociable or outgoing when on the medication (either a concern held when they had first started
taking the medication or as a current undesirable effect). In addition, parents often view
medication as a last resort as they are concerned about adverse and long-term effects (Charach et
al., 2014). Parents may reject pharmacological treatment altogether (Lerner & Wigal, 2008;
Pelham et al, 2004), leaving youth with few treatments alternative.
2.32.32.32.3 PsychosocPsychosocPsychosocPsychosocial Interventions for ADHDial Interventions for ADHDial Interventions for ADHDial Interventions for ADHD
The term psychotherapy has been used to describe, “an array of non-medical interventions
designed to alleviate non-normative psychological distress, reduce maladaptive behaviour
through counseling, interaction, a training program or predetermined treatment plan” (Weiss,
Doss, & Hayley, 2005, p.338). Current psychotherapy interventions for children and adolescents
with ADHD are diverse and include cognitive-behavioural therapy, mindfulness interventions,
family-focused treatments, social skills training, and behavioural parent training. In this
systematic review I use the term child-focused psychosocial intervention rather than
psychotherapy to refer to interventions wherein a trained therapist teaches children a set of skills
aimed at reducing internalizing or externalizing symptoms and behaviours, or improving
maladaptive social skills, peer relationships and family functioning.
Psychosocial treatments offer alternatives to the above presented challenges with medication.
Psychosocial treatments have more impact on peer relationships and family functioning
(Chronis, Jones, & Raggi, 2006), and internalizing (anxiety and depression) and externalizing
(disruptive behaviours) symptoms (Pisterman, Firestone, McGrath, Goodman, Webster, et al.,
1992; Rapport, Chung, Shore, & Isaacs, 2001). If introduced with pharmacological treatments,
13
they often allow for lower doses of medications (Fabiano, Pelham, Gnagy, Burrows-MacLean,
Coles, et al., 2007; Hoza et al., 2007; Pelham & Hinshaw, 1992). This practice is often known as
“combined or multimodal treatments”. Some even argue that once psychosocial interventions are
well established, these can often allow for medication to be discontinued (Carr, 2009).
Furthermore, if children tend to drop the pharmacological treatments after the age of 12 (e.g.,
Marcus et al., 2005; Meaux et al., 2006), then they (and their parents) are left with a set of
behavioural and psychosocial skills that might contribute to more competent functioning. Some
researchers caution that medications do not substitute for the skills that children and adolescents
with ADHD need to acquire and use (Watson, Richels, Michalek, & Raymer, 2015).
Additionally, not all children and adolescents with ADHD require medication. As Barkley
(2015) states in his extensive review of the literature, children with mild ADHD symptoms and
only minimal impairment in daily functioning may respond to a combination of psychoeducation
about the disorder and evidence-based psychotherapy approaches without the use of combined
medications.
Psychosocial treatments of children and adolescents with ADHD can be divided into three
overarching categories: 1) Parent-focused programs (e.g., behavioural parent training); 2)
Teacher-focused programs (e.g., classroom behavioural management); and 3) Child-focused
interventions including CBT, SST, mindfulness training, and family therapy.
2.3.12.3.12.3.12.3.1 ParentParentParentParent----Focused InterventionsFocused InterventionsFocused InterventionsFocused Interventions
This treatment modality typically involves training parents in child-behaviour management
methods and involves two components: 1. Enhanced parental attention to compliant child
behaviour, and 2. Immediate time out for non-compliant behaviour (for review see Mash &
Barkley, 2006; McMahon & Forehand, 2003). Child-behaviour management interventions have
been primarily targeted at school-aged children with conduct or disruptive behaviour problems
and were then applied to children who have co-occurring ADHD symptoms (Mash & Barkley,
2006). These interventions are grouped under the name of behavioural parent training (BPT).
A typical BPT program is manualized and involves parents attending several group meetings and
learning how to apply behaviour management principles to their parenting practices. Skills are
14
taught during group meetings and parents are encouraged to practice the skills between meetings.
Parent training frequently involves a didactic presentation of materials and often takes place at
clinics, community centers, or other public spaces (Evans et al., 2008). When BPT is adapted for
ADHD, the materials taught include psychoeducation sessions on children’s ADHD symptoms,
social learning theory, problem-solving, and behavioural management techniques, such as
methods for giving requests, reinforcing positive and adaptive social behaviours while ignoring
minor misbehaviours, and training for establishing and reinforcing expectations and rules. BPT
programs typically involve a point system with rewards and the use of time-out procedures to
reinforce contingencies across settings. At subsequent meetings, parents share their attempts to
use the techniques and problems encountered are addressed (Chronis et al., 2004; Daly, Creed,
Xanthopoulos, & Brown, 2007; DeNisco, Tiago, & Kravitz, 2005).
BPT treatments are, in general, more effective at targeting child oppositional behaviour than core
ADHD symptoms. Thus, they seem to be more appropriate for use when conflict exists in
families having school-aged children with ADHD (Anastopoulos, Shelton, DuPaul, &
Guevremont, 1993). BPT programs studied with children with ADHD include (but are not
limited to) the community parent education (COPE) program (Cunningham, Bremmer, &
Secord, 1997); the incredible years (Webster-Stratton, 1992); parent-child interaction therapy
(Eyberg & Boggs, 1998); and Barkley’s (1997) program as described in his book, Defiant
Children. Although these programs vary in their format and procedures, all are founded on a
social learning model of disruptive child behaviour (disrupted parenting and social coercion),
and all have demonstrated efficaciousness for reducing disruptive behaviours in children with
ADHD (Chronis, Chacko, Fabiano, Wymbs, & Pelham, 2004; Rajwan, Chacko, & Moeller,
2012).
Meta-analyses support BPT as an effective treatment for children with ADHD and their parents
(e.g., Charach, Carson, Fox, Ali, Beckett, et al., 2013; Lee, Niew, Yang, Chen, & Link, 2012;
Lundahl et al., 2006; Reyno & McGrath, 2006; Zwi, Jones, Thorgaard, York, & Dennis, 2011).
The outcomes measures included parent and teacher standardized questionnaires and direct
observation by clinicians or researchers. Meta-analyses vary with some focusing solely on BPT
without any associated child-focused psychosocial intervention (e.g., Zwi et al., 2011), others
evaluating BPT as part of the broad category of behavioural interventions, including child-
15
focused interventions, and reporting aggregated effect sizes (e.g., van der Oord et al., 2008), and
others evaluating any treatment including BPT where parents were part of the intervention
(Corcoran & Dattalo, 2006). As Fabiano et al. (2015) suggests in his systematic review of the
literature, these meta-analyses vary greatly in their reporting of effect sizes (e.g., statistic
employed, study designs aggregated together) making direct comparison of effect sizes across
meta-analyses imprudent. Nonetheless, it is notable that overall, BPT shows treatment-related
gains in parenting skills, child ADHD symptoms and disruptive behaviour, family relationships,
parental perception of ADHD, and parent reported parenting stress.
However, there are many caveats to the success of these treatments, and the level of
efficaciousness varies and can be limited depending on two general variable categories: Family
adversity and child age (Lundahl, Risser, & Lovejoy, 2006). Family adversity is believed to
undermine the efficaciousness of parent training interventions by disrupting parent training
processes and implementation of recommendations. Low socioeconomic status (SES), single parent
status, young parental age, parental stress (Kazdin, 1995), parental psychopathology (Sonuga-
Barke, Daley, Thompson, Laver-Bradbury, & Weeks, 2001), and unstable housing are all
associated with poorer outcome (for reviews, see Dumas & Wahler, 1983; Firestone & Witt,
1982; Forehand, Middlebrook, Rogers, & Steffe, 1983; Holden, Lavigne, & Cameron, 1990;
Kazdin, Mazurick, & Bass, 1993; Kazdin & Wassell, 1999; Mash & Barkley, 2006; Miller &
Printz, 1990). Children’s age is also believed to influence treatment outcome; because younger
children are more reliant on parents for the fulfilment of their needs, they are expected to be
more responsive to child management skills taught in BPT programs (Dodge, 1993; McCart,
Preister, Davies, & Azen, 2006). In contrast, older children have more advanced and developed
reasoning skills and lower reliance on parents, and are expected to benefit more from non-
behavioural programs which focus on improving parent-child communication patterns (Barkley
& Robin, 2014). These assumptions can be considered partly confirmed in Lundahl, Risser, and
Lovejoy’s meta-analytic review (2006) of parent training programs for parents of 5-12 year-old
children with disruptive behaviour in which effect sizes were greatest for younger children and
lowest for older children.
16
2.3.22.3.22.3.22.3.2 TeacherTeacherTeacherTeacher----Focused InterventionsFocused InterventionsFocused InterventionsFocused Interventions
Because children with ADHD often make careless mistakes in their schoolwork (Raggi &
Chronis, 2006), have significant difficulties with time management, such as planning for the
completion of long-term projects and studying for tests (Mash & Barkley, 2006), and exhibit off-
task, impulsive, and disruptive behaviours in the classroom (Hoza, Pelham, Waschbusch, Kipp,
& Owens, 2001), they often underachieve academically (Barkley, Fischer, Edelbrock, &
Smallish, 1990). Therefore, research has examined the application of psychosocial interventions
for children with ADHD in the classroom. These interventions most often target academic
productivity, organization skills (Langberg, Epstein, Urbanowicz, Simon, & Graham, 2008), and
social interactions (Pelham & Fabiano, 2008), and have been classified as well-established
treatments for almost two decades.
School-focused interventions can be divided into two broad categories based on their goals and
strategies employed to achieve those goals: Academic interventions and skill training
interventions. Academic interventions have the aim to enhance academic functioning by
improving specific areas of academic achievement such as reading and mathematics skills. These
interventions include academic consultation (Jitendra, DuPaul, Volpe, Tresco, Junod, et al.,
2007), peer tutoring (Greenwood, Maheady, & Delquadri, 2002), and computer-aided instruction
(Mautone, DuPaul, & Jitendra, 2005; Ota & DuPaul, 2002). Academic interventions have been
shown to be efficacious at improving academic achievement in specific subjects; however, the
generalization of these academic gains to other academic subjects or to future years in schooling
has not yet been established (Du Paul, Eckert, & Vilardo, 2012). Skill training interventions
employ either contingency management and/or cognitive behavioural strategies, and teach
children with ADHD the necessary skills to help them navigate and succeed in the school
environment, including organization, note-taking, and study-skills (Evans, Pelham, & Grudberg,
1995; Langberg, Bogle, Smith, & Schmidt, 2004). Contingency management interventions use
reinforcement to establish positive or reduce negative school-related behaviours. School-focused
cognitive behavioural interventions have the aim to develop self-control skills (e.g., cognitive
rehearsal, self-instruction) and problem-solving strategies (e.g., self-reinforcement) to regulate
behaviour (Du Paul, Eckert, & Vilardo, 2012). Skill training interventions for children with
17
ADHD are associated with enhanced on-task performance, comprehension of academic material,
test scores (Evans et al., 1995; Langberg et al., 2004), improved classroom preparatory skills
such as punctuality and submission of assignments (Gureasko-Moore, DuPaul, & White, 2006;
Langberg et al., 2008), teacher ratings of academic impairment, and GPA (Langberg et al.,
2008).
Meta-analyses (e.g., Du- Paul & Eckert, 1997; Du Paul et al., 2012; Reid, Trout, & Schartz,
2005; Trout, Ortiz Lienemann, Reid, & Epstein, 2007) have also examined the efficaciousness of
school-focused interventions alone and in combination with a broader range of psychosocial
treatments (Fabiano, Pelham, Coles, Gnagy, Chronis-Tuscano, & et al., 2009; van der Oord,
Prins, Oosterlaan, & Emmelkamp, 2008). Overall, in these meta-analyses the dependent
variables for each study were classified and aggregated into either academic (e.g., GPA) or
behavioural (e.g., on-task classroom behaviour) outcomes, often combining teacher ratings, self-
reports, and direct observations. The findings suggest three conclusions. First, classroom
interventions are associated with clinically significant behavioural change that is moderate in
magnitude (i.e., a change of at least 0.5 standard deviation units). Second, intervention effects are
generally greater for behavioural functioning than for academic performance. Third, effects on
behaviour are equivalent for academic interventions and for contingency management
interventions and both approaches are superior to cognitive behavioural treatment. However,
these findings are applicable for children and not adolescents, because most studies included in
these meta-analyses have focused on interventions for elementary and middle school students
with only a limited set of studies including high school students.
Teacher-focused behavioural interventions, however, also have several barriers to effective
implementation, including teacher personality and teaching style, and token use/reward system
use. These issues affect treatment efficaciousness and whether treatment gains are generalized to
other settings where no treatment procedures are in effect (for a review see Mash & Barkley,
2006). Similarly, it would be ideal if education about ADHD symptomatology and impairment
were provided as part of teacher education. Unfortunately, this is rarely the case, especially for
general education teachers (as opposed to special education teachers; Jones & Chronis-Tuscano,
2008).
18
Although children and adolescents with ADHD are taught predominantly in general education
classrooms (Schnoes, Reid, Wagner, & Marder, 2006), current findings suggest that many
general education teachers have inadequate training in ADHD (Martinussen, Tannock, &
Chaban, 2011). When assessing general and special education teachers’ level of training in
ADHD Jones and Chronis-Tuscano (2008) found that special educators had received more
extensive training in ADHD and reported a higher use of recommended behaviour management
approaches when compared to the general education teachers. However, Martinussen et al.
(2011) found that almost half (41%) of the special education teachers and the majority of general
education teachers (76%) reported having no or brief in-service training in ADHD. This finding
is of great concern, considering that teachers with little training in ADHD may have less positive
attitudes toward students with ADHD (Bekle, 2004), may also hold different views than those
with more extensive knowledge of the acceptability and usefulness of various intervention
approaches, and may be less likely to follow the individualized behaviour management
approaches (e.g., behavioural contracts, daily report cards) to support children with ADHD
(Martinussen et al., 2011).
Additionally, teacher-focused interventions are traditionally tailored for children in the
elementary school years. Only recently have a few school-focused programs been developed and
evaluated at the high school level (e.g., The Challenging Horizons Program, Evans, Schultz,
DeMars, & Davis, 2011). That is likely the case because teachers at large secondary schools
often teach more than 100 different students per day and spend relatively little time with any
given student. However, when children enter adolescence the challenges associated with ADHD
symptomatology prevail (Evans et al., 2011) and it is at this developmental stage when
educational performance becomes the most common reason adolescents with ADHD are referred
for clinical services (Barkely, 2015). To add to these challenges, middle and high school teachers
expect more independence from their students and may often be less eager to implement
recommended interventions strategies (DuPaul & Weyand, 2006).
In sum, parent and teacher intervention programs are based on behavioural procedures where
specific positive and negative behaviours are targeted. Reinforcement and extinction procedures
are used to increase the frequency of positive target behaviours and reduce the frequency of
negative target behaviours, and both types of treatments have their own caveats and barriers to
19
efficaciousness (Carr, 2009). Similarly, as previously mentioned, pharmacological treatments
have their own concerns and limitations. Therefore, it is worthwhile to examine child-focused
psychosocial interventions and what they can offer when other treatment modalities are not as
effective as desired. Given that ADHD is a chronic, life-long disorder, having a treatment
modality alternative that would allow for treatment gains across adolescence and into adulthood,
particularly following the reduction or withdrawal of pharmacological treatment is greatly
needed (Barkley, 2006).
2.3.32.3.32.3.32.3.3 ChildChildChildChild----Focused InterventionsFocused InterventionsFocused InterventionsFocused Interventions
Child-focused psychosocial interventions are interventions that are provided directly to children
by trained therapists. Multimodal interventions also may include a child-focused psychosocial
treatment component that provides direct training to children in social skills (Pfiffner, 2008),
self-regulation skills (Carr, 2009), organizational skills (Abikoff, & Gallagher, 2008) or
anger/frustration-management strategies (Hinshaw, Henker, & Whalen, 1984; Haydicky,
Shecter, Wiener, & Ducharme, 2015), while also including parent treatment and/or teacher
consultation. For the purpose of the present study, I will be referring to child- focused
interventions when referring to interventions during which a child and a therapist have direct
contact (i.e., as opposed to a child and a teacher or a child and a parent).
There are numerous psychosocial interventions targeting childhood and adolescent ADHD
adopting a skill training approach that assume that functional impairment in social interactions or
independence in academic tasks reflects underlying deficits in social skills, life skills, and/or
organizational skills, and that children may need direct instruction to improve functioning in
these domains (Kaiser & Pfiffner, 2011). The present study exclusively focuses on behavioural
or psychosocial treatments for ADHD, including individual and group cognitive behavioural
therapy (CBT), mindfulness training, social skills training (SST) interventions, and/or family
therapy for children and adolescents’ behavioural, emotional, and social outcomes. Although
child-focused psychosocial interventions vary in regard to the specific methods used and their
goals in relation to child outcomes, they all involve an interaction between a child or a group of
children and a therapist who is teaching the children a set of skills aimed at improving child
functioning. In the following section the main types of child-focused psychosocial interventions
20
employed with children and adolescents with ADHD are described. I do not describe the data
supporting the efficaciousness of these treatments because that is the focus of the Results chapter
of this dissertation.
2.3.3.12.3.3.12.3.3.12.3.3.1 Cognitive Behavioural TherapyCognitive Behavioural TherapyCognitive Behavioural TherapyCognitive Behavioural Therapy
Cognitive behavioural therapy (CBT) is based on a scientific understanding of the complex
interplay of thoughts, feelings, and behaviours and how these interact with one another and with
the environment in the etiology and maintenance of a wide range of psychological disorders
(Craske, 2010). Behaviour therapy based on principles of classical and operant conditioning are
merged with cognitive approaches, emphasizing the influence of beliefs, appraisals, and their
modification in the mediation of new learning (Craske, 2010). Clinicians also take an empirical
approach with each individual child, collecting data throughout treatment and modifying
working hypotheses and treatment strategies as needed based on those data (Abikoff, 1987;
Craske, 2010). CBT has as its goals the reduction or elimination of maladaptive or inappropriate
behaviours and the establishment of more efficient and adaptive models of responding. Central to
these goals is the development of self-control skills and reflective problem-solving strategies
(Meichenbaum & Asarnow, 1979; Craske, 2010). CBT operates under the assumption that the
acquisition and internalization of these cognitive and behavioural skills will provide children
with the means for regulating their behaviour by supporting them in the way they interact with
the environment, thereby facilitating generalization and maintenance effects (Abikoff, 1987;
Craske, 2010). Children must use these skills in their daily lives, not merely discuss them in
sessions. There is an emphasis on practicing the skills outside of the session, typically by giving
homework assignments.
A number of different cognitive treatment procedures and approaches have been employed with
children with ADHD, including self-instructional training, cognitive modelling, attentional
training, self-regulation, cognitive problem solving, strategy training, and cognitive behaviour
modification (e.g., Abikoff & Gittelman, 1985; Brown, 1980; Brown, Borden, Wynne, Schleser,
& Clingerman, 1986; Brown, Wynne, & Medennis, 1985; Bugental, Whalen, & Hanker, 1977;
Cohen, Sullivan, Minde, Novak, & Helwig, 1981). However, for the purpose of this study, I will
focus on those CBT treatment trials in which behavioural and/or social outcomes were measured.
21
Earlier CBT interventions, conducted prior to the 1990’s, were different from the more recent
approaches to CBT, and generally involved cognitive training for children with ADHD (Abikoff,
1991). Earlier interventions assumed that children with ADHD could be trained to use self-
instructional statements, also called verbalizations (e.g., “what is it my problem…and what do I
know?”). These verbalizations would allow children to engage in reflective problem solving, and
that this would, in turn, modify their cognitive processes, generalize to new settings, and reduce
impulsive responding (Knouse, 2015). In contrast, current CBT interventions do not purport to
change the underlying processes that produce symptoms; instead, they aim to teach skills for the
children to compensate for their inattentive or hyperactive symptoms (Safren Otto, Sprich,
Winett, Wilens, et al., 2005; Safren, Sprich, Mimiaga, Surman, Knouse, et al., 2010). These
skills include behavioural strategies aimed at improving self-regulation and cognitive reappraisal
to increase the likelihood of effective coping in the presence of distracting or negative emotions.
For example, the therapist might teach skills to reduce distractibility by determining the length of
time children can hold their attention and use the previously learned skills to break tasks into
chunks that take this amount of time. It might incorporate a procedure called ‘‘distractibility
delay’’ adapted from CBT for General Anxiety Dirsorder (Craske, Barlow, & Meadows, 2000),
whereby children are instructed to write down distractions when they emerge rather than act on
the distraction; and then return to the task at hand.
CBT is designed to be short-term, time-limited, goal-directed, and highly structured, directing
child and therapist efforts towards the goal (Carver & Scheier, 2011). CBT can be offered in
individual or group formats. Treatment is often manualized and a workbook containing
psychoeducational information, notes, and homework assignments are part of either format.
Sessions typically follow a structure such as setting an agenda, reviewing self-reported
symptoms and impairments from the prior week, reviewing the results of previous skill practice
(homework), introducing new skill material, troubleshooting possible barriers, and setting the
next assignment (Flannery-Schroeder, & Lamb, 2009).
2.3.3.22.3.3.22.3.3.22.3.3.2 Mindfulness Training TherapiesMindfulness Training TherapiesMindfulness Training TherapiesMindfulness Training Therapies
Instead of targeting and attempting to alter the content, frequency, and form of thoughts and
feelings directly, acceptance and mindfulness-based therapies seek to change the function of
22
internal phenomena so as to reduce their impact (Hayes & Greco, 2008). Mindfulness is the non-
evaluative, present-centred awareness that results from the deliberate focusing and refocusing of
attention on sensations, thoughts and feelings as they arise on a moment-by-moment basis
(Ortner, Kilner & Zelazo; 2007; Semple, Reid & Miller, 2005; Williams, Teasdale, Segal, &
Kabat-Zinn, 2007). Mindfulness, as conceptualized by Bishop, Lau, Shapiro, Carlson, Anderson,
et al. (2004), involves self-regulation of attention and an open accepting orientation towards
experience. Considered a metacognitive or executive functioning skill, as it involves consciously
monitoring cognitive processes, mindfulness can be cultivated with intention and effort through
meditation practice. In meditation practice, attention is consciously directed towards an internal
(e.g., thoughts, emotions) or external stimulus (Semple & Lee, 2008). The diverse processes
involved in mindfulness practice repeatedly engage executive functions (focus, emotion,
memory, action, activation, and effort; Brown, 2006) which may lead to a strengthening of these
abilities as well as changes in self-regulatory skills (Zylowska, Ackerman, Yang, Futrell, Horton,
et al., 2008). In practice (sitting or walking meditation), attention is engaged through the
following steps: 1) bringing attention to an “attentional anchor” (typically breath) through
observation or description; 2) noting that distractions occur and letting go of those distractions by
acting with awareness and not judging the experience; 3) refocusing attention back to the
“attentional anchor” though non-reactivity to one’s inner experience (Baer, Smith, Hopkins,
Krietemeyer, & Toney, 2006; Zylowska et al., 2008).
2.3.3.32.3.3.32.3.3.32.3.3.3 Social Skills TrainingSocial Skills TrainingSocial Skills TrainingSocial Skills Training
Given that a long-term prognosis of problematic peer interactions is characteristic of children
and adolescents with ADHD (Barkley, 2015), social skills training (SST) interventions provide
children with didactic instruction on a variety of social skills allowing for opportunities to
practice and receive reinforcement for appropriate skill display within a group setting (Pelham &
Fabiano, 2008). Children are taught how to adjust their verbal and non-verbal behaviour in their
social interactions. Training generally focuses on teaching the children how to perceive and
interpret the subtle social cues and problem-solve in social interactions (Storebø, Skoog, Damm,
Thomsen, Simonsen, et al., 2011). Topics of instruction typically include making conversation,
sharing, taking turns, good sportsmanship, calming down, dealing with teasing and conflict, and
being able to recognise the emotional expressions of others. A new social skill is often
23
introduced in session each week through discussion, exercises, games, and role-plays and the
clinician has the opportunity to correct children’s behaviours (Pfiffner, 2008; Storebø et al.,
2011). SST programs vary in frequency and length; children commonly attend 50 to 90-minute
sessions once per week for 8 to 12 weeks, with the most intensive format being the summer
treatment programs (STP), which are typically full-day multi-week programs (Pelham, Fabiano,
Gnagy, Greiner, & Hoza, 2004). STPs are manual-based intensive behavioural interventions
typically involving a point system (in which children earn points for positive behaviour and lose
points for negative behaviours) with daily and weekly rewards, time out and SST implemented
by highly trained counsellors in a school or clinic setting with a child recreational activity
component (Hoza, Vallano, & Pelham, 1995; Pelham et al., 2004). Counsellors teach the
curriculum in session and remain with the children to engage in intensive, frequent, and
consistent reinforcement and response cost throughout the day to shape children’s social
behaviours in vivo (Pelham & Hoza, 1996).
There is variability in the extent to which clinicians encourage generalization of appropriate
social skills behaviours outside of the therapeutic context (Barkley, 2015). The traditional
programs involve a group of children receiving training, and parents are informed of the skills
taught each week. Other SST programs also involve simultaneous parent training as friendship
coaches (e.g., Pfiffner, 2008). In these programs, parents are concurrently taught how to
reinforce their children’s display of appropriate social skills outside the session (Frankel &
Mintz, 2011), adopting a similar role to the STP counsellors, who also have the role of shaping
children’s social behaviours in vivo.
2.3.3.42.3.3.42.3.3.42.3.3.4 Family TherapyFamily TherapyFamily TherapyFamily Therapy
Family therapy differs from BPT because in family therapy children participate in sessions with
the therapist. The rationale for including family therapy in the broad category of child
psychosocial treatments is that when children participate in therapy sessions with their parents
(and sometimes siblings) children learn a set of skills intended to enhance their family
relationships. Family therapy treatments for ADHD that have been empirically evaluated
typically have older children and adolescents as participants (i.e., problem-solving
communication therapy and structural family therapy (e.g., Fletcher, & Metevia, 2001).
24
Problem-solving communication therapy (PSCT; Guevremont, Anastopoulous, & Fletcher, 1992;
Barkley, Edwards, Laneri, Fletcher, & Metevia, 2001; Patterson & Forgatch, 1987; Robin &
Foster, 1989) is a manualized treatment that has three major components targeting parent-
adolescent conflict. First, it involves training parents and adolescents in five problem-solving
techniques: Problem definition, brainstorming of possible solutions, negotiation, decision making
about a solution, and implementation of the solution. Second, it offers communication training,
which consists of supporting parents and adolescents in developing more effective
communication skills while discussing family conflicts, such as speaking in an even tone of
voice, paraphrasing others’ concerns before articulating one’s own concerns, providing approval
to others for positive communication, and avoiding insults, put-downs, ultimatums, and other
poor communication skills. Third, these techniques are coupled with aspects of cognitive therapy
(Beck, 1976; Ellis & Grieger, 1977) that focus on restructuring irrational beliefs by offering
cognitive restructuring training. This involves helping families detect, confront, and restructure
irrational, extreme, or rigid belief systems held by adolescents or their parents about their own or
the others’ conduct. During each session these skills are practiced with the therapist who uses
direct instruction, modelling, behaviour rehearsal, role-playing, and feedback as teaching
methods. Adolescents and the parents typically meet with the therapist weekly for 8 to10 one-
hour sessions. Homework assignments are also given that involve the family using PSCT skills
during a conflict discussion at home and audiotyping these for later review by the therapist.
Structural family therapy (SFT) is a manualized family treatment program where adolescents and
parents meet the therapist weekly for 8 to10 one-hour sessions. SFT follows the principles of
Minuchin (1974) and Minuchin and Fishman (1981) in helping families to identify and alter
maladaptive family systems or interaction processes, such as transgenerational coalitions,
scapegoating, and triangulation. The techniques used by the therapist focus on creating
transactions, joining with the family’s transactions, and helping to restructure maladaptive
transactions (i.e., system recomposition, system refocusing, structural modifications). The
concepts of family boundaries, alignment, and power are used by the therapist to analyse family
dynamics and propose possible changes to the current family system. Homework assignments
typically involve instructions to replace ineffective family transactions with novel strategies
(e.g., empowering a parent weak in authority). Between the first and second session of treatment,
25
families review a 90-minute videotape to ensure that they receive the same information about
ADHD.
The key common factor here is that all of these interventions teach children a set of skills
intended to assist and support them self-manage above and beyond parents’ and teachers’
supports. This is especially critical for adolescents who have multiple teachers and who do not
respond to relatively simple reinforcement and extinction methods, for whom contingency-
management programs are not efficacious (Kaizer, Hoza, & Hurt, 2008), and who often seem to
discontinue medication use after the age of 12 (Centres for Disease Control and Prevention,
2005).
2.42.42.42.4 Moderating Variables That May Contribute to ChildModerating Variables That May Contribute to ChildModerating Variables That May Contribute to ChildModerating Variables That May Contribute to Child----Focused Focused Focused Focused
Psychosocial Psychosocial Psychosocial Psychosocial Treatment OutcomeTreatment OutcomeTreatment OutcomeTreatment Outcome
Treatment may be differentially effective depending on characteristics of the child, the family,
the treatment itself, and the outcomes measured. These characteristics are referred to as
moderators (Lipsey & Wilson, 2001). In relation to children with ADHD, the literature points to
a number of variables that might influence treatment outcome including child characteristics
(age, gender, medication status, subtype of ADHD, comorbidity with other disorders),
intervention characteristics (duration and frequency of intervention), and outcome measure
characteristics (standardized self, parent, or teacher report measures; direct observations by
parents, teachers, clinicians and researchers). In addition, it is important to examine study
characteristics (publication type, year of publication, country of study, and quality of study) in
order to determine whether these impact whether an intervention is found to be efficacious
(Lipsey & Wilson, 2001).
2.4.12.4.12.4.12.4.1 ChildChildChildChild CCCCharacteristics haracteristics haracteristics haracteristics
AgeAgeAgeAge
There is considerable data that different types of interventions might be appropriate for children
of different ages. With regard to CBT, investigators (Knouse, 2015; Toplak, Connors, Shuster,
26
Knezevic, & Parks, 2008) suggested that older children, adolescents and adults may benefit more
from CBT than younger children because younger children do not have sufficient
neuropsychological development, particularly of their executive functions, to acquire the skills.
This may also be true for mindfulness interventions because more developed executive functions
would enable older children and adolescents to regulate their attention by deliberately focusing
on sensations, thoughts, and feelings as they arise on a moment-by-moment basis. Indeed, there
is preliminary evidence on the efficaciousness of mindfulness training interventions for adults
with ADHD in improving externalizing symptoms and behaviours, and social problems
(Zylowska et al., 2008).
In regards to SST, although the social impairment of children with ADHD has been shown to
persist across adolescence and young adulthood (e.g., Bagwell, Molina, Pelham, & Hoza, 2001;
Hoza, 2007), children of different ages tend to value different social skills. Younger children’s
friendships are typically based on play and shared activities and older children’s friendships are
characterized by intimacy and companionship (Bagwell, Newcomb, & Bukowski, 1998;
Bukowski, Newcomb, & Hoza, 1987). Therefore, it is possible that children participating in SST
interventions have different goals based on their developmental needs and respond differently to
these interventions according to their age.
GenderGenderGenderGender
Previous research has not shown that child gender is a moderator of CBT interventions (Boyer,
Doove, Geurts, Prins, Van Mechelen et al., 2016; Kendall, Flannery-Schroder, Panichelli-
Mindel, SouthamGerow, Benin et al., 1997). Previous research has not investigated whether
gender is a moderator of mindfulness training nor have researchers postulated that it might be
(e.g., Zylowska et al., 2008). Gender has been related to treatment outcome in some family
therapy studies (Barrett, 1996), but not in others (Greenbaum, Wang, Henderson, Kan, Hall, et
al., 2015). In a study comparing a family therapy intervention plus CBT to a CBT-only
intervention aimed at improving internalizing symptoms, girls responded better to the family
therapy plus CBT treatment condition, but boys did equally well in both treatment conditions.
Nonetheless, Greenbaum and colleagues (2015) found that family therapy was an efficacious
treatment for use among adolescents of both genders. De Boo and Prins (2007) suggested that
27
gender might be a moderator of the efficaciousness of SST interventions for children with
ADHD because in early and middle childhood boys and girls tend to engage in same-sex play.
Furthermore, boys and girls develop different patterns of interactions with their peers, and value
somewhat different characteristics in friendships (Keenan & Shaw, 1997). Therefore, it is
possible that SST programs that are more efficacious might have curricula that are gender-
specific and tailored to the specific types of friendship skills that are valued by each gender (de
Boo & Prins, 2007). As most samples of intervention studies on children with ADHD have a
higher proportions of boys than girls in the sample (for review see Barkley, 2015), it is possible
that in the case of group interventions, the skills that are valued by boys are emphasized and girls
involved in mixed-gender groups may benefit less from treatment.
The literature is mixed in terms of whether boys or girls with ADHD have greater social
impairment. Furthermore, the severity of social impairment may influence the response to
psychosocial treatment, particularly those conducted in groups. One meta-analysis (Gershon,
2002) reported no gender differences in peer problems. Nonetheless, in community samples,
boys with ADHD are more likely than girls with ADHD to have comorbid aggressive behaviour,
and the presence of aggression is strongly associated with being disliked by peers (Mikami,
2015). For example, research has found that relative to typically developing children boys
(Melnick & Hinshaw, 1996), but not girls, with ADHD (Thurber, Heller, & Hinshaw, 2002)
expressed having social goals prioritizing attention seeking at the expense of rules. When girls
with ADHD present with equivalent aggression to that found in boys, however, they are more apt
to be rejected by peers than boys (Mikami & Lorenzi, 2011). Mikami and Lorenzi suggested that
the reason why girls with ADHD may have greater social impairment might be because
aggression is considered more deviant in female peer groups. Supporting these findings, Thurber
and colleagues (2002) found that when girls with ADHD were presented with hypothetical
situations involving ambiguous peer provocation, they generated more aggressive, ineffective
solutions to peer conflicts in comparison to typically developing girls. In their meta-analysis,
Gershon (2002) also found that in comparison to boys with ADHD, girls with ADHD had lower
ratings of externalizing problems and more internalizing problems than boys with ADHD. Taken
together, the evidence suggests that it is worthwhile to explore gender as a potential moderator of
child-focused psychosocial treatment response, and that this is most important for SST.
28
Medication StatusMedication StatusMedication StatusMedication Status
The literature is mixed in terms of whether child-focused psychosocial treatment for children and
adolescents with ADHD is more efficacious when offered as a stand-alone treatment or when it
is combined with medication. Majewicz-Hefley and Carlson’s (2007) systematic review and
meta-analysis including a combination of pharmacological and psychosocial treatments have
found it to be advantageous to combine psychosocial treatments with pharmacotherapy in
enhancing functional outcomes. Specifically, psychosocial treatments with concurrent
medication appeared to have the largest and most significant impact on core ADHD symptoms
and on social skills. It is possible that medication is facilitative because it might provide children
with the capacity to focus on the specific strategies they need to learn or execute the skills being
taught. For example, it is possible that medication might help children meditate for longer
periods, which might contribute to the effectiveness of mindfulness training interventions.
However, in their systematic review and meta-analysis, Pelham and Fabiano (2008) have
suggested that child-focused SST interventions with concurrent medication may not produce
effects that generalize beyond the skills training context. They suggested that a possible limiting
factor is that children were concurrently medicated with stimulants, and this perhaps limited the
ability to detect the intervention effects. According to these investigators, concurrent medication
does not facilitate the impact of SST intervention. Therefore, further investigation on whether
child-focused psychosocial treatment for children and adolescents with ADHD is more
efficacious when offered as a stand-alone treatment or when it is combined with medication is
warranted.
ADHD Subtype ADHD Subtype ADHD Subtype ADHD Subtype
Research suggests that children with ADHD-Inattentive Type may be more responsive to SST
interventions than children with ADHD-Hyperactive/Impulsive or ADHD-Combined Type
(Pfiffner, 2003). Barkley (2015) suggests that it is possible that this is due to children with
ADHD-Inattentive Type generally tending not to show the positive bias prevalent in children
with ADHD-Hyperactive/Impulsive and ADHD-Combined Type (Owens & Hoza, 2003).
Positive bias refers to children’s tendency to overestimate their own competence and
performance in academic, social, and behavioural domains (Hoza, Murray-Close, Arnold,
29
Hinshaw, Hechtman, et al., 2010; Owens, Goldfine, Evangelista, Hoza, & Kaiser, 2007).
Therefore, if children with ADHD-Inattentive Type are less likely to overestimate the extent of
their social competence, this subgroup of children with ADHD may be more motivated to change
and more responsive to SST (Barkley, 2015). This hypothesis could be extended to child-focused
psychosocial treatment in general.
Comorbidity with Other Disorders Comorbidity with Other Disorders Comorbidity with Other Disorders Comorbidity with Other Disorders
The literature shows that children with ADHD and comorbid anxiety may be more responsive
than children with ADHD alone to psychosocial treatment in general (Jensen et al., 2001; Schatz
& Rostain, 2006). Furthermore, both individual and group CBT has been shown to be an
efficacious treatment for children with anxiety disorders (e.g., Manassis, Mendlowitz, Scapillato,
Avery, Fiksenbaum, et al., 2002). It is therefore important to examine whether co-occurring
anxiety is a moderator of treatment.
In addition, several investigators have suggested that children with ADHD and comorbid ODD
are more likely than children with ADHD alone to have a positive bias (Hoza et al., 2010; Owens
et al., 2007). Because of this positive bias, this subgroup of children with ADHD and ODD
might be less motivated to change and might be resistant to psychosocial treatment in general
(Mikami, Calhoun, & Abikoff, 2010). In addition, children with ADHD and comorbid ODD may
benefit less from SST interventions than children with ADHD and no co-occurring disruptive
behaviour. Pfiffner, Calzada, and McBurnett (2000) argue that because children with ODD are
more resistant to taking direction from an adult about the appropriate ways to behave, they may
be less likely to benefit from training in social skills.
A high percentage of children with ADHD have a learning disability (LD), with estimates
ranging from 20 to 60% (Willcutt, Pennington, Olson, & Defries, 2007). LD is a neurobiological
disorder affecting the ability to acquire, organize, retain, understand, and use information
(Learning Disabilities Association of Canada, 2005). It is therefore possible that children with
ADHD and comorbid LD may struggle to learn and apply the strategies taught in child-focused
psychosocial interventions.
30
Family CharaFamily CharaFamily CharaFamily Characteristics cteristics cteristics cteristics
There are several family variables that can impact psychosocial treatment including
socioeconomic status, single parent status, young parental age, parental stress (Kazdin, 1995),
parental psychopathology (Sonuga-Barke et al., 2001) including parental ADHD (Johnson, Mash
& Miller (2012), and marital conflict (e.g., Mash & Barkley, 2006). Families with fewer
financial resources and social supports typically find it more challenging to ensure that their
children are able to adhere to treatment. Barkley and Robin (2014) suggested that the
efficaciousness of psychosocial treatments where parents are involved might be reduced when
parents are divorced or in the process of divorcing. Because parents who are divorcing are more
likely to exhibit more open hostility toward each other, they may be unable to work as a team
and follow the strategies taught in the sessions (Barkley, 2015). This is particularly relevant to
family therapy.
2.4.22.4.22.4.22.4.2 IIIIntervention Cntervention Cntervention Cntervention Characteristics haracteristics haracteristics haracteristics
Child-focused psychosocial interventions vary in their length (i.e., number of sessions) and
frequency (e.g., daily as in summer treatment programs, weekly, bi-weekly). Although clinicians
and researchers sometimes assume that longer and more intensive treatment is more efficacious
(Haase, Frommer, Franke, Hoffmann, Schulze-Muetzel, et al., 2008), brief or time-limited
treatment has been shown to have better attendance and lower dropout rates (Crits-Christoph,
1992; Pekarik, 1994). Furthermore, in his review of SST interventions for children with social
difficulties, Schneider (1992) found that although length of treatment as measured by the total
number of sessions did not correlate with effect size, SST intervention studies with some of the
highest effect sizes were those with treatments with relatively short duration (i.e., 5 to 10
sessions as opposed to 12 sessions or more). Schneider speculated that many of the shorter
interventions might be better defined and less subject to drift from the prescribed procedures and
that the reduced impact of some multimodal treatments may be attributable to their relative
complexity, which may impede their being administered properly or understood fully by the
children.
31
2.4.32.4.32.4.32.4.3 Outcome Measure Characteristics Outcome Measure Characteristics Outcome Measure Characteristics Outcome Measure Characteristics
Outcome of psychosocial interventions with children is typically measured by standardized
rating scales that are completed by the children themselves, their parents, or teachers, researcher
developed rating scales, and by direct observation by clinicians and researchers (Lollard, 2008).
In the current systematic review and meta-analysis, I only included studies that involved
standardized rating scales because their psychometric properties have been examined, and
because direct observations are more typically used in time series designs (see section 2.6
below). Nevertheless, among the standardized rating scales, the informant may be a potential
moderator of efficaciousness. Self-reports, for example, have been shown to be a more valid
measure of child internalizing symptoms (Kazdin, 1990; La Greca, 1990; Martin, 1988), whereas
parent and teacher reports may be a more valid measure of externalizing symptoms (Loeber,
Green, Lahey, & Stouthamer-Loeber, 1989). Outcomes as reported by self, parents, and teachers
were not combined in the meta-analyses done for the current research. However, outcome
measure is examined as a moderator in relation to the systematic review.
2.4.42.4.42.4.42.4.4 Study Level Characteristics Study Level Characteristics Study Level Characteristics Study Level Characteristics
It is common practice when conducting a systematic review and meta-analysis to explore
whether study methodology may impact the results of the interventions being examined (Lipsey
& Wilson, 2001). Thus, the current systematic review also examines variables such as
publication status, year of publication, country of study, and quality of the included studies.
In summary, several factors may impact the efficaciousness of child-focused psychosocial
treatment in children and adolescents with ADHD. These factors include child characteristics,
intervention characteristics, outcome measure characteristics, and study level characteristics.
These moderators are investigated in this systematic review and meta-analysis in relation to the
efficaciousness of child-focused psychosocial interventions that are associated with reductions in
internalizing and externalizing symptoms and behaviours, and improvements in social skills,
peer relationships, and family functioning.
32
2.52.52.52.5 Advantages and Disadvantages of Systematic ReviewsAdvantages and Disadvantages of Systematic ReviewsAdvantages and Disadvantages of Systematic ReviewsAdvantages and Disadvantages of Systematic Reviews
and and and and MetaMetaMetaMeta----analyses analyses analyses analyses
Decisions about the utility of an intervention or the validity of a hypothesis should not be based
on the results of a single (primary/independent) study, because results sometimes vary across
studies. Rather, a mechanism is needed to synthesize data across studies. Narrative reviews have
been used for the purpose of synthesizing information. A narrative review summarizes different
primary studies from which conclusions may be drawn based on the investigator’s experience
(Lipsey & Wilson, 2001). There are disadvantages to using only narrative reviews to draw broad
conclusions regarding a body of empirical literature (Borenstein et al., 2009). The author makes
subjective judgements regarding methodological and theoretical quality when deciding which
studies to include in the review and which studies should receive the most emphasis. Such
decisions become challenging when there are a large number of studies available for potential
inclusion in the review (Lipsey & Wilson, 2001). Narrative reviews have also been criticized for
their under emphasis on the methodological features of studies as explanations for similarities
and differences in results and for their general failure to look at moderating variables that might
impact their findings (Borenstein et al., 2009). A systematic review addresses many of these
weaknesses. A systematic review makes the research summarizing process transparent and
explicit; each step is documented and open to scrutiny. It involves outlining specific criteria for
including studies, and to define the population of study findings, organized search strategies to
identify and retrieve eligible studies, and formal coding of study characteristics. Readers have
access to authors’ assumptions, procedures, and evidence and can make an informed decision
regarding the merits of the authors’ conclusions.
There are three additional core advantages to systematic reviews that incorporate meta-analysis
over narrative reviews (Borenstein et al., 2009; Lipsey & Wilson, 2001). The first advantage is
that systematic reviews with meta-analysis incorporate data analysis to support their conclusions.
Through encoding of the magnitude and direction of each statistical relationship in a collection
of studies, meta-analysis effect sizes can provide a summary that is sensitive to findings of
different strength across studies and weights their contribution to the overall conclusions
accordingly. Second, a meta-analysis is capable of finding effects and relationships that might be
33
obscured by other methods. The systematic nature of the coding of study characteristics,
treatment types, study design, and measurement procedures allows for an analytically precise
means of scrutinizing methodological differences between studies. Third, a quantitative review is
an organized and systematic way of handling a vast amount of information.
Despite all these advantages, meta-analyses are not without their disadvantages (Lipsey &
Wilson, 2001). First, the “apples and oranges” criticism is often used to describe the potential in
meta-analysis for its use of overly broad categories when averaging across dependent or
independent variables (e.g., aggregating all the outcome data into a unitary measure of
improvement or change rather than separating out conceptually different outcomes or sources
providing the outcome data). In the present study this problem was circumvented by analysing
conceptually different outcomes separately ensuring comparison of homogenous outcomes.
2.62.62.62.6 Measurement of Child OutcomesMeasurement of Child OutcomesMeasurement of Child OutcomesMeasurement of Child Outcomes
All of the studies included in the current meta-analysis and systematic review reported in this
dissertation measured children’s psychosocial outcomes on standardized instruments with strong
psychometric properties as reported by the children, their parents, and their teachers (see
Appendix A). These instruments measure internalizing behaviours and disorders (e.g., anxiety,
depression), externalizing behaviours and disorders (e.g., aggression, rule breaking, ODD, CD),
social skills, peer relationships, and family functioning. Although studies solely evaluating the
efficaciousness of interventions in relation to core ADHD symptom outcomes were not included,
ADHD core symptoms outcomes were coded when available. ADHD core and associated
symptoms and impairment are typically measured by seeking information from key adults in the
settings where children with ADHD spend most of their time (i.e., home and school), by direct
observations of behaviour by clinicians, researchers or research assistants, and by child self-
report (Lollard, 2008).
Parent and teacher reports of child outcome typically provide valid estimates of children’s
functioning because these individuals have ongoing opportunities to observe children in the key
settings where they function (Fabiano, Pelham Jr., Majumdar, Evans, Manos et al., 2013;
Lollard, 2008; Pelham, Fabiano, & Massetti, 2005). Parent and teacher reports, however, have
34
been criticised because they often are aware that the children are receiving specific treatments,
which may inflate effect sizes (Jadad, Moore, Carroll, Jenkinson, Reynolds, et al. 1996). It may
not be possible, however, to find individuals who are familiar with the participants’ behaviour
who are unaware of treatment status.
Behavioural observations by clinicians and researchers or research assistants are often used in
studies that have time-series designs (e.g., Coles, Pelham, Gnagy, Burrows-MacLean, Fabiano,
et al., 2005). The behavioural observation protocols are typically created by the researchers to
examine changes in specific behaviours targeted by the intervention. The advantages of using
direct behavioural observations are that the behaviours assessed may be specific, and that the
observers may be blind as to whether the child participants are involved in treatment or the type
of treatment (Evans et al., 2014). On the other hand, direct behavioural observations are costly,
and because the target behaviours vary across studies, they may be difficult to compare in a
meta-analysis (Pelham, Fabiano, & Massetti, 2005). Furthermore, conducting enough
observations to obtain valid indices of outcome, tracking infrequent behaviours, and measuring
constructs that are not easily observable (e.g., reciprocal peer relationships) make it difficult to
rely on direct behavioural observations (Evans, Owens, & Bunford, 2014). For all these reasons,
studies that exclusively used direct behavioural observations by clinicians or researchers were
not included in the present review.
Self-reports are often used to assess psychosocial outcomes, especially for treatment studies
where the participants are older children or adolescents (e.g., Haydicky et al., 2015). Self-reports
are especially useful for adolescents because their parents or teachers often do not observe them
in some of the settings in which they interact (Evans et al., 2014). There are two major problems
with child and adolescent self-report as a measure of outcome. First, similar to parent and teacher
ratings, children and adolescents are aware that they are receiving treatment. Second, and as
previously mentioned, children and adolescents with ADHD have been found to overestimate
their own competence and performance in academic, social, and behavioural domains (Hoza et
al., 2010; Owens et al., 2007) and to underestimate the extent of their problematic behaviours
(Wiener et al., 2012) compared to parent and teacher ratings. The implications of this positive
bias for interpreting results of treatment studies where self-reports are the outcome measures is
that treatment effects may be obscured because the children or adolescents overestimate their
35
competence or underestimate their problem behaviours at pre-test, resulting in little room for
improvement at post-test. As a result of this problem, in the current study we consider child self-
report results separately from parent ratings and teacher ratings.
In sum, parent and teacher report, clinician or researcher direct observation, and self-report data
each have strengths and weaknesses. Due to the above mentioned measurement challenges, it has
been suggested that investigators take a multi-informant approach to assessing the constructs that
are intended to change as a function of an intervention (AAP, Subcommittee on ADHD, 2011).
Furthermore, it is important for investigators conducting meta-analyses and systematic reviews
to be cognizant of these strengths and weaknesses and to take them into account when
interpreting the data.
2.72.72.72.7 Conclusions From Previous Conclusions From Previous Conclusions From Previous Conclusions From Previous MetaMetaMetaMeta----analyses analyses analyses analyses ofofofof Psychosocial Psychosocial Psychosocial Psychosocial
Treatments for Children and Adolescents With ADHDTreatments for Children and Adolescents With ADHDTreatments for Children and Adolescents With ADHDTreatments for Children and Adolescents With ADHD
Several meta-analyses have been conducted examining psychosocial interventions for children or
adolescents with ADHD; however, the majority have been devoted to examining the
efficaciousness of BPT (e.g., Charach et al., 2013; Lee et al., 2012; Lundahl et al., 2006; Reyno
& McGrath, 2006; Zwi et al., 2011) or teacher-focused interventions (e.g., Du Paul, Eckert, &
Vilardo, 2012; DuPaul and Eckert, 1997). As shown in Table 1 (page 43), I have identified 16
meta-analyses that have included child-focused psychosocial interventions conducted between
1999 to 2016. The rationale for inclusion of meta-analyses since 1999 was to ensure that the
most updated literature was being reviewed2. Three of these meta-analyses were updates (Evans,
Owens, & Bunford, 2014; Pelham & Fabiano, 2008; Majewicz-Hefley & Carlson, 2007) of
previous reviews (Klassen et al., 1999; Pelham & Fabiano, 2008; Pelham, Wheeler, & Chronis,
1998). Although several of these reviews are strong methodologically and meet the standards to
be included in the Cochrane database of systematic reviews, they each have one or more of six
2 Initially the literature review of previous meta-analyses started in the year 2000, with the aim of reviewing the last fifteen years of research in this area. However, because the Majewicz-Hefley & Carlson (2007) review was an update of Klassen et al. (1999) meta-analysis, the latter was also included in this summary.
36
limitations that make it difficult to establish the efficaciousness of child-focused psychosocial
interventions in general, and specific types of child-focused psychosocial interventions (i.e.,
CBT, SST, family therapy, and mindfulness interventions) for children and adolescents with
ADHD.
First, several meta-analyses and systematic reviews have been done to evaluate behavioural
treatments for children with ADHD where the investigators combined child-focused
psychosocial interventions with BPT and/or classroom management training when calculating
effect sizes and drawing conclusions about the efficaciousness of these interventions (Daley, van
der Oord, Ferrin, Danckaerts, Doepfner, Cortese, & Sonuga-Barke, 2014; Evans, Owens, &
Bunford, 2014; Fabiano et al., 2009; Hodgson, Hutchinson, & Denson, 2012; Majewicz-Hefley &
Carlson, 2007; Pelham & Fabiano, 2008; van der Oord, Prins, Oosterlan, & Emmelkamp, 2008).
Although these reviews provide a valuable comparison between psychosocial and
pharmacological interventions, between psychosocial interventions and no-treatment, or between
psychosocial and pharmacological interventions separately and combinations of psychosocial
and pharmacological treatments, they do not provide data that specifically evaluate the
efficaciousness of child-focused psychosocial interventions. In the present systematic review
child-focused psychosocial intervenitons were explicitly examined.
Second, some meta-analyses examining the efficaciousness of child-focused psychosocial
interventions for children and adolescents with ADHD only examined reduction in ADHD
symptoms as an outcome variable (Bjornstad & Montgomery, 2010; Cairncross & Miller, 2016;
Fabiano et al., 2009; Klassen et al., 1999) or ADHD symptoms and neuropsychological and other
outcomes that are not the scope of this review (e.g., Cortese, Ferrin, Brandeis, Buitelaar, Daley et al.,
2015). Although some of the results of these reviews (e.g., Cortese et al., 2015; Klassen et al., 1999)
suggest that psychosocial interventions do not tend to be associated with a reduction in ADHD
symptoms, it is possible that these interventions are associated with other positive outcomes such as
improvements in parent-child and peer relationships. The major focus of this systematic review was
examining internalizing and externalizing symptoms and behaviours, social skills, peer relationships,
and family functioning. This systematic review was not confined to the study of core ADHD
symptom outcomes.
37
Third, several meta-analyses required that the study be a randomized control trial of child-
focused psychosocial treatments to be included (Bjornstad and Montgomery, 2010; Storebø,
Skoog, Damm, Thomsen, Simonsen et al., 2011). The results of these reviews suggest that there
is little evidence and that it is currently not possible to recommend or refute family therapy
(Bjornstad & Montgomery, 2010) or SST (Storebø et al., 2011) as efficacious interventions for
children with ADHD. A limitation of these studies, as some researchers (e.g., Fabiano et al.,
2009) have previously noted, is that many classical behavioural intervention studies are excluded
if the investigator opts for inclusion of randomized control trials (RCT) only, leaving a sample of
treatment studies that is not representative. Although RCTs were included in the current
systematic review, other research designs were also examined, including within-subject design
and between-group design with a control group that did not receive a child-focused psychosocial
treatment (e.g., wait-list no treatment, psychosocial equivalent treatment without the therapeutic
components, treatment as usual in the community, or ADHD medication) and one or more
intervention groups that reported both pre-test and post-test scores for each group.
Fourth, several meta-analyses of child-focused psychosocial interventions for children with
ADHD that included internalizing behaviours and disorders, externalizing behaviours and
disorders, or social relationships as outcome variables aggregated child, parent and teacher
reports of outcomes when calculating effect sizes (Pelham & Fabiano, 2008; Purdie et al., 2002).
Although, as discussed above, it is advisable to use a multi-method and multi-informant
approach (AAP, Subcommittee on ADHD, 2011), aggregating these scores when calculating
effect sizes could be problematic because parents and teachers observe children in different
settings where the demands may elicit different behaviours (Rowland, Skipper, Rabiner,
Umbach, Stallone, et al., 2008; Valo & Tannock, 2010). Furthermore, the positive bias in self-
reports of children and adolescents with ADHD may minimize the possibility of reports of
change following the intervention, and thereby reduce overall effect sizes. In this systematic
review outcome variables were not aggregated.
Fifth, the samples of one of the reviews of child-focused psychosocial interventions included a
broad age range (i.e., young children, older children, adolescents, and adults). The precise age
range of the sample was not reported, however, and data were aggregated across age ranges
(Purdie, 2002). In the present systematic review age range is explicitly reported.
38
Sixth, several meta-analyses calculated effect sizes for between-group and within-subject designs
together (Purdie et al., 2002; Sibley, Kuriyan, Evans, Waxmonsky, & Smith, 2014). According
to Borenstein et al. (2011), reporting separate effect sizes according to experimental study design
is preferred to reduce the heterogeneity of the studies. Some reviews included all study designs
(e.g., Fabiano et al., 2009; Pelham & Fabiano, 2008), and others excluded all but RCTs (e.g.,
Bjornstad & Montgomery, 2010; Klassen et al., 1999). The number of intervention trials included in
each review ranged from two (Bjornstad & Montgomery, 2010) to 116 (Fabiano et al., 2009). Some
meta-analyses reported effect sizes for each study design separately (e.g., Fabiano et al., 2009),
whereas others collapsed across designs (e.g., Purdie et al., 2002). Additionally, some meta-analyses
calculated several effect sizes for each study depending on the number of outcomes measured (e.g.,
Hodgson et al., 2012; Purdie et al., 2002), whereas others combined outcomes to yield a single effect
size from each individual study (Fabiano et al., 2009). This variability in the approach used to review
psychosocial treatments for children and adolescents with ADHD may also contribute to the
differences in findings across meta-analyses (Fabiano et al., 2015; Vallerand, Kalenchuk, &
McLennan, 2014). Innovative methods for calculating effect sizes in a consistent manner across
study designs were recently developed and have the potential of enhancing future meta-analyses
(Fabiano et al., 2015; Shadish, Hedges, & Pustejovsky, 2013). In the current systematic review effect
sizes are calculated and reported separately for between-group and within-subject design studies.
In their appraisal of the meta-analyses and systematic reviews on psychosocial treatments for
children with ADHD up to age 18 from 1998 to 2010, Watson and colleagues (Watson, Richels,
Michalek, & Raymer, 2015) concluded that there are many shortcomings amongst most
systematic reviews (13) and meta-analyses (8), including inadequate descriptors of data
extraction methods and quality ratings of trials not included in the reviews. Describing data
extraction would permit replication, whereas including a measure of the quality of the
intervention studies reviewed would be helpful in understanding the findings, as any conclusions
need to be balanced by the integrity of the studies that lead to that conclusion. Although these
previous meta-analyses have highlighted important findings in regards to psychosocial
treatments of ADHD for children and adolescents, a new meta-analysis and systematic review is
needed in order to address the limitations of the reviews described above and in Table 1(page
43). In addition, since the publication of all but one of the reviews (Cairncross & Miller, 2016),
39
several studies have been conducted evaluating the efficaciousness of mindfulness training with
children and adolescents with ADHD (e.g., Harrison, Manocha, & Rubia, 2004; Haydicky,
Shecter, Wiener, & Ducharme, 2015; Jensen & Kenny, 2004; van de Weijer-Bergsma, Formsma,
de Bruin, & Bogels, 2012). The Cairncross and Miller meta-analysis, however, only examined
mindfulness training interventions in terms of the effects on core ADHD symptoms in children
and did not assess the effect on associated behavioural symptoms and social impairments.
2.82.82.82.8 SummarySummarySummarySummary
In summary, psychosocial interventions for children and adolescents with ADHD offer an
alternative to medication management for several important reasons: 1) some children cannot
tolerate medications because they experience side effects (Pliszka, 2007; Vitiello et al., 2012); 2)
pharmacological treatment is not always effective, as there is a 20-30% non-response rate
(Pliszka, 2007); 3) a major barrier to the efficaciousness of stimulants is the tendency for
adolescents to discontinue medication (e.g., Charach et al., 2014; Meaux et al., 2006); and 4)
parents may reject pharmacological treatment altogether (Lerner & Wigal, 2008). Additionally,
specific evidence-based psychosocial approaches are better at targeting the ADHD associated
behavioural symptoms and social impairments (Chronis et al., 2006; Rapport et al., 2001).
Psychosocial treatments of children and adolescents with ADHD can be divided into three types:
1) parent-focused programs, 2) teacher-focused programs, and 3) child-focused interventions
including CBT, SST, mindfulness training, and family therapy. Parent and teacher intervention
programs are based on behavioural procedures where specific positive and negative behaviours
are targeted, but they are not consistently effective, or not practical with adolescents (Carr,
2009). Therefore, it is worthwhile to examine child-focused psychosocial interventions and what
they can offer when other treatment modalities are not as effective as desired. Given that ADHD
is a chronic, life-long disorder, having a treatment modality alternative that would allow for
treatment gains across adolescence and into adulthood, particularly following the reduction or
withdrawal of pharmacological treatment, is greatly needed (Barkley, 2006).
Child-focused psychosocial interventions are interventions that are provided directly to children
by trained therapists and typically have the aim to help children to develop a set of skills (Kaiser
40
& Pfiffner, 2011). A child-focused psychosocial intervention may be part of a larger multimodal
program that offers a concurrent parent treatment and/or teacher consultation (e.g., MTA
Cooperative, 1999). All of these interventions teach children a set of skills intended to assist and
support them self-manage above and beyond parents’ and teachers’ supports. This is especially
critical for adolescents who have multiple teachers, who do not respond to relatively simple
reinforcement and extinction methods, for whom contingency-management programs are not
efficacious (Kaizer et al., 2008), and who seem to discontinue medication use after the age of 12
(Centres for Disease Control and Prevention, 2005). The question still remains in regard to which
child-focused treatment is best tailored at targeting the various ADHD associated behaviours and
symptoms and social impairments (i.e., internalizing and externalizing symptoms and
behaviours, social skills, peer relationships and family functioning).
Several meta-analyses have been conducted examining psychosocial interventions for children or
adolescents with ADHD; however, the majority have been devoted to examining the
efficaciousness of BPT (e.g., Charach et al., 2013; Lee et al., 2012; Zwi et al., 2011) or teacher-
focused interventions (e.g., Du Paul et al., 2012; DuPaul and Eckert, 1997). Only a few meta-
analyses conducted since 1999 to 2016 have included child-focused psychosocial interventions
(e.g., Evans et al., 2014; Pelham & Fabiano, 2008; Majewicz-Hefley & Carlson, 2007; Pelham et
al., 1998). Although several of these systematic reviews are strong methodologically and meet
the standards to be included in the Cochrane database of systematic reviews, they each have one
or more limitations that make it difficult to establish the efficaciousness of child-focused
psychosocial interventions in general, and specific types of child-focused psychosocial
interventions (i.e., CBT, mindfulness interventions, SST, and family therapy) for children and
adolescents with ADHD. Several meta-analyses examining the efficaciousness of child-focused
psychosocial interventions for children and adolescents with ADHD only examined reduction in
ADHD symptoms as an outcome variable (Bjornstad & Montgomery, 2010; Cairncross & Miller,
2016; Fabiano et al., 2009; Klassen et al., 1999) or ADHD symptoms and neuropsychological and
other outcomes that are not the scope of this review (e.g., Cortese et al., 2015). Other meta-analyses
required that the study be an RCT of child-focused psychosocial treatments to be included (Bjornstad
and Montgomery, 2010; Storebø et al., 2011). The results of these reviews suggest that there is little
evidence and that it is currently not possible to recommend or refute family therapy (Bjornstad &
41
Montgomery, 2010) or SST (Storebø et al., 2011) as efficacious interventions for children with
ADHD. Other meta-analyses of child-focused psychosocial interventions for children with
ADHD that included internalizing behaviours and disorders, externalizing behaviours and
disorders, social skills, or peer relationships as outcome variables aggregated child, parent and
teacher reports of outcomes when calculating effect sizes (Pelham & Fabiano, 2008; Purdie et
al., 2002). Last, other meta-analyses calculated effect sizes for between-group and within-subject
designs together (Purdie et al., 2002; Sibley, Kuriyan, Evans, Waxmonsky, & Smith, 2014).
In sum, although previous meta-analyses and systematic reviews have highlighted important
findings with regard to psychosocial treatments for children and adolescents with ADHD, none
of these reviews have specifically examined the effects of child-focused psychosocial treatments
on their internalizing and externalizing behaviours and disorders, social skills, peer relations, and
family relationships and functioning as reported by children, parents, and teachers, separately.
2.92.92.92.9 Objectives Objectives Objectives Objectives of the Systematic Review and Mof the Systematic Review and Mof the Systematic Review and Mof the Systematic Review and Metaetaetaeta----analysisanalysisanalysisanalysis
The purpose of the present dissertation is to provide a systematic review and meta-analysis of
child-focused psychosocial intervention studies for children or adolescents with ADHD that are
purported to reduce their internalizing and externalizing behaviours, or improve their social
skills, their peer relationships, and family functioning. Establishing which types of interventions
are efficacious for treating these aspects of the social impairment of children and adolescents
with ADHD is important because of the potential to identify recommendations for intervention
that clinicians should use to address their specific challenges. The scope of this systematic
review and meta-analysis included primary studies that have been published or prepared (in
press, online, under review, or dissertation) prior to November 2015.
The systematic review and meta-analysis were guided by three objectives:
1. To investigate the degree to which child-focused psychosocial interventions (CBT, SST,
mindfulness training, and family therapy) are efficacious for improving internalizing behaviours
and disorders (e.g., anxiety, depression), externalizing behaviours and disorders (e.g., aggression,
rule-breaking, ODD, CD), social skills, peer relationships, and family functioning (e.g., parent-
42
child attachment, number and intensity of parent-child conflicts, sibling relationships), as these
outcomes reflect the social impairment associated with ADHD. Although studies solely
evaluating core ADHD symptom outcomes were not eligible for inclusion in the review, when
provided in an eligible study, data for core ADHD symptoms were extracted and analyzed.
2. To determine whether the addition of concurrent treatment components (medication, parent
treatment and/or teacher consultation) to child-focused psychosocial interventions affects
treatment outcomes.
3. To identify the potential variables that may moderate treatment outcome and how such
variables might interact to influence behaviour change in children and adolescents receiving
treatment. The literature points to a number of variables that might influence treatment outcome
including children’s characteristics (children’s age, gender, subtype of ADHD, comorbidity with
other disorders), intervention characteristics (intervention type, frequency and duration of
intervention), outcome measure characteristics (self, parent, or teacher report), and study
characteristics (publication type, year of publication, country of study, and quality of study).
43 Note. * Not specifically school-aged children (6 to 18), i.e., included preschoolers and school-aged children or children and adults. ** Conclusions of these meta-analyses are not applicable to the efficaciousness of exclusively child-focused psychosocial interventions on the outcomes of interest of the present study and will not be discussed herein.
Table 1. Conclusions and Limitations of Previous Meta-analyses of Child-Focused Psychosocial Interventions for Children or Adolescents with
ADHD.
Reference Findings for child-focused psychosocial interventions
Included studies
published between
Aggregated behavioural
interventions
Only ADHD
symptoms
RCT only
Aggregated by
informant
Broad age
range*
Aggregated by design
Klassen, Miller, Raina, Lee, & Olsoen (1999)
Evaluated the effects of combined pharmacological and behavioural treatments on ADHD symptoms on children (up to 18). Behavioural therapies were not found to produce significant differences in ADHD symptomatology on teacher or parent-reported measures.
1973-1997 √ √ √
Purdie, Hattie, & Carroll (2002)
Studies grouped as either a behavioural, cognitive, educational, parental and/or pharmacological interventions for Kindergartens to adults.
1990-1998 √ √ √ √
Reid, Trout, & Schartz (2005)
Evaluated the efficaciousness of four types of self-regulation (self-monitoring, self-monitoring plus reinforcement, self-management, and self-reinforcement) interventions in children (up to 18). Authors concluded that since combined effect sizes for these treatments were greater than 1.0 for on-task behaviour, inappropriate behaviour, and academic accuracy and productivity, that these interventions can be useful for children with ADHD; however, the small number of participants (N = 51, only 3 of which were female) limits the extent to which the results can be generalized.
Up to 2003 √
Majewicz-Hefley & Carlson (2007)
Combined pharmacological and non-pharmacological treatments updating Klassen et al., 1999, adding social skills and academics outcomes in children (5-12). Combined treatment approaches appeared to show the largest and most significant impact on core ADHD symptoms and in the domain of social skills.
1980-2004 √
44
Table 1. Conclusions and Limitations of Previous Meta-analyses of Child-Focused Psychosocial Interventions for Children or Adolescents
with ADHD (continued).
Reference Findings for child-focused psychosocial interventions Included
studies published between
Aggregated behavioural
interventions
Only ADHD
symptoms
RCT only
Aggregated by
informant
Broad age
range*
Aggregated by design
van der Oord, Prins, Oosterlan, & Emmelkamp (2008)
Both methylphenidate and psychosocial (behavioural or cognitive-behavioural) treatments were effective in reducing ADHD symptoms in children (6-12). Authors concluded that psychosocial treatment yielded smaller effects than both other treatment conditions, then it has no additional value to methylphenidate for the reduction of ADHD and teacher rated ODD symptoms. However, for social behaviour and parent rated ODD the three treatments were equally effective. For improvement of academic functioning no treatment was effective.
1985- 2006 √
Pelham & Fabiano (2008)
Updating Pelham et al.’s review (1998) on psychosocial treatments - participant age not specified. Outcomes reported included academic productivity, academic achievement, cognitive tests, and peer relationships. Authors concluded that behavioural parent training, behavioural classroom management, and intensive peer-focused behavioural interventions are well established treatments for children with ADHD.
1998-2006 √ √
Fabiano, Pelham, Coles, Gnagy, Chronis, & Connor (2009)**
Evaluated efficaciousness of behavioural treatments in children (up to 18), the majority of studies contained a parent-focused component (e.g., 85% of the between-group designs) compared to a child-focused component (e.g., 35% of the between-group designs).
1976-2008 √ √
Note. * Not specifically school-aged children (6 to 18), i.e., included preschoolers and school-aged children or children and adults. ** Conclusions of these meta-analyses are not applicable to the efficaciousness of exclusively child-focused psychosocial interventions on the outcomes of interest of the present study and will not be discussed herein.
45
Table 1. Conclusions and Limitations of Previous Meta-analyses of Child-Focused Psychosocial Interventions for Children or Adolescents
with ADHD (continued).
Reference Findings for child-focused psychosocial interventions Included
studies published between
Aggregated behavioural
interventions
Only ADHD
symptoms
RCT only
Aggregated by
informant
Broad age
range*
Aggregated by design
Bjornstad & Montgomery (2010)
Evaluated the effects of family therapy treatment without medications in children and adolescents (age not specified) on ADHD symptoms, school expulsions, grades in school, and juvenile offending. Authors concluded that a meta-analysis could not be conducted because the two studies that met eligibility criteria were too heterogeneous to be compared.
Up to 2004 √ √
Storebø, Skoog, Damm, Thomsen, Simonsen et al. (2011)
Evaluated the effects of Social Skills training for children (5 to 18) as a stand-alone treatment or as an adjunct to pharmacological treatment. Found no significant effects either on social skills competences (positive value = better for the intervention group) (SMD 0.16; 95% CI -0.04 to 0.36; 5 trials, n = 392), on the teacher-rated general behaviour (negative value = better for the intervention group) (SMD 0.00; 95% CI -0.21 to 0.21; 3 trials, n = 358), or on the ADHD symptoms (negative value = better for the intervention group) (SMD -0.02; 95% CI -0.19 to 0.16; 6 trials, n = 515).
Up to 2011 √
Hodgson, Hutchinson, & Denson (2012)**
Evaluated the effects of non-pharmacological treatments (including behaviour modification, neurofeedback, multimodal psychosocial treatment, school-focused programs, working memory training, parent training, and self-monitoring) on children (5-10). Exclusion criteria included the presence of comorbidities including ODD and CD.
1994-2009 √
Note. * Not specifically school-aged children (6 to 18), i.e., included preschoolers and school-aged children or children and adults. ** Conclusions of these meta-analyses are not applicable to the efficaciousness of exclusively child-focused psychosocial interventions on the outcomes of interest of the present study and will not be discussed herein.
46
Table 1. Conclusions and Limitations of Previous Meta-analyses of Child-Focused Psychosocial Interventions for Children or Adolescents
with ADHD (continued).
Reference Findings for child-focused psychosocial interventions Included
studies published between
Aggregated behavioural
interventions
Only ADHD
symptoms
RCT only
Aggregated by
informant
Broad age
range*
Aggregated by
design
Sonuga-Barke, Brandeis, Cortese, Daley, Ferrin, et al. (2013)**
Evaluated the effects of psychological (behavioural, cognitive training, and neurofeedback) and dietary (restricted elimination diets, artificial food colour exclusions, and fatty free acid supplementation) interventions for children (3 to 18).
Up to 2012 √ √ √ √ √
Sibley, Kuriyan, Evans, Waxmonsky, & Smith (2014)**
Evaluated the effects of pharmacological, behavioural and cognitive enhancement interventions on children (10-19.9) on core ADHD symptoms, externalizing symptoms, internalizing symptoms, family relations, academic skills, and driving skills.
1999-2012 √ √ √
Daley, van der Oord, Ferrin, Danckaerts, Doepfner, Cortese, & Sonuga-Barke (2014)**
Evaluated the effects of behavioural interventions (mainly parent and teacher mediated behaviour therapy) and cognitive behaviour therapy (including self-instruction, problem-solving strategies, and social skills training)) for children (3 to 18). Outcomes included child ADHD, conduct problems, social skills, and academic achievement, positive and negative parenting, parenting self-concept, parent anxiety and depression.
Up to 2013 √ √ √
Note. * Not specifically school-aged children (6 to 18), i.e., included preschoolers and school-aged children or children and adults. ** Conclusions of these meta-analyses are not applicable to the efficaciousness of exclusively child-focused psychosocial interventions on the outcomes of interest of the present study and will not be discussed herein.
47
Note. * Not specifically school-aged children (6 to 18), i.e., included preschoolers and school-aged children or children and adults. ** Conclusions of these meta-analyses are not applicable to the efficaciousness of exclusively child-focused psychosocial interventions on the outcomes of interest of the present study and will not be discussed herein.
Table 1. Conclusions and Limitations of Previous Meta-analyses of Child-Focused Psychosocial Interventions for Children or Adolescents
with ADHD (continued).
Reference Findings for child-focused psychosocial interventions Included
studies published between
Aggregated behavioural
interventions
Only ADHD
symptoms
RCT only
Aggregated by
informant
Broad age
range*
Aggregated by
design
Evans, Owens, & Bunford (2014)**
Updated Pelham and Fabiano’s review (2008), on psychosocial treatments (defined as any intervention that is not medication or diet) on children (minimum age not provided - up to 17 years old). Outcomes included were those in Pelham and Fabiano’s review (2008), and externalizing and internalizing symptoms and behaviours, family functioning, peer relationships, social skills, working memory, self-correction, homework completion, tracking and monitoring of assignments, and ADHD symptoms and behaviour. Authors concluded that behavioural parent training, behavioural classroom management, peer-focused behavioural interventions, and organization training are well established treatments for children with ADHD, while cognitive training met criteria for experimental treatment, neurofeedback training met criteria for possibly efficacious, and social skills training was deemed as not effective.
2007-2013 √ √
Cortese, Ferrin, Brandeis, Buitelaar, Daley et al., (2015)**
Updated Sonuga-Barke et al.’s review (2013) only as pertaining to the effects of cognitive training interventions for children (3 to 18) on ADHD symptoms and added parent ratings of executive functioning, standardized measures of reading and arithmetic ability, and laboratory-based measures of verbal and visual working memory, inhibition, and attention.
Up to 2014 √
Cairncross & Miller (2016)
Evaluated the effects of mindfulness training in children (age not specified). Hyperactivity/impulsivity (d = -.53, 9 trials), Inattention (d = -.66, 10 trials). Authors concluded that mindfulness training was effective in reducing symptoms of ADHD.
Up to 2014 √
48
3333 MMMMETHODSETHODSETHODSETHODS
This chapter starts with a description of and rationale for the criteria for study selection. This is
followed by a description of the search and retrieval of the included studies. In this section data
extraction, variable coding, and methods for data management are described in detail. This
chapter concludes with a description of the statistical approach employed for the meta-analyses.
A full description of the final sample of studies is in chapter 4.
3.13.13.13.1 Criteria for Study SelectionCriteria for Study SelectionCriteria for Study SelectionCriteria for Study Selection
In order to address the main objective of this systematic review, which is to assess the
efficaciousness of child-focused psychosocial interventions for improving symptoms and
behaviours associated with ADHD, inclusion/exclusion criteria were established using an
adaptation of the population, interventions, comparison, outcomes (PICO) framework—that is,
study design, population, interventions, outcomes (SPIO; Joanna Briggs Institute, 2008). SPIO is
commonly used to define the parameters of systematic reviews where designs other than
randomized controlled trials (RCTs) are also considered (Joanna Briggs Institute, 2008). See
Table 2 (page 57).
3.23.23.23.2 Search and Retrieval of StudiesSearch and Retrieval of StudiesSearch and Retrieval of StudiesSearch and Retrieval of Studies
The preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines
were followed in terms of the identification, screening, and eligibility of the reports included in
the study (Moher, Liberati, Tetzlaff, & Altman, 2009). PRISMA is a set of principles created for
authors conducting systematic reviews and meta-analyses. To be included in this systematic
review, each study had to be reported in English and published or prepared (in press, online,
under review, or dissertation) prior to November 2015. Both published and unpublished studies
were included in order to reduce publication bias; i.e., studies that produce either statistically
significant results or demonstrate practical significance in their respective field are more likely to
be published than studies that do not (Borenstein et al., 2009; Dwan et al., 2008; Lipsey &
Wilson, 2001).
49
The initial step in the research process involved the identification of the child-focused
psychosocial treatments for children or adolescents with ADHD that examined the
efficaciousness of the treatment in relation to the following outcomes: internalizing (anxiety or
depression) or externalizing (aggression, CD, rule breaking, ODD) behaviours or disorders, or
social skills, peer relationships, or family relationships and functioning. In order to do so, 25
comprehensive computerized literature online searches were conducted in five databases
including 15 searches on the ProQuest platform (5 ERIC, 5 ProQuest Dissertations & Theses
Global and 5 PsycInfo) and 10 on the OVID platform, 5 of which were in Embase (Embase
Classic + Embase 1947 to 2015) and 5 in Medline (OVID Medline (R) 1946-current + OVID
Medline (R) In-Progress and Non-Indexed Citations October 20, 2015). All of the databases
were searched for studies from their inception date, up to September 18, 2015 in the ProQuest
platform databases (ERIC, ProQuest Dissertations & Theses Global, and PsycInfo), September
20, 2015 in Embase, and October 20, 2015 in Medline. Search terms were developed by the
author in consultation with two librarians from the University of Toronto. With the exception of
ProQuest Dissertations & Theses Global, the searches were conducted by requesting the
databases to find all of the studies containing the specific search terms in the studies’ abstract
and full text. On ProQuest Dissertations & Theses Global only the abstracts were searched
because previous trial searches of both abstracts and full text identified over 80,000 papers
containing the terms “ADHD” and “Aggression”. The majority of these studies were not relevant
to the topic of this review, because the search terms were used once or twice in the extensive
literature reviews that are typically part of graduate theses.
Search terms comprised treatment descriptors (e.g., treatment, therapy, intervention), research
descriptors (e.g., outcome, comparison, effect-, efficacious-, evaluat-, influence, impact, result-,
assess-), target population descriptors (e.g., adolesc-, child-, juvenile-, pre-adolescen-, youth-,
kid-) with ADHD (e.g., Attention Deficit Disorder with Hyperactivity, Attention Deficit
Disorder, Hyperactivity, Hyperkinesis, Minimal Brain Dysfunction, behaviour, and inattention
problems). Separate search terms were developed for each of the outcomes of interest.
Internalizing behaviours and disorders (e.g., anxiety, depression, mood disorder), externalizing
behaviour and disorders (e.g., aggression, CD, disruptive behav-, ODD), and social impairment
50
in peer and parent relationships (e.g., social skills, parent-child relat-, peer relat-). The complete
list of search terms is shown in Appendix B.
The citation indexes of PsycInfo, ERIC, ProQuest, Medline and Embase were also searched for
studies citing those studies already identified. The reference lists of relevant eligible studies were
reviewed for appropriate studies not identified elsewhere. In addition, systematic reviews and
meta-analyses (e.g., Fabiano et al., 2009; Hoza et al., 2007; Sibley et al., 2014; Watson et al.,
2015) and books (e.g., Barkley 2015; Weisz & Kazdin, 2010) were consulted, and researchers in
the area of ADHD treatment (e.g., Barkley, Fabiano, Hinshaw, and Pelham) were contacted to
solicit papers in press or in preparation that were not available through the computerized online
searches.
3.2.13.2.13.2.13.2.1 Data ExtractionData ExtractionData ExtractionData Extraction
EndNote software version X6.0.2 was employed to retrieve the references from the online
databases. The references produced by the 25 separate computerized bibliographic searches were
screened for eligibility through several steps (see Figure 1). First, the list of references from each
database was compared against one another to identify duplicate studies. When there were
duplicates the article with the least information was removed. Second, the references were
screened for study selection based on the titles and abstracts using the eligibility criteria
described above. Third, all studies with titles or abstracts that appeared relevant to this study
moved on to the next screening stage for a more detailed full manuscript evaluation. For
organizational purposes, each study at this stage was: a) referred to as a potential study, b)
assigned a unique study number, and c) entered into an Excel tracking file. Fourth, each
manuscript was read in its entirety and was scrutinized using the criteria for study selection. Each
reference that passed this stage and met all of the eligibility criteria was referred to as an eligible
study, and included in the final analyses. The studies that did not meet the eligibility criteria were
excluded from further analysis and the reasons for exclusion were recorded in the PRISMA flow
diagram (Figure 1). Fifth, the eligible references were subjected to a backward and forward
51
reference search3 to find additional studies that may have been missed in the initial database
searches (Card, 2012). The references produced by the backward and forward searching
underwent the screening procedure as described above. The number of studies retrieved through
this process were also recorded in the PRISMA flow diagram as additional records identified
through other sources (Figure 1).
When multiple reports of the same study were available, published reports were included over
unpublished reports except when information was missing from the former. In some cases, the
same data were reported in more than one publication. To ensure that each participant
contributed only one observation per outcome construct, the most comprehensive publication
was used and any additional published or unpublished reports were used only if they presented
unique data4.
When there were missing data in a primary study, and if the study met all other eligibility
criteria, an effort was made to contact the principal investigator, or when unavailable, the second
author to request the missing data. This also was done when results were reported simply as a
non-significant finding without supporting data (Card, 2012). Missing outcome data or
clarification regarding sample sizes were requested from 22 authors via email. From the nine
authors who responded to the inquiry of missing data, four provided the necessary data to be
included in this systematic review, and five were unable to provide the requested data.
3.2.23.2.23.2.23.2.2 Variable CodingVariable CodingVariable CodingVariable Coding
Eligible studies were reviewed and coded by the author using Survey Wizard Version 2.0. In
total 3246 variables were coded (see detailed coding form, Appendix C), including study
descriptor, methodology, intervention description, demographic variables, and outcomes of
3 A backward reference search refers to checking study’s reference list for possible studies that meet the eligibility criteria, whereas a forward reference search is the process of checking for references that have cited a given publication.
4 The issue of multiple reports for the same study arose for the research done by the MTA Cooperative (1999). As other investigators have previously argued when conducting systematic reviews on psychosocial treatments for ADHD (e.g., Pelham & Fabiano, 2008), including all of the MTA reports would lead to excessive weight given to publications involving the same participants. Therefore, the present review included only the MTA primary outcome study.
52
interest. Mean age, percentage of male participants, and percentage of ethnic minority youth
were coded for each study.
The Quality Assessment Tool for Quantitative Studies developed by the Effective Public Health
Practice project (EPHPP) in Canada was used to code for study quality. This tool has been
employed by other investigators in systematic reviews and content and construct validity have
been established (Armijo-Olivo et al., 2012; Deeks et al., 2003). The EPHPP rates primary
studies in a systematic review according to their selection bias, study design, confounders,
blinding, data collection methods, withdrawals and dropouts, and intervention integrity. A global
rating for each study is obtained by combining these categories (EPHPP tool and manual are
shown in Appendix C). Strong studies have no weak ratings in any of these categories, moderate
studies have one weak rating, and weak studies have two or more weak ratings. The EPHPP is a
stringent measure and in order for a primary study to obtain a ‘strong’ rating on the blinding
domain, the intervention evaluated had to be double-blinded. That is, two conditions need to be
met: (a) assessors should be described as blinded to which participants were in the intervention
and control groups, and (b) study participants should not be aware of (i.e., blinded to) the
research question. The purpose of blinding the participants is to protect against reporting bias.
However, it may not be possible to find knowledgeable sources for ratings of children’s
behaviour (parent or teacher) that are unaware of treatment status. Therefore, EPHPP blinding
was adjusted in this review; to obtain a rating of ‘strong’ in the blinding domain only (a) or (b)
(as opposed to the two in the original EPHPP manual) had to be met. A ‘moderate’ rating was
given when blinding was not described, and a ‘weak’ rating when neither (a) nor (b) were
present.
Reliability was assessed at two stages of this systematic review. The searches were verified for
reliability by having a statistician with expertise in systematic reviews and meta-analysis and
familiar with the goals of this study to review all potentially eligible studies for
inclusion/exclusion criteria. At this stage, the studies were further evaluated according to their
study design and available statistics to ensure their appropriateness for inclusion. There were not
any substantive disagreements between the main searcher and the statistician. Only two records
were identified as not eligible in this manner, supporting the thoroughness of the searches. To
assess for intercoder reliability a graduate student was trained as a second coder by the author in
53
the procedures in four sessions where the principles of meta-analysis, the purpose of the present
systematic review, and the nature of the coding scheme were discussed. The second coder then
independently coded a randomly selected sample (20%) of the studies. She coded sample studies
with discussion and feedback until acceptable agreement was reached on all constructs (e.g.,
coding of study design, treatment type, and outcomes of interest). As there were no
disagreements between the primary coder and the secondary coder, calculating Cohen’s kappa
was not required (Card, 2012).
Self-, parent-, and teacher-reported outcome data was extracted from several frequently used
standardized behaviour rating scales (see Appendix A). Standardized behaviour rating scales that
conceptually measured the same outcome domains (e.g., CD symptoms) and had similar
psychometric properties were compared quantitatively (e.g., Adolescent self-report Conners-3SR
and Youth Self Report; Achenbach, 2001). The utility, standardization, and psychometric
properties of these instruments have been reported and reviewed elsewhere (Aylward 1994;
Barkley, 2015; 1997; Merrell, 1994).
3.2.33.2.33.2.33.2.3 Data manData manData manData managementagementagementagement
Once the data was coded in Survey Wizard Version 2.0, it was extracted to six separate Excel
spread sheets: Study descriptors, sample characteristics, intervention characteristics, outcome
instruments used, statistics, and study quality tool.
3.33.33.33.3 StatiStatiStatiStatistical Approach for stical Approach for stical Approach for stical Approach for MetaMetaMetaMeta----analyses analyses analyses analyses
Of the studies that met the inclusion criteria and were selected for systematic review, subsets of
studies that could be meta-analysed together were identified. In order to be used together in a
meta-analysis, the studies were required to be homogenous with respect to the following: 1.
Study design (between-group vs. within-subject design), 2. Child-focused psychosocial treatment
provided (i.e., SST, Group CBT, etc.), 3. Construct domain measured (e.g., assertion, CD
symptoms), and 4. Informant (i.e., self, parent, or teacher). Because the majority of the studies of
treatments involving children or adolescents with ADHD are based on data from mothers (Barkley,
54
2015), and most studies do not indicate which parent completed the parent measures, when two
parental ratings were provided, mother reports were used.
Individual meta-analyses were performed to address the primary research objective: To
investigate the degree to which child-focused psychosocial interventions (CBT, SST,
mindfulness training, and family therapy) are efficacious for improving internalizing behaviours
and disorders (e.g., anxiety, depression), externalizing behaviours and disorders (e.g., aggression,
rule-breaking, ODD, CD), social skills, peer relationships, and family functioning (e.g.,
attachment, number and intensity of conflicts), as these outcomes reflect the social impairment
associated with ADHD.
Separate effect sizes were calculated for studies using a between-group design and for studies
using a within-subject design. For between-group studies the means, standard deviations, and
sample sizes in each of the two groups at post-test were extracted. Given that the correlations
between pre and post scores within each group were not reported in any of the between-group
studies, in order to use the post-test data only for meta-analyses, the group equivalence at pre-
treatment had to first be established for each study. Using SPSS software Version 22.0 (IBM
Corp., 2013), Independent sample t-tests were conducted within each study, comparing the
groups. A p value of .01 was used for these tests. If the p value of the t-test was not significant,
the groups were assumed to be equivalent at pre-treatment and the meta-analyses could
legitimately be based on post-test scores (see Appendix D). Group equivalence could have been
assumed without testing it at all as the fact that the authors conducted the between-group studies
without controlling for pre-existing differences in statistical analyses implies it. However, it was
decided to be more conservative in the decision about group equivalence and to conduct these
independent sample t-tests. Results indicated that in none of the studies the group differences
were significant at a p ≤ .01 level. For within-subject studies t, z, or p statistics and means,
standard deviations, and sample sizes for pre and post-test were entered.
In the meta-analyses, a random effects model was used because it assumes that the true effect
could vary from study to study, which was the case in the current systematic review, and it is
seen as most appropriate for studies in the health field (Ades & Higgins, 2005; Fleiss & Gross,
55
1991). Although the studies were sufficiently similar to synthesize the data, they typically
differed on one or more moderators.
Effect sizes from at least two unique studies were required to conduct a given meta-analysis
(Borenstein et al., 2011). Overall, 26 meta-analyses were conducted to establish the effect sizes
of each relevant outcome using Comprehensive Meta-Analysis Version 3.0 (CMA; Borenstein,
Hedges, Higgins, & Rothstein, 2013). Effect sizes were reported as standardized mean
differences whereby the difference in outcome (using continuous measures) between the
intervention and control groups was divided by the pooled standard deviation to estimate
intervention efficaciousness. The standardized mean difference expresses the size of the
intervention effect in each outcome relative to the variability observed in that outcome (Higgins,
Green, & Cochrane, 2011). Effect sizes are calculated by using the difference between the post-
test means in the numerator of the equation and standard deviation units in the denominator. This
standardization allows for direct comparisons across studies using the same index of effect
(Durlak, 2009). The two most common standardized mean difference statistics are Hedges’ g and
Cohen's d. Population effect sizes are almost always estimated on the basis of samples, and all
population effect size estimates based on sample averages overestimate the true population effect
(for a more detailed explanation, see Thompson, 2006). Therefore, corrections for bias are used
by making adjustments in the formula (see the formulas in Appendix E), even though these
corrections do not always lead to a completely unbiased effect size estimate. In the d family of
effect sizes, the correction for Cohen's d is known as Hedges' g. Therefore, Hedges’s g effect
sizes were calculated for 20 between-group design outcomes and 6 for within-subject design
outcomes in the present study.
Heterogeneity is a measure of the variability of the studies included in the systematic review
(Borenstein et al., 2011; Higgins & Green, 2011). Clinical diversity (sometimes called clinical
heterogeneity) refers to variability in the sample of participants, interventions and outcomes
studied, and methodological diversity refers to the variability in study design and risk of bias.
Statistical heterogeneity refers to the variability in the intervention effects being evaluated in the
different studies and is a consequence of clinical diversity or methodological diversity, and
manifests itself in the observed treatment effects being more different from each other than one
would expect due to chance alone (Higgins & Green, 2011). Cochran’s Q is a statistical measure
56
of heterogeneity that is calculated as the weighted sum of squared differences between individual
study effects and the pooled effect across studies, with the weights being those used in the
pooling method. Q is distributed as a chi-square statistic with number of studies (k) minus 1
degrees of freedom. Q has low power as a comprehensive test of heterogeneity, especially when
the number of studies is small (Gavaghan, Moore, & McQay, 2000). The I-squared (I²) statistic,
used in the meta-analyses in the present study, describes the percentage of variation across
studies that is due to heterogeneity rather than chance (Borenstein et al., 2011; Higgins &
Thompson, 2002). I-squared (I² = 100% x (Q-df)/Q) is an expression of the inconsistency of
studies’ results. Unlike Q it does not inherently depend upon the number of studies considered
and therefore was considered more appropriate.
To be able to explore which variables may potentially moderate treatment response, moderator
analyses need to be performed. To be able to conduct moderator analyses (subgroup for
categorical variables and meta-regressions for the continues variables) two conditions need to be
met: there has to be sufficient sample of studies to be subgrouped as well as sufficient variability
in the potential moderators.
57
Table 2. SPIO (Study Design, Population, Interventions, Outcomes) Framework.
Include Exclude Study Design
- Between-group design with a control group that did not receive a child-focused psychosocial treatment (e.g., wait-list no treatment, psychosocial equivalent treatment without the therapeutic components, treatment as usual in the community, or ADHD medication) and one or more intervention groups that reported both pre-test and post-test scores for each group. If the study had multiple intervention groups, then each group was required to receive a different intervention. A minimum requirement of 18 participants (n = 9 per group) was established to enhance reliability, ensuring that individual studies had enough power to detect the effects of the intervention (Borenstein et al., 2011). - Consistent with previous systematic reviews and meta-analyses (e.g., van der Oord et al., 2008) within group effect sizes were considered appropriate for inclusion. Specifically, within-subject design in which each participant receives the same intervention with outcomes assessed on at least two occasions, before and after the intervention. A minimum requirement of 9 participants was established.
- Between-group design studies comparing two (or more) child-focused psychosocial interventions without a control gropu (wait-list no treatment, psychosocial equivalent treatment without the therapeutic components, treatment as usual in the community, or ADHD medication; e.g., Barkley et al., 2001). Between-group design studies were compared according to the intervention of interest with no intervention. Therefore, the studies comparing two interventions did not make it to meta-analyses because they do not fit this criterion. Statistically, including studies with no control group among the intervention- control groups between studies would be like mixing “apples and oranges”. Because these studies do not have a reference point to compute the effect size (neither the pre-test scores, nor the control group). I did not want to contaminate the effect sizes comparing the treatment with control group by including the comparison with other treatment groups. - Time series designs or single-case studies were excluded from inclusion consistent with other previous systematic reviews and meta-analyses (e.g., van der Oord et al., 2008). The rationale for this decision was that researchers (DuPaul & Eckert, 1997) reviewing interventions for individuals with ADHD have reported much larger effect sizes (two to three times larger) for single-case studies than for between-group designs (van der Oord et al., 2008). Including single-case designs could have inflated the meta-analyses results. - Studies not involving a quantitative comparison of child-focused psychosocial interventions (e.g., case studies, review papers, qualitative designs). - Studies not providing sufficient information from which effect sizes could be calculated (between-group designs without means, standards deviations, and sample size; within-subject design studies not providing t, z, or p statistics).
Population - Children or adolescents with ADHD (or with clinically significant symptoms of ADHD and therefore at high risk for ADHD). - Mean age of the child sample was required to range from 6 to 18 years of age (or 72 to 216 months) and the range could not extend beyond 18 years old in order to confine this systematic review to school-age children and adolescents.
- Samples where a diagnosis of ADHD (or clinically significant symptoms of ADHD) was not required for inclusion (e.g., Fabiano, Pelham, Karmazin, Kreher, Panahon, et al., 2008; Fung & Tsang, 2007). - Samples including children with intellectual disabilities defined as an IQ of 75 or lower, or children with ADHD and co-occurring Pervasive Developmental Disorders, Psychotic Disorders, and Bipolar Disorder, due to the possibility that these disorders may have independent effects on children’s and adolescents’ outcomes (e.g., Schmelzer-Benisz, 2003; Gooding, 2010).
58
Table 2. SPIO (Study Design, Population, Interventions, Outcomes) Framework (continued).
Include Exclude
Intervention - Psychosocial interventions where there was direct child-therapist contact (e.g., social skills training, cognitive behavioural therapy, mindfulness training, and family therapy). - Multimodal studies that included a treatment group with concurrent pharmacological, parent teacher or teacher consultation in addition to a psychosocial child-focused psychosocial treatment (e.g., Waxmonsky et al., 2010).
- Interventions in which the therapist or clinical researcher (e.g., graduate student, research assistant, etc.) solely trained parents or teachers for them to provide the intervention. - Interventions addressing cognitive functioning, academic achievement and attainment, driving skills, and sleep difficulties. - Interventions provided to every child in a given setting (with or without ADHD) such as school-based interventions aimed at increasing the social competence, stress-management, or emotion regulation of the entire classroom where the ADHD group was not separated out for analysis.
Outcomes - Assessing at least one of the following child social or behavioural functioning domains: internalizing or externalizing symptoms or behavioural disorders; social skills, peer relationships, or family functioning using self-report, parent report, or teacher report in standardized rating scales. - Follow-up data when data were directly comparable with the data presented for the pre- and post-test, and the time frame was limited to two years following post-test. Because several studies (e.g., MTA Cooperative, 1999) have multiple subsequent publications of the same study where the outcomes are further combined and aggregated and are no longer directly comparable to the primary study outcomes, and conclusions about treatment maintenance become spurious.
- Studies examining exclusively cognitive functioning, academic achievement and attainment, driving skills, and sleep outcomes have been excluded because it was considered that child-focused psychosocial interventions do not necessarily target these outcomes. For example, driving skills are more likely to be targeted in adult populations with ADHD, and academic skills are more likely to be targeted by academic interventions. - Due to many previous and fairly recent meta-analyses having explored exclusively core ADHD symptoms (e.g., Bjornstad & Montgomery (2010); Fabiano, Pelham, Coles, Gnagy, Chronis, & Connor (2009); Klassen, Miller, Raina, Lee, & Olsoen (1999); Sonuga-Barke, Brandeis, Cortese, Daley, Ferrin, et al. (2013) studies investigating exclusively these outcomes have been excluded. - Follow-up data extending beyond two years (e.g., 4.5 years, van der Oord, Prins, Oosterlaan, & Emmelkamp, 2012) because after that period of time it is very rare to continue experiencing treatment effects (Barkley, 2015). - Combined outcomes at follow-up where different outcome domains or reporting sources (e.g., parent and teachers) have been aggregated together (e.g., Jensen, Arnold, Swanson, Vitiello, Abikoff, et al., 2007).
Notes. a. However, when provided in an eligible study, data for core ADHD symptoms was extracted and analyzed.
59
Figure 1. PRISMA Flow Diagram
Notes. a. 102 studies did not include a child-focused intervention of interest; 141 studies did not provide sufficient information from which effect sizes could be calculated; 21 studies did not report outcomes of interest; and in the remaining studies the sample did not meet inclusion criteria because of age (12) or it was too diverse (164) or too small (31) to be informative. Detailed reasons for exclusion of each study are reported in Appendix F. b. Five studies were publications reporting the findings from different outcomes of the same intervention for a single sample (Abikoff et al., 2004a, 2004b; Hechtman et al., 2004a, 2004b; Klein et al., 2004).
Medline Embase ERIC PsycInfo ProQDiss 1282 2016 1300 5096 762
10456 records identified through electronic
database searches
Scr
een
ing
Inclu
ded
E
lig
ibil
ity
Identi
fica
tion
102 additional studies identified through reviews of the literature and
hand searches
10558 records identified in total
6325 study abstracts screened for eligibility
after duplicates (n = 4233) removed
5828 records excluded based on screening of abstracts using
eligibility criteria (Table 2)
497 retrieved full text article for more detailed
evaluation
471 studies excluded after full text review due to not meeting
all inclusion criteriaa
26 studies included in
qualitative synthesis
(22 samples)b
14 studies included in
quantitative synthesis
(meta-analysis) (14 samples)
60
4444 RESULTSRESULTSRESULTSRESULTS
This chapter is divided in two parts: a) a description of the included studies in this systematic
review, and b) the results of the systematic review and meta-analyses. Specifically in part a) I
describe the studies’ publication status and country of origin. This is followed by a description of
the characteristics of the pooled sample of participants. Then I describe the characteristics of the
included studies by intervention type; cognitive behavioural therapy (CBT), mindfulness
training, and social skills training. I describe their study aims, design (i.e., within-subject and
between-group design), and time points. Social skills training (SST) interventions are presented
in order of increasing complexity; first the SST stand-alone intervention studies are described,
followed by the SST plus concurrent parent and teacher involvement studies, and finally the SST
plus medication and parent and teacher involvement studies are described. In part b) I present the
results of the systematic review and meta-analyses. Specifically, I describe the results of the
individual studies divided by intervention type (CBT, mindfulness training, and SST), outcome
(internalizing and externalizing symptoms and behaviours, social skills, peer relationships,
family functioning, and core ADHD symptoms), and study design. The rationale for this
presentation of the data is to be able to better understand what each child-focused psychosocial
intervention type has to offer for children and adolescents with ADHD in regards to specific
outcomes. Whenever available, I finish each subsection with the statistical results of the meta-
analyses. The tables referred to in this chapter (Tables 3 to 13) are inserted at the end of this
chapter (pages 116 to 145).
PPPPartartartart A: A: A: A: Description of Studies Description of Studies Description of Studies Description of Studies
4.14.14.14.1 Studies’ Publication Status and Country of OriginStudies’ Publication Status and Country of OriginStudies’ Publication Status and Country of OriginStudies’ Publication Status and Country of Origin
The literature search procedure yielded data from 10,456 potential articles for inclusion. Through
reviews of the literature and hand searches, 102 additional studies were identified, for a total of
10,558 records. After removing 4,169 duplicate references, the titles and abstracts of 6,308
articles were examined, to eliminate studies that clearly did not meet inclusion criteria. As a
result of these efforts, 5,828 records were excluded, and the full texts of 497 studies were
61
retrieved for a more detailed evaluation. These full texts were retrieved from the University of
Toronto library (online or from the stacks), through intralibrary loans, or directly from the
author. After a full-text review, 471 studies were excluded from inclusion for not meeting all
inclusion criteria. The remaining 26 studies (with 22 samples) were included in the systematic
review of the literature; 14 of these were included in the meta-analyses (14 samples), because
these were sufficiently comparable based on the outcomes measured to be combined in meta-
analyses (further explained in chapter 4). Details of the search and study selection are provided
in Figure 1 (chapter 3).
The characteristics of the 26 eligible studies are presented in Table 3 (page 116). Eleven studies
were conducted in the United States (Antshel et al., 2014; Antshel & Remer, 2003; Bloomquist
et al., 1991; Brown et al., 1986; Evans et al., 2011; Frankel et al., 1997; Molina et al., 2008;
Pfiffner & McBurnett, 1997; Pfiffner et al., 2007; Villodas et al. 2014; Waxmonsky et al., 2010)
and three studies were conducted in Canada (Corkum et al., 2010; Haydicky et al., 2012, 2015).
Six studies were dual-sited in the United States and Canada, one of which reported results from a
sample collected from five sites in the United States and one in Canada (MTA Cooperative,
1999), and five which were publications that reported findings from different outcomes on the
same intervention for a single sample (Abikoff et al., 2004a, 2004b; Hechtman et al., 2004a,
2004b; Klein et al., 2004). Two studies were conducted in the Netherlands (van der Oord et al.,
2007; van der Weijer-Bergsma et al., 2012), two were conducted in Australia (Jensen & Kenny,
2004; Harrison et al., 2004); one was conducted in Israel (Lufi & Parish-Plass, 2011), and the
remaining study was conducted in Korea (Choi & Lee, 2015).
Although publication status was not set as a limitation in this systematic review, all of the studies
that met eligibility criteria were published in peer-reviewed journals between 1986 and 2015, and
most were conducted in the United States. One study was published in the 1980s, four studies in
the 1990s, 12 studies between 2000 and 2009, and nine studies between 2010 and 2015. Of the
26 studies, 19 used a between-group design, and seven employed a within-subject design.
A total of 130 different outcomes were extracted from the 26 studies; 46 were child-reported, 55
parent-reported, and 29 teacher-reported. Studies ranged in terms of the number of outcomes of
interest reported, from 1 to 21. One study did not report on any outcomes (Klein et al., 2004) but
62
was included because it described the sample characteristics of the shared sample of four other
included studies that reported results on different outcomes (Abikoff et al., 2004a, 2004b;
Hechtman et al., 2004a, 2004b).
In sum, 130 different outcomes were extracted from the 26 studies that met eligibility criteria to
be included in this systematic review.
4.24.24.24.2 Pooled SPooled SPooled SPooled Sample of Participantsample of Participantsample of Participantsample of Participants
As shown in Tables 3 (page 116) and 4 (page 124), the total number of participants in the studies
included in this systematic review ranged from 10 to 579, with a total of 1,568 participants
across the 26 studies (22 samples). The majority of studies (64%) enrolled between 23 and 82
participants. Most of the participants were male (n = 1,225, 78%), with a mean age of 10 years, 8
months (SD = 2 years, 8 months). All participants met diagnostic criteria for ADHD based on the
Diagnostic and Statistical Manual of Mental Disorders (3rd ed., DSM-III, American Psychiatric
Association, 1980; 3rd ed., revised, DSM III-R, American Psychiatric Association, 1987; 4th ed.,
DSM IV, American Psychiatric Association, 1994; 4th ed., text rev., DSM IV-TR, American
Psychiatric Association). The diagnoses were confirmed using standardized measures (including
BASC, Conners-3-P, and DISC; see Tables 3 and 4 on pages 116 and 124, respectively). Of the
26 studies (22 samples), 10 samples (or 45%) reported the prevalence of ADHD subtypes. Of
these 10 studies, nine reported having a range of 12.5% to 51% of ADHD-Inattention (M =
34%), five reported a range of 1.8% to 76% (M = 20%) of ADHD-Hyperactive/Impulsive, and
eight reported a range of 43% to 100% (M = 65%) ADHD-Combined type. The majority of
studies (17 of the 22 samples, or 77%) reported participants’ clinical comorbidities. The most
common comorbidity reported was ODD, present in 12 samples (range = 21.42% to 70.37%).
The second most common comorbidity was anxiety disorder, with seven samples reporting a
range of 6% to 33.5% (see Table 4, page 124).
For 16 of the 22 included samples (73%), ethnicity or race of study participants was provided.
Most participants were Caucasian (81%). In two of the six studies where ethnicity information
was not available for the children, ethnicity or country of birth was reported for the parents of the
child participants. Medication status during the child-focused psychosocial treatment was
63
assessed in the majority of studies (19 of 22 samples, or 86%) with 17 samples (77%) reporting
that at least some participants received medication (M = 62%). Medication treatment was held
constant in all of the samples where this status was reported. Parental marital status was reported
in 11 samples (50%), and most children were from two-parent homes; nine samples reported a
range of 7.4% to 30% of children living in single-parent households (M= 17%) (See Table 4,
page 124).
Socioeconomic status (SES) was inconsistently reported across the studies, making it difficult to
compare the samples. Of the 22 included samples, eight samples used parent level of education
(Haydicky et al., 2015; van der Oord et al., 2007), and/or income range (Evans et al., 2011;
Harrison et al. 2004; Jensen & Kenny 2004; MTA Cooperative, 1999; Pfiffner et al., 2007;
Villodas et al., 2014). Six samples calculated SES with the Hollingshead Two-Factor Index of
Social Position5 (Abikoff et al., 2004; Antshel & Remer, 2003; Frankel et al., 1997; Corkum et
al., 2010; Molina et al., 2008; Pfifner & McBurnett, 1997). Two samples employed the
socioeconomic index6 (Brown et al., 1986; Waxmonsky et al. 2010). One sample (Choi & Lee,
2015) used the Meyers and Bean scale (1968). Two samples reported the percentage of children
in their sample who were qualified for free lunch in the school setting where the intervention was
conducted (Bloomquist et al, 1991; Villodas et al., 2014). In two samples (Jensen & Kenny,
2004; Lufi & Parish-Plass, 2011) it was not clearly stated how SES was obtained, and for the
remaining two samples, SES data were not provided (Haydicky et al., 2012; van de Weijer-
Bergsma et al., 2012). Even among the studies reporting SES seemingly in the same manner
(e.g., the Hollingshead Two-Factor Index of Social Position), the values reported varied by
study; some reported participants’ mean level (e.g., Corkum et al., 2010; Frankel et al., 1997)
while others reported the range (e.g., Antshel et al., 2014; Pffifner & McBurnett, 1997).
The percentage of children who had previous experience with a psychosocial treatment was only
provided by three of the 22 included samples (13.6%), and it ranged from 50% to 53% (50% in
Haydicky et al., 2015; 52% in Pfiffner & McBrunett, 1997; 52.94% in Antshel et al., 2014).
5 Hollingshead, 1975; Hollingshead & Redlich, 1985.
6 Nakao & Treas (1994)
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In sum, a total of 1,568 children and adolescents with ADHD participated in the 26 studies (22
samples) included in this systematic review. Most participants were Caucasian males from two-
parent homes, with a mean age of 10 years, 8 months. In terms of the prevalence of ADHD
subtypes, nine studies reported having a range of 12.5% to 51% of ADHD-Inattention, five
studies reported a range of 1.8% to 76% of ADHD-Hyperactive/Impulsive, and eight studies
reported a range of 43% to 100% of ADHD-Combined Type. The most commonly reported
comorbidity was ODD, followed by anxiety disorder. Most participants received medication for
ADHD during the child-focused psychosocial treatment, and medication was held constant in all
of the samples where this status was reported. The percentage of children who had previous
experience with a psychosocial treatment was only provided by three of the 22 included samples
and consisted of approximately half of the sample in each case.
4.34.34.34.3 Description of Included Studies by Intervention TypeDescription of Included Studies by Intervention TypeDescription of Included Studies by Intervention TypeDescription of Included Studies by Intervention Type
In the following section, studies are described according to the type of intervention being
evaluated (cognitive behavioural therapy, mindfulness training, and SST) and their study design,
sample size, study aims, EPHPP quality rating, and attrition rates. The rationale for this
presentation of the studies was to be able to better understand what each intervention type had to
offer for children and adolescents with ADHD in each of the specific ADHD’s associated
comorbidities and functional impairments (externalizing symptoms, internalizing symptoms,
social skills, peer relationships and family functioning) and core ADHD symptoms of
inattention, hyperactivity, and impulsivity. Dividing the studies by intervention type may provide
a better understanding of whether the vast number of outcomes measured by each intervention
are hypothesized by investigators to be affected by each intervention, or are incidental.
No study evaluating the efficaciousness of a family therapy intervention met inclusion criteria
for this systematic review. The two identified treatment studies that evaluated family therapy for
treating adolescents with ADHD were conducted by Barkley and colleagues (Barkley, Edwards,
Laneri, Fletcher, & Metevia, 2001; Barkley, Guevremont, Anastopoulos, & Fletcher, 1992). The
authors compared behavioural parenting training, family therapy, and problem-solving
communication training. Neither study met inclusion criteria, because their study designs were
between-group designs without a wait-list no-treatment, psychosocial equivalent treatment
65
without the therapeutic components, treatment as usual in the community, or ADHD medication
control group (refer to SPIO; Table 2 on page 57). In both studies, a group of children receiving
a child-focused psychosocial intervention was compared to one or more groups of children
receiving other child-focused psychosocial interventions.
4.3.14.3.14.3.14.3.1 Cognitive Behavioural Treatment StudiesCognitive Behavioural Treatment StudiesCognitive Behavioural Treatment StudiesCognitive Behavioural Treatment Studies
As shown in Tables 3 (page 116) and 5 (page 129), four of the 26 included studies described 10-
to-16-week-long CBT interventions (Antshel et al., 2014; Bloomquist et al., 1991; Brown et al.,
1986; van der Oord et al., 2007). There were no apparent differences in the interventions’ length.
Two interventions were weekly (Antshel et al., 2014; van der Oord et al., 2007) and two were bi-
weekly (Brown et al., 1986; Bloomquist et al., 1991). Two of the CBT studies (Antshel et al.,
2014; Brown et al., 1986) studied individual CBT treatment, and two studied group CBT
treatment (Bloomquist et al., 1991; van der Oord et al., 2007). One of these studies (Antshel et
al., 2014) used a within-subject design with a standard pre-posttreatment design and the other
three used a between-group design.
The sample for the Antshel et al. (2014) study were adolescents, ages 14 to 18; the samples for
the other studies consisted of children between the ages of 5 and 13.
4.3.1.14.3.1.14.3.1.14.3.1.1 Individual CBTIndividual CBTIndividual CBTIndividual CBT
The Antshel et al. (2014) and the Brown et al. (1986) studies both had as study aims an
evaluation of the efficaciousness of individual CBT therapy. Antshel et al. aimed at improving
parent-reported and teacher-reported core ADHD symptoms of inattention and hyperactivity,
plus other functional impairment outcomes including academic domains (not in the scope of this
dissertation) and social and family domains. Parents were very involved in the treatment,
attending half of the sessions. Parents were not in the therapy room for the communication skills
and the anger management modules. They were informed of the topics but not of the content
discussed. Teachers were blind to the children’s CBT participation. Brown et al. aimed to
investigate the efficaciousness of concurrent CBT and stimulant medications for ADHD, such as
methylphenidate. Specifically, these investigators wanted to evaluate whether CBT would
improve the maintenance of treatment gains in terms of the core ADHD symptoms, as well as
66
classroom behaviour and school achievement (school achievement was not in the scope of this
review). Parents, teachers, and treatment staff directly in contact with the children were unaware
of their medication situation. The CBT-and-medication group was compared to three other
groups, including a group receiving medication only, a medication placebo group, and an
attention control/medication placebo group. Parent involvement in the CBT-and-medication
treatment group was scantily described in the study, and was limited to the generalization to the
home and school of the academic and social skills taught during CBT.
In terms of their EPHPP global quality rating, Antshel et al. (2014) obtained a rating in the
moderate range; the investigators claimed that teachers, who completed rating scales, were blind
to (i.e., not aware of) the adolescents’ participation in CBT but that parents were aware of their
children’s participation. Brown et al. (1986) obtained a strong rating, despite being an older
study with a small sample due to the fact that medications were double-blinded for parents,
teachers, and project staff directly in contact with the children (i.e., none of them were aware of
the medication status of the children). The Antshel et al. study had a sample size of 82 and the
Brown et al. study had a total sample size of 33 (nine in the CBT-and-medication group). The
higher global rating of the Brown study was partly due to the research design, which was a
randomized control trial (RCT) as opposed to the single group pre-post design (with no control
group) used in Antshel et al. study.
As shown in Table 3 (page 116), both Antshel et al. (2014) and Brown at al. (1986) had low
attrition rates; 80% to 100% of participants completed the study.
4.3.1.24.3.1.24.3.1.24.3.1.2 Group CBTGroup CBTGroup CBTGroup CBT
Two of the 26 studies (Bloomquist et al., 1991; van der Oord et al., 2007) evaluated the
efficaciousness of group CBT treatment for children with ADHD. Both studies used an RCT
study design. For their study aims, Bloomquist et al. hypothesized that for children with ADHD,
CBT delivered with an active parent treatment and concurrent teacher consultation would have
better outcomes than a teacher-consultation-only group and a wait-list no-treatment group. Their
study goal was not as detailed as more recent studies. It was described as “reducing symptomatic
behaviours and improving adjustment in children with ADHD” (Bloomquist et al., 1991, p. 592).
67
Outcomes of interest measured were teacher reported including the core ADHD symptoms of
inattention, hyperactivity, and impulsivity; CD symptoms; social competence; and peer-preferred
social behaviour. Bloomquist et al. evaluated a multimodal group-CBT intervention for the
children with concurrent parent treatment and teacher consultation, and they compared this group
of children to two other groups. The second group was a wait-list, no-treatment, control group,
and in the third group only the teachers received treatment—not the children or the parents.
Unlike the Bloomquist et al. study, van der Oord et al.’s (2007) study goal was to investigate the
efficaciousness of stimulant medications for ADHD, such as methylphenidate, and concurrent
group-CBT for the children compared to a medication-only group. The parents and teachers of
the children in the CBT-and-medications group were simultaneously part of treatment. Van der
Oord et al. hypothesized that combined multimodal treatment—group CBT with medications,
parent, treatment and teacher consultation—would outperform the medication-only group for
core ADHD and related symptoms such as anxiety, CD, ODD, and social skills.
Bloomquist et al. (1991) obtained an EPHPP quality global rating in the moderate range, and did
not describe any blinding procedures, while van der Oord et al. (2007) obtained a strong rating,
partly because it was an RCT design and described blinding of the therapists in terms of the
medication status of the children; parents and teachers were not blinded in terms of treatment
because they were involved in CBT treatment and consultation, respectively. In addition, the
higher rating of the van der Oord study was partly due to a lower attrition rate. Bloomquist et
al.’s study had a total sample size of 52 (20 in the combined multimodal group), while the van
der Oord et al. study had a total sample size of 45 (24 in the CBT-and-medication group). As
shown in Table 3 (page 116), 60%–79% of Bloomquist et al.’s participants completed treatment,
yielding a higher attrition rate than the van der Oord et al. (2007) study, where 80%–100% of
participants completed treatment.
In sum, four studies (2 of strong, and 2 of moderate global study quality) that evaluated the
efficaciousness of individual and group CBT interventions were included in this systematic
review. Two evaluated individual CBT. Antshel et al. (2014) evaluated CBT with a strong parent
involvement component in the adolescents’ treatment. In Brown et al. (1986), a CBT
intervention was evaluated as administered with a concurrent pharmacological treatment in
comparison to three groups—a medication-only group, a medication placebo group, and an
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attention control/medication placebo group. Bloomquist et al. (1991) and van der Oord et al.
(2007) both concurrently included parents and teachers in the group CBT treatment. In addition,
in the van der Oord et al. study, the children in the group were took part in concurrent
pharmacological treatment.
In general, the CBT interventions aimed at improving core ADHD symptoms of inattention and
hyperactivity and other social and family functioning outcome domains. When combined with
medication, the goal of individual CBT was to improve the maintenance of treatment gains in
terms of core ADHD symptoms and classroom behaviour (Brown et al., 1986). When combined
with medication, parent treatment and teacher consultation, the goal of group CBT was to
outperform the medication-only group for core ADHD and other associated symptoms and
functional impairments, including anxiety, CD, ODD, and social skills (van der Oord et al.,
2007).
4.3.24.3.24.3.24.3.2 Mindfulness Training Intervention StudiesMindfulness Training Intervention StudiesMindfulness Training Intervention StudiesMindfulness Training Intervention Studies
As shown in Tables 3 (page 116) and 5 (page 129), five of the 26 studies described 6- to 20-week
long mindfulness training interventions (Harrison et al., 2004; Haydicky et al., 2012, 2015;
Jensen & Kenny, 2004; van de Weijer-Bergsma et al., 2012). There were no apparent differences
in the interventions’ length, with three of them being between 6 and 8-weeks long (Harrison et
al., 2004; Haydicky et al., 2015; Jensen & Kenny, 2004), and two of them being 20-weeks long
(Haydicky et al., 2012; van de Weijer-Bergsma et al., 2012). All the interventions were given
weekly, with the exception of Harrison et al., (2004), which was bi-weekly. In all the
mindfulness intervention studies, with the exception of Haydicky et al., parents received
mindfulness training treatment simultaneously. In the Haydicky et al. (2012) study, parents were
not treatment receivers, but met periodically with the child and the child’s therapist to be
informed of treatment progress.
Three of the five studies (Harrison et al., 2004; Haydicky et al., 2015; van de Weijer-Bergsma et
al., 2012) were within-subject design studies. In regards to sample sizes and time points,
Harrison et al. (N = 48) and van de Weijer-Bergsma et al. (N = 10) both had a single-group, pre-
posttreatment design. Harrison et al. used three time points (pretreatment, mid-treatment, and
69
posttreatment) and van de Weijer-Bergsma et al. used four time points (pre-test, post-test, 4
months’ follow-up, and 8-months’ follow-up). Haydicky et al. (2015) (N = 18) also used four
time points; baseline 8 weeks prior to treatment, in addition to a pretreatment, posttreatment, and
6-week follow-up. The remaining two mindfulness training intervention studies (Haydicky et al.,
2012; Jensen & Kenny, 2004) were between-group design studies comprising two groups each.
Haydicky et al.7 (N = 33) compared a group of children receiving a mindfulness training
intervention with a wait-list no-treatment control group, and Jensen and Kenny8 (N = 14)
compared a group of children receiving a mindfulness training intervention and medication with
a wait-list control group receiving an equivalent psychosocial treatment without the core
therapeutic components.
In terms of treatment aims, Haydicky et al. (2012) evaluated the impact of mindfulness martial
arts, a mindfulness training intervention incorporating martial arts, in a group of adolescents with
LD. For purposes of this systematic review, only the data for the subgroup of children with LD
and ADHD-Inattentive Type was included. Haydicky et al. aimed at reducing internalizing and
externalizing symptoms, and social problems. They also looked at reducing executive
functioning variables, such as inhibition and cognitive flexibility, which were not within the
scope of this review. Haydicky et al.’s (2015) and van de Weijer-Bergsma et al.’s (2012) studies
evaluated MyMind, a mindfulness training intervention for adolescents and their parents aimed
at reducing adolescents’ inattention and internalizing and externalizing symptoms. Haydicky et
al. had additional secondary goals, including the improvement of the quality of peer and parent-
child relationships. Both studies evaluating the MyMind intervention had the additional goal of
improving other variables such as mindfulness, executive functioning, and parent variables,
which are not within the scope of this systematic review. Harrison et al.’s (2004) study, with a
simultaneous mindfulness parent training intervention, had the primary aim of reducing core
ADHD symptoms of inattention, hyperactivity, and impulsivity, and frustrated mood. They also
studied other variables, including self-esteem, that were not in the scope of this review. Last,
7 The subgroup of children with LD and ADHD-Inattentive type was used here.
8 In this study five participants acted as self-controls and were in both conditions, first in the wait-list control group and then in the treatment group.
70
Jensen and Kenny (2004) evaluated the impact of Sahaja yoga meditation on children and their
parents, with the aim of reducing core ADHD symptoms of inattention, hyperactivity, and
impulsivity, but also examined other outcomes such as anxiety, emotional lability, ODD, and
social problems.
In regards to their EPHPP study quality global rating, all mindfulness training intervention
studies (Harrison et al., 2004; Haydicky et al., 2012, 2015; Jensen & Kenny, 2004) obtained a
rating in the moderate range, with the exception of one study (van de Weijer-Bergsma et al.,
2012) that obtained a weak global rating, partly due to an underreporting of their recruitment
procedures, which precluded any calculation of their participation consent rate. None of the
evaluations of mindfulness training interventions described any blinding procedures.
Of the five studies, three (Harrison et al., 2004; Haydicky et al., 2015; Jensen & Kenny, 2004)
had a low attrition rate; 80%–100% of participants completed the treatment. Attrition rates at
posttreatment were not available for two of the studies. In one study (Haydicky et al., 2012) it
was not possible to discern the percentage of participants with ADHD-Inattentive Type who
were treatment completers, because the 4.6% attrition rate reported included treatment receivers
who did not have ADHD. For the van der Weijer-Bergsma et al. (2012) study the attrition rate
reported (20%) was at 16-week follow-up time point, with no attrition reported at posttreatment.
In sum, five studies evaluating the efficaciousness of mindfulness training interventions were
included in this systematic review (Harrison et al., 2004; Haydicky et al., 2012, 2015; Jensen &
Kenny, 2004; van de Weijer-Bergsma et al., 2012). All mindfulness training intervention studies
obtained a global rating in the moderate range, with the exception of van de Weijer-Bergsma et
al. (2012). Blinding was not present in any of these evaluations of mindfulness training
interventions. In all but Haydicky et al. (2012), parents received mindfulness training
simultaneously. Additionally, in Jensen and Kenny’s (2004) study, children received concurrent
pharmacological treatment. All mindfulness training interventions aimed at improving
inattention. Most studies (Harrison et al., 2004; Haydicky et al., 2012, 2015; van der Weijer-
Bergsma et al., 2012) also had the aims of reducing internalizing and externalizing symptoms.
One study had the additional goal of improving hyperactivity and impulsivity (Harrison et al.,
2004). Another study had the primary goal of improving the core ADHD symptoms of
71
inattention, hyperactivity, and impulsivity, but also measured social problems, and internalizing
and externalizing symptoms (Jensen & Kenny, 2004). Last, two studies had the primary aim of
reducing inattention and internalizing and externalizing symptoms, and had the additional
secondary goal of improvement of the quality of peer (Haydicky et al., 2012, 2015) and parent-
child (Haydicky et al., 2015) relationships.
4.3.34.3.34.3.34.3.3 Social Skills Training Intervention StudiesSocial Skills Training Intervention StudiesSocial Skills Training Intervention StudiesSocial Skills Training Intervention Studies
As shown in Tables 3 (page 116) and 5 (page 129), 17 of the 26 studies described 13 samples
receiving 8- to 96-week-long SST interventions (Abikoff Group, 2004; Antshel & Remer, 2003;
Choi & Lee, 2015; Corkum et al., 2010; Evans et al., 2011; Frankel et al., 1997; Lufi & Parish-
Plass, 2011; Molina et al., 2008; MTA Cooperative, 1999; Pfiffner & McBurnett, 1997; Pfiffner
et al., 2007; Villodas et al., 2014; Waxmonsky et al., 2010). The majority (69%) of the
interventions were 8 to 12 weeks long. Five publications reported results of different outcomes
evaluated in the same intervention provided to the same sample of participants (Abikoff et al.,
2004a, 2004b; Hechtman et al., 2004a, 2004b; & Klein et al., 2004). The Abikoff et al. (2004a,
2004b) publications are described collectively herein as the Abikoff Group (2004). With the
exeption of the Abikoff Group, which was 96-weeks long; the longest SST interventions were
20-weeks long (Table 5, page 129). In terms of their frequency, nine of the 13 SST interventions
had weekly sessions (Antshel & Remer, 2003; Choi & Lee, 2015; Corkum et al., 2010; Frankel
et al., 1997; Lufi & Parish-Plass, 2011; Pfiffner & McBurnett, 1997; Pfiffner et al., 2007;
Villodas et al., 2014; Waxmonsky et al., 2010), three had bi-weekly sessions (Abikoff Group,
2004; Evans et al., 2011; Molina et al., 2008), and the MTA Cooperative (1999) study offered
daily sessions.
All the SST studies are described in order of increasing complexity in their designs and methods,
starting with the single group within-subject designs, and following with designs that had two or
more treatment groups. Studies wherein the SST was provided to children as a stand-alone
treatment are described first, followed by studies that had concurrent parent treatment and
teacher consultation, and then by studies wherein the efficaciousness of SST was evaluated with
concurrent medications.
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At least one of the SST groups was evaluated concurrently with some level of parent
involvement during the children’s treatment (e.g., psychoeducation about ADHD, parent
behavioural training, problem-solving sessions) in all but two of the 13 SST interventions9 (Choi
& Lee, 2015; Lufi & Parish-Plass, 2011). Two of the SST interventions included concurrent
parent treatment (Antshel & Remer, 2003; Frankel et al., 1997), six included concurrent parent
treatment and teacher consultation (Corkum et al., 2010; Evans et al., 2011; Molina et al., 2008;
Pfiffner & McBurnett, 1997; Pfiffner et al., 2008; Villodas et al., 2014), and three included
concurrent medication, parent treatment and teacher consultation (Abikoff Group, 2004; MTA
Cooperative, 1999; Waxmonsky et al., 2010).
As shown in Table 3 (page 116), the study design of the 13 SST studies included 10 that had a
between-group design, and three that had a within-subject design (Corkum et al., 2010; Luffi &
Parish-Plass, 201110; Villodas et al., 2014). In regards to sample sizes and time points of the
single-group design studies, Corkum et al. (N = 16) and Villodas et al. (N = 57) had a pre-
posttreatment design. Luffi and Parish-Plass (N = 15) also had a pre-posttreatment design, which
included an additional one-year follow-up. Of the ten between-group design studies, eight had an
RCT design (Abikoff Group, 2004; Choi & Lee, 2015; Evans et al., 2011; Molina et al., 2008;
MTA Cooperative, 1999; Pfiffner & McBurnett, 1997; Pfiffner et al., 2007; Waxmonsky et al,
2010). In two studies, the allocation was not described as randomized, but the group of children
in the SST treatment group was compared to another group of children in a wait-list, no-
treatment control group (Antshel & Remer, 2003; Frankel et al., 1997). In the next subsection,
the between-group design studies are described in more detail.
The 13 interventions are described here in terms of their aims, in the following order. First, the
two SST interventions that evaluated SST as a stand-alone treatment (i.e., with no concurrent
9 Pfiffner and McBurnett (1997) compared three groups of children, one receiving SST as stand-alone treatment, one receiving SST with concurrent parent treatment and teacher consultation, and a wait-list no-treatment control group. Although this study did evaluate an SST intervention as a stand-alone treatment it will be described in the section of the SST interventions that were offered with concurrent parent treatment and teacher consultation to reflect that this study had two types of SST being evaluated.
10 Although originally this study used a between-group design, only the data for the treatment group of children with ADHD were extracted as a within-subject design (n =15).
73
medication, parent treatment, or teacher consultation) are described (Choi & Lee, 2015; Luffi &
Parish-Plass, 2011). This is followed by descriptions of the two studies (Antshel & Remer, 2003;
Frankel et al., 1997) that had concurrent parent treatment. Next are descriptions of the six studies
that had both parent treatment and concurrent teacher consultation (Corkum et al., 2010; Evans et
al., 2011; Molina et al., 2008; Pfiffner & McBurnett, 1997; Pfiffner et al., 2008; Villodas et al.,
2014). Finally the three studies where the efficaciousness of SST was evaluated with concurrent
medication in at least one of the groups of children are described (Abikoff Group, 2004; MTA
Cooperative, 1999; Waxmonsky et al., 2010).
4.3.3.14.3.3.14.3.3.14.3.3.1 SSTSSTSSTSST as a standas a standas a standas a stand----alone treatmentalone treatmentalone treatmentalone treatment
Two SST interventions (Choi & Lee, 2015; Luffi & Parish-Plass, 2011) evaluated SST as a
stand-alone treatment. Luffi and Parish-Plass evaluated the efficaciousness of a sports-based SST
group therapy in improving the general functioning of boys with ADHD and boys with other
behavioural problems. The investigators aimed at improving social problems as well as reducing
internalizing and externalizing symptoms. For the purpose of this systematic review, only the
boys with ADHD were included, as a single-group design.
In an RCT, Choi and Lee (2015) compared three groups of children, one receiving SST (n = 25),
with one receiving an emotion management training SST (EMT-SST) intervention (n = 23), and
a wait-list, no-treatment control group (n = 24). The SST component in the two treatment groups
in Choi and Lee was an adaptation of Pfiffner and McBurnett’s (1997) child SST program. The
authors provided limited information about the EMT-SST intervention, but they referred to a
manual (Choi, 2011). The intervention is described as consisting of four major components in
addition to SST: (a) identification and labelling of emotion words, (b) emotion recognition and
expression, (c) emotion understanding, and (d) emotion regulation in social situations. Choi and
Lee hypothesized that the EMT-SST intervention would be associated with improvements in
emotion recognition and emotion expression, which they posit contribute to social skill
development, in comparison to the standard SST intervention.
74
4.3.3.24.3.3.24.3.3.24.3.3.2 SSTSSTSSTSST plus concurrent parent treatmentplus concurrent parent treatmentplus concurrent parent treatmentplus concurrent parent treatment
Two intervention studies evaluated SST with concurrent parent treatment to enhance
generalization of the social skills taught to children (Antshel & Remer, 2003; Frankel et al.,
1997). Antshel and Remer compared a group of children receiving an adaptation of Pfiffner &
McBurnett’s (1997) Child Social Skills Training Program (n = 80) with a wait-list, no-treatment
control group (n = 40). The investigators hypothesized that children in the SST group would
improve in their social behaviour. Frankel et al. (1997) also evaluated an SST intervention with
concurrent parent treatment. In this case, the investigators compared four groups of children, two
comprising children with ADHD and two without. For the purpose of this dissertation, only the
two groups of children with ADHD were included. Frankel et al. (1997) compared children
receiving a newly developed SST program (n = 35) with children in a wait-list, no-treatment
control group (n = 12), with the aim of improving children’s social skills.
4.3.3.34.3.3.34.3.3.34.3.3.3 SSTSSTSSTSST plus concurrent parent treatmentplus concurrent parent treatmentplus concurrent parent treatmentplus concurrent parent treatment and teacher consultationand teacher consultationand teacher consultationand teacher consultation
Six of the 13 SST interventions evaluated SST interventions with concurrent parent treatment
and teacher consultation (Corkum et al., 2010; Evans et al., 2011; Molina et al., 2008; Pfiffner
and McBurnett, 1997; Pfiffner et al., 2007; Villodas et al., 2014). Two of these were single-
group designs (Corkum et al., 2010; Villodas et al., 2014) and are described first. Corkum et al.
evaluated the efficaciousness of Working Together Building Children’s Social Skills Through
Folk Literature, a program designed to improve children’s social skills. It involved parents and
teachers to help reinforce and generalize the skills taught across contexts. Villodas et al.
evaluated the efficaciousness of Collaborative Life Skills, a program that included an adaptation
of the Pfiffner and McBrunett’s (1997) Child Social Skills Training Program. Additionally,
parents concurrently received behavioural parent training, and teachers received behavioural
consultation training. The Collaborative Life Skills Program’s aims were to improve a variety of
social and behavioural outcomes including core ADHD symptoms, ODD symptoms, behaviour
problems (a combination of externalizing and internalizing symptoms), and peer and parent-child
relationships.
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The remaining four of the six SST studies that evaluated SST with concurrent parent treatment
and teacher consultation had a between-group design (Evans et al., 2011; Molina et al., 2008;
Pfiffner & McBurnett, 1997; Pfiffner et al., 2007). In an RCT, Evans et al. evaluated the
efficaciousness of the Challenging Horizons Program with concurrent parent and child meetings
with the therapist, which incorporated motivational interviewing techniques to help parents
pursue services and support family coping and solving problems together. The treatment group
(n = 31) was compared with a group of children receiving care as usual in the community (n =
18). The treatment had the aims of improving social skills and academic functioning (the latter
was not within the scope of this review).
In another RCT with a smaller sample, Molina et al. (2008) also evaluated the efficaciousness of
the Challenging Horizons Program, incorporating a parent component similar to Evans et al.
(2011). The treatment group (n = 12) was also compared to a group of children receiving care as
usual in the community (n = 11). Molina and colleagues aimed at testing the feasibility of
conducting an after-school treatment program; they did not hypothesize that the program would
be particularly beneficial for any given outcome. The outcomes of interest they measured were
self-reported aggression and emotional symptoms, and parent-reported externalizing and
internalizing symptoms. Interestingly, despite Challenging Horizons being a program aimed at
improving social and academic skills, the investigators did not measure any social skills or peer
relationship outcomes.
Pfiffner et al. (2007) evaluated the Child Life and Attention Skills (CLAS) program, specifically
designed for ADHD-Inattentive Type, with the aims of improving inattention and social skills11
(as well as other outcomes not in the scope of this review, including organizational skills and
other cognitive variables). In an RCT design, a group of children receiving CLAS and concurrent
parent treatment and teacher consultation (n = 36) were compared with a group of children
receiving care as usual in the community (n = 33). In another RCT with a small sample, Pfiffner
& McBurnett (1997) compared a group of children receiving SST as a stand-alone treatment (n =
11 Given that the study employed parent-teacher composites, only one outcome, self-reported social skills knowledge, was extracted.
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9), with a group of children receiving SST and concurrent parent treatment and teacher
consultation (n = 9), and with a wait-list, no-treatment control group (n = 9). The SST
intervention evaluated was the Child Social Skills Training Program, aimed at improving
children’s social skills knowledge and social behaviour. In the group with concurrent parent
treatment and teacher consultation, parents were trained to support their children’s generalization
of skills to everyday use. The investigators hypothesized that this group of children with
concurrent parent treatment would improve on skill knowledge and ratings of social behaviour
compared to the other groups of children.
4.3.3.44.3.3.44.3.3.44.3.3.4 SST plus concurrent medication and SST plus concurrent medication and SST plus concurrent medication and SST plus concurrent medication and parent treatment and teacher consultationparent treatment and teacher consultationparent treatment and teacher consultationparent treatment and teacher consultation
Finally, three of the 13 SST interventions evaluated a group of children receiving concurrent
SST and medications along with parent treatment and teacher consultation, in an RCT design
(Abikoff Group, 2004; MTA Cooperative, 1999; Waxmonsky et al., 2010). The Abikoff Group
compared three groups of children: children receiving concurrent SST and medications and
parent treatment and teacher consultation (n = 34); children receiving medication alone (n = 34):
and children receiving medication and an equivalent control psychosocial treatment without the
core therapeutic components (i.e., attention control intervention; n = 35). The SST treatment
evaluated was an adaptation of the Getting Along with Others: Teaching Social Effectiveness to
Children Program (Jackson et al., 1983) and the ACCEPTS Program (Walker et al., 1983). The
goals of the SST were to improve children’s social and emotional coping skills (and other
outcomes, including academic skills, that were not the scope of this review). The Abikoff Group
hypothesized that the group of children receiving SST plus concurrent medication and
multimodal psychological treatment (i.e., parent treatment and teacher consultation) would
improve more than the group of children treated with medication alone.
The MTA Cooperative (1999) study compared four groups of children: children receiving
concurrent SST and medications, parent treatment, and teacher consultation (n = 145); children
receiving concurrent SST and parent treatment and teacher consultation (n = 144); children
receiving medication only (n = 144); and children receiving care as usual in the community (n =
146). The SST component evaluated was the Summer Treatment Program (Pelham et al., 1996),
77
an adaptation of Pelham’s Summer Treatment Program (1998, 2010), and was aimed at
improving children’s social and academic skills.
Waxmonsky et al. (2010) compared a group of children receiving SST concurrent with
medication, parent treatment and teacher consultation (n = 29) with a group of children receiving
medication alone (n = 27). The investigators hypothesized that combining medication
(atomoxetine) with a multimodal psychosocial treatment (i.e., behavioural parent training and
teacher consultation) would improve the children’s academic and social skills. The primary
outcomes of this study consisted of children’s classroom observations, which were not included
in this study. The study also measured internalizing and externalizing symptoms, peer
relationship impairment, parent-child relationship impairment, social skills, and core ADHD
symptoms of inattention, and hyperactivity/impulsivity.
4.3.3.54.3.3.54.3.3.54.3.3.5 Summary of Summary of Summary of Summary of SSTSSTSSTSST intervention studiesintervention studiesintervention studiesintervention studies
In terms of EPHPP study quality, five of the 17 studies describing 13 SST interventions received
a global rating in the strong range (Abikoff Group, 200412; Evans et al. 2011; Molina et al.,
2008; MTA Cooperative, 1999; Pfiffner & McBurnett 1997) and seven received a rating in the
moderate range (Antshel & Remer 2003; Choi & Lee, 2015; Frankel et al., 1997; Lufi & Parish-
Plass, 2011; Pfiffner et al., 2007; Villodas et al., 2014; Waxmonsky et al., 2010). Only one of the
13 SST intervention studies (Corkum et al., 2010) received a global weak rating, due to
inadequate blinding and an underreporting of their recruitment procedures that precluded any
calculation of participation consent rate. In terms of blinding, the majority of the SST
intervention studies (k = 9) did not describe any blinding procedures. That is, therapists who
carried out the intervention as well as parents or parents and teachers, who completed the
standardized rating scales on children’s functioning, were aware of the children’s treatment. This
was mostly due to parents and teachers being concurrently involved in psychosocial treatment
12 Abikoff Group (2004) five SST studies that correspond to the same sample of participants, four report results on different outcomes (Abikoff et al., 2004a, 2004b; Hechtman et al., 2004a, 2004b) and one describes the sample characteristics (Klein et al., 2004).
78
and teacher consultation, respectively. Even in Choi and Lee (2015) where parents13 were not
involved in treatment, blinding was not possible because parents of children in the wait-list no-
treatment control groups were informed that their children would be receiving treatment after the
first round of treatment. There were four studies where one or more of the blinding conditions
(described in chapter 3) were met or partially met. In the Pfiffner et al. (2007) study, interviewers
who administered the Test of Life Social and Skills Knowledge (TOSLK; Pfiffner & Mikami,
200514) were blind to the children’s group assignment; however, parents and teachers were not
blind to treatment as they were involved in psychosocial treatment and consultation. In the MTA
Cooperative (1999) study, the therapists administering SST treatment to two of the four groups
were initially blinded to medication status while medication doses were being calibrated. After
agreement on best dose, the blinding was broken. In the Waxmonsky et al. (2010) study,
although parents and teachers who completed measures reporting on the children’s behaviours
were aware of the children’s treatment, the research assistants who conducted the classroom
observations were blinded to treatment status; the classroom observation measure, however, was
not included in the current systematic review and meta-analysis. In the Abikoff Group (2004)
study, parents and teachers were unaware of the medication status (medication versus placebo) of
the children in the SST and concurrent medication group, but were aware of the children’s
psychosocial treatment due to their own involvement in the treatment.
Overall, the attrition rates reported for the SST intervention studies were low, with 80% to 100%
of participants completing all studies; three studies had no attrition (Antshel & Remer 2003;
Evans et al. 2011; Pfiffner & McBurnett 1997).
Seventeen studies evaluating the efficaciousness of 13 SST interventions were included in this
systematic review (Abikoff Group, 2004; Antshel & Remer, 2003; Choi & Lee, 2015; Corkum et
al., 2010; Evans et al., 2011; Frankel et al., 1997; Lufi & Parish-Plass, 2011; Molina et al., 2008;
MTA Cooperative, 1999; Pfiffner & McBurnett, 1997; Pfiffner et al., 2007; Villodas et al., 2014;
13 Teachers were not involved in concurrent consultation and did not complete standardized instruments in respect to the children’s functioning.
14 The TOSLK is a measure of social skills knowledge administered individually to each child at pre- and post-test and included questions pertaining to the skills taught in SST.
79
Waxmonsky et al., 2010). In all the studies except two (Choi & Lee, 2015; Lufi & Parish-Plass,
2011), parents received treatment simultaneously. Additionally, six studies evaluated SST
interventions with concurrent teacher consultation (i.e., not parent treatment only; Corkum et al.,
2010; Evans et al., 2011; Molina et al., 2008; Pfiffner & McBurnett, 1997; Pfiffner et al., 2007;
Villodas et al., 2014). Three studies evaluated SST concurrent with medications, parent treatment
and teacher consultation (Abikoff Group, 2004; MTA Cooperative, 1999; Waxmonsky et al.,
2010).
The SST treatment aims varied greatly according to the study. Most of the studies aimed at
improving children’s social skills. When offered as a stand-alone treatment, the aim was to
improve social problems and internalizing and externalizing symptoms (Luffi & Parish-Plass,
2011). When offered as a stand-alone treatment and incorporating an EMT component, the study
aimed at improving emotion recognition and emotion expression15 (Choi & Lee, 2015). When
SST was offered with concurrent parent treatment (Antshel & Remer, 2003; Frankel et al., 1997),
or with concurrent parent treatment and teacher consultation (Corkum et al., 2010; Evans et al.,
2011; Pfiffner et al., 2007; Pfiffner & McBurnett, 1997; Villodas et al., 2014), the aim was to
enhance the generalization of the social skills taught in the children’s group. Pfiffner et al.
(2007), in addition to aiming at improving social skills, had the goal of reducing inattention
symptoms. Villodas et al. (2014) aimed at improving the core ADHD symptoms of inattention
and hyperactivity/impulsivity, ODD symptoms, behaviour problems (the combination of
externalizing and internalizing symptoms), and peer and parent-child relationships. Last, and less
precise in their treatment goals, Molina et al. (2008) offered SST with concurrent parent
treatment and teacher consultation in order to test the feasibility of conducting an after-school
treatment program. This study evaluated the same program as Evans et al. (2011), the
Challenging Horizons Program (using a different sample), that is described as having the goal of
improving social (and academic) skills. Molina et al., however, did not measure any social skills
or peer relationship outcome. When SST was offered with concurrent SST and medications, and
15 Which the investigators pose contribute to social skill development.
80
parent treatment, and teacher consultation, the aims included improving social skills16 (Abikoff
Group, 2004; MTA Cooperative, 1999; Waxmonsky et al., 2010). Additionally, one study also
aimed at improving emotional coping skills (Abikoff Group, 2004).
4.3.4 4.3.4 4.3.4 4.3.4 Summary of Study DescriptionsSummary of Study DescriptionsSummary of Study DescriptionsSummary of Study Descriptions
In sum, this systematic review included a total of 26 studies (22 interventions provided to 22
samples) evaluating the efficaciousness of a child-focused psychosocial intervention. No study
evaluating the efficaciousness of a family therapy intervention met inclusion criteria. Two
studies evaluated individual CBT, one as a stand-alone treatment with concurrent parent
treatment (Antshel et al., 2014) and one with concurrent medication (Brown et al., 1986). Two
studies evaluated a group CBT intervention as part of a multimodal treatment with concurrent
parent treatment and teacher consultation (Bloomquist et al. 1991), and concurrent medication
(van der Oord et al., 2007). Of the five studies that evaluated mindfulness training interventions
(Harrison et al., 2004; Haydicky et al., 2012, 2015; Jensen & Kenny, 2004; van de Weijer-
Bergsma et al., 2012), only one (Haydicky et al., 2012) did not have a concurrent parent
treatment component. Seventeen studies reported the results of 13 SST interventions. Five were
publications of different outcomes of the same sample (Abikoff Group, 2004). Of the 13 SST
interventions, two evaluated SST as a stand-alone treatment (Choi & Lee, 2015; Luffi & Parish-
Plass, 2011), two evaluated SST with concurrent parent treatment (Antshel & Remer, 2003;
Frankel et al., 1997), six evaluated SST interventions with concurrent parent treatment and
teacher consultation (Corkum et al., 2010; Evans et al., 2011; Molina et al., 2008; Pfiffner &
McBurnett, 1997; Pfiffner et al., 2007; Villodas et al., 2014), and three evaluated concurrent SST
and medications, and parent treatment and teacher consultation (Abikoff Group, 2004; MTA
Cooperative, 1999; Waxmonsky et al., 2010).
In regards to differential treatment aims, the CBT interventions sought to decrease core
inattention, hyperactivity, and other social and family outcome domains. Additionally, when
16 As well as academic skills that were not the scope of this review. The study also measured internalizing and externalizing symptoms, peer relationship imparment, parent-child relationship impairment, and core ADHD symptoms of inattention, and hyperactivity/impulsivity.
81
combined with medication, the goal of individual CBT was to improve the maintenance of
treatment gains (Brown et al., 1986). When combined with medication, parent treatment and
teacher consultation, the goal of group CBT was to outperform the children in medication-only
groups in regards to core ADHD and other associated symptoms and functional impairments,
including anxiety, CD, ODD, and social skills (van der Oord et al., 2007).
Overall, the aim of mindfulness training interventions was to reduce inattention. Most studies
(Harrison et al., 2004; Haydicky et al., 2012, 2015; van de Weijer-Bergsma et al., 2012) also had
the aims of reducing internalizing and externalizing symptoms. Harrison et al. (2004) had the
additional goal of improving hyperactivity and impulsivity symptoms. Jensen and Kenny (2004)
had the primary aim of improving inattention, hyperactivity, and impulsivity, but also measured
social problems, and internalizing and externalizing symptoms. Last, two studies had the primary
aim of reducing inattention, internalizing and externalizing symptoms and had the additional
secondary goal of improving the quality of peer (Haydicky et al., 2012, 2015) and parent-child
(Haydicky et al., 2015) relationships.
The aim of all the SST interventions, with the exception of one (Molina et al., 2008), was to
improve children’s social skills Additionally, two studies (Abikoff Group, 2004; Choi & Lee,
2015) sought to improve emotional coping skills. The goal of another study was to reduce
internalizing and externalizing symptoms (Luffi & Parish-Plass, 2011). Yet another study had the
goal of reducing inattention symptoms (Pfiffner et al., 2007). The aims of one ambitious study
were to reduce ADHD symptoms of inattention and hyperactivity/impulsivity, ODD symptoms,
and behaviour problems,17 and improve peer and parent-child relationships (Villodas et al.,
2014). Molina et al. (2008) tested the feasibility of conducting an after-school SST treatment
program. Interestingly, they did not measure any social skills or peer relationships outcome.
In terms of EPHPP study quality, overall, most studies obtained a global rating in the strong (k =
7) or in the moderate (k = 13) range. Only two studies had a global rating of weak, a mindfulness
training study (van de Weijer-Bergsma et al., 2012) and an SST study (Corkum et al., 2010), due
17 The combination of internalizing and externalizing symptoms.
82
to inadequate blinding and an underreporting of their recruitment procedures, which precluded
calculation of participation consent rate. Two of the four CBT studies obtained a strong global
rating (Brown et al., 1986; van der Oord et al., 2007) and two a rating in the moderate range
(Antshel et al., 2014; Bloomquist et al., 1991). No mindfulness training intervention study
obtained a global rating of strong; with the exception of one study, all mindfulness training
intervention studies (Harrison et al., 2004; Haydicky et al., 2012, 2015; Jensen & Kenny, 2004)
obtained a rating in the moderate range. Van de Weijer-Bergsma et al. (2012) obtained a weak
global rating. Of the 13 SST intervention studies, five received a rating in the strong range
(Abikoff Group, 2004; Evans et al. 2011; Molina et al., 2008; MTA Cooperative, 1999; Pfiffner
& McBurnett 1997), seven received a rating in the moderate range (Antshel & Remer 2003; Choi
& Lee, 2015; Frankel et al., 1997; Lufi & Parish-Plass, 2011; Pfiffner et al., 207; Villodas et al.,
2014; Waxmonsky et al., 2010), and one (Corkum et al., 2010) in the weak range. Eight of the 13
SST intervention studies were RCTs, which typically obtain higher global study quality ratings,
in comparison to none of the mindfulness training studies and three CBT studies out of the four
included. In general, when compared to SST intervention studies, a smaller sample size
characterized CBT intervention studies (ranging from N = 33 to 82) and mindfulness training
intervention studies (ranging from N = 10 to 48). Six of the 13 SST intervention studies had
samples between about 50 and 100+ participants. No other salient methodological differences
were observed when comparing the studies.
All of the 26 included studies (describing 22 samples) had a low attrition rate; 80% to 100% of
participants completed all the child-focused psychosocial treatment studies. Two studies
(Bloomquist et al., 1991; Harrison et al., 2004) had a slightly higher rate of participant drop-out;
60% to 79% of participants completed each study. Bloomquist et al. evaluated a 10-week group
CBT intervention and Harrison et al. evaluated a six-week mindfulness training intervention. In
terms of treatment length or demands, it was noted that there was nothing particularly different in
these studies compared to other studies offering similar interventions. Similarly, when examining
83
the reasons for attrition18 of these studies, which were very detailed, there was no indication that
either treatment posed more complications than other similar treatments.
Part B: Systematic Review and MetaPart B: Systematic Review and MetaPart B: Systematic Review and MetaPart B: Systematic Review and Meta----Analyses ResultsAnalyses ResultsAnalyses ResultsAnalyses Results
In this next section I describe the results of the individual studies divided by intervention type
(CBT, mindfulness training, and SST), outcome (e.g., internalizing and externalizing symptoms
and behaviours, social skills, peer relationships, family functioning, and core ADHD symptoms),
and study design (i.e., within-subject and between-group design). As previously mentioned, the
rationale for this presentation of the data is to be able to better understand what each child-
focused psychosocial intervention type has to offer for children and adolescents with ADHD in
regards to each of the specific outcomes. Whenever available, I end each subsection with the
statistical results of the meta-analyses.
Meta-analyses may be applied to as few as two studies (Lipsey & Wilson, 2001); however, with
very few studies meta-analytic results can be very unstable (Rosenthal, 1995). Given that all the
meta-analyses used in this systematic review comprised only a few studies each (k ≤ 5), only a
few outcomes were comparable in each intervention; none in individual CBT, one in group CBT,
four in mindfulness training, and 21 in social skills training. Thus, a descriptive approach to
understanding the studies’ findings will also be incorporated.
As shown on Tables 5 (page 129) and 6 (page 132), the child-focused psychosocial interventions
varied with regard to type of psychosocial approach used, mode of delivery, treatment setting,
treatment frequency and length, additional treatment components, and outcomes measured.
The guidelines suggested by Cohen (1988) in which an effect size of 0.2 is a small effect, an
effect size of 0.5 is a medium effect, and an effect size of 0.8 is a large effect, have been widely
adopted in the interpretation of effect sizes (e.g., Cohen’s d, Hedges g).
18 Reasons for attrition included parents failing to comply with behavioural parent training, participants not being able to wait in the wait-list no-treatment control group, participants opting to take medications instead (Bloomquist et al., 1991), and families travelling long distances to the clinic where the treatment took place (Harrison et al., 2004).
84
In the following section the results of the interventions are summarized according to the main
research objectives: The first objective of this systematic review and meta-analysis is to
investigate the degree to which child-focused psychosocial interventions (CBT, SST,
mindfulness training, and family therapy) are efficacious for reducing internalizing behaviours
and disorders (e.g., anxiety, depression), externalizing behaviours and disorders (e.g., aggression,
rule-breaking, ODD, CD), and improving social skills, peer relationships, and family functioning
(e.g., attachment, number and intensity of conflicts), as these outcomes reflect the social
impairment associated with ADHD. Although studies solely evaluating core ADHD symptom
outcomes were not eligible for inclusion in the review, when provided in an eligible study, data
for core ADHD symptoms was extracted and analyzed.
The second objective is to determine whether the addition of concurrent treatment components
(medication, parent treatment or teacher consultation) to child-focused psychosocial
interventions affects treatment outcomes.
The third objective is to identify the potential variables that may moderate treatment outcome
and how such variables might interact to influence behaviour change in children and adolescents
receiving treatment. The literature points to a number of variables that might influence treatment
outcome including children’s characteristics (children’s age, gender, subtype of ADHD,
comorbidity with other disorders), intervention characteristics (intervention type, frequency and
duration of intervention), study characteristics (publication type, year of publication, country of
study, and quality of study), and outcome measure characteristics (standardized self, parent, or
teacher report measures).
4.44.44.44.4 Cognitive Behavioural Treatment InterventionsCognitive Behavioural Treatment InterventionsCognitive Behavioural Treatment InterventionsCognitive Behavioural Treatment Interventions
As shown in Table 3 (page 116), four studies were included in the systematic review that
evaluated CBT interventions. The results of these CBT studies, two of which (Antshel et al.,
2014; Brown et al., 1986) involved individual treatment, and two that involved group treatment
(Bloomquist et al., 1991; van der Oord et al., 2007) are presented here.
85
4.4.14.4.14.4.14.4.1 Individual Individual Individual Individual Cognitive Behavioural TherapyCognitive Behavioural TherapyCognitive Behavioural TherapyCognitive Behavioural Therapy
Antshel et al. (2014) and Brown et al. (1986) evaluated the efficaciousness of individual CBT
therapy, Antshel et al. with concurrent parent treatment in a sample of 14- to 18-year old
adolescents and Brown et al. with concurrent medication in a sample of 5- to 13-year old
children. The results of these studies are shown in Table 6 (page 132). It is important to note that
despite the fact that the Antshel et al. study did not incorporate medication as part of the
treatment, it was noted that 100% of their study sample also participated in concurrent
pharmacotherapy. The results of the two individual CBT intervention studies are presented next,
organized by outcome domain (internalizing symptoms and behaviours, externalizing symptoms
and behaviours, social skills and peer relationships, family functioning, and core ADHD
symptoms). It was not possible ot conduct meta-analyses because the outcomes measured by the
included studies were not sufficiently comparable.
4.4.1.14.4.1.14.4.1.14.4.1.1 Internalizing symptoms and behavioursInternalizing symptoms and behavioursInternalizing symptoms and behavioursInternalizing symptoms and behaviours
As shown in Table 6 (page 132), Antshel et al. (2014) reported medium effects for parent-
reported internalizing behaviours. Small effects were found for teacher-reported internalizing
behaviours, self-reported internalizing behaviours, and emotional symptoms. These were
measured by an index from the BASC-2 consisting of three scales: anxiety, depression, and
social stress, where high scores represent significant emotional distress. Brown et al. (1986) did
not measure these outcomes.
4.4.1.24.4.1.24.4.1.24.4.1.2 Externalizing symptoms and behavioursExternalizing symptoms and behavioursExternalizing symptoms and behavioursExternalizing symptoms and behaviours
Only Antshel et al. (2014) reported large effects for parent-reported externalizing behaviours and
medium effects for teacher-reported externalizing. In contrast the Brown (1986) study found no
significant reduction of teacher-reported ODD symptoms.
4.4.1.34.4.1.34.4.1.34.4.1.3 Social sSocial sSocial sSocial skills, kills, kills, kills, peer relationshipspeer relationshipspeer relationshipspeer relationships, and family functioning, and family functioning, and family functioning, and family functioning
Antshel et al. (2014) reported small effects for teacher-reported peer relations. The Brown (1986)
study found no significant improvement in teacher-reported self-control and social skills. As
86
shown in Table 6 (page 132), Antshel et al. (2014) reported large effects for parent-reported
family relations, medium effects for parent-reported parent-child relations, and small and
insignificant effects for parent-reported sibling relations. Brown et al. (1986) did not measure
these outcomes.
4.4.1.44.4.1.44.4.1.44.4.1.4 Core ADHD symptoms Core ADHD symptoms Core ADHD symptoms Core ADHD symptoms
Antshel et al. (2014) reported large effects for parent- and teacher-reported inattention. Medium
effects were found for parent- and teacher-reported hyperactivity and self-reported inattention,
and small and insignificant effects for self-reported hyperactivity. In contrast, the Brown et al.
(1986) study found no significant decrease in parent-reported hyperactivity, or in teacher-
reported inattention, hyperactivity, or impulsivity.
4.4.24.4.24.4.24.4.2 Group Group Group Group Cognitive Behavioural TherapyCognitive Behavioural TherapyCognitive Behavioural TherapyCognitive Behavioural Therapy
Two of the 26 studies evaluated the efficaciousness of group CBT treatment (Bloomquist et al.,
1991; van der Oord et al., 2007) for children with ADHD. Both studies had an RCT study design
and samples of children between the ages of 5 and 13. The results of the two group CBT
intervention studies are presented next, organized by outcome domain (internalizing symptoms
and behaviours, externalizing symptoms and behaviours, social skills, peer relationships, family
functioning, and core ADHD symptoms; Table 6, page 132). Whenever available, the results of
meta-analyses will be shown at the end of each section.
4.4.2.14.4.2.14.4.2.14.4.2.1 Internalizing symptoms and behavioursInternalizing symptoms and behavioursInternalizing symptoms and behavioursInternalizing symptoms and behaviours
Van der Oord et al. (2007) reported large time effects for parent-, teacher-, and self-reported
anxiety, but no significant group by time effects. The children in group CBT and concurrent
medication and parent treatment did not differ from the children receiving only medication. This
outcome domain was not measured in the Bloomquist et al. (1991) study.
4.4.2.24.4.2.24.4.2.24.4.2.2 Externalizing symptoms and behavioursExternalizing symptoms and behavioursExternalizing symptoms and behavioursExternalizing symptoms and behaviours
Bloomquist et al. (1991) reported no reduction of teacher-reported CD or ODD behaviours. The
van der Oord et al. (2007) study found large time effects for parent- and teacher-reported CD and
87
ODD behaviours, but no significant group by time effects on either parent or teacher reports,
implying that the CBT component did not have an additive value to medication management.
Meta-analyses: The two CBT group intervention studies, with a between-group design,
(Bloomquist et al., 1991; van der Oord et al., 2007), (total N = 69, control n = 34, intervention n
= 35) were sufficiently comparable based on teacher-reported CD symptoms to be combined in a
meta-analysis. As shown in Table 7 (page 139), the combined effect size was small (g = 0.07,
95% CI = -0.41 to 0.54), I2 = 0%; although in the direction favouring the treatment group, it was
not statistically significant.
4.4.2.34.4.2.34.4.2.34.4.2.3 Social skills, Social skills, Social skills, Social skills, peer relationshipspeer relationshipspeer relationshipspeer relationships, and family functioning, and family functioning, and family functioning, and family functioning
In the Bloomquist et al. (1991) study the CBT group showed no improvement in teacher-
reported, peer-preferred social behaviour (peer values and relations in social situations)19 and
social competence, in comparison to the teacher consultation group or the wait-list, no-treatment
control group. In the van der Oord et al. (2007) study, although there were large time effects for
parent- and teacher-reported social skills in total, there were no significant group by time effects
on either parent or teacher reports, implying that the group CBT component did not have an
additive value to medication. Family functioning was not measured in the Bloomquist et al.
(1991) or the van der Oord et al. (2007) studies.
4.4.2.44.4.2.44.4.2.44.4.2.4 Core ADHD symptoms Core ADHD symptoms Core ADHD symptoms Core ADHD symptoms
No improvement was reported in this outcome domain for group CBT. In the Bloomquist et al.
(1991) study the CBT group showed no reductions of teacher-reported core ADHD symptoms of
inattention, hyperactivity, and impulsivity, in comparison to a teacher consultation group or a
wait-list, no-treatment control group. Van der Oord et al. (2007) compared children receiving
group CBT treatment with concurrent medication, parent treatment and teacher consultation with
19 As measured by the Walker-McConnell Scale of Social Competence and School Adjustment (Walker & McConnell, 1988), a checklist that samples behaviour and social and academic competence domains according to three scales: teacher-preferred social behaviour, peer-preferred social behaviour, and school adjustment. The peer-preferred social behaviour scale has 17 items that address peer values and relations in social situations. Items include "Invites peers to play or share activities" and "Compromises when the situation calls for it."
88
children who received medication alone. Although there were large time effects for parent- and
teacher-reported ADHD symptoms,20 there were no significant group by time effects on either
parent or teacher reports, implying that the CBT component did not have an additive value to
medication.
4.4.34.4.34.4.34.4.3 Potential Potential Potential Potential Variables That May Moderate Variables That May Moderate Variables That May Moderate Variables That May Moderate Response to Response to Response to Response to Cognitive Behavioural Cognitive Behavioural Cognitive Behavioural Cognitive Behavioural
Therapy Therapy Therapy Therapy InterventioInterventioInterventioInterventionsnsnsns
Potential variables that may moderate the response to CBT treatment are explored in a
descriptive manner. As previously mentioned, to be able to conduct moderator analyses
(subgroup for categorical variables and meta-regressions for the continuous variables), two
conditions need to be met: there has to be sufficient sample of studies to be subgrouped and
sufficient variability in the potential moderators. Because the one meta-analysis performed
involving CBT intervention was conducted in a sample of two studies (for teacher-reported ODD
symptoms), the sample was too small to be further analyzed by investigating moderator variables
(Borenstein et al., 2011; Lipsey & Wilson, 2001). Additionally, Cochrane guidelines (Ryan,
2014) indicate that heterogeneity between 0% to 40% is low, suggesting that it is not appropriate
to investigate potential moderator variables to explain the variability. As described in chapter 2,
comorbidity with anxiety disorder and ODD are indicated in the literature as potential
moderators of the response to psychosocial treatment in general (Jensen et al., 2001), including
CBT. Additionally, child age is indicated as potential moderator of efficaciousness of CBT
(Knouse, 2015).
4.4.3.14.4.3.14.4.3.14.4.3.1 AAAAgegegege
Some investigators have argued that response to CBT may be age-related (Knouse, 2015; Toplak
et al., 2008). According to this argument, older children and adults have sufficient
neuropsychological development, particularly of their executive functions, to benefit from CBT.
The sample with 14- to 18-year old adolescent participants in Antshel et al. (2014) had lower
20 Calculated ADHD composite from the hyperactivity/impulsivity and inattention subscales of the Disruptive Behaviour Disorders Rating Scale (Pelham et al., 1992).
89
levels of internalizing and externalizing behaviours, and improved peer and family functioning
post-intervention than pre-intervention. These gains were not found in the other three CBT
studies with samples with between 5- and 13-year old children (Bloomquist et al., 1991; Brown
et al., 1986; van der Oord et al., 2007). It is therefore possible that the age of the children
participants played a role in treatment response.
4.4.3.24.4.3.24.4.3.24.4.3.2 Comorbidity witComorbidity witComorbidity witComorbidity with h h h other dother dother dother disordersisordersisordersisorders
The literature suggests that children with ADHD and comorbid anxiety may be more responsive
to psychosocial treatment in general than children with ADHD alone (Jensen et al., 2001; Schatz
& Rostain, 2006). As shown in Table 4 (page 124), of the four studies included in the systematic
review that evaluated CBT interventions (Antshel et al., 2014; Bloomquist et al., 1991; Brown et
al., 1986; van der Oord et al., 2007), only one study reported the rate of comorbidity with anxiety
disorders. Antshel et al. reported that 32.9% of the sample at pretreatment had comorbidity with
anxiety. If we were to consider that one-third of the sample in the Antshel et al. study was
potentially more likely to be responsive to treatment, it would partially explain their positive
findings.
The literature also suggests that children with ADHD and comorbid ODD are more likely than
children with ADHD alone to have positive bias; that is, they are more likely to overestimate
their scholastic, social, athletic, and behavioural competence (Hoza et al., 2004). Because of
positive bias, the subgroup of children with ADHD and ODD might be less motivated to change
and might be resistant to psychological treatment (Mikami, Calhoun, & Abikoff, 2010). Antshel
et al. (2014) reported that almost half of their sample (45.1%) had comorbid ODD.
Similar to the Antshel et al. study, the van der Oord et al. (2007) study reported a high
comorbidity with ODD in their sample (46%). Bloomquist et al. (1991) reported a comorbidity
with ODD in 35% of their sample; Brown et al. (1986) did not report proportion of children with
ODD (only reporting the comorbidity with CD of 16%). Three of the four CBT treatment studies
(Bloomquist et al., 1991; Brown et al., 1986; van der Oord et al., 2007) did not report on
potential moderators of treatment response. Only one study (Antshel et al., 2014) reported that in
their sample, adolescents with ADHD and comorbid ODD were rated by their parents as
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benefiting less from the individual CBT intervention, and adolescents with ADHD and anxiety as
well as adolescents with ADHD and depression improved more than the adolescents with ADHD
only.
In terms of a LD diagnosis, only one of the CBT studies reported the proportion of children with
comorbid LD, which was 6.1% in the Antshel et al. (2014) study. However, no subgroup
analyses were conducted, and the investigators only hypothesized that it is possible that the
learning difficulties of some of the children in the sample might have interfered in their learning
of the intervention strategies.
4.4.44.4.44.4.44.4.4 Summary of CBT InterventionsSummary of CBT InterventionsSummary of CBT InterventionsSummary of CBT Interventions
In summary, meta-analytic data, which were only available for two between-group studies that
were sufficiently comparable based on one outcome, indicated that group CBT interventions did
not decrease children’s CD symptoms as reported by teachers. Nonetheless, results of this
systematic review suggest that individual CBT with parent treatment seems to be promising for
decreasing internalizing and externalizing symptoms and behaviours consistent with ODD, and
anxiety, improving parent-child relationships, and reducing the core ADHD symptoms in some
adolescents concurrently on medication (Antshel et al., 2014). Otherwise, none of the studies
showed that individual or group CBT was efficacious. It is therefore important to consider these
conclusions about the utility of individual and group CBT interventions with caution.
4.54.54.54.5 Mindfulness Training InterventionsMindfulness Training InterventionsMindfulness Training InterventionsMindfulness Training Interventions
Of the 26 studies, five described 6- to 20-week long mindfulness training interventions (Harrison
et al., 2004; Haydicky et al., 2012, 2015; Jensen & Kenny; 2004; van de Weijer-Bergsma et al.,
2012). In all these studies, with the exception of Haydicky et al. (2012), parents received a
mindfulness training treatment simultaneously. In the Haydicky et al. (2012) study, parents were
not treatment receivers, but met periodically with their child and the child’s therapist, to be
informed of treatment progress. Only one of the mindfulness training intervention studies
(Jensen & Kenny, 2004) evaluated the intervention with concurrent medication and compared it
to a wait-list control group receiving a concurrent medication and an equivalent psychosocial
91
intervention without the core therapeutic components. The results of the five mindfulness
training intervention studies will be presented next, organized by outcome domain: internalizing
symptoms and behaviours, externalizing symptoms and behaviours, social skills and peer
relationships, family functioning, and core ADHD symptoms. Whenever available, the results of
meta-analyses can be found at the end of each section.
4.5.14.5.14.5.14.5.1 Internalizing Symptoms and BehavioursInternalizing Symptoms and BehavioursInternalizing Symptoms and BehavioursInternalizing Symptoms and Behaviours
As shown in Table 6 (page 132), only one of the five mindfulness training intervention studies
(Jensen & Kenny, 2004) found significant reduction of internalizing symptoms at post-test.
Jensen and Kenny found medium effects for the parent-reported global emotional lability
index,21 reflecting a reduction in mood swings, temper outbursts, and crying fits. Results of other
mindfulness training interventions (van de Weijer-Bergsma et al., 2012) found a nearly
significant (p = .09) reduction in self-reported internalizing at a four-month follow-up.
Meta-analyses: Of the five mindfulness training interventions (Harrison et al., 2004; Haydicky et
al., 2012, 2015; Jensen & Kenny; 2004; van de Weijer-Bergsma et al., 2012), only two within-
subject design studies (Haydicky et al., 2015; van de Weijer-Bergsma et al., 2012) were
sufficiently comparable, based on two outcomes, self- (total N = 28) and parent-reported (total N
= 26) internalizing symptoms, to be combined in a meta-analysis (Table 8, page 140). Self-
reported internalizing symptoms showed a combined medium effect size (g = -0.4, 95% CI = -
0.79 to -0.02), I2 = 0%, indicating that these mindfulness training interventions significantly
reduced children’s self-reported internalizing symptoms. Parent-reported internalizing symptoms
with a combined effect size of -0.09 (95% CI = -0.48 to 0.3), I2 = 0% was not statistically
significant.
21 Index from the CPRS-R:L consisting of symptoms such as irritability, hot temper, low frustration tolerance, and sudden unpredictable shifts towards negative emotions such as anger and sadness.
92
4.5.24.5.24.5.24.5.2 Externalizing Symptoms andExternalizing Symptoms andExternalizing Symptoms andExternalizing Symptoms and BehavioursBehavioursBehavioursBehaviours
As shown in Table 6 (page 132), three of the four mindfulness training studies measuring
externalizing symptoms and behaviours found little to no improvements from pre- to post-test.
Van de Weijer-Bergsma et al. (2012) found no reductions in parent-, teacher-, or self-reported
externalizing behaviours, Haydicky et al. (2012) found no change in self- or parent-reported
externalizing and ODD behaviours, Haydicky et al. (2015) found no reductions in parent-
reported ODD, and adolescents did not report changes in externalizing symptoms during the
intervention. However, Haydicky et al. (2015) reported a medium effect for parent-reported CD
and Jensen and Kenny (2004) found a medium effect in parent- but not teacher- reported ODD
symptoms.
4.5.34.5.34.5.34.5.3 Social Social Social Social Skills, Skills, Skills, Skills, Peer RelationshipsPeer RelationshipsPeer RelationshipsPeer Relationships, and Family Functioning, and Family Functioning, and Family Functioning, and Family Functioning
Two of the three mindfulness training interventions measuring peer relationship outcomes
reported small effects in social problems and peer relationships respectively (Haydicky et al.,
2012, 2015); however, one of them (Jensen & Kenny, 2004) found no improvement in parent-
reported social problems (Table 6, page 132). As shown in Table 6, mindfulness training
interventions findings are inconsistently effective in reducing parent-child conflict. Although
Harrison et al. (2004) reported significant change (no effect sizes provided) at post-test in the
parent-reported quality of the parent-child attachment relationship and significant decrease in
conflict in the parent-child relation, Haydicky et al. (2015) reported no change in self- or parent-
reported family relations or number or intensity of parent-child conflicts.
4.5.44.5.44.5.44.5.4 Core ADHD Symptoms Core ADHD Symptoms Core ADHD Symptoms Core ADHD Symptoms
As shown in Table 6 (page 132), three of the five mindfulness training interventions found
reductions in parent-reported core ADHD symptoms (Harrison et al., 2004; Haydicky et al.,
2015; Jensen & Kenny, 2004). Harrison et al. reported significant change22 in parent-reported
22 The size of the effect was not provided.
93
combined inattentive and hyperactive/impulsive symptoms. Haydicky et al. (2015) found small
effects in parent-reported inattention that were maintained at a 6-week follow-up. Parents did not
report significant change in hyperactivity/impulsivity, and adolescents did not report changes in
either domain. In Jensen and Kenny (2004), where children were concurrently receiving
medication, medium effects in parent-reported global index restless/impulsive (which combines
hyperactivity and impulsivity) and no reduction of parent- or teacher-reported ADHD symptoms
(combined inattention and hyperactivity/impulsivity) were reported. Two of the five mindfulness
training intervention studies (Haydicky et al., 2012; van de Weijer-Bergsma et al., 2012) did not
find any decrease of ADHD symptoms. Haydicky et al. (2012) reported no change in parent- or
teacher-reported ADHD symptoms (combined inattention and hyperactivity/impulsivity
symptoms) and van de Weijer-Bergsma et al. did not report any change in self-, parent- or
teacher-reported inattention.
Another aspect to consider when examining the different mindfulness training study results is
that more than half of the participants were concurrently taking ADHD medications in the
samples of the three studies reporting reductions of ADHD symptoms (Harrison et al., 2004,
61%; Jensen and Kenny, 2004; 85.71%;23 Haydicky et al., 2015, 76.82%). In contrast, only 10%
of the sample in one of the two mindfulness training interventions that did not show reductions
of core ADHD symptoms were concurrently taking ADHD medications (van de Weijer-Bergsma
et al., 2012), or the percentage was not provided (Haydicky et al., 2012).
Meta-analyses: Of the five mindfulness training interventions (Harrison et al., 2004; Haydicky et
al., 2012, 2015; Jensen & Kenny; 2004; van de Weijer-Bergsma et al., 2012), only two within-
subject design studies (Haydicky et al., 2015; van de Weijer-Bergsma et al., 2012) were
sufficiently comparable with regard to ADHD symptoms (Table 8, page 140). Self-reported
inattention (total N = 28), with a combined effect size of -0.16 (95% CI = -0.87 to 0.55), I2 = 0%,
and parent-reported inattention (total N = 27) with combined effect size of -0.18 (95% CI = -0.56
to 0.2), I2 = 0%, were not statistically significant.
23 As reported in the original study. This study had the goal of evaluating the efficaciousness of Mindfulness Training with concurrent medication but for reasons not explained in the original study, two of the participants (or 14.29%) did not received medication during the intervention.
94
4.5.54.5.54.5.54.5.5 Potential Potential Potential Potential Variables That May Moderate Variables That May Moderate Variables That May Moderate Variables That May Moderate Response to Mindfulness Training Response to Mindfulness Training Response to Mindfulness Training Response to Mindfulness Training
Interventions Interventions Interventions Interventions
Quantitative moderator analyses could not be performed due to the limited number of
comparable mindfulness training intervention studies through meta-analyses (two studies in each
meta-analysis) and the low heterogeneity (I-squared = 0) in the four meta-analyses performed
(i.e., for self- and parent-reported inattention and self- and parent-reported internalizing
symptoms). Values on the order of 25%, 50%, and 75% are considered as low, moderate, and
large respectively for I² (I-squared; Higgins et al., 2003). If I² nears zero, as is the case in all the
meta-analyses conducted for mindfulness training interventions, then almost all the observed
variance is spurious. I therefore report the evidence for potential moderators by examining
individual studies.
4.5.5.14.5.5.14.5.5.14.5.5.1 AAAAgegegege
There is some evidence that child age might be a moderator of treatment response to mindfulness
training interventions with regard to peer relations; the two studies reporting reductions in peer
relationships problems (Haydicky et al., 2012, 2015) had older samples than the study (Jensen &
Kenny, 2004) finding no improvement.
4.5.5.24.5.5.24.5.5.24.5.5.2 Comorbidity with other disordersComorbidity with other disordersComorbidity with other disordersComorbidity with other disorders
Three variables are considered potential moderators of treatment response of children with
ADHD to psychosocial interventions in general: comorbidity with anxiety disorders, comorbidity
with ODD, and comorbidity with LD, are explored descriptively in the mindfulness training
intervention studies. Of the five mindfulness training interventions included in this review, three
did not report on their sample comorbidities with anxiety or ODD (Harrison et al., 2004;
Haydicky et al., 2012; van de Weijer-Bergsma et al., 2012). The Haydicky et al. (2012) study
had a sample of adolescents with LD (100%) and a subgroup who also had ADHD-Inattentive
Type, which were included in this review. Two other studies with very small samples reported
comorbidities with ADHD. Jensen and Kenny (2004) reported that 21.4% (or n = 3) of their
sample had comorbid ODD, and 21.4% (or n = 3) of their sample had LD, but did not report on
95
the prevalence of anxiety disorders, and Haydicky et al. (2015) had a sample were parents did
not disclose diagnosis of ODD or CD in spite of the elevated scores on the ODD subscale of the
Conners Parent Rating Scale (Conners, 2008), 67% (or n = 12) reported having an LD and 6%
(or n = 1) reported having a comorbid anxiety disorder. Noe of these studies had samples that
were large enough to conduct subgroup analyses and compare differential effects of treatment for
children with comorbid anxiety, ODD, or LD.
4.5.64.5.64.5.64.5.6 Summary of Mindfulness Training Interventions Summary of Mindfulness Training Interventions Summary of Mindfulness Training Interventions Summary of Mindfulness Training Interventions
In summary, meta-analytic data, which were only available for two within-subject study designs
sufficiently comparable based on four outcomes (self- and parent-reported inattention and
internalizing symptoms) indicated that only self-reported internalizing symptoms were reduced
after the mindfulness training interventions. The systematic review suggests, however, that
mindfulness training may also hold promise in improving the peer relationships of adolescents
(Haydicky, 2012; 2015), parent-child relationships (Harrison et al., 2004), and core ADHD
symptoms (Harrison et al., 2004). Nevertheless, these conclusions should be made with caution,
because they are based on five studies that had small sample sizes and lacked a randomized
control group, which makes it difficult to assess the representativeness and generalizability of
results. Potentially significant intervention effects may also have been masked due to the limited
power in the statistical analyses resulting from small sample sizes.
4.64.64.64.6 Social Skills Training Interventions Social Skills Training Interventions Social Skills Training Interventions Social Skills Training Interventions
As shown in Tables 3 (page 116) and 5 (page 129), of the 26 studies, 17 described 13 SST
interventions. Five publications reported results of different outcomes evaluated in the same
intervention provided to the same sample of participants (Abikoff et al., 2004a, 2004b;
Hechtman et al., 2004a, 2004b; & Klein et al., 2004), and are grouped under the name of the
Abikoff Group (2004). The results of the 13 SST intervention studies are described in order of
increasing complexity. The results of the two SST studies (Choi & Lee, 2015; Luffi & Parish-
Plass, 2011) wherein SST was provided to children as a stand-alone treatment are described first
(Choi & Lee, 2015; Lufi & Parish-Plass, 2011), followed by the 11 studies with concurrent
parent treatment. Of these 11 interventions, two provided SST to children, with parent treatment
96
(Antshel & Remer, 2003; Frankel et al., 1997), six provided SST to children with concurrent
parent treatment and teacher consultation (Corkum et al., 2010; Evans et al., 2011; Molina et al.,
2008; Pfiffner & McBurnett, 1997; Pfiffner et al., 2008; Villodas et al., 2014), three provided
SST to children, some of whom were also in a group that received systematically calibrated
medication, with concurrent parent treatment and teacher consultation (Abikoff Group, 2004;
MTA Cooperative, 1999; Waxmonsky et al., 2010). The results of the 13 SST interventions are
organized by outcome domain - internalizing symptoms and behaviours, externalizing symptoms
and behaviours, social skills and peer relationships, family functioning, and core ADHD
symptoms (see Table 6, page 132). Whenever available, the results of meta-analyses are shown
at the end of each section.
4.6.14.6.14.6.14.6.1 Internalizing Symptoms and BehavioursInternalizing Symptoms and BehavioursInternalizing Symptoms and BehavioursInternalizing Symptoms and Behaviours
As shown in Table 5, of the 13 SST interventions, three provided an SST intervention as a stand-
alone treatment (Choi & Lee, 2015; Lufi & Parish-Plass, 2011; Pfiffner & McBurnett, 1997).
Two of these three studies measured internalizing symptoms and behaviours (Choi & Lee; Lufi
& Parish-Plass); the results vary by informant and outcome measured. Choi and Lee compared a
group of children receiving SST and children receiving an emotion management training (EMT)
type of SST intervention with a wait-list, no-treatment control group. They found that children in
the SST showed greater reductions (large effects) of self-reported anxiety than children receiving
SST-EMT and children in the wait-list no-treatment control group. However, self-reported
depression did not change in either of the SST groups when compared with the wait-list, no-
treatment control group. Using a single-group design, Lufi and Parish-Plass’s (2011) was the
other study that evaluated SST without a concurrent parent treatment component. These authors
found that the SST intervention was associated with self-reports of reduced somatic symptoms
and anxiety, and the latter was sustained at one-year follow-up (no effect sizes provided; see
individual study results in Table 6, page 132). However, the same study found no reduction in
self- or parent-reported internalizing symptoms combining anxiety and depression, or in self- or
parent-reported thought problems or withdrawal, or parent-reported somatic symptoms (Lufi &
Parish, 2011).
97
Of the 10 SST interventions that offered SST with concurrent parent treatment, five measured
internalizing outcomes (Abikoff Group, 2044; Molina et al., 2008; MTA Cooperative, 1999;
Waxmonsky et al., 2010). Molina et al. found medium effects for parent-reported internalizing
symptoms and self-reported emotional symptoms (from the BASC-I; combines social stress,
anxiety, depression, sense of inadequacy, interpersonal relationships, and self-esteem).
Waxmonsky et al. (2010) found medium effects for self-reported depression. However, other
studies found no reductions when measuring self-reported anxiety or teacher-reported
internalizing symptoms (MTA Cooperative, 1999). Waxmonsky et al. found no change in self-
reported suicidal ideation and the Abikoff Group found that self-reported depression decreased
equally over time for the SST and concurrent parent treatment and medication management
group, compared with the medication management only group, suggesting no advantage for the
SST intervention component. In contrast, the MTA Cooperative study (1999)24 used SST
treatment concurrently with parent treatment, teacher consultation, and medications, with
significantly lower medication doses than given in medication management alone. This
combination was found to be superior to medication management or SST and concurrent parent
treatment and teacher consultation but no medication with regard to parent-reported internalizing
symptoms. This suggests that the psychosocial treatment, namely the SST intervention with
parent treatment and teacher consultation, played an important role in allowing for lower
medication doses in the reductions of parent-reported internalizing symptoms.
Meta-analyses: SST interventions were only sufficiently comparable based on two internalizing
symptom outcomes with between-group design: parent and teacher-reported internalizing
symptoms. Four samples25 (Molina et al., 2008; MTA Cooperative Group Meds, 1999; MTA
Cooperative Group, 1999; Pfiffner & McBurnett, 1997) were comparable in respect to parent-
reported internalizing symptoms (total N = 541, control n = 263, intervention n = 278) and three
24 The MTA study compared four conditions: SST with concurrent parent treatment and teacher consultation; SST with concurrent parent treatment, teacher consultation, and medications; medications alone; and community care.
25 As previously mentioned, the two SST intervention groups of the MTA study were entered into meta-analysis separately as they were considered different enough to warrant independent examination. One of the SST interventions was provided with concurrent parent treatment and teacher consultation and was compared to community care as usual, and the other was provided with those same treatment components with the addition of concurrent medication and was compared to medication alone.
98
samples (MTA Cooperative Group Meds, 1999; MTA Cooperative Group, 1999; Pfiffner &
McBurnett, 1997) (total N = 432, control n = 213, intervention n = 219) were comparable in
regards to teacher-reported internalizing symptoms (Table 9, page 141). Parent-reported
internalizing symptoms had a combined effect size of 0.09 (95% CI = -0.08 to 0.26), I2 = 0% and
teacher-reported internalizing symptoms had a combined effect size of 0.09 (95% CI = -0.20 to
0.37), I2 = 0%. Both outcomes were in the direction favouring the treatment group, but were not
statistically significant.
In sum, it appears that, overall, the SST interventions seem to have relatively more success with
self-reports of anxiety, as opposed to anxiety as reported by parents or teachers. Also, it appears
that self-reports of depression or internalizing symptoms, including depression, do not change as
a result of the SST interventions. Meta-analyses comparing the effects of SST interventions with
concurrent parent treatment and teacher consultation on parent- and teacher-reported
internalizing symptoms showed no reductions of either outcome. It would also appear that the
addition of a concurrent parent treatment to the child-focused SST did not make a difference
when it pertained to the reductions of self-reports of anxiety. As seen in some studies (e.g., Choi
& Lee, 2015; Lufi & Parish-Plass, 2011), children in the SST interventions who did not have a
concurrent parent treatment nonetheless reported reductions of their self-reports of anxiety.
4.6.24.6.24.6.24.6.2 Externalizing Symptoms and BehavioursExternalizing Symptoms and BehavioursExternalizing Symptoms and BehavioursExternalizing Symptoms and Behaviours
As shown in Table 5 (page 129) of the 13 SST interventions, three provided an SST intervention
as a stand-alone treatment (Choi & Lee, 2015; Lufi & Parish-Plass, 2011; Pfiffner & McBurnett,
1997). Only one of these studies directly measured externalizing symptoms and behaviours (Lufi
& Parish-Plass). They found that SST was associated with reductions of parent- but not self-
reported aggression, delinquency, and externalizing symptoms (effect sizes not provided).
Pfiffner and McBurnett (1997) used the behaviour problem scale of the Social Skills Rating
Scale (SSRS; Gresham & Elliot, 1998), which combines internalizing and externalizing
symptoms and behaviours. These outcomes (for which raw data were available and entered in the
meta-analyses) as separately reported by parents and teachers are discussed below in the meta-
analyses results section. When conducting their own statistical analyses, Pfiffner and McBurnett
created one composite by combining informants (parents and teachers). As stated in the
99
eligibility criteria of this systematic review, this parent-teacher outcome was not eligible as it
was not comparable with other studies; thus their results will not be discussed here.
Of the 10 SST interventions that offered SST with concurrent parent treatment, six measured
externalizing outcomes (Abikoff Group, 2004; MTA Cooperative, 1999; Molina et al., 2008;
Villodas et al., 2014; Waxmonsky et al. 2010). These six SST interventions were also offered
with concurrent teacher consultation. Villodas et al. (2014), in a single-group design combining
SST with concurrent parent treatment and teacher consultation, reported large effects in parent-
reported behaviour problems, medium effects in teacher-reported behaviour problems, and
medium effects in parent- and teacher-reported ODD (Table 6, page 132). With regards to the
efficaciousness of SST interventions and concurrent parent treatment and teacher consultation in
reducing externalizing behaviours and symptoms as measured in between-group design studies,
findings are inconsistent (MTA Cooperative, 1999; Molina et al., 2008; Waxmonsky et al. 2010).
Waxmonsky et al., who compared children receiving medication alone with children receiving
concurrent SST, medication, parent treatment and teacher consultation, found medium effects in
parent-but not teacher-reported behaviour problems, small effects in teacher-reported ODD, and
medium effects for time but not group for parent-reported ODD. In the latter outcome, the two
groups did not differ in the extent of improvement, implying there was no additive value of the
SST and concurrent parent and teacher interventions over medications on parent-reported ODD.
In contrast, the MTA Cooperative study (1999) found that combined SST with concurrent parent
treatment, teacher consultations, and medications, with significantly lower medication doses than
used in medication management alone, were superior to medication management or SST alone
on parent-reported ODD symptoms. This finding implies that it was not medications alone or
SST with concurrent parent treatment or teacher consultation, but their combination, which
contributed to the decreases in ODD symptoms.
The one outcome in the externalizing domain that no SST intervention study reported any
efficaciousness for was CD behaviours and symptoms, regardless of the informant or study
design (Abikoff Group, 2004; Waxmonsky et al., 2010). Molina et al. (2008) found that self-
reported aggression (combined delinquency and CD behaviours from the Aggression and
Conduct Problems Scale, American Psychiatric Association, 1994) did not change for the SST
with concurrent parent treatment and teacher consultation group; however, the medications-only
100
control group experienced deterioration, suggesting that the SST intervention had a preventive
role. This study also found no change in parent-reported externalizing.
Meta-analyses: SST interventions were sufficiently comparable based on six externalizing
symptom and behavioural outcomes in between-group design studies: parent-reported
externalizing symptoms, ODD symptoms, behavioural problems (combination of internalizing
and externalizing symptoms), and teacher-reported CD symptoms, ODD symptoms, and
behaviour problems. As shown in Table 10 (page 142), two samples (Molina et al., 2008;
Pfiffner & McBurnett, 1997) were comparable in respect to parent-reported externalizing
symptoms (total N = 38, control n = 18, intervention n = 20), three samples26 (MTA Cooperative
Group Meds, 1999; MTA Cooperative Group, 1999; Waxmonsky et al., 2010) (total N = 569,
control n = 278, intervention n = 291) were comparable in regards to parent-reported ODD
symptoms, and three samples (MTA Cooperative Group Meds, 1999; MTA Cooperative Group,
1999; Waxmonsky et al., 2010; see fn. 25) were comparable in regards to teacher-reported ODD
symptoms (total N = 557, control n = 275, intervention n = 282). Two samples (Abikoff et al.,
2004; Waxmonsky et al., 2010) were comparable for teacher-reported CD symptoms (total N =
124, control n = 61 , intervention n = 63), two samples (Pfiffner & McBurnett, 1997;
Waxmonsky et al., 2010) were comparable in regards to parent-reported behaviour problems
(total N = 74, control n = 36 , intervention n = 38), and two samples (Pfiffner & McBurnett,
1997; Waxmonsky et al., 2010) were comparable for teacher-reported behaviour problems (total
N = 74, control n = 36 , intervention n = 38 ).Only parent-reported ODD symptoms had a
statistically significant small combined effect size of 0.19 (95% CI = 0.03 to 0.35), I2 = 0%
favouring the treatment group. In the direction favouring the treatment group, but not statistically
significant, were: parent-reported externalizing symptoms (g = 0.86, 95% CI = -0.31 to 2.02), I2
= 0%, parent-reported behaviour problems (g = 0.92, 95% CI = -0.13 to 1.96), I2 = 0%, teacher-
reported ODD symptoms (g = 0.06, 95% CI = -0.10 to 0.23), I2 = 0%, and teacher-reported
26 As previously mentioned, the two SST intervention groups of the MTA study were entered into meta-analysis separately as they were considered different enough to warrant independent examination. One of the SST interventions was provided with concurrent parent treatment and teacher consultation and was compared to community care as usual, and the other was provided with those same treatment components with the addition of concurrent medication and was compared to medication alone.
101
behaviour problems (g = 0.16, 95% CI = -0.28 to 0.61), I2 = 0%. In the direction favouring the
control group and not statistically significant were teacher-reported CD symptoms (g = 0.00,
95% CI = -0.35 to 0.35), I2 = 0%.
In summary, in terms of the efficaciousness of SST interventions in reducing externalizing
symptoms and behaviours as reported by self, parent, or teacher, the only outcome that meta-
analytic data showed a small combined effect size favouring the SST treatment group (with
concurrent parent treatment and teacher consultation), was parent-reported ODD symptoms.
When examining the systematic review data, findings on the efficaciousness of SST on
externalizing behaviours and symptoms are small, with no SST intervention reporting reductions
of CD behaviours and symptoms regardless of the informant.
4.6.34.6.34.6.34.6.3 Social Skills and Peer RelationshipsSocial Skills and Peer RelationshipsSocial Skills and Peer RelationshipsSocial Skills and Peer Relationships
As shown in Table 6 (page 132), of the 13 SST interventions, three provided an SST intervention
as a stand-alone treatment and reported improvement in one or more social skills outcomes (Choi
& Lee, 2015; Lufi & Parish-Plass, 2011; Pfiffner & McBurnett, 1997). Lufi and Parish (2011), in
a single-group design, found improvements at posttreatment in parent-reported social problems
(effect sizes not provided). Choi and Lee (2015) found that children in both SST interventions
(standard SST and EMT-SST), in comparison with children in the wait-list, no-treatment control
group, showed large effect size improvement at posttreatment in self-reported initiative, social
skills total, poor emotional awareness27 (difficulties noticing, attending to, and differentiating
internal emotional cues) and expressive reluctance (difficulties in the expression of emotions; see
fn 26). Choi and Lee found that when the two SST interventions were compared to one another,
the EMT-SST group performed better in all social skills outcomes in comparison to the standard
SST (Table 6, page 132). Pfiffner and McBurnett (1997) compared three groups of children: one
receiving SST as stand-alone treatment, one receiving SST with concurrent parent treatment and
teacher consultation, and a wait-list, no-treatment control group. They found that the two SST
intervention groups did not differ significantly in any outcome, including parent- and teacher-
27 Scale from the Emotion Expression Scale for Children (EESC; Penza-Clyve & Zeman, 2002), Korean adaptation (Choi, 2011).
102
reported social skills total. Both SST groups improved in parent- but not teacher-reported social
skills total at posttreatment in comparison to the wait-list, no-treatment control group (small
effect size, Table 6, page 132), suggesting that the concurrent parent and teacher generalization
component did not add to the efficaciousness of the SST intervention. Improvement in parent-
reported social skills total was maintained at a four-month follow-up. Pfiffner and McBurnett
(1997) also found large effects for self-reported social skills knowledge at posttreatment, when
the SST interventions were compared with the wait-list, no-treatment control group, indicating
that the two SST interventions (with or without concurrent parent treatment and teacher
consultation) were associated with greater child knowledge of the skills taught in SST. There
was no follow-up assessment done for this outcome.
Of the 10 SST interventions28 that offered an SST intervention with concurrent parent treatment,
nine measured social skills and/or peer relationships (Abikoff Group, 2004; Antshel & Remer,
2003; Corkum et al., 2010; Evans et al., 2011; Frankel et al., 2007; MTA Cooperative, 1999;
Pfiffner et al., 2007; Villodas et al., 2014; Waxmonsky et al., 2010). Their results are presented
here.
In a between-group design, two of these nine studies evaluated social skills outcomes in an SST
intervention with concurrent parent treatment (but no teacher consultation), comparing an SST
intervention with a wait-list, no-treatment control group (Antshel & Remer, 2003; Frankel et al.,
2007). Both studies found some improvements in the social skills domain. Antshel and Remer
(2003) reported small effects in both self- and parent-reported assertion. However, this study
found no improvement in parent-reported cooperation, responsibility, or self-control, or self-
reported cooperation, empathy, or self-control. Frankel et al. (2007) found large effects in both
parent-reported assertion and self-control (Frankel et al., 2007; Table 6 on page 132).
In a single-group design, two of these nine studies evaluated social skills outcomes in an SST
intervention with concurrent parent treatment and teacher consultation (Corkum et al., 2010;
28 The one study missing in this section from the 10 studies that evaluated SST with concurrent parent treatment is Molina et al. (2008). Interestingly, Molina et al., which evaluated the efficaciousness of an SST intervention with concurrent parent treatment and teacher consultation in comparison with a control community care, did not measure any social skill or peer relationship outcome.
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Villodas et al., 2014). Corkum et al. showed improvement as reported by the child, parent, and
teacher in social skills total at posttreatment (effect sizes not provided). Villodas et al. reported
large effects for self-reported social skills knowledge and social skills total, medium effects in
parent- and teacher-reported total social skills, and small effects in parent- and teacher-reported
peer relations at posttreatment (Table 6, page 132). Nonetheless, both studies lacked a no-
treatment control group.
In a between-group design, two of the nine studies evaluated social skills outcomes in an SST
intervention with concurrent parent treatment and teacher consultation (Evans et al., 2011;
Pfiffner et al., 2007). Evans et al. found no improvement in parent- and teacher-reported peer
relations, the only social skills domain measured. Pfiffner et al. measured only one outcome, and
reported medium effects for self-reported social skills knowledge at posttreatment (Table 6, page
132).
In a between-group design, three of these nine studies evaluated social skills outcomes in an SST
intervention with concurrent parent treatment, teacher consultation, and medication (Abikoff
Group, 2004; MTA Cooperative, 1999; Waxmonsky et al., 210). Table 6 describes the results of
these studies. The MTA study found that teacher- but not parent-reported social skills total
improved equally for the children receiving the SST intervention with concurrent parent and
teacher treatment and medications, as compared with the children receiving only the
medications. The other two other SST interventions with concurrent parent and teacher treatment
and medications found no improvement in any social skills or peer relationship outcome
measured. The Abikoff Group found no improvement in self- or parent-reported social skills
total or teacher-reported social problems in any of the three groups of children being compared29.
Waxmonsky et al. found no improvement in either parent- or teacher-reported peer relations, or
parent and teacher social skills total in either the SST group with concurrent parent treatment,
teacher consultation, and medications or the medication-only control group. These results seem
to suggest that, first; children receiving SST and concurrent parent treatment and teacher
29 SST intervention with concurrent parent treatment, teacher consultation, and medication, the medications only group, or the medications and equivalent psychosocial treatment without the therapeutic component group.
104
consultation do not differ from children receiving medications alone (Abikoff Group, 2004;
Waxmonsky et al., 2010) in their improvements in social skills or peer relationships. Second, it
appears that when children are in SST with concurrent parent treatment, teacher consultation and
medications (MTA Cooperative, 1999), the inclusion of SST would allow for lower doses of
medication, and changes in social skills would still be noticeable by teachers.
Meta-analyses: SST interventions were sufficiently comparable based on nine social skills and
peer relationship outcomes, two in within-subject design studies and seven in between-group
design studies. Two SST interventions with concurrent parent treatment and a within-subject
design (Corkum et al., 2010; Villodas et al., 2014) were sufficiently comparable, based on two
outcomes, parent-reported social skills total (total N = 83) with a large combined effect size of
0.78 (95% CI = 0.52 to 1.04), I2 = 0%, and teacher-reported social skills total (total N = 83) with
a medium combined effect size of 0.69 (95% CI = 0.44 to 0.94), I2 = 0% (Table 11, page 143). In
both cases, the combined effect sizes were statistically significant.
In terms of between-group study designs evaluating SST interventions with concurrent parent
treatment, data were sufficiently comparable on seven social skills and peer relationship
outcomes (Table 12, page 144): parent-reported assertion (Antshel & Remer, 2003; Frankel et al.
1997; total N = 167, control n = 52, intervention n = 115), parent-reported self-control (Antshel
& Remer, 2003; Frankel et al. 1997; total N = 167, control n = 52, intervention n = 115), parent-
reported social skills total (Abikoff et al., 2004; MTA Cooperative Group Meds, 1999; MTA
Cooperative, 199930; Pfiffner & McBurnett, 1997; Waxmonsky et al., 2010; total N = 645,
control n = 315, intervention n = 330), teacher-reported social skills total (Pfiffner & McBurnett,
1997; MTA Cooperative Group Meds, 1999; MTA Cooperative Group, 1999; Waxmonsky et al.,
2010; see footnote 29; total N = 488, control n = 240, intervention n = 248), parent-reported peer
relations (Evans et al., 2011; Waxmonsky et al., 2010; total N = 105, control n = 45, intervention
n = 60), teacher-reported peer relations (Evans et al., 2011; Waxmonsky et al., 2010; total N =
30 As previously mentioned, the two SST intervention groups of the MTA study were entered into meta-analysis
separately as they were considered different enough to warrant independent examination. One of the SST interventions was provided with concurrent parent treatment and teacher consultation and was compared to community care as usual, and the other was provided with those same treatment components with the addition of concurrent medication and was compared to medication alone.
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105, control n = 45, intervention n = 60), and self-reported social skills knowledge (Pfiffner &
McBurnett, 1997; Pfiffner et al., 2007; total N = 55, control n = 25, intervention n = 30 ). Results
of the meta-analyses showed that only parent-reported assertion (g = -0.89, 95% CI = -1.23 to -
0.55), I2 = 0%, and self-reported social skills knowledge (g = -2.13, 95% CI = -2.92 to -1.35), I2
= 0% had large combined effect sizes that favoured the treatment group that were statistically
significant. All the other outcomes, although in the direction favouring the treatment group, were
not statistically significant: parent-reported self-control (g = -0.61, 95% CI = -1.39 to 0.17), I2 =
0%, parent-reported social skills total (g = -0.19, 95% CI = -0.46 to 0.08), I2 = 35%, teacher-
reported social skills total (g = -0.07, 95% CI = -0.25 to 0.10), I2 = 0%, parent-reported peer
relations (g = -0.15, 95% CI = -0.65 to 0.35), I2 = 0%, and teacher-reported peer relations (g = -
0.04, 95% CI = -0.34 to 0.42), I2 = 0%.
4.6.44.6.44.6.44.6.4 Family FunctioningFamily FunctioningFamily FunctioningFamily Functioning
As shown in Table 5 (page 129), of the 13 SST interventions, three provided an SST intervention
as a stand-alone treatment (Choi & Lee, 2015; Lufi & Parish-Plass, 2011; Pfiffner & McBurnett,
1997). None of these studies measured family functioning outcomes, likely because improving
these outcomes was not part of their intended study aims.
Of the 11 SST interventions that offered SST with concurrent parent treatment, four measured
family functioning outcomes (Abikoff Group, 2004; MTA Cooperative, 1999; Villodas et al.,
2014; Waxmonsky et al., 2010). One of these four studies (Villodas et al., 2014) evaluated SST
with concurrent parent treatment and teacher consultation in a single-group design. The study
found medium-effect improvements in parent-reported parent-child relation impairment (Table 6,
page 132). The Abikoff Group (2004) compared three groups of children—children receiving
medication alone, children receiving SST with concurrent medication, and children receiving
medication and concurrent equivalent psychosocial treatment without the core therapeutic
components. No change was reported in the children’s perception of fathers’ or mothers’ positive
parenting. Despite significant improvement over time (effect sizes not provided) in the children’s
perception of both father-negative parenting and mother-negative parenting, there were no group
differences, suggesting no advantage of SST intervention with concurrent medication over
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medication alone or concurrent medication and a control intervention without the therapeutic
components.
Similar findings were found in respect to the lack of additive value of the SST intervention with
concurrent parent treatment and teacher consultation over medication management in the MTA
Cooperative (1999) and Waxmonsky et al. (2010) studies. The MTA Cooperative study found
that children receiving the SST intervention with concurrent parent treatment and teacher
consultation and concurrent medications, and the children receiving medications alone did not
significantly differ in their improvement, but in this case, were all superior to community care
when it came to parent-reported personal closeness in parent-child relations. Waxmonsky et al.
(2010) compared a group of children receiving SST with concurrent medications with a group of
children receiving medication alone, and reported no group differences, except for a small effect
in parent-reported sibling relationship impairment at posttreatment. Neither group improved in
parent-reported parent-child relationship impairment or family relationship impairment, implying
that the SST treatment component did not have an additive value to medication management.
Meta-analyses were not conducted in regards to family functioning outcomes because of the
heterogeneity of the outcomes being evaluated by the four SST intervention studies that
measured them. The outcome measures were: parent-reported parent-child relationship
impairment; parent-reported sibling relationship impairment; parent-reported family relationship
impairment; parent-reported personal closeness in parent-child relationships; self-reported
mother-positive parenting, self-reported father-positive parenting; self-reported mother-negative
parenting; and self-reported father-negative parenting. There was only one instance of overlap
between outcome measures used. Villodas et al. (2014) and Waxmonsky et al. (2010) both
measured parent-reported parent-child relationship impairment, using exactly the same
instrument. However, their studies had a different study design that precluded the calculation of a
combined effect size. Villodas et al. (2014) had a within-subject design whereas Waxmonsky et
al. (2010) had a between-group design.
107
4.6.54.6.54.6.54.6.5 Core ADHD Symptoms Core ADHD Symptoms Core ADHD Symptoms Core ADHD Symptoms
As shown in Table 5 (page 129), of the 13 SST interventions, three provided an SST intervention
as a stand-alone treatment (Choi & lee, 2015; Lufi & Parish-Plass, 2011; Pfiffner & McBurnett,
1997). Only one of the three SST intervention studies where SST was provided as a stand-alone
treatment measured core ADHD outcomes (Lufi & Parish-Plass, 2011). Lufi and Parish-Plass
found significant reductions of (size of effect not provided) parent- but not self-reported
inattention.
Of the 10 SST interventions that offered SST with concurrent parent treatment, four measured
core ADHD symptoms (Abikoff Group, 2004; Evans et al., 2011; Villodas et al., 2014;
Waxmonsky et al., 2010). As shown in Table 6 (page 132), three of these four SST interventions
reported reductions (Evans et al., 2011; Villodas et al., 2014; Waxmonsky et al., 2010). Villodas
et al. found large effects in parent- and teacher-reported ADHD symptoms of combined
inattention and hyperactivity/impulsivity. Evans et al. found large effects in parent-reported
hyperactivity. Waxmonsky et al. compared a group of children receiving concurrent SST,
medication and parent treatment and teacher consultation, with a group of children receiving
medication alone. Authors found medium effects for parent-reported ADHD symptoms of
combined inattention and hyperactivity/impulsivity, and small effects for teacher-reported
inattention. Nonetheless, one study (Abikoff Group, 2004) found no reductions of any core
ADHD outcome (i.e., parent- or teacher-reported hyperactivity or number and severity of home
or school problematic situations). The Abikoff Group found no advantage in respect to the core
ADHD symptoms of children receiving SST and medication over the children receiving
medication alone.
Meta-analyses: SST interventions were sufficiently comparable based on four core ADHD
symptom outcomes in between-group design studies; parent- and teacher-reported inattention
and hyperactivity/impulsivity (Table 13, page 145). Four samples were sufficiently comparable
based on parent and teacher reports of ADHD symptoms (Evans et al., 2011; MTA Cooperative,
1999; Waxmonsky et al., 2010). The two SST intervention groups of the MTA study were
entered separately, as they were considered different enough to warrant independent
examination. One of the SST interventions was provided with concurrent parent treatment and
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teacher consultation and was compared to community care as usual; the other was provided with
those same treatment components with the addition of concurrent medication, and was compared
to medication alone. Neither parent- nor teacher-reported inattention or hyperactivity/impulsivity
were statistically significant: Parent-reported inattention (total N = 618, control n = 296,
intervention n = 322) was in the direction favouring the treatment group, but was not statistically
significant (g = 0.19, 95% CI = -0.05 to 0.42), I2 = 25%. Parent-reported
hyperactivity/impulsivity (g = -0.13, 95% CI = -1.14 to 0.88), I2 = 0% (total N = 618, control n =
296, intervention n = 322) was in the direction favouring the control group, but was not
statistically significant. Teacher-reported inattention (g = 0.02, 95% CI = -0.14 to 0.18), I2 = 0%
(total N = 606, control n = 293, intervention n = 313), and teacher-reported
hyperactivity/impulsivity (g = 0.09, 95% CI = -0.07 to 0.25), I2 = 0% (total N = 606, control n =
293, intervention n = 313), were in the direction favouring the treatment group, but were not
statistically significant.
4.6.64.6.64.6.64.6.6 Potential Potential Potential Potential Variables That May Moderate Variables That May Moderate Variables That May Moderate Variables That May Moderate Response to Response to Response to Response to Social Skills TrainingSocial Skills TrainingSocial Skills TrainingSocial Skills Training
InterventionsInterventionsInterventionsInterventions
Potential variables that may moderate the response to SST interventions are explored in a
descriptive manner. As previously mentioned, to be able to conduct moderator analyses,
subgroup for categorical variables and meta-regressions for the continuous variables, two
conditions need to be met: There has to be sufficient sample of studies to be subgrouped as well
as sufficient variability in the potential moderators. Since most meta-analyses in this study were
conducted in samples of two or three studies, the samples were too small to be further analyzed
by investigating moderator variables (Borenstein et al., 2011; Lipsey & Wilson, 2001). Only two
meta-analyses had four and five samples of studies respectively, in between-group design parent-
reported total social skills (I2 = 35%) and parent-reported inattention symptoms (I2 = 25%).
Values on the order of 25%, 50%, and 75% are considered as low, moderate, and large
respectively for I² (I-squared; Higgins et al., 2003). If I² nears zero, as is the case in 19 of the 21
meta-analyses involving SST interventions performed, then almost all of the observed variance is
spurious. Additionally, Cochrane guidelines (Ryan, 2014) indicate that heterogeneity between
0% to 40% is low, suggesting that it is not appropriate to investigate potential moderator
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variables to explain the variability. Nonetheless, there are two variables that are considered
potential moderators of treatment response of children with ADHD to psychosocial interventions
in general: comorbidity with anxiety disorders, and comorbidity with ODD. Additionally, and
specifically in regards to SST interventions, various child moderators have been suggested to
diminish responsiveness to treatment, including child age, gender, medication status, and ADHD
subtype. These six variables are explored descriptively in the next section in respect to the 13
included SST intervention studies.
4.6.6.14.6.6.14.6.6.14.6.6.1 Comorbidity with Comorbidity with Comorbidity with Comorbidity with oooother disordersther disordersther disordersther disorders
Three variables are considered potential moderators of treatment response in children with
ADHD to psychosocial interventions in general: comorbidity with anxiety disorders,
comorbidity with ODD, and comorbidity with LD.
Of the 13 SST interventions included in this review, two offered SST as a stand-alone treatment;
one of these studies did not report on its sample comorbidities with ADHD (Choi & Lee, 2015),
or reported no comorbidities (Lufi & Parish-Plass, 2011). Despite having a sample (N = 72) that
may have allowed for subgroup analyses, Choi and Lee did not explore the potential differential
effects of SST in children with ADHD. In the Lufi and Parish-Plass study, the sample (N = 15)
was not large enough to conduct subgroup analyses and compare differential effects of treatment
for children with comorbid anxiety or ODD. In terms of the other 11 SST interventions that were
offered with concurrent parent treatment, LD was the comorbidity that was most under-reported,
with only one study (Corkum et al., 2010) reporting a prevalence of 12.5% (or n = 2) in their
sample, but the small sample precluded subgroup analyses. The Abikoff Group (2004) had LD as
part of their exclusionary criterion for inclusion. Two studies did not report on comorbidity with
anxiety disorders or ODD (Evans et al., 2011; Molina et al., 2008; Table 4, page 124).
Nine SST interventions provided information on the prevalence of anxiety and ODD
comorbidities (Table 4, page 124). However, only three explored comorbidities between ADHD
and ODD as a potential moderator of treatment response (Antshel & Remer, 2003; MTA
Cooperative, 1999; Villodas et al., 2014), and only one study explored the comorbidity between
ADHD and anxiety as a potential moderator of treatment response (MTA Cooperative, 1999).
110
Antshel and Remer (2003) reported that 9.16% of their sample of children with ADHD had
comorbid anxiety and 44.16% had comorbid ODD. This study reported that children with ADHD
and comorbid ODD seemed to have less improvement in social skills following SST than
children with ADHD and no disruptive behaviour comorbidities. Children with ADHD without
ODD improved more in self-reported empathy and parent-reported assertion and cooperation at
posttreatment when compared with children with ADHD and comorbid ODD, and these group
differences were maintained at a three-month follow-up. This study’s results do not support the
efficaciousness of SST interventions for children with ADHD and comorbid ODD. Villodas et
al. (2014) reported that 51% of the study sample had comorbid ODD and no prevalence of
anxiety was reported. This single-group design study with concurrent parent treatment and
teacher consultation found that children with ADHD and ODD did not show differential
responses to treatment from children with ADHD alone in any of the outcomes measured,
including parent- and teacher-reported behaviour problems, parent-reported parent-child
relationships, parent- and teacher-reported social skills total. Similar to Villodas et al.’s (2014)
findings, in a later publication of the MTA Cooperative (1999) study (Jensen et al., 2001), it was
reported that children with ADHD and ODD did not show differential response to treatment.
The MTA study reported that 33.5% of their sample had comorbid anxiety and 39.9% had
ADHD and comorbid ODD (Table 4, table 124). This study was the only SST intervention study
that explored the potential moderator role of comorbid ADHD and anxiety to treatment response
in a later publication (Jensen et al., 2001). Children with ADHD and any comorbid anxiety
disorders showed a better response to SST and concurrent parent and teacher treatment and to
SST and concurrent parent, teacher, and medication treatments than children with ADHD
without an anxiety disorder. For children with ADHD and anxiety disorders, the response to SST
and concurrent parent and teacher treatment was comparable to the medication management
treatment, and the response to SST and a combined, concurrent parent and teacher and
medication treatment was even better. Children with ADHD and anxiety disorders, without a
disruptive disorder comorbidity, responded equally well to the SST and concurrent parent and
teacher treatment, SST and concurrent parent and teacher treatment and medication, and
medication alone. For those children with ADHD and comorbid anxiety disorders and ODD,
SST with concurrent parent and teacher treatment and medication was better than either
111
medication alone or SST with concurrent parent and teacher treatment. The MTA study (MTA
Cooperative, 1999), however, did not have sufficient sample size to assert precisely which
anxiety disorders might be at play in this regard.
The remaining six SST intervention studies provided information on the prevalence of
comorbidities with ADHD in their samples, but did not provide information pertaining to the
potential moderator role of treatment response of comorbidity of ADHD and anxiety or ADHD
and ODD. Some of these studies (Pfiffner & McBurnett, 1997) did not explore these potential
moderators of treatment response; some studies (Abikoff Group, 2004; Corkum et al., 2010;
Pfiffner et al., 2007; Waxmonsky et al., 2010) did not explore any potential moderators of
treatment response, in some cases because these studies did not have samples large enough to
explore differential treatment response of children with ADHD; and some studies explored this
issue but in their total sample, which included children who did not have ADHD (Frankel et al.,
1997). For instance, Corkum et al. (2010) reported no ODD or CD, and no prevalence of anxiety
in their sample. In any case, the sample (N = 16) was not large enough to conduct subgroup
analyses and compare differential effects of treatment. Frankel et al. reported 51.06% of children
in their sample with comorbid ODD, but no prevalence of anxiety was reported (Table 4, page
124). However, this prevalence was reported for the total sample; only a subgroup of children
with ADHD was included in that review. It originally had four groups of children, and only the
data for two groups of children with ADHD were included, those receiving SST and concurrent
parent treatment and those in a wait-list, no-treatment control group. Although Frankel et al.
explored ODD as a potential moderator of treatment response, given that not all the children with
ODD had comorbid ADHD, these results are not relevant to this review.
4.6.6.24.6.6.24.6.6.24.6.6.2 AAAAgegegege
Another potential moderator of SST treatment response is the child age. Of the 13 SST
interventions included in this review, none performed subgroup analyses to explore the potential
differential effects of SST in children with ADHD of different ages. This was probably due to
the fact that each study included only a limited age range (Table 4, page 124). For instance, the
MTA Cooperative (1999) and Abikoff Group (2004), respectively, included children between 7
and 9 years of age. The SST intervention studies that included a larger age range, such as 6 to 12
112
years in Frankel et al. (1997) or 8 to 12 years in Antshel and Remer (2003), did not have large
enough sample sizes to evaluate this question.
4.6.6.34.6.6.34.6.6.34.6.6.3 GGGGender ender ender ender
Of the 13 SST interventions included in this review, as previously mentioned, the two that
offered SST as a stand-alone treatment did not perform subgroup analyses to explore the
potential differential effects of SST in children with ADHD (Choi & Lee, 2015; Lufi & Parish-
Plass, 2011). In terms of the other 11 SST interventions that were offered with a concurrent
parent treatment, nine studies did not explore child gender as a potential moderator. Only two of
these studies (MTA Cooperative, 1999; Pfiffner & McBurnett, 1997) explored child gender as a
potential moderator of SST treatment response. The authors explored this potential moderator
and reported that the efficaciousness of SST was not moderated by child gender. It is possible
that the reason most of the SST intervention studies have not explored gender as a potential
treatment response is because their samples comprise either all males (90% to 100%; Abikoff
Group, 2004; Lufi & Parish-Plass, 2011) or mostly males (60% to 90%) in a sample size not
large enough to be able to explore this moderator (Antshel & Remer, 2003; Corkum et al., 2010;
Evans et al., 2011; Frankel et al., 1997; Molina et al., 2008; Pfiffner et al., 2007; Villodas et al.,
2014; Waxmonsky et al., 2010).
4.6.6.44.6.6.44.6.6.44.6.6.4 MMMMedication statusedication statusedication statusedication status
Of the 13 SST interventions included in this review, as previously mentioned, the two that
offered SST as a stand-alone treatment did not perform subgroup analyses to explore the
potential differential effects of SST in children with ADHD (Choi & Lee, 2015; Lufi & Parish-
Plass, 2011). In terms of the other 11 SST interventions that were offered with concurrent parent
treatment, four studies (Abikoff Group, 2004; Antshel & Remer, 2003; Frankel et al., 1997;
Waxmonsky et al., 2010) have the limitation that all of the children were medicated during the
SST intervention, so that this potential moderator of treatment response could not be explored.
One study (Pfiffner & McBurnett, 1997) did not report whether the children received medication
during the SST intervention. The remaining six SST intervention studies reported the percentage
of children receiving medication during the SST treatment (Corkum et al., 2010; Evans et al.,
113
2011; Molina et al., 2008; Pfiffner et al., 2007; MTA Cooperative, 1999; Villodas et al., 2014)
but only one study (Evans et al., 2011) examined medication use as potential moderator of SST
treatment response. This study reported that 52% of their sample was on medication and found
that medication use did not differ between the SST treatment and community care control group,
and medication use did not significantly interact with any outcome; that is, did not moderate
treatment response.
Last, in one study, medication was not explicitly examined as a potential moderator because it
was one of the treatment types being evaluated (MTA Cooperative, 1999). In this study,
children’s response to an SST intervention with concurrent parent treatment and teacher
consultation, without medications, was not better than response to an SST intervention with
concurrent parent treatment and teacher consultation with concurrent medication. In fact, in
general, all outcomes measured fared better in the latter group. That is, treatment response was
consistently better when medication was included. SST intervention with concurrent parent and
teacher treatment components, however, allowed for lower medication dosages, when compared
with children in the medication-alone group. These findings suggest that contrary to expectations
(e.g., Pelham & Fabiano, 2008), SST interventions without medications do not seem to be more
efficacious for children with ADHD who are concurrently receiving intensive pharmacotherapy.
For the remaining studies that did not explore the potential moderator role of medication status
on SST treatment response, the reasons were possibly twofold: insufficient sample size (e.g.,
Corkum et al., 2010, where N = 16) or a very low rate of participants on medication (e.g.,
Pfiffner et al., 2007, and Villodas et al., 2014, had only two and four participants respectively
receiving medications in their samples).
4.6.6.54.6.6.54.6.6.54.6.6.5 ADHD subtypeADHD subtypeADHD subtypeADHD subtype
Of the 13 SST interventions included in this review, as previously mentioned, the two that
offered SST as a stand-alone treatment did not perform subgroup analyses to explore potential
moderators of treatment response (Choi & Lee, 2015; Lufi & Parish-Plass, 2011). Additionally,
neither study reported on the prevalence of ADHD subtypes in their samples. In terms of the
other 11 SST interventions that were offered with concurrent parent treatment, five reported the
children’s ADHD subtypes at study entry (Antshel & Remer, 2003; Molina et al., 2008; MTA
114
Cooperative, 1999; Pfiffner et al., 2007; Waxmonsky et al., 2010), but only one study explored
the potential moderator role of these ADHD subtypes in treatment response (Antshel & Remer,
2003). Antshel and Remer reported that children with ADHD-I improved more on self and
parent-reported assertion relative to those with ADHD-C at posttreatment and gains were
maintained at a three-month follow-up. In addition, these investigators reported that children
with ADHD-I benefited more from SST when they were placed in groups containing only peers
with ADHD-I. In fact, the children with ADHD-I who were placed in groups containing peers
with ADHD-C got worse in regards to a composite of parent-reported outcomes, including social
skills total, and internalizing and externalizing symptoms, perhaps due to a contagion effect
whereby children with ADHD-C encouraged children with ADHD-I to display disruptive
behaviour. The results of this study support the implementation of SST interventions in
diagnostically homogenous groups.
The potential reasons why ADHD subtypes were not explored as potential moderators are
probably twofold. First, most studies did not have sufficiently large sample sizes to explore
moderators of treatment response in general. Second, in the case of two studies, all children were
homogenous in their ADHD type. In the Pfiffner et al. (2007) study all the children with ADHD
included in the study had ADHD-I, and in the MTA Cooperative (1999) study all the children
had ADHD-C.
4.6.74.6.74.6.74.6.7 Summary of SST InterventionsSummary of SST InterventionsSummary of SST InterventionsSummary of SST Interventions
In summary, this systematic review has indicated that SST interventions, even with concurrent
parent treatment and teacher consultation, show only modest gains in improving children’s social
skills. The only two outcomes that seem to be improved in SST interventions are self-reported
social skills knowledge and parent-reported assertion. In addition, SST interventions may show
relative success in decreasing self- but not parent-reports of anxiety. It would also appear that
adding a concurrent parent treatment to the child-focused SST does not make a difference when
it pertains to the improvement of self-reports of anxiety or social skills knowledge, but it seems
to contribute to improvements in parent-reported assertion. There is some evidence from one
RCT (MTA Cooperative, 1999) that children receiving SST interventions do not differ in the
degree of improvement from children receiving medications on their parent-reported ODD
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symptoms, internalizing symptoms, personal closeness in parent-child relations, and on parent-
and teacher-reported social skills.
In terms of moderators of SST treatment response, children’s gender was found not to moderate
any outcome, and SST interventions do not seem to be more effective for children with ADHD
who are not concurrently receiving intensive pharmacotherapy. The findings pertaining to the
comorbidity between ADHD and ODD as a potential moderator are inconsistent. One study
(Antshel & Remer, 2003) reported that children with ADHD and comorbid ODD seem to benefit
less from SST interventions than children with ADHD and no disruptive behaviour
comorbidities. However, two studies (MTA Cooperative, 1999; Villodas et al., 2014) report no
differential response to treatment. In terms of the comorbidity between ADHD and anxiety as a
moderator of treatment response, the MTA Cooperative (1999) study found that children with
ADHD and any comorbid anxiety disorder showed a better response to SST and concurrent
parent and teacher treatment and to SST and concurrent parent and teacher treatment and
medication than children with ADHD without an anxiety disorder. In regards to ADHD subtype
as a moderator of SST treatment response, Antshel and Remer (2003) found that children with
ADHD-I improved more on self- and parent-reported assertion relative to those with ADHD-C
(at posttreatment and three month follow-up). Children with ADHD-I benefited more from SST
when they were placed in groups containing only peers with ADHD-I. These results support the
implementation of SST interventions in diagnostically homogenous groups. Last, none of the
SST interventions included in this review explored the potential moderator role of children's age,
probably because each study included only a limited age range.
116
Table 3. Description of Included Studies.
Study Qualitya Total
N
Age Range (Mean) in years
% Completing
the study
Study Design
Treatment Comparison
Child Functioning Outcomes Measuredb
Self-reported Parent-reported Teacher-reported
Abikoff et al. (2004a)†
Strong 103 7 to 9 (8.2)
80-100 RCT SST+Meds, Meds,
Meds+ EC
Social skills total43 Social skills total 44 Social problems45
Abikoff et al. (2004b)†
Strong 103 7 to 9 (8.2)
80-100 RCT SST+Meds, Meds,
Meds+ EC
Hyperactivity19 Number of home problematic situations32 Severity of home problematic situations32
CD24 Hyperactivity24 Number of school problematic situations53
Severity of school problematic situations53
Antshel et al. (2014)
Moderate 82 14 to 18 (16.4)
80-100 WS Ind CBT Emotional symptoms6 Hyperactivity2
Inattention2 Internalizing6
Externalizing7
Family relations 33
Hyperactivity2 Inattention2 Internalizing7 Parent-child relations33 Peer relations33 Sibling relations33
Externalizing8 Hyperactivity2 Inattention2 Internalizing8 Peer relations34
Antshel & Remer (2003)
Moderate 120 8 to 12 (9.6)
80-100 Control grouph
SST, WL
Assertion43 Cooperation43 Empathy43 Self-control43
Assertion44 Cooperation44 Responsibility44 Self-control44
Bloomquist et al. (1991)
Moderate 52 8 to 10c
(NP) 60-79 RCT CBT,
TC, WL
CD22 Hyperactivity22 Impulsivity22 Inattention22 Peer preferred social behaviour58 Social competence58
117
Table 3. Description of Included Studies (continued).
Study Qualitya Total N
Age Range (Mean) in years
% Completing
the study
Study Design
Treatment Comparison
Child Functioning Outcomes Measuredb
Self-reported Parent-reported Teacher-reported
Brown et al. (1986)
Strong 33 5 to13 (9.0)
80-100 RCT Ind CBT +
Meds, Meds,
PMeds, EC+PMeds
Hyperactivity17 Hyperactivity1
Inattention1 ODD1 Self-control55 Social skills total1
Choi & Lee (2015)
Moderate 72 9 to 13 (11.2)
80-100 RCT SST, SST-EMT,
WL
Anxiety50 Cooperation40 Depression11 Expressive reluctance29 Initiative40 Poor emotional awareness29
Social skills total40
Corkum et al. (2010)
Weak 16 8 to 11 (9.9)
NP WS SST Social skills total43
Social skills total44 Social skills total45
Evans et al. (2011)
Strong 49 10 to13
(NP)
80-100 RCT SST, CC
Hyperactivity/impulsivity25 Inattention25 Peer relations33
Hyperactivity/impulsivity27 Inattention27 Peer relations34
Frankel et al. (2007)h
Moderate 47 6 to 12
(NP) NP Control
groupi SST, WL
Assertion44 Self-control44
Harrison et al. (2004)
Moderate 48 4 to 12
(NP) 60-79 WS MD ADHD16
Quality of parent-child attachment relationship13 Open parent-child communication13 Parent-child warmth13 Parent-child conflict13
118
Table 3. Description of Included Studies (continued).
Study Qualitya Total N
Age Range (Mean)
in years
% Completing
the study
Study Design
Treatment Comparison
Child Functioning Outcomes Measuredb
Self-reported Parent-reported Teacher-reported
Haydicky et al. (2015)
Moderate 18 13 to 18
(15.5)
80-100 WS MD Anxiety42 CD21 Depression42
Family relations30 Hyperactivity/impulsivity21 Inattention21
Internalizing42 Parent-child number of conflicts35 Parent-child intensity of conflicts35 ODD21
Anxiety41
CD20 Depression41 Family relations30 Hyperactivity/impulsivity18 Inattention20
Internalizing41
Parent-child number of conflicts35 Parent-child intensity of conflicts35 Peer relations20 ODD20
Haydicky et al. (2012)f
Moderate 33 12 to 18
(NP)
NP Control grouph
MD, WL
ADHD59 CD59 Externalizing59
ODD59 Social problems59
ADHD9 CD9 Externalizing9 ODD9 Social problems9
Hechtman et al. (2004a)†
Strong 103 7 to 9 (8.2)
80-100 RCT SST+Meds, Meds,
Meds+ EC
Father negative parenting39 Father positive parenting39 Mother negative parenting39 Mother positive parenting39
Hechtman et al. (2004b)†
Strong 103 7 to 9 (8.2)
80-100 RCT SST+Meds, Meds,
Meds+ EC
Depression10
119
Table 3. Description of Included Studies (continued).
Study Qualitya Total N
Age Range (Mean) in years
% Completing the study
Study Design
Treatment Comparison
Child Functioning Outcomes Measuredb
Self-reported Parent-reported Teacher-reported
Jensen & Kenny (2004)g
Moderate 14
8 to 13
(NP) 80-100 Control
grouph MD + Meds, EC + Meds
ADHD18 Anxiety18 Emotional lability18 Hyperactivity18 Impulsivity18 Inattention18 ODD18 Perfectionism18 Social problems18 Psychosomatic symptoms18
ADHD23 Anxiety23 Emotional lability23 Hyperactivity23 Impulsivity23 Inattention23 ODD23 Perfectionism23 Social problems23 Psychosomatic symptoms23
Klein et al. (2004)†
Strong 103 7 to 9 (8.2)
80-100 RCT SST+Meds, Meds,
Meds+ EC
Lufi & Parish-Plass (2011)d
Moderate 15 8 to 13 (10.8)
80-100 WS SST Aggression59 Anxiety59 Delinquency59 Externalizing59 Inattention59 Internalizing59 Social problems59 Somatic symptoms59 Thought problems59 Withdrawal59
Aggression9 Anxiety9 Delinquency9 Externalizing9 Inattention9
Internalizing9 Social problems9 Somatic symptoms9 Thought problems9 Total problems9 Withdrawal9
Molina et al. (2008)
Strong 23 11 to 14 (12.9)
80-100 RCT SST, CC
Aggression3 Emotional symptoms4
Externalizing5 Internalizing5
120
Table 3. Description of Included Studies (continued).
Study Qualitya Total
N
Age Range (Mean) in years
% Completing
the study
Study Design
Treatment Comparison
Child Functioning Outcomes Measuredb
Self-reported Parent-reported Teacher-reported
MTA Cooperative (1999)
Strong 579 7 to 9 (8.5)
80-100 RCT SST, SST+Meds,
Meds, CC
Anxiety37 Hyperactivity/impulsivity51 Inattention51 Internalizing44 ODD51 Personal closeness in parent-child relations38 Social skills total44
Hyperactivity/impulsivity52 Inattention52 Internalizing45 ODD52 Social skills total45
Pfiffner & McBurnett (1997)
Strong 27 8 to 10
(NP) 80-100 RCT SST,
SST+PC+TC,WL
Social skills knowledge57
Behaviour problemse, 44 Social skills total44
Behaviour problemse, 45 Social skills total45
Pfiffner et al. (2007)
Moderate 69 7 to 11 (8.7)
80-100 RCT
SST, CC
Social skills knowledge56
van de Weijer-Bergsma et al. (2012)
Weak 10 11 to 15 (13.4)
80-100 WS MD Externalizing59 Fatigue31 Inattention59 Internalizing59
Externalizing9 Inattention9 Internalizing9
Externalizing54 Inattention54 Internalizing54
van der Oord et al. (2007)
Strong 45 8 to 12 (9.9)
80-100 RCT
CBT+Meds, Meds
Anxiety49 ADHD26 CD26 ODD26 Social skills total44
ADHD28 CD28 ODD28 Social skills total45
121
Table 3. Description of Included Studies (continued).
Study Qualitya Total
N
Age Range (Mean) in years
% Completing
the study
Study Design
Treatment Comparison
Child Functioning Outcomes Measuredb
Self-reported Parent-reported Teacher-reported
Villodas et al. (2014)
Moderate 57 7 to 10 (8.1)
80-100 WS SST Social skills knowledge56
ADHD14 Behaviour problemsg, 47 ODD14 Parent-child relations33 Peer relations33 Social skills total47
ADHD15 Behaviour problemsg, 47 ODD15 Peer relations34
Social skills total47
Waxmonsky et al. (2010)
Moderate 56 6 to 12 (8.6)
80-100 RCT SST+Meds, Meds
Suicidal ideation12 Depression12
Behaviour problemse, 46
CD18 Family Relations33 Hyperactivity/impulsivity20 Inattention18 ODD18 Parent-child relations33 Peer relations33 Sibling relations33 Social skills total46
Behaviour problemse, 47
CD23 Hyperactivity/impulsivity23 Inattention23 ODD23 Peer relations34 Social skills total47
Note. Child-focused psychosocial interventions of interest have been bolded. † Five studies correspond to the same sample of participants, four report results on different outcomes (Abikoff et al., 2004a; 2004b; Hechtman et al., 2004a; 2004b) and one describes the sample characteristics (Klein et al., 2004). Abbreviations: C = control group; CBT= cognitive behavioural therapy; CC = community care; CD = conduct disorder; EC= equivalent control psychosocial treatment without the core therapeutic components; Ind= Individual; EMT= emotion management training; Meds = ADHD Medications; MD = mindfulness training; NP = not provided in the study; ODD = oppositional defiant disorder; PC = parent treatment component; PMeds = placebo ADHD medications; RCT = randomized controlled trial; SST= social skills training; (T) = treatment group; TC = teacher consultation; WL=wait-list control; WS= within-subject design. a. As measured by the Quality Assessment Tool for Quantitative Studies developed by the Effective Public Health Practice project (EPHPP; Armijo-Olivo et al. 2012). b. Outcomes relevant to this systematic review. See Appendices A and B for more information on the instruments used to measure the outcomes of interest. c. Estimated from the age means reported by group but not specified in the study. d. Although the study uses a between-group design, only data for the treatment group of children with ADHD has been extracted (n =15). e. Combination of internalizing and externalizing symptoms. f. The subgroup of children with LD and ADHD-Inattentive Type was used here. g. In this study five participants acted as self-controls and were in both conditions, first in the wait-list control group and then in the treatment group. h. Attrition rate was reported in the original study was for the entire sample (15%). However, for the purpose of this systematic review, only the two groups of children with ADHD (from the original four groups) of the study were included. i. Control group was used to describe a study design where groups are assembled according to whether or not exposure to the intervention has occurred. In these cases there was no random assignment to treatment conditions.
122
1. ADD-H Comprehensive Teacher Ratings Scale (ACTeRS; Ullmann, 1986). 2. ADHD Rating Scale–IV (ADHD-RS-IV; DuPaul et al., 1998). 3. Aggression and Conduct Problems Scale (American Psychiatric Association, 1994). 4. Behavioral Assessment System for Children System for Children –Self-report (BASC-I; Kamphaus & Frick, 1996). 5. Behavioral Assessment System for Children System for Children –Parent Rating (BASC-I; Kamphaus & Frick, 1996). 6. Behavioral Assessment System for Children System for Children-Self-Report - 2nd edition (BASC-II; Reynolds & Kamphaus, 2004). 7. Behavioral Assessment System for Children System for Children-Parent Rating -2nd edition (BASC-II; Reynolds & Kamphaus, 2004). 8. Behavioral Assessment System for Children System for Children-Teacher Rating -2nd edition (BASC-II; Reynolds & Kamphaus, 2004). 9. Child Behavior Checklist (CBCL; Achenbach 1991) 10. Children’s Depression Inventory Total Score (CDI; Kovacs, 1992). 11. Children’s Depression Inventory Total Score (CDI; Kovacs, 1992) Korean adaptation (Cho & Lee, 1990). 12. Children’s Depression Rating Scale-Revised (CDRS-R; Poznanski & Mokros, 2007). 13. Child–Parent Relationship Scale (CPRS) (Pianta, 1990). 14. Child Symptom Inventory - Parent version (CSI; Gadow & Sprafkin, 1994). 15. Child Symptom Inventory – Teacher version (CSI; Gadow & Sprafkin, 1994). 16. Conners Abbreviated Symptom Questionnaire (ASQ-P; Conners, 1990). 17. Conners Parent Rating Scale – Short Form (CPRS; Conners, 1978). 18. Conner Parent Rating Scale –Long Form (CPRS:L; Conners, 1997). 19. Conners Parent Rating Scales Revised: Short Form (CPRS-R:S; Conners, 1997) 20. Conners Parent Rating Scale – 3rd Edition (Conners, 2008). 21. Conners Self-report Conners-3SR (Conners, 2008). 22. Conners Teacher Rating Scale (CTRS; Goyette et al., 1978). 23. Conners Teacher Rating Scale – Long Form (CTRS:L; Conners, 1997). 24. Conners Teacher Rating Scale Revised: Short-Form (CTRS-R:S; Conners,1997) 25. Disruptive Behavior Disorders Rating Scale (DBD; Pelham, Gnagy, Greenslade, & Milich, 1992). 26. Disruptive Behavior Disorders Rating Scale (DBD; Pelham, Gnagy, Greenslade, & Milich, 1992). Dutch adaptation. (Oosterlaan, Scheres, Antrop, Roeyers, Sergeant, 2000) 27. Disruptive Behavior Disorders Rating Scale –Teacher version (DBD-T; Pelham et al., 1992). 28. Disruptive Behavior Disorders Rating Scale –Teacher version (DBD-T; Pelham et al., 1992). Dutch adaptation. (Oosterlaan, Scheres, Antrop, Roeyers, Sergeant, 2000) 29. Emotion Expression Scale for Children (EESC; Penza-Clyve & Zeman, 2002), Korean adaptation (Choi, 2011). 30. Family Assessment Device – Parent report (FAD; Epstein et al., 1983) . 31. Flinders Fatigue Scale (FFS; Gradisar et al. 2007). 32. Home Situations Questionnaire (HSQ; Barkley, 1990). 33. Impairment Rating Scale – Parent Version (IRS; Fabiano et al., 2006). 34. Impairment Rating Scale – Teacher Version (IRS; Fabiano et al., 2006). 35. Issues Checklist (IC; Robin, 1975; Prinz et al., 1979). 36. Family Assessment Device – Self-report (FAD; Epstein et al., 1983). 37. Multidimensional Anxiety Scale for Children Total MASC Score (MASC, March et al., 1997). 38. Parent-Child Relationship Questionnaire (PCRQ; Furman & Giberson, 1995) 39. Parent Perception Inventory – Child rating. (Hazzard, Christenser, & Margolin, 1983). 40. Peer Relational Skills Scale – Self-report (Yang & Oh, 2005). 41. Revised Children’s Anxiety and Depression Scale – Parent Report (Chorpita, 2014). 42. Revised Children’s Anxiety and Depression Scale – Self-Report (Chorpita, 2014). 43. Social Skills Rating Scale – Self-report (SSRS; Gresham & Elliot, 1998). 44. Social Skills Rating Scale – Parent Version (SSRS; Gresham & Elliot, 1998).
123
45. Social Skills Rating Scale – Teacher Version (SSRS; Gresham & Elliot, 1998). 46. Social Skills Improvement System – Parent Version (SSIS; Gresham & Elliot, 2008). 47. Social Skills Improvement System – Teacher Version (SSIS; Gresham & Elliot, 2008). 48. State-Trait Anxiety Inventory for Children (STAIC; Spielberger, Edwards, Lushene, Montuori, & Platzek, 1973) 49. State-Trait Anxiety Inventory for Children (STAIC; Spielberger, Edwards, Lushene, Montuori, & Platzek, 1973) Dutch adaptation (August, Realmuto, MacDonald, Nugent,
Crosby, 1996). 50. State-Trait Anxiety Inventory for Children (STAIC; Spielberger, 1973). Korean adaptation (Cho & Choi, 1989). 51. Swanson, Nolan, and Pelham Rating Scale – Parent Version (SNAP, Swanson et al. 1992). 52. Swanson, Nolan, and Pelham Rating Scale – Teacher Version (SNAP, Swanson et al. 1992). 53. Taxonomy of Problem Situations – Teacher Version (Dodge et al., 1985) 54. Teacher Report Form (TRF; Achenbach 1991). 55. Teacher Report of Self-control (Humphrey, 1982). 56. Test of Social Like Skill Knowledge – Child report (TOSLK; Pfiffner & Mikami, 2005). 57. Test of Social Like Skill Knowledge – Child report (TOSLK; (Pfiffner & McBurnett, 1997). 58. Walker-McConnell Scale of Social Competence and School Adjustment (Walker & McConnell, 1988). 59. Youth Self Report (YSR; Achenbach 1991).
124
Table 4. Description of Sample Characteristics.
Study Total N
Male Female
and (% Male)
Age Range and
(Mean) in years
Ethnicity/Race
Parents’ Marital Status
ADHD Diagnosis Comorbidity % Concurrently on ADHD Meds during
psychosocial intervention
Abikoff et al. (2004a)†
96M 7F
(93.2%)
7 to 9 (8.2)
AA 13% C 84% H 2%
Other 1%
Married 81.2% Single parent
12.6% Mother and
stepfather 5.8%
DSM-IIIg by DISC-P + hyperactivity factor of CTRS
≥ 1.5
CD, LD, Tic, or Tourette’s disorder exclusionary
Anxiety disorder 16.5% Depression disorder 3.9% ODD 53.4% by DISC-P
100%
Antshel et al. (2014)
51M 31F
(62.1%)
14 to 18 (16.4)
AA 13% C 81% H 3%
NP DSM-IVf by KSADS-P ADHD-C 49% ADHD-I 51%
CD 14.6% Anxiety disorder 32.9%
LD 6.1% Major depressive disorder 29.3%
OCD 14.6% ODD 45.1%
Substance abuse disorder 29.3%
by KSADS-P
100%
Antshel & Remer (2003)
90M 30F
(75%)
8 to 12 (9.6)
AA 5% Asian 2%
C 93%
NP Mental health professionals referred children with
diagnosis + DSM-IV by DICA-R-P + attention
subscale CBCL >1.0 SD above norm
ADHD-I 49.16% ADHD-C 50.83%
Anxiety disorder 9.2% ODD 44.2%
Mood disorder 24.2% Tic disorders 4.2% by DICA-R-P
100%
Bloomquist et al. (1991)
36M 16F
(69.2%)
8 to 10a
C 95% NP Inattentive factor TRF
T-score ≥ 60 + Inattentive factor CBCL T-score ≥ 65 +
DICA-R-Ph
No CD and 35% ODD by DICA-R-P
NP
Brown et al. (1986)
28M 5F
(84.8%)
5 to13 (9.0)
NP NP DSM-IIIf by CTRS + CPRS ≥ 15
ADHD-I 24% ADHD-HI 76%
CD 16%i 100%
Choi & Lee (2015)
32M 40F
(44.4%)
9 to 13 (11.2)
Asian NP% (Korean study)
NP DSM-IVg + ADHD CBCL clinical range
NP 100%
125
Table 4. Description of Sample Characteristics (continued).
Study Total N
Male Female
and (% Male)
Age Range and
(Mean) in years
Ethnicity/Race
Parents’ Marital Status
ADHD Diagnosis Comorbidity % Concurrently on ADHD Meds during
psychosocial intervention
Corkum et al. (2010)
10M 6F
(62.5%)
8 to 11 (9.9)
C 100% NP School personnel referred children with previous diagnosis
h + CPRS-R:S and CTRS-R:S
No CD/ODD OCD 6.2% LD 12.5%
Tourette’s disorder 6.2% by parent reporti
56.25%
Evans et al. (2011)
35M 14F
(71.4%)
10 to 13a
AA 14% Asian 4%
C 70% H 12%
Divorced 19% Foster home parents 2%
Legally separated 6%
Married 55% Single parent 14%
Parent phone interview+ K-SADS+ parent and teacher
BASC and social or academic above the cut off IRS+ Du Paul
ADHD Rating Scalef
NP 52%
Frankel et al. (1997)b
34M 13F
(72.3%)
6 to 12a
AA 1.5% Asian 4.5%
C 88% H 4.5%
Mixed 1.5%b
NP DSM-III-R by ADHD Clinic Parent Interviewf
ODD 51.1% by ADHD Clinic Parent Interview
100%
Harrison et al. (2004)
41M 7F
(85.4%)
4 to 12a NPj
Married or coupled relationship 75% Single parent s or
guardians 25%
Previous diagnosis of DSM-IV ADHD + CTRS + CPRS ≥ 15
NP 76.92%
Haydicky et al. (2015)
13M 5F
(72.2%)
13 to 18 (15.5)
NPj Married or cohabitating 77% Single, Separated,
or Divorced 23% b
Previous DSMh diagnosis from mental health professional +
Inattentive factor Conners-3-P T-score ≥ 65 or
Hyperactive/Impulsive factor Conners-3-P T-score ≥ 65
ADHD-I 28% ADHD-HI 6%
No CD or ODD Anxiety disorder 6%
Depressive disorder 22% LD 67%
As disclosed by participants
61%
126
Table 4. Description of Sample Characteristics (continued).
Study Total N
Male Female
and (% Male)
Age Range and
(Mean) in years
Ethnicity/Race
Parents’ Marital Status ADHD Diagnosis Comorbidity % Concurrently
on ADHD Meds during psychosocial intervention
Haydicky et al. (2012)k
33Mc
(100%) 12 to 18a NP NP DSMh Inattentive factor CPRS
T-score ≥ 65 LD 100% inclusion criteria NP
Jensen & Kenny (2004)
14Mcd
(100%) 8 to 13a C 92.85%
Chinese 7.15%
NP DSM-IVg + Inattentive and Hyperactive/Impulsive factors
CPRS T-score > 65 ADHD-C 79% ADHD-I 21%
LD 21.4% ODD 21.4%
85.71%
Lufi & Parish-Plass (2011)
15Mc
(100%) 8 to 13 (10.8)
100% from Northern
Israel
NP DSM-IV-TRfg 0%
0%
Molina et al. (2008)
17 6F
(73.1%)
11 to 14 (12.9)
C 52.17% Minority 47.83%
Two-parent household 79%
Single parent 21%
DSM-IV by Du Paul ADHD rating scale + DISC-P + semi- structured
interview ADHD-I 50%
ADHD-C 43.47%
NP 25%
MTA Cooperative (1999)
465M 114F
(80.3%)
7 to 9 (8.5)
AA 20% C 61% H 8%
Two-parent household 69%
Single parent 30% Other 1%
DSM-IV ADHD-C f inclusion criteria
by 1 SD above mean on Hyperactivity factor CPRS + 1.5 SD above mean on Hyperactivity CTRS
+ DISC-P
Affective disorder 3.8% Anxiety disorder 33.5%
CD 14.3% Mania/hypomania 2.2 %
ODD 39.9% Other (bulimia, enuresis)
0.2% Tic disorder 10.9%
by DISC-P
100%
0%e
Pfiffner & McBurnett (1997)
19M 8F
(70.3%)
8 to 10 a AA 3.7%
C 96.3%
Two-parent household 92.6%
Single parent 7.4%
DSM-III-R by Barkley’s semistructured interview f + 1.5 SD above mean on either: Inattention or Hyperactivity/Impulsivity factor of CLAM-P or SNAP or T-score ≥ 60 attention problems subscale CBCL
Anxiety disorder 33.3% CD 11.1%
Dysthymic disorder 7.4% ODD 70.4%i
NP
Pfiffner et al. (2007)
46M 23F
(66.6%)
7 to 11 (8.7)
AA 6% Asian 16%
C 51% H 10%
Mixed 17%
Two-parent household 75%
Single parent 25%
DSM-IV ADHD-I inclusion criteria + KSADS-P
Anxiety disorder 12%, No CD, Depressive disorder 1%,
ODD 23%. By KSADS-P
5.5%
127
Table 4. Description of Sample Characteristics (continued).
Study Total N
Male Female
and (% Male)
Age Range and (Mean) in years
Ethnicity/Race
Parents’ Marital Status
ADHD Diagnosis Comorbidity % Concurrently on ADHD Meds during
psychosocial intervention
van de Weijer-Bergsma et al. (2012)
5M 5F
(50%)
11 to 15 (13.4)
NP Biological parents living
in same household
100%
DSM-IVi ADHD-C 50% ADHD-I 40%
ADHD-HI 10%
NP 10%
van der Oord et al. (2007)
40M 5F
(88.8%)
8 to 12 (9.9)
C 89% Caribbean 2%
Mixed 9%
NP DSM-IV by DISC-P ADHD-C 62% ADHD-I 32% ADHD HI 6%
CD 4% ODD 46% by DISC-P
100%
Villodas et al. (2014)
40M 17F
(70%)
7 to 10 (8.1)
AA 12% Asian 12%
C 40% H 11%
Mixed 21% Native
American 2%
Two-parent household
74% Single parent
26%
DSM-IV by clinically-elevated ADHD symptoms
CSI-P or CSI-T
ODD 51% by CSI-P or CSI-T
7%
Waxmonsky et al. (2010)
45M 11F
(80.3%)
6 to 12 (8.6)
AA 10.7% C 80.4%
8.9% Mixed
NP DSM-IV-TR f + parent and teacher DBD+
DISC-P ADHD-I 12.5% ADHD-HI 1.8% ADHD-C 85.7%
CD 39.3% ODD 42.9%
by DBD parent and teacher + DISC-P
100%
128
Note. † Since Abikoff et al., 2004a; 2004b; Hechtman et al., 2004a; 2004b; and Klein et al., 2004 used the same database, data from these five studies are displayed here. Abbreviations: AA= African American; ADHD-C = ADHD combined type; ADHD-HI = ADHD hyperactive/impulsive type; ADHD-I = ADHD inattentive type; BASC = Behavioral Assessment System for Children; C= Caucasian; CBCL= Child Behavioral Checklist Parent Rating; CBCT=Child Behavioral Checklist Teacher Rating; CSI-P= Child Symptom Inventory-Parent Interview; CSI-T= Child Symptom Inventory-Teacher Interview; CD= conduct disorder; CLAM-P= Revision of the Iowa Conners Scale -Parent interview; CPRS-R:S= Conners Parent Rating Scales Revised: Short Form; CTRS-R:S= Conners Teacher Rating Scale Revised: Short-Form; DBD= Disruptive Behavior Disorders Rating Scale; DISC-P = Diagnostic Interview Schedule for Children- Parent Interview; DICA-R-P= Diagnostic Interview for Children and Adolescents-Revised-Parent Version; H= Hispanic; IRS= Impairment Rating Scale; K-SADS = Kiddie Schedule for Affective Disorders and Schizophrenia; K-SADS-PL = Kiddie Schedule for Affective Disorders and Schizophrenia Parent Interview; NP = not provided in the study; ODD = oppositional defiant disorder; SNAP= Swanson, Nolan, and Pelham rating scale. a. Studies did not report the total sample mean age. b. Study had originally several groups of children, some without ADHD, and ethnicity was provided only for the entire sample. However, only outcome data for children with ADHD were extracted (leaving out data for non-ADHD children). c. Sample was 100% male. d. 5 participants acted as self-controls and were in both conditions. e. The MTA study had 2 intervention conditions; the first value corresponds to the Social Skills Training and ADHD Meds condition, and the second value to the Social Skills Training alone condition. f. Based on clinical interview by mental health practitioner to child and parents. g. Clinical diagnosis by psychologist, paediatrician, or other mental health professional h. Which DSM used is not stated. i. Not clearly stated how diagnosis was made. j. Ethnicity reported of parents (In Haydicky et al., 2015 as country of birth), not of children. k. Study had originally 3 groups of participants; data was extracted only for the ADHD-Inattentive subgroup
129
Table 5. Description of the Interventions.
Study Child intervention component
Frequency & Length of Intervention Primary/Follow-up
Characteristics of intervention Mode of delivery Location of delivery Concurrent intervention components
Group Individual Self-directed
Clinic School Home ADHD Meds
Parent involvement
Teacher consultation
Abikoff et al. (2004a)†
SST Bi-weekly 96 weeks
√ √ √ √ √
Abikoff et al. (2004b)†
SST Bi-weekly 96 weeks
√ √ √ √ √
Antshel et al. (2014)
CBT Once/week 16 weeks
√ √ √ √ √
Antshel & Remer (2003)
SST Once/week 8 weeks/3 months
√ √ √
Bloomquist et al. (1991)
CBT Bi-weekly 10 weeks/6 weeks
√ √ √ √ √ √
Brown et al. (1986)
CBT Bi-weekly 22 weeks/3 months
√ √ √ √
Choi & Lee (2015) SST-EMT Once/week 16weeks
√ √
Choi & Lee (2015) SST Once/week 16weeks
√ √
Corkum et al. (2010)
SST Once/week 10weeks
√ √ √ √
Evans et al. (2011) SST Bi-weekly 20weeks
√ √ √ √ √ √
Frankel et al. (1997)
SST Once/week 12weeks
√ √ √
Harrison et al. (2004)
MD Bi-weekly 6weeks
√ √ √ √ √
Haydicky et al. (2015)
MD Once/week 8weeks/6weeks
√ √ √ √ √
Haydicky et al. (2012)
MD Once/week 20weeks
√ √ √ √ √ √
130
Table 5. Description of the Interventions (continued).
Study Child intervention
component Frequency & Length of Intervention Primary/Follow-up
Characteristics of intervention
Mode of delivery Location of delivery Concurrent intervention components
Group Individual Self-directed
Clinic School Home ADHD Meds
Parent involvement
Teacher consultation
Hechtman et al. (2004a)†
SST Bi-weekly 96 weeks
√ √ √ √ √
Hechtman et al. (2004b)†
SST Bi-weekly 96 weeks
√ √ √ √ √
Jensen & Kenny (2004)
MD Once/week 20 weeks
√ √
Klein et al. (2004)† SST Bi-weekly 96 weeks
√ √ √ √ √
Lufi & Parish-Plass (2011)
SST Once/week 20 weeks/1 year
√ NR NR NR
Molina et al. (2008) SST Bi-weekly 10 weeks
√ √ √ √
MTA Cooperative (1999)
SST Daily 8 weeks*
√ √ √ √ √ √
MTA Cooperative (1999)
SST Daily 8 weeks*
√ √ √ √ √ √ √
Pfiffner & McBurnett (1997)
SST Once/week 8 weeks/4 months
√ √ √ √
Pfiffner & McBurnett (1997)
SST Once/week 8 weeks/4 months
√ √
Pfiffner et al. (2007) SST Once/week 12 weeks/5 months
√ √ √ √ √ √
van de Weijer-Bergsma et al. (2012)
MD Once/week 8 weeks/4 months
√ √ √ √ √
131
Table 5. Description of the Interventions (continued).
Note. † Studies report on different outcomes evaluated during the same intervention provided to the same sample of participants. * Child component was 8-weeks long, however, post measures were taken at 56 weeks (or 14 months) after pre-test, once the parent and teacher treatment components were also completed. Abbreviations. CBT= cognitive behavioural therapy; EMT=emotion management training; MD = mindfulness training; NR= not reported; SST = social skills training.
Study Child intervention component
Frequency & Length of Intervention Primary/Follow-up
Characteristics of intervention Mode of delivery Location of delivery Concurrent intervention components
Group Individual Self-directed
Clinic School Home ADHD Meds
Parent involvement
Teacher consultation
van der Oord et al. (2007)
CBT Once/week 10 weeks
√ √ √ √ √ √ √
Villodas et al. (2014)
SST Once/week 10 weeks
√ √ √ √ √ √
Waxmonsky et al. (2010)
SST Once/week 8 weeks
√ √ √ √ √ √
132
Table 6. Results of Child-Focused Psychosocial Intervention Studies by Intervention Type.
Study Interventions Compared
Child Functioning Resultsb
Self-reported Parent-reportedc Teacher-reported Follow-up Results and Comments
Abikoff et al. (2004a)†
SST+Meds, Meds,
Meds+ EC
Social skills total – no group differences, all groups improved equally
Social skills total– no group differences, all groups improved equally
Social problems– no group differences, all groups improved equally
F values not provided.
Abikoff et al. (2004b)†
SST+Meds, Meds,
Meds+ EC
Hyperactivity (p < .01) Number of, or Severity (p < .02) of home problematic situations (p = .04)
CD, Hyperactivity, Number of, or Severity of school problematic situations – ns.
F values not provided.
Antshel et al. (2014)
Ind CBT Hyperactivity (d = 26) Inattention (d = .78) Emotional symptoms (d = .30) Internalizing (d = .37)
Hyperactivity (d = .41) Inattention (d = 1.02) Externalizing (d = .85) Family relations (d = 1.00) Internalizing (d = .65) Peer relations (d = 1.51) Parent-child relations (d = .78) Sibling relations (d = .09)
Hyperactivity (d = .61) Inattention (d = 1.39) Externalizing (d = .64) Internalizing (d = .16) Peer relations (d = .32)
t-values not provided.
Antshel & Remer (2003)
SST, WL
Assertion (F (1, 118) = 19.42, p ≤ .001, η2 = .15, RCIg = 4.02) Cooperation, Self-control and Responsibility – ns
Assertion (F (1, 118) = 16.11, p ≤ .001, η2 = .13, RCIg = 2.39) Cooperation, Self-control and Responsibility – ns.
Self and Parent reported Assertion at 3m follow-up F
(1, 118) = 16.55, p ≤ .001, η2 = .12, RCI = 3.42) and F
(1, 118) = 14.97, p ≤ .001, η2 = .11, RCI = 2.10) respectively.
Bloomquist et al. (1991)
Group CBT, TC, WL
Inattention, Hyperactivity, or Impulsivity, CD, Peer preferred social behaviour, and Social competence all ns.
Groups did not differ from each other on any measure at 6-week follow up either. MANOVAS calculated by aggregating CD with core ADHD symptoms and CD. Peer preferred social behaviour and social competence were also combined with other variables that are out of the scope of interest of this review.
133
Table 6. Results of Child-Focused Psychosocial Intervention Studies by Intervention Type (continued).
Study Interventions
Compared Child Functioning Resultsb
Self-reported Parent-reportedc Teacher-reported Follow-up Results and Comments
Brown et al. (1986)
Ind CBT + Meds, Meds,
PMeds, EC+PMeds
Hyperactivity (F (2, 28) = 1.68, ns)
Hyperactivity (F (2, 20) = 2.32, ns) Inattention (F (2, 20) = 0.32, ns) Impulsivity (F (2, 19) = 0.81, ns). ODD (F (2, 20) = 0.08, ns) Self-control (F (2, 20) = 1.29, ns) Social skills total (F value not available, ns).
Medication was discontinued during the week that the children were evaluated at post-test; authors suggest that children may have been dysphoric following discontinuation, which could explain why no improvements on the core ADHD symptoms were present on the medication management conditions either.
Choi & Lee (2015)
SST, SST-EMT,
WL
Anxiety (F = 6.81, p < .01, η2 =. 16) SST>WL Depression and Cooperation – ns (EMT=SST=WL) Initiative (F = 7.19, p < .001, η2 = . 35) Social skills total (F = 6.68, p < .01, η2 = . 31)- EMT > WL Expressive reluctance (F = 3.23, p < .05, η2 = . 39) Poor emotional awareness (F = 4.93, p < .05 η2 = . 34) EMT > SST> WL
No degrees of freedom for the ANOVAs provided.
Corkum et al. (2010)
SST Social skills total (t(15) = -1.88, p= .08)
Social skills total (t(11) = -2.37, p= .04)
Social skills total (t(15) = -2.11, p= .05)
Evans et al. (2011)
SST, CC
Hyperactivity/impulsivity t(163)
= -3.37, p < .01, d = -1.03) Inattention and Peer relations - ns
Hyperactivity/impulsivity, Inattention, and Peer relations– ns
No statistics provided for non-significant findings.
Frankel et al. (2007)
SST, WL
Assertion (F (1, 50) = 11.12, p <
.01, = 1.10) Self-control F (1, 37, η2= 3.12, p
< .05, η2 = 1.34)
134
Table 6. Results of Child-Focused Psychosocial Intervention Studies by Intervention Type (continued).
Study Interventions
Compared Child Functioning Resultsb
Self-reported Parent-reportedc Teacher-reported
Follow-up Results and Comments
Harrison et al. (2004)
MD ADHD Index (t = 8.23, p < .001) Conflict in the parent-child relation (t = 3.08, p < .01) Open communication in parent-child relation (t = -1.20, ns). Quality of the parent-child attachment relationship (t = -3.34, p < .01) Warmth (t = -0.82, ns)
Reductions of parent-reported ADHD symptoms were similar for the children who were concurrently on ADHD medication to those for the children who were not on medication.
Haydicky et al. (2015)
MD Hyperactivity/impulsivity, Inattention, CD, and number or the intensity of conflicts with parent - ns. ODD (t = -1.91, p = .219, d = -.45) Anxiety (t = 2.27, p = .111, d = .54) Depression (t = 1.83, p = .256, d = .43), Internalizing (t = 2.28, p = 1.08, d = .54) Family relations (t = -1.43, p = .509, d = -34).
Hyperactivity/impulsivity, Anxiety, Depression, Family relations, Internalizing, Number or Intensity of conflicts with child, and ODD - ns. Inattention (t = 2.49, p = .74, d = .62) CD (t = 2.80, p = .40, d = .70) Peer relations (t = 4.28, p = .002, d = 1.07)
Parent reported inattention at 6 weeks follow-up (t (14) = 0.74, p < .5, d =. 20). Adolescents maintained reductions in peer relationship problems at follow-up, and reported significant changes at follow-up in anxiety (d = 1.02), depression (d = .64), and internalizing problems (d = 1.01).
Haydicky et al. (2012)e
MD, WL
ADHD Index (F (1, 25) = 0.13, p = .73,
η2 = 0.01) CD (F (1, 25) = 1.20, p = .28, η2 = 0.05), Externalizing (F (1, 25) = 2.20, p = .15,
η2 = 0.08) ODD (F (1, 25) = 0.2, p = .88, η2 = 0.00) Social problems (F (1, 25) = 0.07, p = .80, η2 = 0.00)
ADHD Index (F (1, 23) = 2.63, p = .12,
η2 = 0.10) CD (F (1, 23) = 1.68, p = .21, η2 = 0.07) Externalizing (F (1, 23) = 2.36, p = .14,
η2 = 0.09) ODD (F (1, 23) = 1.96, p = .018, η2 = 0.08). Social problems MD > WL (F (1, 23) = 4.99, p = .04, η2 = 0.18)
Hechtman et al. (2004a)†
SST+Meds, Meds,
Meds+ EC
Improvement in child’s perception of both Father negative parenting and Mother negative parenting (p < .05). Child’s perception of Father and Mother positive parenting – ns.
F values not provided.
Hechtman et al. (2004b)†
SST+Meds, Meds,
Meds+ EC
Depression (p < .0001) F values not provided.
135
Table 6. Results of Child-Focused Psychosocial Intervention Studies by Intervention Type (continued).
Study Interventions
Compared Child Functioning Resultsb
Self-reported Parent-reportedc Teacher-reported Follow-up Results and Comments Jensen & Kenny (2004)f
MD + Meds, EC + Meds
ADHD Index, Inattention, and Impulsivity, and Psychosomatic symptoms – ns.
Global Index Restless Impulsive (p = .008, d = .73), Emotional symptoms (p = .003, d = .77) and ODD (p = .001, d = .79) MD > EC Hyperactivity (p = .004, d = .39) and Social problems (p = .034, d = .85) EC > MD Anxiety (p = .028, d = .59) and Perfectionism (p = .32, EC p = .028, d = .58) MD = EC
Hyperactivity, Inattention, Anxiety, Emotional symptoms, ODD, Perfectionism, Social problems, and Psychosomatic symptoms – ns.
Lufi & Parish-Plass (2011)e
SST Reductions of Anxiety and Somatic symptoms. Inattention, Internalizing symptoms, Aggression, Thought problems, Withdrawal, Delinquency, Externalizing, and Social problems - ns
Reductions of Hyperactivity, Inattention, Aggression, Anxiety, Delinquency, Externalizing, and Social problems. Internalizing, Somatic symptoms, Thought problems, or Withdrawal - ns.
F values not provided since the study compared an ADHD group with a group of children with other behavioural problems. Data from this study was extracted as a within-subject design. Decreases in parent and self-reported Anxiety at 1-year follow-up
Molina et al. (2008)
SST, CC
Aggression (F (1, 18) = 3.47, p <
.10, d = .34). Emotional symptoms (F (1, 18) = 2.18, p > .05, d = .59)
Externalizing (F (1, 18) = 1.71, p
> .05). Internalizing (F (1, 18) = 5.48, p
< .05, d = .55)
136
Table 6. Results of Child-Focused Psychosocial Intervention Studies by Intervention Type (continued).
Study Interventions
Compared Child Functioning Resultsb
Self-reported Parent-reportedc Teacher-reported Follow-up Results and Comments MTA Cooperative (1999)
SST, SST+Meds,
Meds, CC
Anxiety (F (3, 529) = 0.6, p = .65)
Hyperactivity/impulsivity F (3, 609)= 21.5, p <. 001) and Inattention (F (3, 669)= 21.5, p <. 001) SST+Meds >CC Meds> CC Meds > SST Internalizing (F (3, 883) = 9.2, p < .001) SST+Meds > CC SST+Meds > SST SST = Meds ODD (F (3, 892)= 7.4, p <. 001) SST = Meds SST+Meds > SST SST+Meds > CC Personal closeness in parent-child relations (F (3, 908) = 2.0, p = .0008) all treatment groups > CC Social skills total (F (3, 887) = 2.2, p = .09) SST = Meds SST+Meds = SST SST+Meds = Meds
Hyperactivity/impulsivity (F (3, 669)= 10.0, p <. 001) and Inattention (F (3, 666)= 10.6, p <. 001) SST+Meds >CC Meds> CC Meds > SST Internalizing (F (3, 679) = 12.1, p = .10) SST = Meds ODD (F (3, 663)= 6.5, p <. 0003) SST = Meds Social skills total (F (3, 668) = 6.1, p = .0004) SST = Meds All treatment groups > CC
Pfiffner & McBurnett (1997)
SST,
SST+PC+TC, WL
Social skills knowledge t (1) = 5.83, p < .0001; d = 2.39)
Problem Behaviour composite aggregating Externalizing, Behaviour problemsh, and Internalizing was calculated and the pooled treatment group (SST and SST+PC+TC) (t (1) = - 1.85, p = .38; d = -0.76). 2 SST conditions t (1)= 0.14, p > 1; d = 0.07) Social skills total t (1)= 5.71, p < .0001; d = 2.34) SST groups > WL 2 SST conditions t (1)= 0.32, p > 1; d = 0.15).
Problem Behaviour the 2 SST groups (t (1) = 0.76, p > .1; d = 0.36). Social skills total (t (1) = 1.23, p > 1) (d = 0.5) 2 SST groups (t (1) = 0.77, p > .1; d = 0.36).
Analyses conducted used composites within domains. Parent rated Social skills total increases in the 2 SST groups sustained at 4m follow-up SST+PC+TC t (8)= - 6.08, p < .001; d = - 2.03), and SST t (8)= - 3.58, p < .01; d = - 1.19). Parent rated Problem Behaviour composite decreases at 4m follow-up SST+PC+TC t (8)= - 1.94, p < .045; d = 0.65), and SST t (8) = 3.01, p < .01; d = 1.0). Teacher rated Social skills total improved from pre-test to 4m follow-up on the SST+PC+TC group t (8)= - 3.01 p < .01; d = 1.0 but not on the SST alone t (8)= 0.24, p > .1; d = 0.08).
137
Table 6. Results of Child-Focused Psychosocial Intervention Studies by Intervention Type (continued).
Study Interventions
Compared
Child Functioning Resultsb Self-reported Parent-reportedc Teacher-reported Follow-up Results and
Comments Pfiffner et al. (2007)
SST, CC Social skills knowledge F (1, 434 = 61.39= p = .0001; η2 = .644)
van de Weijer-Bergsma et al. (2012)
MD Inattention (t (9) = -1.8, ES = 0.5, ns), Externalizing (t (9) = 0.9, ES = 0.1, ns), Internalizing (t (9) = -0.6, ES = 0.1, ns) Fatigue (t (9) = 1.6, ES = 0.0, ns).
Inattention (t (8) = -0.7, ES = 0.1, ns), Externalizing (t (9) = 1.0, ES = 0.2, ns), or Internalizing (t (9) = -0.7, ES = 0.1, ns).
Inattention (t (6) = -1.7, ES = 0.3, ns) Externalizing (t (6) = -1.1, ES = 0.2, ns), Internalizing (t (6) = -0.7, ES = 0.2, ns).
At 4-months follow-up adolescents reported internalizing (95% CI -7.06 to .073, p = .09)
van der Oord et al. (2007)
Group
CBT+Meds, Meds
Anxiety (F (1,43) = 14.49, p ≤ .01, η2 = 0.25).
ADHD (time effects (F (1,39) = 56.26, p ≤ .01, η2 = 20.59) CD (F (1,42) = 14.09, p ≤ .01, η2 =0.24), ODD (F (1,42) = 14.09, p ≤ .01, η2 =0.25) Social skills total F (1, 35) = 19.80, p ≤ .01, η2
=0.36)
ADHD (F (1,40) = 44.85, p ≤ .01, η2 = 0.53) or CD F (1, 38) = 13.55, p ≤ .01, η2 =0.26), ODD (F (1,41) = 18.90, p ≤ .01, η2 =0.31) Social skills total F (1, 39) = 22.65, p ≤ .01, η2 =0.37)
All participating children were medication naïve at baseline. No evidence was found for the additive effect of CBT to medication management treatment.
Villodas et al. (2014)
SST Social skills knowledge (z = 15.02, p < .001, ES = 1.55)
ADHD Index (z = 6.74, p < .001, ES = 1.09) Behaviour problemsh (z = 6.62, p < .001, ES = .87) ODD (z = 4.25, p < .001, ES = .59) Parent-child relation impairment (z = 7.91, p < .001, ES = .64) Peer relation impairment (z = 3.84, p < .001, ES = .36) Social skills total (z = 6.60, p < .001, ES = .66)
ADHD Index (z = 11.45, p < .001, ES = 1.23) Behaviour problemsh(z = 2.62, p = .009, ES = 47) ODD (z = 2.72, p = .006, ES = 30) Peer relation impairment (z = 2.59, p = .10, ES = 47) Social skills total (z = 5.76, p < .001, ES = 60)
Waxmonsky et al. (2010)
SST+Meds, Meds
Depression (d = 0.51) (F (1, 47) = 4.72 = p = .0842). SST+ Meds > Meds Suicidal ideation (d = 0.49) SST+ Meds = Meds
Hyperactivity/impulsivity (F (1, 54) = 2.72 = p = .10) (d = 0.54), and Inattention (F (1, 46) = 7.35 = p = .0094) (d= 0.54) Meds >SST+ Meds Behaviour problemsh F (1, 46) = 316.73 = p = .0002 (d = 0. 56) and Sibling relations F (1, 47) = 2.76 = p = .10) (d = 0.38) SST+ Meds > Meds. ODD F (1, 46) = 3.76 = p = .0585) (d= 0. 37), CD (d = 0.00), Peer relations (d = 0.09), Parent-child relations (d = -0.05), Family Relations d = -0.01) and Social skills total (d = -0.13) SST+ Meds = Meds
Hyperactivity/impulsivity (d =- 0.06) Meds >SST+ Meds Inattention (d = 0.29) and ODD (d = 0.18) SST+ Meds > Meds Behaviour problemsh (d = 0. 10), CD (d = 0.00), Peer relations (d = 0.02) and Social skills total (d =
-0.08) SST+ Meds = Meds
138
Note. In this table statistics were reported (e.g., p values) as detailed as reported in the original studies. Klein et al. (2004) was not included in this table because this reference is a description of the sample in Abikoff et al. (2004a, b) and Hetchman et al. (2004a, b). Abbreviations: C= Control Group; CBT= Cognitive Behavioural Therapy; CC= Community Care; CD= Conduct Disorder; EC= Equivalent control psychosocial treatment without the core therapeutic components; Ind= Individual; EMT= Emotion Management Training; FT(number)= Family Therapy(number of sessions included); m= months; Meds= ADHD Medications; MD= Mindfulness Training; NP=not provided in the study; ODD= Oppositional Defiant Disorder ; PC=Parent Treatment Component; PMeds=Placebo ADHD Medications; RCT= Randomized Controlled Trial; SST= Social Skills Training; (T)=Treatment Group; TC=Teacher Consultation; WL=Wait-list control. a. As measured by the Quality Assessment Tool for Quantitative Studies developed by the Effective Public Health Practice project (EPHPP; Armijo-Olivo et al. 2012), where a rating of Strong: no weak ratings, Moderate: 1 weak rating, Weak: 2 or more weak ratings. b. Outcomes relevant to this systematic review. For example Pfiffner et al. (2007) reported on parent-teacher composites of social skills and core ADHD symptoms that were not included because they are not in the scope of this review. c. Because the majority of the studies of treatments involving children or adolescents with ADHD are based on data from mothers (Barkley, 2015), and most studies do not indicate which parent filled in the "parent measures", when two parental ratings were provided, mother reports were used. d. Study did not report sample mean age. e. The subgroup of children with LD and ADHD-Inattentive Type was used here. f. It is originally a between-groups study design, wherein a group of children with ADHD was compared to children with other behaviour and emotional problems, but for the purpose of this systematic review, only the data for the group of children with ADHD has been extracted (n =15) as a within-subject design. g. Reliable Change Index (RCI) (1.96 or greater indicates clinical significance at an alpha level of .05) used to assessed magnitude of change attributable to SST. h. It is a measure of the combination of internalizing and externalizing symptoms.
139
Table 7. Meta-analyses Results. Cognitive Behavioural Therapy Interventions, Between-Group Design Studies, Teacher-Reported Conduct Disorder Symptoms.
Outcome Variable
Source Hedges's g (95% CI) Sample Size (Control/Intervention)
Forest Plot Effect Size 95% CI
Teacher- reported CD symptoms
van der Oord et al. (2007) 0.15 (-0.44 to 0.74) 21 24
Bloomquist et al. (1991) -0.09 (-0.89 to 0.72) 13 11
0.07 (-0.41 to 0.54), I2 = 0% 34 35
Favouring control
group
Favouring treatment group
Note. Sample size as reported at post-test.
-1.50 -0.50 0.50 1.50
140
Table 8. Meta-analyses Results. Mindfulness Training Interventions, Within-Subject Design Studies, Self and Parent-Reported Inattention and Internalizing Symptoms.
Outcome Variable Source Hedges's g (95% CI) Sample Size
Forest Plot Effect Size 95% CI
Self-reported inattention symptoms
Haydicky et al. (2015) 0.16 (-0.3 to 0.63) 18 van de Weijer-Bergsma et al. (2012)
-0.57 (-1.24 to 0.10) 10
0.16 (-0.87 to 0.55), I2 = 0% 28 Parent-reported inattention symptoms
Haydicky et al. (2015) -0.15 (-0.63 to 0.33) 17 van de Weijer-Bergsma et al. (2012)
-0.22 (-0.85 to 0.41) 10
-0.18 (-0.56 to 0.2), I2 = 0% 27 Self-reported internalizing symptoms
Haydicky et al. (2015) -0.54 (-1.03 to -0.04) 18 van de Weijer-Bergsma et al. (2012)
-0.19 (-0.82 to 0.44) 10
-0.4 (-0.79 to -0.02), I2 = 0% 28 Parent-reported internalizing symptoms
Haydicky et al. (2015) -0.01 (-0.50 to 0.48) 16 van de Weijer-Bergsma et al. (2012)
-0.22 (-0.85 to 0.41) 10
-0.09 (-0.48 to 0.3), I2 = 0% 26
Improvement Decline
Note. Sample size as reported at post-test.
-1.50 -0.50 0.50 1.50
141
Table 9. Meta-analyses Results. Social Skills Training Interventions, Between-Group Design Studies, Parent and Teacher-Reported Internalizing Symptoms.
Outcome Variable
Source Hedges's g (95% CI) Sample Size (Control/Intervention)
Forest Plot Effect Size 95% CI
Parent-reported internalizing symptoms
Molina et al., 2008 0.48 (-0.38 to 1.34) 9 11 Pfiffner & McBurnett, 1997 0.38 (-0.51 to 1.27) 9 9 MTA Cooperative, 1999 0.00 (-0.25 to 0.25) 120 127 MTA Cooperative, 1999 0.12 (-0.12 to 0.36) 125 131 0.09 (-0.08 to 0.26), I2=0% 263 278
Teacher-reported internalizing symptoms
Pfiffner & McBurnett, 1997 0.20 (-0.68 to 1.08) 9 9 MTA Cooperative, 1999 -0.11 (-0.38 to 0.16) 99 108 MTA Cooperative, 1999 0.26 (-0.01 to 0.53) 105 102 0.09 (-0.20 to 0.37), I2 = 0% 213 219
Favouring
control group Favouring
intervention group
Note. Sample size as reported at post-test.
-2.00 -1.00 0.00 1.00 2.00
142
Table 10. Meta-analyses Results. Social Skills Training Interventions, Between-Group Design Studies, Parent and Teacher-Reported Externalizing Symptoms and
Behavioural Problems.
Outcome Variable Source Hedges's g (95% CI) Sample Size (Control/Intervention)
Forest Plot Effect Size 95% CI
Parent-reported externalizing symptoms
Molina et al., 2008 0.29 (-0.56 to 1.14) 9 11
Pfiffner & McBurnett, 1997 1.48 (0.48 to 2.49) 9 9
0.86 (-0.31 to 2.02), I2 = 0% 18 20
Parent-reported ODD symptoms
Waxmonsky et al., 2010 0.35 (-0.17 to 0.87) 27 29
MTA Cooperative, 1999 0.26 (0.01 to 0.51) 121 133
MTA Cooperative, 1999 0.08 (-0.16 to 0.33) 130 129
0.19 (0.03 to 0.35), I2 = 0% 278 291
Teacher-reported ODD symptoms
MTA Cooperative, 1999 0.04 (-0.21 to 0.29) 128 119
MTA Cooperative, 1999 0.06 (-0.19 to 0.30) 120 134
Waxmonsky et al., 2010 0.21 (-0.31 to 0.73) 27 29
0.06 (-0.1 to 0.23), I2 = 0% 275 282
Teacher-reported CD symptoms
Abikoff et al., 2004 0.00 (-0.47 to 0.47) 34 34
Waxmonsky et al., 2010 0.00 (-0.52 to 0.52) 27 29
0.00 (-0.35 to 0.35), I2 = 0% 61 63
Parent-reported behaviour problems
Pfiffner & McBurnett, 1997 1.55 (0.53 to 2.56) 9 9
Waxmonsky et al., 2010 0.47 (-0.06 to 0.99) 27 29
0.92 (-0.13 to 1.96), I2 = 0% 36 38
Teacher-reported behaviour problems
Pfiffner & McBurnett, 1997 0.37 (-0.52 to 1.25) 9 9
Waxmonsky et al., 2010 0.10 (-0.42 to 0.61) 27 29
0.16 (-0.28 to 0.61), I2 = 0% 36 38
Favouring control
group Favouring treatment
group
Note. Sample size as reported at post-test. Behaviour problems are a combination of internalizing and externalizing symptoms.
-1.50 -0.50 0.50 1.50 2.50 3.50
143
Table 11. Meta-analyses Results. Social Skills Training Interventions, Within-Subject Design Studies, Parent and Teacher-Reported Social Skills.
Outcome Variable Source Hedges's g (95% CI) Sample Size
Forest Plot Effect Size 95% CI
Parent-reported social skills total
Corkum et al. (2010) 0.56 (0.06 to 1.07) 16
Villodas et al. (2014) 0.86 (0.56 to 1.16) 57
0.78 (0.52 to 1.04), I2 = 0% 83 Teacher-reported social skills total
Corkum et al. (2010) 0.50 (0.00 to 1.00) 16
Villodas et al. (2014) 0.75 (0.46 to 1.04) 57
0.69 (0.44 to 0.94), I2 = 0% 83
Decline Improvement
Note. Sample size as reported at post-test.
-1.50 -0.50 0.50 1.50
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Table 12. Meta-analyses Results. Social Skills Training Interventions, Between-Group Design Studies, Parent, Teacher, and Self-Reported Social Skills and Peer
Relations.
Outcome Variable
Source Hedges's g (95% CI) Sample Size (Control/Intervention)
Forest Plot Effect Size 95% CI
Parent-reported assertion social skills
Antshel, & Remer, 2003 -0.90 (-1.29 to -0.50) 40 80 Frankel et al., 1997 -0.86 (-1.52 to -0.19) 12 35 -0.89 (-1.23 to -0.55), I2 = 0% 52 115
Parent-reported self-control social skills
Antshel, & Remer, 2003 -0.26 (-0.64 to 0.12) 40 80 Frankel et al., 1997 -1.06 (-1.74 to -0.38) 12 35 -0.61 (-1.39 to 0.17), I2 = 0% 52 115
Parent-reported social skills total
Klein et al., 2004 -0.40 (-0.87 to 0.07) 34 34 Pfiffner & McBurnett, 1997 -1.32 (-2.30 to -0.34) 9 9 MTA Cooperative, 1999 -0.19 (-0.44 to 0.06) 120 127 MTA Cooperative, 1999 0.00 (-0.24 to 0.24) 125 131 Waxmonsky et al., 2010 0.14 (-0.38 to 0.65) 27 29 -0.19 (-0.46 to 0.08), I2 = 35% 315 330
Teacher-reported social skills total
Pfiffner & McBurnett, 1997 -0.40 (-1.29 to 0.49) 9 9 MTA Cooperative, 1999 -0.03 (-0.30 to 0.24) 105 102 MTA Cooperative, 1999 -0.13 (-0.40 to 0.14) 99 108 Waxmonsky et al., 2010 0.08 (-0.44 to 0.60) 27 29 -0.07 (-0.25 to 0.10), I2 = 0% 240 248
Parent-reported peer relations
Waxmonsky et al., 2010 0.09 (-0.42 to 0.61) 27 29 Evans et al., 2011 -0.42 (-1.00 to 0.16) 18 31 -0.15 (-0.65 to 0.35), I2 = 0% 45 60
Teacher-reported peer relations
Evans et al., 2011 0.06 (-0.52 to 0.63) 18 31 Waxmonsky et al., 2010 0.03 (-0.49 to 0.54) 27 29 0.04 (-0.34 to 0.42), I2 = 0% 45 60
Self-reported social skills knowledge
Pfiffner & McBurnett, 1997 -1.67 (-2.71 to -0.64) 9 9 Pfiffner et al., 2007 -2.48 (-3.33 to -1.63) 16 21 -2.13 (-2.92 to -1.35), I2 = 0% 25 30
Favouring treatment group
Favouring control group
Note. Sample size as reported at post-test.
-4.00 -2.00 0.00 2.00
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Table 13. Meta-analyses Results. Social Skills Training Interventions, Between-Group Design Studies, Parent and Teacher-Reported Inattention and
Hyperactivity/Impulsivity Symptoms.
Outcome Variable Source Hedges's g (95% CI) Sample Size (Control/Intervention)
Forest Plot Effect Size 95% CI
Parent-reported inattention symptoms
Waxmonsky et al., 2010 0.72 (0.18 to 1.25) 27 29 Evans et al., 2011 -0.15 (-0.72 to 0.42) 18 31 MTA Cooperative, 1999 0.15 (-0.10 to 0.39) 121 133 MTA Cooperative, 1999 0.13 (-0.11 to 0.38) 130 129 0.19 (-0.05 to 0.42), I2 = 25% 296 322
Teacher-reported inattention symptoms
Evans et al., 2011 -0.07 (-0.64 to 0.50) 18 31 MTA Cooperative, 1999 -0.01 (-0.26 to 0.23) 120 134 MTA Cooperative, 1999 0.01 (-0.24 to 0.26) 128 119 Waxmonsky et al., 2010 0.32 (-0.20 to 0.84) 27 29
0.02 (-0.14 to 0.18), I2 = 0% 293 313 Parent-reported hyperactivity/ impulsivity symptoms
Waxmonsky et al., 2010 0.51 (-0.01 to 1.04) 27 29 Evans et al., 2011 0.34 (-0.24 to 0.92) 18 31 MTA Cooperative, 1999 -1.47 (-1.74 to -1.19) 121 133 MTA Cooperative, 1999 0.15 (-0.09 to 0.40) 130 129 -0.13 (-1.14 to 0.88), I2 = 0% 296 322
Teacher-reported hyperactivity/ impulsivity symptoms
Evans et al., 2011 -0.25 (-0.82 to 0.33) 18 31 MTA Cooperative, 1999 0.10 (-0.15 to 0.35) 120 134 MTA Cooperative, 1999 0.19 (-0.06 to 0.43) 128 119 Waxmonsky et al., 2010 -0.07 (-0.58 to 0.45) 27 29 0.09 (-0.07 to 0.25), I2 = 0% 293 313
Favouring control group
Favouring intervention group
Note. Sample size as reported at post-test.
-2.00 -1.00 0.00 1.00 2.00
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5555 DISCUSSIONDISCUSSIONDISCUSSIONDISCUSSION
The purpose of this dissertation was to assess the efficaciousness of child-focused psychosocial
interventions for children and adolescents with ADHD that are purported to reduce their
internalizing and externalizing symptoms and behaviours, and/or improve their social skills, peer
relationships and family functioning. For this purpose, a systematic review of previous studies
was conducted. My intention in undertaking this systematic review was to be able to provide
clinicians with guidelines for treatment for children and adolescents with ADHD with specific
associated symptoms, functional impairments, and comorbid disorders. Although studies solely
evaluating core ADHD symptom outcomes were not eligible, when provided in an eligible study,
data for core ADHD symptoms were extracted and analyzed. As discussed below, in spite of
identifying 26 studies that met criteria for this review, the data were insufficient to meet my goal
to recommend, with confidence, any specific child-focused psychosocial intervention to treat
specific child problems or to achieve specific outcomes.
In this chapter, I discuss the findings in relation to cognitive behavioural therapy (CBT; 4
studies), mindfulness training (5 studies), and social skills training (SST) interventions (17
publications, 13 studies). As discussed further in the limitations section, no studies on family
therapy met inclusion criteria for this review. I intended to conduct meta-analyses for every
outcome examined in this systematic review; however, given the heterogeneity of the outcomes
being measured in the included studies, only a few meta-analyses were possible. None of the
outcomes were comparable for individual CBT, one for group CBT, four for mindfulness
training, and 21 for SST. Additionally, each of the meta-analyses comprised five or fewer
studies. Meta-analyses may be applied to as few as two studies (Lipsey & Wilson, 2001);
however, with very few studies, meta-analytic data can be unstable (Rosenthal, 1995). Therefore,
a descriptive approach to understanding the findings of the studies was also incorporated.
To be able to conduct moderator analyses, two conditions need to be met: there has to be
sufficient sample of studies to be subgrouped, as well as sufficient variability in the potential
moderators. As these conditions were not met, a descriptive approach to the potential variables
that might moderate response to CBT, mindfulness training, and SST interventions was included.
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This chapter also includes a description of the limitations of this review. Although I cannot
conclude with recommendations for clinical practice, as intended, this review generated several
directions for further research, which are discussed in detail.
5.15.15.15.1 Cognitive Behavioural Therapy InterventionsCognitive Behavioural Therapy InterventionsCognitive Behavioural Therapy InterventionsCognitive Behavioural Therapy Interventions
Of the 26 included studies in this systematic review, four described 10- to 16-week long CBT
interventions (Antshel et al., 2014; Bloomquist et al., 1991; Brown et al., 1986; van der Oord et
al., 2007). Two of the studies (Antshel et al., 2014; Brown et al., 1986) involved individual CBT
treatment, and two involved group CBT treatment (Bloomquist et al., 1991; van der Oord et al.,
2007).
5.1.15.1.15.1.15.1.1 Individual Cognitive Behavioural TherapyIndividual Cognitive Behavioural TherapyIndividual Cognitive Behavioural TherapyIndividual Cognitive Behavioural Therapy
Two studies evaluated the efficaciousness of individual CBT. In Antshel et al. (2014), a CBT
intervention was evaluated with a strong parent involvement component in the adolescents’
treatment. In Brown et al. (1986), a CBT intervention administered concurrently with a
pharmacological treatment, was evaluated in comparison to three groups (a medication only
group, a medication placebo group, and an attention control/medication placebo group). The
individual CBT interventions had the goal of reducing core ADHD symptoms of inattention and
hyperactivity and improving other social and family functioning outcome domains. Additionally,
when combined with medication, the goal of individual CBT was to improve the maintenance of
treatment gains in terms of core ADHD symptoms and classroom behaviour (Brown et al.,
1986).
Meta-analyses were not available for individual CBT interventions, given the heterogeneity of
the outcomes measured. Nonetheless, results of this systematic review suggest that individual
CBT seems to be promising in reducing externalizing and internalizing symptoms, improving
parent-child relationships, and decreasing core ADHD symptoms (inattention, hyperactivity, and
impulsivity) in adolescents concurrently on medication with simultaneous parent treatment
(Antshel et al., 2014). However, these conclusions are based on only one study of moderate
quality, and therefore should be taken with caution. Individual CBT does not seem as effective in
samples of younger children also concurrently on medication and without parent treatment
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(Brown et al., 1986). It is possible that parent involvement played an important role in the teens’
ability to generalize the skills they learned in treatment (Pfiffner, 2008). Parents’ involvement in
concurrent treatment may also be important because youth with ADHD have a significant impact
on their parents, siblings, and family life in general. For example, if parents of youth with ADHD
are stressed, there is a greater sibling conflict, and there are higher rates of conflict in the family
(Johnston & Mash, 2007). Moreover, parents of children and adolescents with ADHD are more
likely to exhibit more ineffective parenting; they may be inconsistent, harsh, or permissive, and
have lower sense of parenting competence (Chronis, Chacko, Fabiano, Wymbs, & Pelham,
2004). A coercive cycle may develop, where child and parent behaviours continue to escalate
leading to more challenging child behaviour and more ineffective parenting (Barkley, 2013).
Thus, having parents involved in a concurrent treatment, particularly one that directly addresses
parenting practises and coping strategies, may be helpful in improving children’s outcome
(Chronis et al., 2004; Rajwan, Chacko, & Moeller, 2012). Nonetheless, the efficaciousness of the
addition of a concurrent parent treatment to individual CBT needs to be further investigated.
As previously mentioned in chapter 1, research has also suggested that response to CBT may be
age-related, with older children and adults having sufficient neuropsychological development,
particularly of their executive functions, to benefit from CBT (Holmbeck, Greenly, & Franks,
2003; Knouse, 2015; Toplak et al., 2008). The sample with 14-to-18-year-old adolescent
participants in Antshel et al.’s study (2014) benefitted from an individual CBT intervention
whereas the sample in the Brown et al. (1986) study did not. It is therefore possible that the age
of the children played a role in treatment response. Only the Antshel et al. (2014) study explored
other variables influencing differential treatment response to individual CBT, and found that
individual CBT treatment outcomes were similar for adolescent males and females with ADHD-
Inattentive and ADHD-Combined Type. Nonetheless, adolescents with comorbid ODD benefited
less from individual CBT than the adolescents with only ADHD or ADHD and comorbid anxiety
or depressive disorders. A possible explanation for this is that children with ADHD and
comorbid ODD are more likely than children with ADHD alone to have positive bias; that is,
they are more likely to overestimate their competences (Hoza et al., 2004). Because of this
positive bias, this subgroup of children with ADHD and ODD might be less motivated to change
and might be resistant to psychological treatment (Mikami, Calhoun, & Abikoff, 2010). Antshel
et al. also found that adolescents with ADHD and anxiety or depression benefitted more from
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individual CBT according to parent and teacher reports. However, the exact type of anxiety
disorder (such as generalized anxiety disorder or phobias) remains unknown. The literature
suggests that children with ADHD and comorbid anxiety may be more responsive than children
with ADHD alone to psychosocial treatment in general (Jensen et al., 2001; Schatz & Rostain,
2006). As reported by Antshel et al. (2014), it also appears that over the course of individual
CBT treatment, lower doses of medications were needed to maintain the adolescents’ functional
improvements. The efficaciousness of individual CBT is currently unknown for samples of
medication-free children and adolescents, given that in both studies (Antshel et al., 2014; Brown
et al., 1986), 100% of the sample participated in concurrent pharmacotherapy. Nonetheless, these
conclusions should be taken with caution given that this systematic review had only the
secondary goal of examining core ADHD symptoms, and the inclusion of these CBT
interventions was based on the fact that these studies examined other commonly associated
behavioural symptoms and social impairments (e.g., internalizing, externalizing, social skills,
peer, and/or family functioning).
As stated in chapter 1, research shows that CBT treatments conducted prior to the 1990’s were
different from more recent approaches to CBT (Knouse, 2015). This important difference
between the two included individual CBT studies (Antshel et al., 2014; Brown et al., 1986) may
explain the differential findings pertaining to core ADHD and externalizing symptoms. Earlier
interventions, such as the Brown et al. (1986) study involved cognitive training for children with
ADHD and turned out to be largely unsuccessful (Abikoff, 1991). The therapist aimed to teach
the children about the necessary skills that are important for children to apply in their contexts.
Earlier interventions were based on the idea that children with ADHD could be trained to use
self-instructional statements or also called verbalizations (e.g., “what is it my problem…and
what do I know?”) that would allow them to engage in reflective problem solving, and that this
would, in turn, modify cognitive processes, generalize to new settings, and reduce impulsive
responding (Knouse, 2015). In contrast, current CBT approaches, such as the Antshel et al.
(2014) study, do not purport to change the underlying processes that produce symptoms; instead,
they teach compensatory skills for the child to compensate for their inattentive or hyperactive
symptoms (Safren Otto, Sprich, Winett, Wilens, et al., 2005; Safren, Sprich, Mimiaga, Surman,
Knouse, et al., 2010). These skills include behavioural strategies aimed at improving self-
regulation and cognitive reappraisal to increase the likelihood of effective coping in the presence
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of negative emotions. Particularly in the past 15 years, CBT interventions incorporate strategies
designed to help children implement the skills (Ramsay, 2010). Homework assignments in CBT
are an example of a key feature that focuses on implementation of the skills. The therapist and
children decide on a new skill to be tried out every week, including where, when, and how the
skill will be implemented and what barriers they can anticipate. The effects of treatment are not
assumed to extend beyond the children’s use of the specific compensatory skills taught (Knouse,
2015; Ramsay, 2010). Because the functional impairment associated with ADHD arises from the
interactions of the children with the environment, then it is possible that the more recent CBT
approaches addressing the implementation of the knowledge by incorporating modifications of
the children’s behaviours and of the environment maybe helpful in ameliorating that functional
impairment (Knouse & Safren, 2010). In fact, the literature on CBT interventions for adults with
ADHD seems to show medium to large effect sizes in internalizing, externalizing, and core
ADHD symptom improvement for interventions with these characteristics (Bramham, Young,
Bickerdike, Spain, McCartan, et al., 2009; Knouse & Safren, 2010; Knouse & Safren, 2013;
Philipsen, Richter, Peters, Alm, Sobanski, et al., 2007).
5.1.25.1.25.1.25.1.2 Group Cognitive Behavioural TherapyGroup Cognitive Behavioural TherapyGroup Cognitive Behavioural TherapyGroup Cognitive Behavioural Therapy
Two studies evaluated the efficaciousness of group CBT: Bloomquist et al. (1991; moderate
quality) and van der Oord et al. (2007; strong quality). Both had concurrent parent treatment and
teacher consultation. However, in the van der Oord et al. study, the children in the CBT group
were additionally taking part in concurrent pharmacological treatment. In terms of the study
aims, Bloomquist et al. hypothesized that CBT for children with ADHD, when delivered with an
active parent treatment component and concurrent teacher consultation, would have better
outcomes than a teacher- consultation-only group and a no-treatment wait-list group. Their study
goal was not as detailed as reported in more recent studies, and it was described as “reducing
symptomatic behaviours and improving adjustment in children with ADHD” (p. 592). Outcomes
of interest measured were all teacher reported. They included core ADHD symptoms of
inattention, hyperactivity, and impulsivity, CD symptoms, social competence, and peer-preferred
social behaviour. When combined with medication, parent treatment and teacher consultation,
the goal of group CBT was to outperform the medication-only group for core ADHD and other
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associated symptoms and functional impairments such as anxiety, CD, ODD, and social skills
(van der Oord et al., 2007).
Meta-analysis results indicated that group CBT interventions did not reduce children’s CD
symptoms as reported by teachers. Results of this review suggest that group CBT with
concurrent parent treatment and teacher consultation (without medication) is largely not
efficacious in reducing core ADHD symptoms, CD behaviours, or improving social behaviour of
children with ADHD (Bloomquist et al., 1991). When compared to a medication-alone treatment,
medications and group CBT with concurrent parent treatment and teacher consultation do not
seem to offer an advantage over medications alone in reducing the core ADHD symptoms, CD,
ODD, or anxiety symptoms of children with ADHD (van der Oord et al., 2007). Nonetheless, it
is important to note that there may also be issues of sample size influencing the findings.
Potentially significant intervention effects may have been masked due to the limited power in the
statistical analyses resulting from small sample sizes. In addition, neither of the two group CBT
studies (Bloomquist et al., 1991; van der Oord et al., 2007) evaluated potential moderators of
treatment response in their samples.
Finally, it is important to consider these conclusions about the utility of individual and group
CBT interventions with caution, given that they are based on only two studies respectively,
which were largely not comparable using the more reliable meta-analytic procedures because of
the heterogeneity of the outcomes measured (i.e., different domains and informants).
5.25.25.25.2 Mindfulness Training InterventionsMindfulness Training InterventionsMindfulness Training InterventionsMindfulness Training Interventions
Five studies described 6- to 20-week long mindfulness training interventions (Harrison et al.,
2004; Haydicky et al., 2012, 2015; Jensen & Kenny, 2004; van de Weijer-Bergsma et al., 2012).
With the exception of van de Weijer-Bergsma et al. (which was weak), these studies obtained a
moderate EPHPP study quality rating. With the exception of Haydicky et al. (2012), parents in
these interventions received a mindfulness training treatment simultaneously. In the Haydicky et
al. (2012) study, parents were not treatment receivers, but met periodically with the child and the
child’s therapist to be informed of treatment progress. Additionally, in Jensen and Kenny (2004),
children received concurrent pharmacological treatment. All mindfulness training interventions
had the goal of reducing inattention. Most studies (Harrison et al., 2004; Haydicky et al., 2012,
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2015; van der Weijer-Bergsma et al., 2012) also had the goal of reducing internalizing and
externalizing symptoms. Harrison et al. (2004) had the additional goal of reducing hyperactivity
and impulsivity, not only inattention. Jensen and Kenny (2004) had the primary purpose to
reduce strictly core ADHD symptoms of inattention, hyperactivity, and impulsivity, but also
investigated other outcomes such as anxiety, emotional lability, ODD, and social problems. Last,
two studies had the primary aim to reduce inattention, internalizing and externalizing symptoms,
and had the additional secondary goal of improving the quality of peer relationships (Haydicky et
al., 2012, 2015) and reducing parent-adoelscent conflict (Haydicky et al., 2015).
Meta-analyses and systematic review results indicated that mindfulness training interventions
may hold promise in reducing internalizing symptoms and peer problems, and they may foster
better parent-child relationships. Additionally, mindfulness training interventions may hold
promise in decreasing ADHD symptoms.
Results from the current review suggest that mindfulness training may be helpful in reducing the
internalizing symptoms of adolescents with ADHD 6 to 16 weeks after treatment completion
(i.e., at follow-up; Haydicky et al., 2015; van de Weijer-Bergsma et al., 2012), as it is plausible
that it takes time and practise with mindfulness training for the effect of treatment on
internalizing symptoms to reach a level that adolescents can detect (Mitchell et al., 2015).
In terms of peer relationships, it is possible that child age impacts the treatment response to
mindfulness training interventions. The two studies that reported reductions in peer relationship
problems (Haydicky et al., 2012, 2015) had older samples than the study that found no
improvement (Jensen & Kenny, 2004).
There is also some promising evidence that mindfulness training interventions might foster better
family functioning, especially pertaining to the quality of attachment and parent-child conflict
(Harrison et al., 2004). However, from the two studies (Harrison et al., 2004; Haydicky et al.,
2015) evaluating family functioning, only Harrison et al. found encouraging results with 4-to-12-
year-old children. It is possible that the instruments used in Harrison et al.’s (2004) and
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Haydicky et al.’s (2015)31 studies measured different constructs. For example, the investigators
in the Haydicky et al. (2015) study used the General Functioning subscale of the self- and parent-
reported Family Assessment Device (FAD; Epstein et al., 1983), which required participants to
rate their functioning in several domains including problem-solving, communication, roles,
affective responses, affective involvement, and behaviour control32 using a 4-point scale. The
investigators posited that this 4-point scale might not capture the subtle changes occurring in
response to the treatment. In contrast, Harrison et al. (2004) measured change in family
functioning with the Attachment and Conflict in the Parent Child-Relationship subscales of the
parent-reported Parent-Child Relationship Scale (CPRS). This instrument is an adaptation from
Pianta’s 1990 Student-Teacher Relationship Scale (Harrison et al., 2003) and has 30 items and a
5-point scale. It is noteworthy that by employing the General Functioning subscale of the FAD,
Haydicky et al. (2015) measured a significantly larger domain of the parent-child relationship in
comparison to the less broad domains of attachment and conflict measured by the CPRS in
Harrison et al. study. Thus, it is possible that the measurement instruments used in Harrison et
al.’s and Haydicky et al.’s (2015) studies measured different constructs, which could partially
explain the disparate findings.
Thus, more studies with more homogenous instruments evaluating whether children and their
parents concurrently receiving mindfulness training intervention can benefit from less conflictual
parent-child relationships are needed. It will also be important to investigate the same research
question in different age groups of children, to explore whether children and adolescents can
equally achieve more harmonious parent-child relationships through mindfulness training
interventions, particularly given that adolescence is characterized by higher levels of conflict in
parent-child relationships (Markel & Wiener, 2014).
31 Hayidicky et al. (2015) also measured parent reported parenting stress and mindful parenting, however, these outcomes were not within the scope of the current review. Only outcomes directly relevant to child (and not parent) functioning were included in this systematic review.
32 Problem-solving: the ability to resolve problems that threaten the family; Communication: the ability to exchange information in a clear and direct manner; Roles: the ability to assign and carry out tasks essential for family functioning; Affective responses: the extent to which family members experience an appropriate range of affective responses; Affective involvement: the extent to which family members are interested in one another’s activities and feelings, and Behaviour control: the way family upholds standards of behaviour; General functioning: overall health of the family unit.
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This systematic review suggests that mindfulness training may hold promise in reducing ADHD
symptoms, even when children are not concurrently on medication. Given that only one study
(Harrison et al., 2004) examined the treatment response of children with and without concurrent
medication, more studies examining this question would be needed to draw stronger conclusions.
Harrison et al. examined response to treatment as change in parent-reported ADHD symptoms
(combined inattention and hyperactivity/impulsivity symptoms). Therefore, it is also not yet
clear whether change as a result of mindfulness training interventions is to be expected in the
domain of inattention as Haydicky et al. (2012, 2015) have suggested, or whether inattention and
hyperactivity/impulsivity may equally be reduced as a result of this type of intervention.
Nonetheless, another recent systematic review (Cairncross & Miller, 2016) exclusively
evaluating the effects of mindfulness training interventions with regard to hyperactive/impulsive
and inattentive symptoms reported that these interventions were efficacious in reducing both
types of symptoms of ADHD.
Last, in terms of externalizing symptoms, only one study with children (Jensen & Kenny, 2004)
found reductions of parent-reported ODD symptoms; one study with adolescents (Haydicky et
al., 2015) found decreases in parent-reported CD symptoms. Nonetheless, the majority of
mindfulness training intervention studies evaluating these outcomes found little to no reductions
in this area, varying by outcome informant (self, parent, or teacher) and domain (ODD, CD, or
externalizing symptoms) with no specific noticeable trend. Potentially significant intervention
effects may have been masked due to the limited power in the statistical analyses resulting from
small sample sizes. The sample sizes ranged from 10 to 48 participants each.
Sample size also limited the ability of these studies to conduct subgroup analyses to explore
whether the treatment response to mindfulness training interventions was different for males or
females, and younger or older children. Also limited was the ability of these studies to examine
the differential effects for children taking medication, or for children with diverse comorbidities,
particularly anxiety and ODD. Last, these results should be taken with caution because they are
based on four studies of moderate quality and one study of weak quality.
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5.35.35.35.3 Social Skills Training InterventionsSocial Skills Training InterventionsSocial Skills Training InterventionsSocial Skills Training Interventions
Seventeen publications described 13 samples receiving 8-to-96-week-long SST interventions.
The majority of the interventions were 8-to-12 weeks long. Five publications, referred to as the
Abikoff Group (2004), reported results of different outcomes evaluated in the same intervention
provided to the same sample of participants (Abikoff et al., 2004a, 2004b; Hechtman et al.,
2004a, 2004b; & Klein et al., 2004).
Of the 13 SST interventions, in all but two SST interventions33 (Choi & Lee, 2015; Lufi &
Parish-Plass, 2011) at least one of the SST groups was evaluated concurrently with some level of
parent involvement, such as psycho-education about ADHD, parent behavioural training, and
problem-solving sessions during the child’s treatment. Two of the SST interventions had
concurrent parent treatment (Antshel & Remer, 2003; Frankel et al., 1997), six had concurrent
parent treatment and teacher consultation (Corkum et al., 2010; Evans et al., 2011; Molina et al.,
2008; Pfiffner & McBurnett, 1997; Pfiffner et al., 2007; Villodas et al., 2014), and three had
concurrent medication, parent treatment and teacher consultation (Abikoff Group, 2004; MTA
Cooperative, 1999; Waxmonsky et al., 2010).
SST treatment aims vary greatly according to the study. Most studies had the goal of improving
children’s social skills. When offered as a stand-alone treatment, the aims were to improve social
problems and reduce internalizing and externalizing symptoms (Lufi & Parish-Plass, 2011).
When offered as a stand-alone treatment incorporating an emotion management training (EMT)
component, the study’s aims were to improve emotion recognition and emotion expression34
(Choi & Lee, 2015). When offered with a concurrent parent treatment (Antshel & Remer, 2003;
Frankel et al., 1997), or with parent treatment and teacher consultation (Corkum et al., 2010;
Evans et al., 2011; Pfiffner et al., 2007; Pfiffner & McBurnett, 1997; Villodas et al., 2014), the
goals were to enhance generalization of children’s social skills to home and school
33 Pfiffner & McBurnett (1997) compared three groups of children, one receiving SST as stand-alone treatment, one receiving SST with concurrent parent treatment and teacher consultation, and a waitlist no-treatment control group. Although it did evaluate an SST intervention as a stand-alone treatment it will be described in the section of the SST interventions that were offered with concurrent parent treatment and teacher consultation to reflect that this study had two types of SST being evaluated.
34 Which the investigators posed contributed to social skill development.
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environments. Pfiffner et al. (2007), in addition to having the aim to improve social skills, had
the goal of reducing inattention symptoms. Villodas et al. (2014) had the aim to reduce ADHD
symptoms of inattention and hyperactivity/impulsivity, ODD symptoms, behaviour problems
(the combination of externalizing and internalizing symptoms), and improve peer and parent-
child relationships. Last, and less precise in their treatment goals, Molina et al. (2008) offered
SST with concurrent parent and teacher treatment, with the goal of testing the feasibility of
conducting an after-school treatment program. This study evaluated the same program that Evans
et al. (2011) used, Challenging Horizons, albeit with a different sample. The program is
described as having the aim to improve social and academic skills. However, Molina et al. did
not measure any social skills or peer-relationships outcome. When SST was offered with
concurrent medications and parent treatment and teacher consultation, the aims included
improving social skills35 (Abikoff Group, 2004; MTA Cooperative, 1999; Waxmonsky et al.,
2010). The Abikoff Group had the additional goal of improving emotional coping skills.
Only two SST interventions exclusively provided SST without any concurrent parent, teacher, or
medication intervention (Choi & Lee, 2015; Lufi & Parish-Plass, 2011) but these studies could
not be combined in a meta-analysis because of the different outcomes measured. Their individual
results, however, suggest some reductions of self-reported internalizing symptoms that would
have to be verified in future research.
Of the 21 meta-analyses conducted in regards to SST interventions with a concurrent parent
treatment or parent treatment and teacher consultation, four outcomes showed significant
improvement: parent-reported total social skills; teacher-reported social skills; parent-reported
assertion; and self-reported social skills knowledge. Results of the systematic review and of
meta-analyses support each other. Although improvement in total social skills was evident, these
improvements were evident only in within-subject design studies where there was no control
group and had weak and moderate EPHPP quality ratings, respectively (Corkum et al., 2010;
Villodas et al., 2014). The improvements in parent-reported assertion and self-reported social
skills knowledge, however, were robust with large effect sizes from studies with between-group
designs with moderate and strong quality ratings.
35 As well as academic skills, which were not within the scope of this review.
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These findings are inconsistent with the findings of a previous systematic review and meta-
analysis evaluating the effects of SST interventions for children and adolescents with ADHD
(Storebø et al., 2011). Storebø and colleagues found no significant effects on social skills.
However, Storebø and colleagues combined all social skills domains and informants into one
overall social skills composite. It is possible that the creation of this composite may have
obscured the significant effects in self-reported social skills knowledge and parent-reported
assertion skills. Another difference between the present review and Storebø and colleagues’
review that may explain the disparate findings is that the latter only included studies with an
RCT design.
Another suggestion from the present review is that it appears that SST interventions with
concurrent parent and/or teacher interventions plus medication are not more efficacious than
medication alone. Nonetheless, one RCT (MTA Cooperative, 1999) showed that children
receiving the SST intervention with parent treatment and teacher consultation showed similar
reductions of parent-reported internalizing symptoms, ODD symptoms, personal closeness in
parent-child relations, and parent- and teacher-reported social skills to children receiving
medications. This is important because some children experience impairing side effects from
stimulant or nonstimulant medications (Pliszka, 2007; Vitiello et al., 2012) and because there is a
20%–30% nonresponse rate to pharmacological treatment (Pliszka, 2007). In addition, some
parents reject pharmacological treatment (Lerner & Wigal, 2008; Pelham et al., 2004) and many
adolescents discontinue medication (Charach et al., 2014; Marcus et al., 2005; Meaux et al.,
2006).
Although it was not possible to test moderators in the meta-analyses, there were some indications
of potential moderators from the systematic review. The MTA Cooperative (1999) study found
that children with ADHD and comorbid anxiety disorders showed a better response to SST and
concurrent parent and teacher treatment, and to SST and concurrent parent and teacher treatment
and medication, than children with ADHD without an anxiety disorder, but the sample size was
not sufficient to differentiate between types of anxiety disorders. Antshel and Remer (2003)
found that children with ADHD-Inattentive Type improved more on self- and parent-reported
assertion relative to those with ADHD-Combined Type (at posttreatment and at three-month
follow-up), especially when the inattentive children were placed in groups containing only peers
with ADHD-Inattentive Type. It is unclear whether children with comorbid ODD are less
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responsive to SST interventions; one study suggested that this was the case (Antshel & Remer,
2003) while two studies (MTA Cooperative, 1999; Villodas et al., 2014) reported no differential
response to treatment. Child gender was found not to moderate any outcomes of SST
interventions and age was not investigated in any of the studies, largely because the studies
typically had a limited age range of participants.
Frequency of the sessions of the SST interventions did not seem to be associated with treatment
response. Only the MTA study had a frequency of daily sessions (as opposed to weekly or bi-
weekly sessions), and did not show substantial more gains when compared to other SST
interventions. In terms of treatment length, particularly for SST interventions, longer
interventions do not appear to be associated with dramatically more positive outcomes and that
would be necessary given the cost. This finding is consistent with Schneider’s (1992) findings.
As previously mentioned in chapter 2, Schneider speculated that perhaps the lesser impact of the
multimodal treatment lengthy packages is also attributable to their relative complexity, which
may impede their being administered properly or understood fully by the children. The Abikoff
Group (2004) study, with 96-weeks, was the longest SST intervention, and obtained relatively
smaller effect sizes when compared to the other shorter interventions. However, there was no
apparent differential treatment response in the SST interventions that were 8 to 10-weeks long
when compared to the 20-weeks long interventions.
Although this systematic review suggests that SST interventions supplemented by parent
treatment or parent treatment and teacher consultation show improvements in assertion and
social skills knowledge, it is premature to conclude that SST interventions are efficacious, for
several reasons. First, of the 17 studies describing 13 SST interventions, three studies used
within-subject designs (Corkum et al., 2010; Lufi & Parish-Plash, 2011; Villodas et al., 2014),
making it difficult to determine whether potential improvements occurred due to maturation or
other factors. Of those studies with control groups, some had a no-treatment control group and
others had a medication control group, which made cross-study comparisons difficult. Second, of
the seven SST intervention studies showing gains (Choi & Lee, 2015; Corkum et al., 2010;
Frankel et al., 1997; MTA Cooperative, 1999; Pfiffner et al., 2007; Pfiffner & McBurnett, 1997;
Villodas et al., 2014), some were offered with concurrent parent treatment, some with parent
treatment and teacher consultation, and some with the addition of medication. It is therefore
difficult to tease out the degree to which SST was the potent component of the intervention.
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Third, although six of the studies used the Social Skills Improvement System (SSIS; Gresham &
Elliot, 2008) as the instrument to measure social skills outcomes, the studies often were not
comparable using meta-analysis because of the different informants and domains of social skills
measured, and their different study designs (Abikoff Group, 2004; Antshel & Remer, 2003;
Corkum et al., 2010; Frankel et al., 199; MTA Cooperative, 1999; Pfiffner & McBurnett, 1997).
Finally, the 17 studies36 provided evaluations of different SST programs. Five studies were
evaluations or an adaptation of Pfiffner and McBurnett’s (1997) Child Social Skills Training
Program (Antshel & Remer, 2003; Choi & Lee, 2015; Pfiffner et al., 2007; Villodas et al., 2014),
and two studies (Evans et al., 2011; Molina et al., 2008) evaluated the Challenging Horizons
Program (Evans et al., 2009). Six studies evaluated the following diverse interventions: Corkum
et al. (2010) evaluated the Working Together Building Children’s Social Skills Through Folk
Literature Program (Cartledge & Keefeld, 1994) and Waxmonsky et al. (2010) evaluated the
Social Skills Program (Pelham et al., 1998; 2010). Two studies evaluated interventions they
designed; Lufi and Parish-Plass (2011) evaluated a Sports-Based Group Therapy Program and
Frankel et al. (1997) evaluated the UCLA Children’s Social Skills Program. The two remaining
SST interventions evaluated two different comprehensive multimodal programs directed to the
children, parents, and teachers (Abikoff Group, 2004; MTA Cooperative, 1999). It is possible
that one or more of these manualized programs were efficacious, but there are not enough studies
with similar outcome measures to assess this.
5.45.45.45.4 Quality of the Included Studies Quality of the Included Studies Quality of the Included Studies Quality of the Included Studies
A total of 26 studies (22 interventions provided to 22 samples) evaluated the efficaciousness of
child-focused psychosocial interventions were included in this systematic review. In terms of
EPHPP study quality, overall, most studies obtained a global rating in the strong (k = 7) or in the
moderate (k = 13) range. There were only two included studies with global ratings of weak, a
mindfulness training study (van de Weijer-Bergsma et al., 2012) and a SST study (Corkum et al.,
2010). In both cases this rating was due to inadequate blinding and an under-reporting of their
36 Five studies reported results of different outcomes evaluated in the same intervention provided to the same sample of participants (Abikoff et al., 2004a, 2004b; Hechtman et al., 2004a, 2004b; & Klein et al., 2004), and are referred to as the Abikoff Group (2004).
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recruitment procedures precluding calculation of participation consent rate. Of the 26 studies,
four evaluated CBT interventions (2 strong, 2 moderate), five studies evaluated mindfulness
training interventions (4 moderate, 1 weak), and 17 studies reported the results of 13 SST
interventions (5 strong, 7 moderate, and, 1 weak). This suggests that in relation to CBT and
mindfulness the literature is relative weak, however, with SST there is a much stronger literature
base to consider.
As previously stated in chapter 3, the blinding domain of the EPHPP states the following two
conditions: (a) assessors are described as blinded to which participants were in the intervention
and control groups, and (b) study participants are not be aware of (i.e., blinded to) the research
question. Overall, only one of the 26 studies met both of these conditions, and six met or
partially met one of them. With regard to CBT interventions, both conditions were met by Brown
et al. (1986). Antshel et al. (2014) claimed that teachers, who completed rating scales, were blind
to the adolescents’ participation in CBT but that parents were aware of their children’s
participation, and van der Oord et al. (2007) described blinding of the therapists in terms of the
medication status of the children. None of the evaluations of mindfulness training interventions
described any blinding procedures. The majority of the studies (k = 9) investigating SST did not
report any blinding, mostly due to parents and teachers being concurrently involved in
psychosocial treatment or teacher consultation. In one of the studies where parents were not
involved in treatment, blinding did not occur because parents of children in the wait-list no-
treatment control groups were informed that their children would be receiving treatment after the
first round of treatment. There were four studies where one or more of the blinding conditions
were met or partially met. In the Pfiffner et al. (2007) study, interviewers who administered the
Test of Life Social and Skills Knowledge (TOSLK; Pfiffner & Mikami, 200537) were blind to the
children’s group assignment; however, parents and teachers were not blind to treatment as they
were involved in psychosocial treatment and consultation. In the MTA Cooperative (1999) study,
the therapists administering SST treatment to two of the four groups were initially blinded to
medication status while medication doses were being calibrated. After agreement on best dose,
the blinding was broken. In the Waxmonsky et al. (2010) study, although parents and teachers
37 The TOSLK is a measure of social skills knowledge administered individually to each child at pre- and post-test and included questions pertaining to the skills taught in SST.
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who completed measures reporting on the children’s behaviours were aware of the children’s
treatment, the research assistants who conducted the classroom observations were blinded to
treatment status; the classroom observation measure, however, was not included in the current
systematic review and meta-analysis. In the Abikoff Group (2004) study, parents and teachers
were unaware of the medication status (medication versus placebo) of the children in the SST
and concurrent medication group, but were aware of the children’s psychosocial treatment due to
their own involvement in the treatment.
5.55.55.55.5 LimitationsLimitationsLimitationsLimitations
Although this systematic review adhered closely in terms of methodology to the PRISMA
guidelines, there are some limitations that mainly pertain to the quality and consistency of the
studies that were included. First, the studies measured different outcome domains and, even
when measuring the same outcome, used diverse and rarely overlapping instruments to measure
change in the constructs of interest. As previously indicated, even in studies evaluating the same
intervention the outcomes measured were generally not comparable.
Second, studies had different comparative designs. Several studies had no control group, because
of their within-subject design; others had a no-treatment control group; and others compared the
child-focused psychosocial intervention to a medication control group or a placebo control
group. Some studies compared medication only with a child-focused psychosocial intervention
plus medication.
The third limitation of this systematic review is that its findings are limited because the majority
of participants were Caucasian boys of predominantly middle socioeconomic status (See Table 4,
page 124). Thus, results may not generalize to other populations of children with ADHD.
The fourth limitation involves outcome data typically not provided by sources blind to treatment
condition. This problem is common when interventions include parents and teachers because
these individuals tend to be the most relied upon sources for assessments. The identification of
sources of assessment of data for children’s behavioural and social functioning that can be kept
blind to the intervention condition will be a valuable advancement in our field and improve our
ability to evaluate interventions free from this potential confound.
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Fifth, most parent-reported outcomes involved mothers’ ratings of child functioning. When
maternal and paternal ratings of the same outcome of child functioning were provided in a single
study, only the maternal ratings were included in this systematic review because the majority of the
studies of treatments involving children or adolescents with ADHD were based on data from mothers
(Barkley, 2015). This is a limitation because it is possible that mothers and fathers of children and
adolescents with ADHD have different perceptions of their children’s behavioural and social
functioning (Psychogiou, Daley, Thompson, & Sonuga-Barke, 2007). For example, when
investigating parent-adolescent conflict, Roehling and Robin (1986) found that adolescents’ fathers
had more negative attributions, such as concerning perfectionism and malicious intent, than fathers of
comparison adolescents; however, no differences were found for mothers.
The sixth limitation pertains to the original study goals of including studies evaluating the
efficaciousness of family therapy interventions. The rationale for including family therapy in the
broad category of child psychosocial treatments was that when children participate in therapy
sessions with their parents and sometimes siblings, they learn a set of skills intended to enhance
their family relationships. No study evaluating the efficaciousness of a family therapy
intervention met inclusion criteria for this systematic review. The two identified treatment
studies that evaluated family therapy to treat adolescents with ADHD were conducted by
Barkley and colleagues, comparing behavioural parenting training, structural family therapy, and
problem-solving communication training (Barkley, Edwards, et al., 2001; Barkley, Guevremont,
et al., 1992). Neither study met inclusion criteria because of their between-group designs without
a no-psychosocial treatment or medication only control group. In both studies, a group of
children receiving a child-focused psychosocial intervention was compared to one or more
groups of children receiving other child-focused psychosocial interventions. Not being able to
include family therapy studies in this review is consistent with previous attempts at reviewing
these interventions. In their systematic review on family therapy interventions without
medications in children and adolescents with ADHD, Bjornstad and Montgomery (2010)
concluded that a meta-analysis could not be conducted because the two studies that met
eligibility criteria were too heterogeneous to be compared. Taken together, these findings point
to the need to conduct more studies evaluating family therapy interventions in children and
adolescents with ADHD.
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The seventh limitation, which pertains to the meta-analysis, was that each meta-analysis had five
or fewer studies for comparison, and some had a small sample size, which may have affected
outcomes. Additionally, the included studies had insufficient variability to permit analysis of
moderators such as study level moderators (e.g., publication type, year of publication, country of
study, and quality of study); intervention moderators (e.g., intervention type, combined
pharmacological treatment, frequency and duration of intervention); sample/participant moderators
(e.g., age, gender, comorbidity with anxiety or ODD, previous experience with psychosocial
treatments); and outcome reporter moderators (self, parent, or teacher measures).
Eigth, assessment of the long-term efficaciousness of treatments was not possible. The included
studies that reported follow-up data aggregated different outcome domains (e.g., assertion skills
and peer relationship impairment) and/or reporting sources (e.g., parent and teacher) together
precluding comparison of these outcomes with the outcomes reported at pre-test. When
outcomes are further combined and aggregated they are no longer directly comparable to the
primary study outcomes, and conclusions about treatment maintenance become spurious.
Finally, this systematic review’s search parameters for the generalizability of the results did not
include several types of study design including time series design, case study design, qualitative
research studies, or studies were two or more psychosocial interventions are compared without a
no-psychosocial treatment (e.g., medications only, or equivalent psychosocial treatment without
the core therapeutic components) control group.
5.65.65.65.6 Implications for Future ResearchImplications for Future ResearchImplications for Future ResearchImplications for Future Research
My intention in undertaking this systematic review was to be able to provide clinicians with
guidelines for treatment of children and adolescents with ADHD with specific associated
symptoms, functional impairments, and comorbid disorders. However, I was not able to do that
because none of the psychosocial interventions reviewed (CBT, mindfulness training, and SST
interventions) meet the criteria outlined by the American Psychological Association for an
intervention to be considered well-established or probably efficacious (APA Presidential Task
Force on Evidence-Based Practise, 2006). To be considered a well-established intervention, there
have to be at least two between-group design experiments demonstrating efficaciousness in one
of the following ways: superior (in statistical significance) to another treatment or placebo, or
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equivalent to an already established treatment in experiments with adequate sample size.
Alternatively, there have to be a large series of single-case design experiments (n > 9)
demonstrating efficaciousness. The experiments must have used good experimental designs and
compared the intervention to another treatment. The experiments must be conducted with
treatment manuals, characteristics of the client samples must be clearly specified, and effects
must have been demonstrated by at least two different investigators or investigating teams. For
an intervention to be considered as probably efficacious, two experiments showing the treatment
is superior in statistical significance to a wait-list control group, one or more experiments must
have met all but one of the criteria for well-established treatments. Alternatively, a small series
of single-case design experiments (n > 3) must otherwise meet well-established treatment
criteria. None of the child-focused psychosocial interventions for children with ADHD included
in this systematic review met the above criteria for an efficacious or probably efficacious
treatment.Nine general future research directions for child-focused psychosocial treatments are
discussed below.
First, given that in this review no family therapy study was included, it will be important to
conduct studies evaluating the efficaciousness of family therapy, especially in relation to
structural family therapy (Minuchin & Fishman, 1981) and problem-solving communication
training (Barkley et al., 2001) in comparison to a control group that does not receive a child-
focused psychosocial intervention (e.g., waitlist no-intervention, medications, treatment without
the core therapeutic components, or treatment in the community).
Second, as indicated above in the limitations section, many of the studies did not provide
complete data required for a meta-analysis. Therefore, reports on future child-focused
psychosocial treatment studies should include, at a minimum, pre- and posttreatment sample
size, and means and standard deviations of all outcome variables at pre-test and post-test.
Third, and because this review was also limited by the heterogeneity of outcomes measured in
individual studies, researchers need to come to an agreement on the primary key conceptual
outcome domains to measure change pre-posttreatment for each of the interventions, so that
study results can be compared. Enabling direct comparison between studies would in turn lead to
a better understand and possibly stronger conclusions about the efficaciousness of these
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interventions for a given outcome. Studies using multiple informants (self, parent, and teacher) to
assess outcomes measured are needed.
Fourth, children participating in many of the psychosocial interventions in this review were
heterogeneous in terms of experiencing difficulties in the areas being treated, even though many,
if not most, of the children with ADHD may experience those difficulties. For example,
approximately 45% to 84% of children with ADHD meet diagnostic criteria for either ODD
alone or with CD (Barkley, DuPaul, & McMurray, 1990; Fischer, Barkley, Edelbrock, &
Smallish, 1990; Pliszka, Carlson, & Swanson, 1999); 11% to 25% children with ADHD have
anxiety disorders (Angold et al., 1999; Biederman, Newcorn, & Sprich, 1991; Larson, Russ,
Kahn, & Halfon, 2011); and 50% to 80% of children with ADHD could be classified as rejected
by their peer group (Hoza, 2007). It is possible, however, that children who do not experience
difficulties in a domain measured in a study at pre-test are unlikely to make gains in that domain
(Haydicky et al., 2012), and their lack of improvement should not be indicative of an
inefficacious intervention. Therefore, future child-focused psychosocial treatment studies need to
determine which participants have difficulty in the area being assessed at pre-test, and examine
change in those children. Treatment improvements may be more likely to be evident in the
domains that were of clinical concern at pre-test and which are targeted by the intervention. For
example, when investigating the effects of a mindfulness training intervention on children with
LD, Haydicky et al. (2012) examined the pre-to posttreatment change in ADHD symptoms and
behaviours on a subset of children with LD and ADHD, and the change in anxiety in a subset of
children with LD and anxiety disorders. Although the sample of children with LD receiving
treatment as a whole did not show gains on any of the outcome measures in relation to the wait-
list control group, the subsamples of children with different co-occurring disorders improved in
their respective areas of difficulty.
Fifth, approximately between 20 to 60% of children with ADHD have comorbid LD (Willcutt et
al., 2007) and children with LD have difficulties with social skills and peer relationships (for
review see Wiener & Timmermanis, 2011), it is important for future studies to examine whether
there are differential treatment effects for children with ADHD with and without LD.
Sixth, in future studies it may be important to compare the different child-focused psychosocial
treatments as well as to combine different treatment components. However, there currently is not
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sufficient robust empirical support for any of the reviewed child-focused psychosocial
interventions as viable treatments for ADHD, it is premature to conduct these types of studies
comparing interventions. It is possible that, by combining some of the strategies taught by the
different child-focused psychosocial interventions, children may experience more gains. For
instance, perhaps the social performance challenges of children with ADHD who do not respond
to SST interventions may be improved with mindfulness training intervention components. It is
possible that interventions such as MyMind (Bogels, Hoogstad, van Dunn, de Schutter, &
Restifo, 2008), which provides children with emotion regulation strategies, possibly in
combination with SST, might be helpful for those children who are improving in social skills
knowledge but not on the performance of these social skills.
Seventh, in order to better understand the role that parent and teacher involvement play in
children’s ability to generalize the skills they learn in the child-focused psychosocial treatments,
it might be helpful to compare children receiving a stand-alone child-focused psychosocial
intervention with another group of children whose parents and/or teachers are involved in the
intervention. It is currently unclear whether it is important for parents to be involved in child-
focused psychosocial treatments (CBT, mindfulness training, and SST). However, some
preliminary evidence on the MyMind mindfulness training intervention (Haydicky, Wiener,
Shecter, & Ducharme, 2016) suggests it may be important for this type of intervention.
Eighth, investigating whether child-focused psychosocial treatments might show gains without
concurrent medication treatment, or with lower doses of it, would be important because not all
children can take medications, for several reasons including side effects (Pliszka, 2007; Vitiello
et al., 2012). Adolescents are at a higher risk of discontinuing their use (Charach et al., 2014;
Meaux et al., 2006), and many parents prefer treatments with psychosocial therapy over
treatments with stimulant medication (Waschbusch, Cunningham, Pelham, Rimas, Greiner, et al.,
2011). Moreover, research has shown that parents and teachers tend to evaluate children with
ADHD more positively when they believe the child has been administered
stimulant medication, and they tend to attribute positive changes to medication even
when medication has not actually been administered (Waschbusch, Pelham, Waxmonsky, &
Johnston, 2009). Being able to separate placebo effects from real treatment gains due to child-
focused psychosocial treatments is important.
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Ninth, future research is needed to evaluate treatment maintenance, long-term effects, and
transfer of gains employing similar comparable outcomes to the ones used at pretreatment. The
majority of the studies included in this review used different variables, often, composite scores,
in their follow-up time points when compared to their pre-post measurements. Ensuring that the
variables of interest at the different time points are consistent would allow for direct comparison
of outcomes in respect to time.
In the next section, future research directions specifically pertaining to each of the child-focused
psychosocial interventions evaluated in this systematic review are discussed.
5.6.15.6.15.6.15.6.1 Cognitive Behavioural Therapy InterventionsCognitive Behavioural Therapy InterventionsCognitive Behavioural Therapy InterventionsCognitive Behavioural Therapy Interventions
In regards to CBT studies, more randomized control clinical studies with larger samples of
children and adolescents are needed. This would allow for sufficient statistical power to detect
small to medium effect sizes.
5.6.1.15.6.1.15.6.1.15.6.1.1 Individual Cognitive Behavioural TherapyIndividual Cognitive Behavioural TherapyIndividual Cognitive Behavioural TherapyIndividual Cognitive Behavioural Therapy
No meta-analytic data was available for individual CBT interventions, given the heterogeneity of
the outcomes measured. A future research direction would be to employ more comparable
outcomes, specifically as regards to treatment goals. If individual CBT generally had the aim to
reduce core ADHD symptoms of inattention, hyperactivity, impulsivity, and improve social and
family functioning outcomes, establishing clear and consensual criteria of how to evaluate these
outcomes would be important to be able to draw stronger conclusions in regards to the
efficaciousness of this treatment.
Second, it is important to further investigate and compare the efficaciousness of individual CBT
with and without concurrent parent involvement in treatment, and with and without concurrent
medications. This is particularly important because individual CBT seems to be promising for
decreasing core ADHD symptoms of inattention, hyperactivity, and impulsivity; externalizing
and internalizing symptoms; and improving parent-child relationships in adolescents, particularly
those with comorbid anxiety or depression, concurrently on medication with simultaneous parent
treatment (Antshel et al., 2014). Given that multimodal treatments, treatments with multiple
treatment arms, are generally costly in terms of time and finances (Barkley, 2015), it would be
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important to investigate whether significant effects could be reached with individual CBT
without concurrent parent treatment involvement as well as without concurrent medication
treatment. This would be important not only because it might show whether similar effects could
be achieved by using fewer resources, but also because some parents are not well suited to be
involved in their children’s treatment. For instance, research shows that parents who do not
assume some responsibility for their child’s behaviour through altering contingencies are less
likely to engage in treatment (Peters, Calam, & Harrington, 2005). Similarly, parents with a
lower sense of parenting competence and self-efficacy are less likely to be involved in treatment
to support their children; they may view their efforts as futile (Johnston, Mah, & Regambal,
2010).
Third, as mentioned in the general future research directions section, not all children can take
medications. Thus, investigating whether individual CBT might improve the above mentioned
primary outcomes without concurrent medication treatment would be important. This review also
suggested that over the course of individual CBT treatment, lower doses of medications were
needed to maintain the adolescents’ functional improvements. Further exploration of whether
these findings could be replicated is important. Indeed, the efficaciousness of individual CBT in
a sample of medication-free children and adolescents is currently unknown, given that 100% of
the sample in the studies included in this review participated in concurrent pharmacotherapy.
Nonetheless, and as previously mentioned above, these conclusions should be taken with caution
given that this systematic review had only the secondary goal of examining core ADHD
symptoms, and the inclusion of these CBT interventions was based on the fact that these studies
examined other commonly associated behavioural symptoms and social impairments (e.g.,
internalizing or externalizing symptoms and behaviours, social skills, peer relationships, and/or
family functioning).
Fourth, little is known about the potential moderators of individual CBT treatment response. For
instance, this review suggested that individual CBT does not seem as efficacious in samples of
younger children; therefore, investigating whether child age is actually a moderator of individual
CBT treatment response is important. Furthermore, it appears that adolescents with comorbid
ODD benefited less from individual CBT than the adolescents with only ADHD or comorbid
anxiety or depressive disorders (Antshel et al., 2014). Replicability of this finding in other
samples of children/adolescents receiving individual CBT would be important in order to target
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the specific subgroup of children with ADHD who would benefit from this treatment. Another
comorbidity than needs to be further explored in relation to its potential moderator role of
individual treatment response is anxiety. This review suggested that adolescents with ADHD and
anxiety seem to benefit from individual CBT more than adolescents with ADHD alone,
according to parent and teacher reports. Investigating whether this may be the case as well as
furthering our understanding about which type of anxiety disorders, such as generalized anxiety
disorder or phobias, may be more responsive to individual CBT interventions would allow for
more individually tailored treatments.
5.6.1.25.6.1.25.6.1.25.6.1.2 Group Cognitive Behavioural TherapyGroup Cognitive Behavioural TherapyGroup Cognitive Behavioural TherapyGroup Cognitive Behavioural Therapy
Only one meta-analysis was available for group CBT interventions, given the heterogeneity of
the outcomes measured. Thus, a future research direction would be to employ more comparable
outcomes, specifically in regards to treatment goals. If group CBT generally has the goals of
reducing core ADHD symptoms of inattention, hyperactivity, and impulsivity, and externalizing
and internalizing symptoms, establishing clear and consensual criteria as to how to evaluate these
outcomes is important to be able to draw stronger conclusions about the treatment’s
efficaciousness.
Second, and given that this review failed to show any success of the group CBT interventions,
conducting studies with larger samples would be important, to be able to draw stronger
conclusions about the utility (or lack of thereof) of these interventions for children and
adolescents with ADHD. Potentially significant intervention effects may have been masked, due
to the limited power in the statistical analyses resulting from small sample sizes.
Third, one of the two included group CBT studies only employed teacher-reported outcomes.
Thus, further investigating the utility of group CBT by employing not only teachers, but also
parent- and self-reports would be important. The best practise would be to use a multi-informant
(i.e., reports from self, parent, and teacher) and multisetting method of assessment, which would
tend to reduce the measurement error associated with any single method (Merrell et al., 1997).
Particularly, in regards to internalizing problems, research has stressed the importance of using
self-report forms of assessment (e.g., Kazdin, 1990; La Greca, 1990; Martin, 1988). Children’s
perceptions of their own internalizing problems typically have relatively low agreement with
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objective observations or ratings of their symptoms as reported by parents (Thompson, Merritt,
Keith, Murphy, & Johndrow, 1993) and teachers (Phares, Compas, & Howell, 1989).
Fourth, although this review suggested that group CBT with concurrent parent treatment, teacher
consultation and medication did not seem to offer an advantage over medications alone in
decreasing any of the outcomes (i.e., CD symptoms, ODD symptoms, anxiety symptoms, or core
ADHD symptoms) whether group CBT without medications is equal to medications in reducing
any of these outcomes remains unknown. Particularly considering that the studies that concluded
that “a lack of advantage of group CBT over medications” had very small sample sizes and did
not have a wait-list, no-treatment control group. Therefore, another future direction for group
CBT is to investigate whether the performance of children receiving group CBT alone, without
concurrent medication, is equal to medications alone. This question would be best investigated in
an RCT with three groups of children, the third group being a no-treatment control group. The
primary outcomes of interest would include externalizing (CD/ODD) symptoms, internalizing
symptoms (anxiety/depression), and core ADHD symptoms. As previously mentioned in the
general future research directions section, this is important because not all children can take
medications.
Fifth, given that none of the group CBT studies included in this review examined potential
moderators of treatment response, investigating variables that seem to have an effect on
individual CBT treatment would be important. Specifically, child age, comorbidity with ODD,
and comorbidity with anxiety disorders remain all largely unexplored variables in regards to
group CBT.
Sixth, a future research direction may be to compare the efficaciousness of individual and group
CBT, given that the latter is less costly to implement. This comparison has been done for anxiety
disorders and both modalities of CBT were offered with concurrent parent involvement in
treatment. Clinicians reported significantly improved global functioning and children and parents
reported significantly decreased anxiety regardless of the CBT treatment modality (Manassis,
Mendlowitz, Scapillato, Avery, Fiksenbaum, et al., 2002).
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5.6.1.35.6.1.35.6.1.35.6.1.3 Summary of Cognitive Behavioural Therapy InterventioSummary of Cognitive Behavioural Therapy InterventioSummary of Cognitive Behavioural Therapy InterventioSummary of Cognitive Behavioural Therapy Interventionsnsnsns
In sum, future research directions for CBT studies in general include the following: first, the
need for more randomized control clinical studies with larger samples of children and
adolescents, which would allow for sufficient statistical power to detect small to medium effect
sizes; and second, studies employing more comparable outcomes in regards to the treatment
goals. It is important to further investigate and compare the efficaciousness of individual and
group CBT with and without concurrent parent involvement in treatment, and with and without
concurrent medications. Third, further investigation is needed as to whether lower doses of
medications are needed to maintain adolescents’ functional improvements during CBT
intervention. Similarly, the efficaciousness of CBT in a sample of medication-free children and
adolescents is currently unknown, and would be worthwhile to investigate. Fourth, little is
known about the potential moderators of CBT treatment response. Investigating whether a child
age, comorbidity with ODD, and comorbidity with anxiety disorders moderate treatment
response would be important. Fifth, there is a need to further investigate the utility of these
interventions by employing a multi-informant approach, including self, parent, and teacher
reports.
5.6.25.6.25.6.25.6.2 Mindfulness Training InterventionsMindfulness Training InterventionsMindfulness Training InterventionsMindfulness Training Interventions
Only four meta-analyses, including two studies each, were available for mindfulness training
interventions, given the heterogeneity of the outcomes measured. Thus, a future research
direction would be to employ more comparable outcomes, specifically in regards to the primary
treatment goals. The mindfulness training interventions were generally purported to reduce
inattention and externalizing and internalizing symptoms, and some studies had the additional
secondary goal of improving peer relationships and family functioning. Establishing clear and
consensual criteria as to how to evaluate these outcome domains would therefore be important to
be able to draw stronger conclusions in regards to the efficaciousness of these treatments.
Second, a total of only five studies evaluating mindfulness training interventions were included
in this review. Each had small sample sizes and lacked randomized control groups, which makes
it difficult to assess the representativeness and generalizability of the results. Potentially
significant intervention effects may have been masked, due to the limited power in the statistical
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analyses resulting from small sample sizes. Therefore, it would be important to conduct further
studies with larger sample sizes comparing children receiving mindfulness training as a stand-
alone treatment, without concurrent medication or parent treatment components; children
receiving mindfulness training and concurrent medication; and children receiving mindfulness
training with concurrent parent treatment compared to a wait-list, no-treatment control group.
There are several reasons why these comparisons would aid our understanding on the
efficaciousness of mindfulness training. For instance, it is important to understand whether
mindfulness training interventions are as efficacious as medications, or whether being on
medications facilitates children’s skill in learning meditation and therefore leads to better
outcomes.
Third, it is also important to understand whether concurrent parent involvement in treatment is
absolutely necessary for the success of this intervention, or whether equal treatment gains could
be achieved without the parent treatment components. It is currently unclear whether none, one,
or both parents being involved in simultaneous treatment is important. Nonetheless, a recent time
series design study showed preliminary evidence on MyMind, a mindfulness training
intervention, suggesting that at least one parent involved in concurrent treatment may be
important (e.g., Haydicky, Wiener, Shecter, & Ducharme, 2016).
Fourth, this systematic review suggested that mindfulness training may hold promise in reducing
ADHD symptoms, particularly inattention, even when children are not concurrently on
medication. Nonetheless, it is also not yet clear whether change as a result of mindfulness
training interventions is to be expected in the domain of inattention as some studies (Haydicky et
al., 2012, 2015) have suggested, or whether inattention and hyperactivity/impulsivity may be
equally decreased as a result of this type of intervention (Harrison et al., 2004).
Fifth, this review suggested that mindfulness training interventions might also reduce the
internalizing symptoms of adolescents at a later time, such as at follow-up (Haydicky et al.,
2015; van de Weijer-Bergsman, et al., 2012). Hence, it is also important to further examine
whether the effects of internalizing symptoms take more time for adolescents to reach a level that
they can detect. Perhaps offering additional sessions in mindfulness training interventions would
allow for the youth to have more time to practise the recently acquired skills. This hypothesis
could be tested by comparing children’s internalizing symptoms after receiving mindfulness
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training interventions that are exactly the same and only differing in their duration (i.e., one
longer than the other).
Sixth, sample size also has limited the ability to conduct subgroup analyses at a meta-analysis
level and at the individual study level. Mindfulness training approaches to psychotherapy are
fairly recent and their use with children and adolescents with ADHD is even more novel.
Therefore, there is not enough research available to draw firm conclusions in respect to potential
moderators that specifically apply to mindfulness training interventions (Mitchell et al., 2015).
Thus, whether treatment response to mindfulness training interventions is different for males
versus females, or younger versus older children; or whether there are differential effects for
children taking medication, or for children with diverse comorbidities, particularly anxiety and
ODD, all remains largely unexplored. The potentially moderating role of these variables should
be investigated in future studies. It would be particularly interesting to further explore whether
response to mindfulness training interventions is age-related. Older children and adults may
benefit more because they would have sufficient neuropsychological development, particularly
of their executive functions, to benefit from these treatments (Knouse, 2015). Children’s age
should be investigated particularly in regards to peer relationship outcomes. The two
mindfulness training intervention studies that reported reductions in peer relationships problems
(Haydicky et al., 2012, 2015) had older samples than the study that found no improvement in this
domain (Jensen & Kenny, 2004).
5.6.2.15.6.2.15.6.2.15.6.2.1 Summary of Mindfulness Training InterventionsSummary of Mindfulness Training InterventionsSummary of Mindfulness Training InterventionsSummary of Mindfulness Training Interventions
In sum, future research directions for mindfulness training intervention include, first, employing
more comparable outcomes in regards to the primary treatment goals (i.e., reducing internalizing
and externalizing symptoms, and although not the main purpose of the current systematic review,
inattention). Second, researchers should strive to tease apart the effects of concurrent medication
and parent involvement in treatment. Third, future studies should further investigate whether
decreases in internalizing symptoms occur over time after posttreatment. Fourth, the potential
moderator role of variables such as child age, gender, comorbidity with ODD, and anxiety
disorders should be investigated in future studies.
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5.6.35.6.35.6.35.6.3 Social Skills Training InterventionsSocial Skills Training InterventionsSocial Skills Training InterventionsSocial Skills Training Interventions
Results of this systematic review support the findings of the meta-analytic data. SST
interventions show modest gains, improving self-reported social skills knowledge and parent-
reported assertion. SST interventions seem to be associated with improvement in children’s
knowledge base about appropriate social behaviours. There seems to be a problem, however, in
the application of these skills to real-life contexts because only parent-reported assertion seems
to change after a thorough training in social skills. In addition, it would also appear that adding a
concurrent parent treatment component to the child-focused SST did not make a difference when
it came to the improvement of self-reports of social skills knowledge, but it did seem to
contribute to improvements in parent-reported assertion.
In this section I discuss the specific characteristics of the SST programs that may importantly
bear on outcomes, then I discuss the issues that may interfere with the efficaciousness of SST
interventions and important future research directions for SST interventions.
In his systematic review and meta-analysis of SST interventions, Schneider (1992) suggested
that SST programs differ in two ways: type of intervention and length of the intervention. In
addition, Gresham and colleagues (2001) and Whalen (2015) suggested that SST programs differ
with respect to comprehensiveness of the skill set taught, and Foster and Bussman (2008) and
Gresham (2002) indicate that they differ in terms of individualization of skills to the needs of the
children. After discussing the findings in relation to these four aspects on which SST
interventions differ, the 13 SST interventions reported on in the current systematic review are
examined in relation to treatment type, length, comprehensiveness, and individualization.
Although components of both types are sometimes included in interventions, most SST
interventions can be classified as either coaching or social cognitive programs. Coaching
interventions involve teaching of specific social skills through explicit verbal instruction,
modelling (either in vivo or videotaped), role-play, and reinforcement. Social cognitive or social
problem solving interventions focus on the instruction of general strategies such as identifying
social problems, generating a set of strategies that might be used to solve these problems,
identifying the most likely consequence of using each strategy, understanding and using the
perspective of others to solve social problems, and determining the means to achieving social
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goals. Instead of explicit verbal instruction, the main teaching technique is verbal mediation,
with group leaders asking children carefully crafted questions to enhance their thinking about
social interactions (Schneider, 1992). In his meta-analysis of 79 studies of social skills
interventions for children who exhibited internalizing and externalizing behaviours, Schneider
(1992) found that interventions tended to be moderately effective in improving social interaction
in natural settings, and that higher effect sizes were reported for programs that mainly involved
coaching compared to social cognitive programs.
Although length of treatment as measured by the total number of sessions did not correlate with
effect size, Schneider (1992) found that the SST intervention studies with some of the highest
effect sizes were those with treatments with relatively short duration (i.e., 5 to 10 sessions as
opposed to 12 sessions and over). Schneider speculated that many of the shorter interventions
might be better defined and less subject to “drift” from the prescribed procedures. He suggested
that perhaps the lesser impact of the multimodal treatment lengthy packages is also attributable
to their relative complexity, which may impede their being administered properly or understood
fully by the children.
SST interventions also differ in terms of the comprehensiveness in their content. Ideally they
should promote the acquisition of social skills, enhance the performance of skills, eliminate
competing problem behaviours, and enable generalization and preservation of gains (Gresham,
Sugai, & Horner, 2001; Whalen, 2015). Furthermore, individualizing interventions to the needs
of participating children has been identified as an essential component of effective SST
interventions (Foster & Bussman, 2008; Gresham, 2002).
The interventions evaluated in the Corkum et al. (2010) and Frankel et al. (1997) studies are both
coaching interventions between 10 and 12 weeks long, have an extensive social skill content, and
the target social skills were individually tailored to the needs of the participants and monitored.
Both interventions only measured (or statistical data was only available from main author for)
improvement in a total of two (Frankel et al., 1997) or three social skills variables (Corkum et
al., 2010). Both studies used the Social Skills Rating System (SSRS; Gresham & Elliot, 1998) to
assess change. Frankel et al. found improvement in parent-reported assertion and self-control and
Corkum et al. found improvement in self, parent and teacher-reported social skills total score.
Although, as discussed above, the Corkum et al. study was a within-subject study with a weak
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quality rating, it is possible that both of these interventions had positive outcomes because they
incorporated the four aspects that previous research (Gresham et al. 2001; Gresham, 2002;
Whalen, 2015; Schneider, 1992) found were characteristic of efficacious SST interventions.
The interventions evaluated by Lufi and Parish Plass (2011) and Waxmonsky et al. (2010) both
had a limited social skill content in that they only focused on the instruction of positive social
skills such as listening skills and cooperation. Neither program taught skills such as dealing with
peer harassment, and conflict resolution with peers or adults that have been consistently found to
be challenging for children with ADHD (Barkley, 2015). Furthermore, the social skills taught
were not individualized to the needs of the participants in either program. Lufi and Paris-Plass
had a relatively long SST program (20 sessions) that involved coaching in the specific skills,
whereas the program evaluated in the Waxmonsky et al. study was short (8 sessions), and had a
social cognitive focus. At post treatment, Waxmonsky et al. found no change in parent-reported
social skills total in the SST treatment conditions (which were combined with medication
management) on the Social Skills Improvement System (SSIS; Gresham & Elliot, 2008), and
Lufi and Paris-Plass found no improvement in self-reported social problems and only modest
(small) improvement in parent-reported social problems on the ASEBA (Child Behaviour
Checklist; Achenbach, 1991). Given that children with ADHD differ in the nature of their social
skills difficulties (Frederick, & Olmi, 1994), it is possible that the combination of a restricted
content and the lack of individualization resulted in these interventions not showing marked
improvements in the social skills of the participants.
The Abikoff group (2004) and the MTA Cooperative (1999) were both coaching interventions of
long duration (Abikoff, (192 sessions, 96 weeks/bi-weekly); MTA Cooperative (40 sessions; 8
weeks/daily). The SST coaching interventions were part of multi-modal treatments that included
calibrated medication management and concurrent parent and teacher intervention. The social
skills that were taught were comprehensive and were individualized to the needs of the
participants. The Abikoff group found no improvements in the social skills domains regardless
of the informant. In contrast, the MTA study found that the stand-alone SST, SST and
medication management, and medication management alone groups improved in parent and
teacher-reported social skills total on the SSRS when compared to the community care group,
but did not differ from each other. Both the MTA the Abikoff group studies were multimodal
lengthy treatment packages with similar relative complexity. Contrary to Schneider’s
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speculations, length alone did not seem to affect the MTA study treatment being administered
properly or understood fully by the children. Additionally, a later publication of the MTA study
(Wells et al., 2000) describes how the SST intervention was also successful in supporting
children’s development of a dyadic friendship. In the MTA’s summer treatment program, each
child was paired up with a buddy with whom the goal was to form a close friendship; they shared
activities both in and out of the therapeutic setting and met regularly with an adult coach who
assisted in resolving potential relationship problems. This is important given that several
researchers have suggested that the development of at least one meaningful positive dyadic
relationship has been suggested to compensate for poor peer group relations (Furman & Robins
1985; Wells et al., 2000). Perhaps it was this pairing with the buddy that was present in the MTA
study intervention and not in the Abikoff group study intervention that was associated with the
different findings. More research, however, would be needed to confirm this hypothesis.
Molina et al. (2008) and Evans et al. (2011) both randomly assigned young adolescents to either
the Challenging Horizons Program (CHP; Evans et al., 2009) with a (three session) parent
component or a community care control group, which in both cases consisted of 67% of the
children on ADHD medications. The CHP is a 10-session weekly after school program that
instructs children in educational skills (e.g., study skills, homework completion) and has an SST
intervention component called “interpersonal skills group”. This SST coaching intervention
involved individualizing the skills taught to the needs of the participants. The two studies are
similar in design, but the outcome measures differed. Molina measured internalizing and
externalizing behaviours and emotional symptoms on the Behavioral Assessment System for
Children (BASC; Kamphaus & Frick, 1996) and did not directly assess social skills or peer
relationships. Evans et al. examined ADHD symptoms on the Disruptive Behavior Disorders
Rating Scale (DBD; Pelham, Gnany, Greenslade, & Milich, 1992) and peer relationships on the
Impairment Rating Scale (IRS; Fabiano et al., 2006). Neither intervention found improvement in
a social skills or peer relationship outcome. Perhaps this type of SST intervention had the
disadvantage in comparison to the other SST interventions, of having to divide the session time
between educational and social skills goals, leaving fewer total minutes of instruction and
practice of interpersonal skills.
The remaining five SST intervention studies are all evaluations of or an adaptation of the Pfiffner
and McBurnett (1997) Child Social Skills Training Program (CSSTP). Pfiffner and McBurnett
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and Antshel and Remer (2003) offered 8 sessions, Pffifner et al. (2007) offered 12 sessions, the
adaptation by Villodas et al. (2014) was 10 sessions long, and the Korean adaptation in the Choi
and Lee study (2015) offered 16 sessions. The CSSTP is a coaching intervention that is short,
teaches a comprehensive set of social skills, and individualizes the skills taught to the needs of
the participants. The Korean adaptation, however, was longer, and seemed to only involve
explicit verbal instruction of targeted skills without modelling, role-play, or feedback. Villodas et
al.’s (2014) adaptation seems to be the most comprehensive because it incorporated additional
coaching on completing chores independently, homework skills, and making friends. The
Villodas et al. study reported marked improvement in all outcome domains measured on the
Social Skills Improvement System (SSIS; Gresham & Elliot, 2008) and Impairment Rating
System (IRS; Fabiano et al., 2006); self-reported social skills knowledge (consistent with
Pfiffner and McBurnett and Pffifner et al. , and not measured by Antshel and Remer or Choi and
Lee), and parent and teacher-reported social skills total (consistent with Pfiffner & McBurnett).
In interpreting the Villodas findings, however, it is important to consider that it used a within-
subject design; there was no comparison with a control group. Additionally, Antshel and Remer
(2003) reported improvements in self- and parent-reported assertion on the Social Skills Rating
System (SSRS; Gresham & Elliot, 1998), and Choi and Lee (2015) reported improvements in
self-reported anxiety, emotional ability, and emotional awareness.
In sum, it is possible that the effectiveness of SST interventions in regards to social skills and
peer relations outcomes is related, as previous research (i.e., Foster & Bussman, 2008; Gresham
et al. 2001; Gresham, 2002; Schneider, 1992; Whalen, 2015) suggested, to the intervention
having a coaching component, inclusion of a comprehensive set of social skills content, and
individualization of social skills taught to the needs of the participants. Given that the treatments
that achieved positive outcomes varied in treatment length, this might not be a key component in
relation to children with ADHD. There was some evidence, however, that inclusion of an explicit
friendship component in which children are paired with potentially compatible peer buddies and
receive coaching on friendship making together might be an important component.
In respect to issues that may influence the efficaciousness of SST interventions for children and
adolescents with ADHD, two main issues will be discussed next. The first issue pertains to the
reasons why children with ADHD display problematic social behaviour, even after exposure to
SST interventions where they were taught the appropriate social skills to be used. Below I
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discuss whether the problematic social behaviour of children with ADHD is due to a deficit in
their social skills knowledge or in their ability to carry out that knowledge. The second issue
offers a potential explanation for why, even after exposure to SST interventions, children with
ADHD continue to have impaired peer relations. Peers may have cognitive biases against them,
and peers’ cognitive biases against children whom they dislike predispose them to maintain their
negative perceptions even in the face of disconfirming evidence such as positive behaviour
change in the disliked child.
The first issue that may influence the efficaciousness of SST interventions is whether youth with
ADHD display problematic social behaviour (e.g., lack of prosocial behaviours) because of a
deficit in their social skills knowledge or because of a social performance deficit (Gresham,
Cook, Crews, & Kern, 2004). In other words, is the problem that children with ADHD not know
the appropriate social behaviours they are supposed to use, or is the problem that children with
ADHD cannot perform the social appropriate behaviours they know in context? There is some
evidence that suggests the latter; that a social performance deficit is interfering with the ability of
children with ADHD to carry out their knowledge about appropriate social behaviour (Gresham
et al., 2004; Mikami, Jia, & Na, 2014). As a result of executive functioning impairments in
behavioural inhibition, children with ADHD, particularly ADHD-Combined Type, may be
unable to enact their knowledge of appropriate, socially skilled behaviours because they have
problems suppressing motoric, verbal, and affective impulses (Maedgen & Carlson, 2000). Other
investigators have suggested that children with ADHD have a deficit in generalization. Whether
they get distracted by stimuli or become overwhelmed by negative emotions in the heat of the
moment, children with ADHD appeared to be impaired when enacting abstract knowledge in
real-life situations (e.g., Abikoff, 2009). In fact, children with ADHD-Combined Type and
typically developing children were not found to differ on a measure of social knowledge when
asked to report on the correct way that someone should respond in hypothetical social scenarios
(Maedgen & Carlson, 2000). Similarly, other research has suggested that executive functioning
deficits partially mediate the relationships between ADHD and peer problems (Huang-Pollock,
Mikami, Pfiffner, &McBurnett, 2009; Tseng & Gau, 2013).
Historically, SST interventions have focused on remediating social skills knowledge deficits and
not social performance deficits (Gresham et al., 2004); that is, SST interventions have focused on
teaching social skills knowledge, assuming that children need to learn the appropriate social
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behaviours to enact with their peers. The assumption underlying these interventions is that once
children with ADHD learn what behaviours they should be doing, such as starting a conversation
or giving compliments, they will naturally be able to carry them out (Hoza, Gerdes, Mrug,
Hinshaw, Bukowski, et al., 2005; Mikami et al., 2014). This review shows that most recent SST
programs include elements such as role-plays in which children practise their social skills with
the peer group, in an attempt to address children’s performance deficits. Eleven of the 13 SST
intervention studies included in this review additionally offered concurrent parent treatment or
parent treatment and teacher consultation where parents or both parents and teachers were
instructed to reinforce children’s performance of learned social skills in their everyday peer
interactions. Nonetheless, evidence from this review shows only modest gains in improving the
performance of social skills as reported by self, parents, and teachers. The only social behaviour
performance outcome improved was parent-reported assertion.
Mikami and colleagues (2014) have suggested that perhaps a social cognitive deficit associated
with a difficulty interpreting social information (as opposed to knowledge about what to do in a
certain social situation) is what impedes the efficaciousness of SST interventions for children
with ADHD. Such a social cognitive deficit would be responsible for incorrect interpretations in
ambiguous situations with peers, difficulty attending to key components of social interactions,
and difficulty interpreting peers’ emotions. This is supported by studies indicating that children
with ADHD have challenges with social perspective taking (e.g., Marton, Rogers, Wiener,
Moore, & Tannock, 2009). Nonetheless, whether attending to these social cognitive deficits
improves the efficaciousness of SST for children with ADHD remains unknown (de Boo &
Prins, 2007) and could be investigated in future studies.
It is important to note that these hypotheses in terms of problems with social performance, as
opposed to social skills knowledge, may be less applicable for children with ADHD-Inattentive
Type; some researchers (Maedgen & Carlson, 2000; Wheeler & Carlson, 1994) have found
deficits in social skills knowledge in children with ADHD-Inattentive Type. This finding might
help explain Antshel and Remer’s (2003) study findings in this review pertaining to children
with ADHD-Inattentive Type. These authors found that an SST intervention with concurrent
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parent treatment showed greater efficaciousness38 in children with ADHD-Inattentive Type when
compared to children with ADHD Combined Type. Children with ADHD-Inattentive Type
benefited more from SST when they were placed in groups containing only peers with ADHD-
Inattentive Type. These results support the implementation of SST interventions in diagnostically
homogenous groups.
A second issue that may influence the efficaciousness of SST interventions could be the lack of
attention to social context; that is, to the characteristics of the actual real-life peer group of the
child with ADHD (Mikami, Lerner, & Lun, 2010). Historically, an assumption underlying SST
interventions was that most of the reasons why children with ADHD have problems with their
peers were internal to them. Children with ADHD have been described in the literature as
negative social catalysts who are likely to lead to the disruption of the social interactions in
which they are involved (Mikami et al., 2014). Thus, the children with ADHD, not their peer
have been the objects of the intervention. Another assumption underlying most SST
interventions is that if children with ADHD improve their social behaviour, such as by
displaying more prosocial and less disruptive behaviour, then peers will consequently respond by
increasing their liking of these children (Mikami, 2015). Nonetheless, some findings in the
literature suggest that these assumptions may not be fully valid.
Such assumptions ignore the fact that peer relationships are reciprocal, and that the children with
ADHD and their peers contribute to the social behaviours, social cognitions, and peer regard of
the children involved (Mikami et al., 2010). The behaviours displayed by the children with
ADHD towards their peers do not occur completely independently of the behaviours displayed
by peers towards them. If peers are welcoming and accepting, this is likely to encourage children
with ADHD to display more prosocial behaviours in return. Similarly, if peers are not
welcoming, it is likely that children with ADHD will display more disruptive/offensive
behaviour in return (Nesdale & Lambert, 2007; Schwartz, McFadyen-Ketchum, Dodge, Pettit, &
Bates, 1998). Research also suggests that peers have cognitive biases against children whom they
dislike and are often resistant to changing their negative impressions (Mrug & Hoza, 2007).
Consequently, peers tend to interpret ambiguous behaviours on the part of the rejected children
38 On self- and parent-reported assertion at posttreatment and three-month follow-up.
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as hostile. Peers also tend to selectively remember the disruptive behaviours of the disliked
children, while forgetting their prosocial behaviours. Moreover, peers are more likely to attribute
the disruptive behaviours of the disliked children to internal, global, and stable causes, and to
attribute their prosocial behaviours to external, specific, and unstable causes (Peets, Hodges, &
Salmivalli, 2008). Peers’ cognitive biases against children whom they dislike predispose them to
maintain their negative perceptions even in the face of disconfirming evidence such as positive
behaviour change in the disliked children (Mrug & Hoza, 2007). These findings imply that even
if the children with ADHD do improve their social skills and social behaviours, it will not
necessarily lead to their peers noticing and being able to alter their impressions of the children
with ADHD accordingly.
In order to address the contributions of the peer groups’ behaviours to the social deficits of
children with ADHD, future interventions may consider targeting the entire classroom where
children with ADHD spend significant amounts of their time. For example, Mikami and
colleagues (Mikami, Griggs, Lerner, Emeh, Reuland, et al., 2013) developed the Making
Socially Accepting Inclusive Classrooms (MOSAIC) program, an intervention administered by
classroom teachers to the entire classroom (children with ADHD were not identified to their
classmates) with the aim of helping peers to be more socially inclusive of children with ADHD.
This intervention is a modification of traditional SST that was designed to address the two
identified potential barriers to SST interventions; performance deficits, and attention to the social
contextual factors in the peer group that might be influencing peer relationships. MOSAIC aims
to change peers’ negative impressions and cognitive biases towards children with ADHD. In this
intervention, teachers are trained so that they can model for the classroom that children with
ADHD are worthy of being liked. Some of the strategies employed in this intervention include
enforcing explicit nonexclusionary social classroom rules, such as assigning children to work in
teams for collaborative activities, in which they must work together in order to succeed. Teachers
also challenge peers’ negative impressions of children with ADHD by drawing positive attention
to the children’s behaviour in a way that influences the children’s reputation with peers.
Preliminary evidence evaluating this program may indicate that children with ADHD (ages 6 to
9) were better liked and less disliked by peers and had more reciprocated friendships, as assessed
via peer sociometric measures, when they were in classrooms where MOSAIC was added to the
traditional SST intervention (Mikami et al., 2013).
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Another important issue when evaluating the efficaciousness of SST interventions is how change
is measured. This review did not collect sociometric measures of children’s peer regard. In fact,
only one of the 13 included SST intervention studies employed this measurement method (MTA
Cooperative, 1999). Sociometric measures are collected through classroom peers, who nominate
the children they like, dislike, and consider friends (Coie, Dodge, & Coppotelli, 1982) or rate
classmates on a Likert scale in terms of the degree to which they like them (Mikami, 2015).
Traditionally, evaluations of SST interventions targeting other populations such as children with
emotional and behavioural disorders have employed peer sociometric measures (for a review see
Maag, 2006). However, measures of peer regard such as peer sociometric measures are often
expensive and difficult to collect. This may explain why they have only rarely been used as
outcome measures in intervention studies with children with ADHD (Hoza et al., 2005; Mikami,
2015). Although important work has been accomplished using peer sociometric methods to
describe the peer problems of children with ADHD (for a review, see Mrug, Hoza, & Gerdes,
2001), it is more challenging to demonstrate that SST interventions can normalize social status
with peers. It is possible that sociometric measurement might be a better way to measure change
in the peer relationships of children with ADHD, rather than asking the child, parent, or teacher
to read a description of a behaviour and indicate whether the child engages in that behaviour
rarely, sometimes, or often (as often done in standardized instruments). Although peer
sociometric measurement may not indicate whether particular skills were acquired, they
accurately reflect peers’ current perspectives regarding the target child (Hoza et al., 2005). Given
the strong predictive utility of peer reports for later outcomes, including school dropout,
academic difficulties, delinquency, substance abuse, and development of other psychopathology
(for a review, see Rubin, Bukowski, & Parker, 1998), greater emphasis on peer sociometric
measurement seems important in future SST intervention studies. Nonetheless, the MTA
Cooperative (1999) study, which incorporated and reported results on peer sociometric
measurement in a later publication (Hoza et al., 2005), did not find effects on peer acceptance of
the children with ADHD. These findings have led some researchers to suggest that, given that
SST interventions already face challenges in improving the social behaviours of children with
ADHD, it seems unlikely that it would result in changes in peer acceptance (Mikami et al.,
2010).
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Another suggestion stemming from this systematic review that needs to be further investigated is
whether SST interventions may potentially allow for lower medication dosages. Specifically,
SST with concurrent parent treatment, teacher consultation, and medications did not seem to
offer an advantage over medications alone in improving children’s social skills or peer
relationships. Nevertheless, the inclusion of SST could allow for lower doses of medication, and
changes in social skills would still be noticeable by teachers. This evidence comes from one RCT
(MTA Cooperative, 1999) in which children receiving the SST interventions did not differ on
their parent-reported internalizing symptoms, ODD symptoms, personal closeness in parent-child
relations, and parent- and teacher-reported social skills total from children receiving medications.
Future research is needed to investigate whether this finding could be replicated. As previously
mentioned in this chapter, this is particularly important for several reasons: First, some children
cannot tolerate the side effects of medications (Vitiello et al., 2012). Second, pharmacological
treatment is not always effective (Pliszka, 2007). Third, a major barrier to the efficaciousness of
stimulants is the tendency for adolescents to discontinue medication (Charach et al., 2014), and
fourth, because parents may reject pharmacological treatment altogether (Lerner & Wigal, 2008;
Pelham et al., 2004).
Previous evidence supports the view that SST interventions may in fact offer the advantage of
enabling lower doses of medications. When studying a sample of young children participating in
a SST intervention (a summer treatment camp) while receiving concurrent stimulant medication,
Chacko and colleagues found that the children showed little incremental improvement in social
and academic functioning with a higher dose compared with a lower dose of stimulant
medication (Chacko, Pelham, Gnagy, Greiner, Vallano, et al., 2005). This implies that while the
children were participating in the SST intervention, significant improvement was achieved with
lower than usual doses of medications. A future research direction for SST interventions would
therefore be to further investigate whether these interventions might allow children to function
well, decreasing their internalizing and externalizing symptoms and behaviours, on a lower dose
of medications, which in time might allow for discontinuation of its use.
Last, little is known about moderators of the efficaciousness of SST interventions, such as
comorbidity with ODD or with anxiety. This could be further investigated to improve the
efficaciousness of these interventions. Specifically, the findings pertaining to the comorbidity
between ADHD and ODD as a potential moderator are inconsistent and need to be further
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investigated. Some studies (Antshel & Remer, 2003) reported that children with ADHD and
comorbid ODD seem to benefit less from SST interventions than children with ADHD alone,
and other studies (MTA Cooperative, 1999; Villodas et al., 2014) found no differential treatment
response. Similarly, the comorbidity between ADHD and anxiety as a moderator of treatment
response should be further explored. It will be important to investigate whether the MTA
Cooperative (1999) study findings can be replicated. Specifically, it would be important to
determine whether children with ADHD and any comorbid anxiety disorders showed a better
response to SST and concurrent parent and teacher treatment and to SST and concurrent parent
and teacher treatment and medication, than children with ADHD without an anxiety disorder.
This will be important to suggest whether interventions of this kind should be considered as a
first-line approach for children with ADHD and anxiety disorders, as suggested by the MTA
study investigators.
5.6.3.15.6.3.15.6.3.15.6.3.1 Summary of Social Skills Training InterventionsSummary of Social Skills Training InterventionsSummary of Social Skills Training InterventionsSummary of Social Skills Training Interventions
In sum, five important future directions for research on SST interventions stem from this review.
First, future SST interventions might consider targeting more homogenous groups, that is, groups
comprising all ADHD-Inattentive or ADHD-Combined Type children. In the former, social
skills knowledge would be expected to improve. In contrast, in the latter group, more emphasis
would need to be placed on performance of social behaviours and on teaching of social
perspective taking. Second, researchers might investigate whether modifying SST interventions
that target only the children with ADHD and their parents and instead providing social skill
training within the children’s classroom might lead to better outcomes in peer relationships. By
training the children’s teachers to target the children with ADHD and their peers, MOSAIC
seems to hold some promise in this regard. Third, incorporating peer sociometric measures in
SST intervention studies might prove useful in detecting change in the peer relationships of
children and adolescents with ADHD. Fourth, it may be worthwhile to further investigate
whether the inclusion of SST would allow for lower doses of medication and whether
improvement would still be noticeable. Fifth, little is known about moderators of the
efficaciousness of SST interventions such as comorbidity with ODD and comorbidity with
anxiety. These could be further investigated, as it might improve the efficaciousness of these
interventions.
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5.75.75.75.7 ConclusionsConclusionsConclusionsConclusions
This study was a systematic review and meta-analysis of child-focused psychosocial
interventions for children and adolescents with ADHD that are purported to reduce their
internalizing and externalizing behaviours and disorders, or improve their social skills, their peer
relationships, and family functioning, as these outcomes reflect the social impairment associated
with ADHD. Although studies solely evaluating core ADHD symptom outcomes were not
eligible for inclusion in the review, when provided in an eligible study, data for core ADHD
symptoms were extracted and analyzed.
The results showed that cognitive behavioural therapy, mindfulness training, and social skills
training interventions did not meet the criteria outlined by the American Psychological
Association for an intervention to be considered as well-established or probably efficacious
(APA Presidential Task Force on Evidence-Based Practise, 2006). Individual CBT seems
promising for reducing externalizing and internalizing symptoms, improving family functioning,
and decreasing the core ADHD symptoms of inattention, hyperactivity, and impulsivity, in some
adolescents concurrently on medication with simultaneous parent treatment. Adolescents with
comorbid ODD benefited less from individual CBT than adolescents with only ADHD or
comorbid anxiety or depressive disorders. Group CBT with concurrent parent and teacher
treatment was largely not efficacious in decreasing externalizing symptoms, improving social
behaviour, or reducing core ADHD symptoms of children with ADHD. When compared to a
medication-alone treatment, medications and group CBT with concurrent parent treatment and
teacher consultation did not seem to offer an advantage over medications alone in decreasing the
externalizing or internalizing symptoms or the core ADHD symptoms of children with ADHD.
Mindfulness training may hold promise in reducing ADHD symptoms, even when children are
not concurrently on medication. It may also improve the peer relationships and reduce
internalizing symptoms of adolescents, and might foster better parent-child relationships. In
terms of peer relationships, it is possible that child age impacts the treatment response to
mindfulness training interventions.
SST interventions showed promise in improving social skills knowledge and assertion. Despite
the majority of SST interventions being offered with parent and teacher treatment generalization
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components, there seems to be a problem in the application of social skills knowledge to real-life
contexts; that is, problems in performance. Only assertion seems to change after thorough
training in social skills; there was no change in self-control, cooperation, or peer relationships.
When offered with concurrent parent treatment and teacher consultation and medications, the
inclusion of SST seemed to allow for lower doses of medication and for changes in social skills
that still were noticeable by teachers. Children with ADHD and any comorbid anxiety disorders
showed a better response to SST and concurrent parent and teacher treatment than children with
ADHD without an anxiety disorder. Children with ADHD- Inattentive Type improved more on
self and parent-reported assertion relative to those with ADHD-Combined Type. Children with
ADHD-Inattentive Type benefited more from SST when they were placed in groups containing
only peers with ADHD-Inattentive Type. Nonetheless, as previously indicated, more research is
needed to be able to draw stronger conclusions about the utility of all of these interventions for
specific outcomes.
The key common factor in the reviewed child-focused psychosocial interventions is that they
show some promise in teaching children a set of skills intended to assist and support them to
self-manage, above and beyond parents’ and teachers’ supports. This is especially critical for
adolescents who have multiple teachers and who do not respond to relatively simple
reinforcement and extinction methods, for whom contingency-management programs are not
efficacious (Kaizer, Hoza, & Hurt, 2008), and who often discontinue medication use after the age
of 12 (Centres for Disease Control and Prevention, 2005). Additionally, and as mentioned above,
pharmacological treatments have their own concerns and limitations. Therefore, it is worthwhile
to continue to investigate child-focused psychosocial interventions and determine what they can
offer when other treatment modalities are not as effective as desired. Given that ADHD is a
chronic, life-long, disorder, having a treatment modality alternative that would allow for
treatment gains across adolescence and into adulthood, particularly following the reduction or
withdrawal of pharmacological treatment, is greatly needed.
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APPENDICESAPPENDICESAPPENDICESAPPENDICES
219
Appendix A. Description of Instruments Used for Outcome Measurement
a) Between-groups Design List of Outcome Instruments
Outcome
Category Source
Number of
Instruments Child Outcome Variable Study
Number
of Studies
ADHD
symptoms
Parent
reported
n = 14
Parent reported Disruptive Behavior Disorders Rating Scale (DBD; Pelham et al., 1992). Hyperactivity/Impulsivity and Inattention Subscales. An ADHD
Composite was calculated. (Higher scores indicate more severe symptoms). Dutch adaptation.
van der Oord et al. (2007)
1
Parent Disruptive Behavior Disorders Rating Scale (DBD; Pelham, et al.1992) ADHD-Inattentive Scale
Evans et al. (2011)
Waxmonsky et al. (2010) 2
Parent Disruptive Behavior Disorders Rating Scale (DBD; Pelham, et al.1992) ADHD Hyperactive/Impulsive Scale
Evans et al. (2011),
Waxmonsky et al. (2010) 2
Conners Parent Rating Scale (CPRS; Goyette et al., 1978) Hyperkinesis
Index. Abikoff et al. (2004b)
1
Conners Parent Rating Scale (CPRS; Conners, 1969) the Hyperactivity Index Brown et al. (1986) 1
Conners' Parent Rating Scales Long Version (CPRS-R:L; Conners, 1997). Hyperactivity Scale.
Jensen & Kenny (2004) 1
Conners' Parent Rating Scales Long Version (CPRS-R:L; Conners, 1997). ADHD Index Scale.
Jensen & Kenny (2004) 1
Conners’ Parent Rating Scales Long Version (CPRS-R:L; Conners, 1997). Cognitive Problems- Inattention Scale.
Jensen & Kenny (2004) 1
Conners' Parent Rating Scales Long Version (CPRS-R:L; Conners, 1997). Global Index Restless/Impulsive Scale.
Jensen & Kenny (2004) 1
Conners' Parent Rating Scales Long Version (CPRS-R:L; Conners, 1997). DSM-IV Inattentive Scale.
Jensen & Kenny (2004) 1
Conners' Parent Rating Scales Long Version (CPRS-R:L; Conners, 1997). DSM-IV Hyperactive/Impulsive Scale.
Jensen & Kenny (2004) 1
Parent Reported Child Behavioural Checklist (CBCL; Achenbach, 2001) ADHD Problems Subscale
Haydicky et al. (2012) 1
Parent reported Inattention Subscale Swanson, Nolan, and Pelham Rating Scale (SNAP, Swanson et al. 1992)
MTA Cooperative (1999) 1
220
Outcome
Category Source
Number of
Instruments Child Outcome Variable Study
Number
of Studies
Parent reported Hyperactivity/impulsivity Subscale Swanson, Nolan, and Pelham Rating Scale (SNAP, Swanson et al. 1992)
MTA Cooperative (1999) 1
Teacher
reported
n =18
Teacher reported Disruptive Behavior Disorders Rating Scale (DBD; Pelham et al., 1992). Hyperactivity/Impulsivity and Inattention Subscales. An ADHD
Composite was calculated. (Higher scores indicate more severe symptoms. Dutch adaptation (Oosterlaan, Scheres, Antrop, Roeyers, Sergeant, 2000).
van der Oord et al. (2007)
1
Teacher reported Disruptive Behavior Disorders Rating Scale (DBD; Pelham et al., 1992) ADHD-Inattentive Subscale
Evans et al. (2011),
Waxmonsky et al. (2010) 2
Teacher Disruptive Behavior Disorders Rating Scale (DBD; Pelham et al., 1992) ADHD Hyperactive/Impulsive Subscale
Evans et al. (2011),
Waxmonsky et al. (2010) 2
Teacher reported Inattention Subscale Swanson, Nolan, and Pelham Rating Scale (SNAP, Swanson et al. 1992)
MTA Cooperative (1999) 1
Teacher reported Hyperactivity/Impulsivity Subscale Swanson, Nolan, and Pelham Rating Scale (SNAP, Swanson et al. 1992)
MTA Cooperative (1999)
1
Teacher reported Total Score Abbreviated Conners Rating Scale (ACRS; Conners, 1969).
Brown et al. (1986) 1
Conners Teacher Rating Scale (CTRS; Goyette et al., 1978) Hyperactivity
Index Factor. Abikoff et al. (2004b),
,Bloomquist et al. (1991) 2
Conners Teacher Rating Scale (CTRS; Goyette et al., 1978) Inattention/Passivity Factor
Bloomquist et al. (1991) 1
Conners Teacher Rating Scale (CTRS; Goyette et al., 1978) Impulsivity
Factor. Bloomquist et al. (1991)
1
Conners’ Teacher Rating Scales Long Version (CTRS-R:L; Conners, 1997). ADHD Index Scale.
Jensen & Kenny (2004) 1
Conners' Teacher Rating Scales Long Version (CTRS-R:L; Conners, 1997). Global Index Restless/Impulsive Scale.
Jensen & Kenny (2004) 1
Conners' Teacher Rating Scales Long Version (CTRS-R:L; Conners, 1997) DSM-IV Inattentive Scale.
Jensen & Kenny (2004) 1
Conners' Teacher Rating Scales Long Version (CTRS-R:L; Conners, 1997) DSM-IV Hyperactive/Impulsive Scale.
Jensen & Kenny (2004) 1
Teacher reported ADD-H Comprehensive Teacher Ratings Scale (ACTeRS; Ullmann, 1991). Attention subscale.
Brown et al. (1986) 1
Teacher reported ADD-H Comprehensive Teacher Ratings Scale (ACTeRS; Ullmann, 1991).Hyperactivity subscale.
Brown et al. (1986) 1
221
Outcome
Category Source
Number of
Instruments Child Outcome Variable Study
Number
of Studies
Teacher reported Attention from a measure not described, just a reference of unpublished dissertation provided (Domascus, 1980)
Brown et al. (1986) 1
Teacher Report Form Attention Problems Subscale (TRF; Achenbach, 1991) Jensen & Kenny (2004) 1
Teacher Reported Impulsivity from a measure not described, just a reference of unpublished dissertation provided (Wynne, 1979).
Brown et al. (1986) 1
Self/Child-
reported
n = 1
Youth Self Report (YSR; Achenbach, 2001) ADHD Problems Composite
Haydicky et al. (2012) 1
ODD
symptoms
Parent
reported
n = 3
Parent reported Disruptive Behavior Disorders Rating Scale (DBD; Pelham et al., 1992). ODD Subscale (Higher scores indicate more severe symptoms). Van der oord used a Dutch adaptation. (Oosterlaan, Scheres, Antrop, Roeyers, Sergeant, 2000).
van der Oord et al. (2007)
Waxmonsky et al. (2010) 2
Conners Parent Rating Scales Long Version (CPRS-R:L; Conners, 1997). Oppositional Scale.
Jensen & Kenny (2004) 1
Parent Reported Child Behavioural Checklist (CBCL; Achenbach, 2001) Oppositionality Subscale
Haydicky et al. (2012) 1
Teacher
reported
n = 3
Teacher reported Disruptive Behavior Disorders Rating Scale (DBD; Pelham et al., 1992). ODD Subscale (Higher scores indicate more severe symptoms). Van der Oord used a Dutch adaptation (Oosterlaan, Scheres, Antrop, Roeyers, Sergeant, 2000).
van der Oord et al. (2007)
Waxmonsky et al. (2010) 2
Conners' Teacher Rating Scales Long Version (CTRS-R:L; Conners, 1997). Oppositional Scale.
Jensen & Kenny (2004) 1
Teacher reported ADD-H Comprehensive Teacher Ratings Scale
(ACTeRS; Ullmann, 1991) Oppositional Behaviour Subscale. Brown et al. (1986)
1
Self/Child-
Reported n = 1
Youth Self Report (YSR; Achenbach, 2001) Oppositionality Problems
Composite Haydicky et al. (2012)
1
CD
symptoms
Parent
reported
n = 2
Parent reported Disruptive Behavior Disorders Rating Scale (DBD; Pelham et al., 1992). CD Subscale (Higher scores indicate more severe symptoms). Van der Oord used a Dutch adaptation (Oosterlaan, Scheres, Antrop, Roeyers, Sergeant, 2000).
van der Oord et al. (2007)
Waxmonsky et al. (2010) 2
Parent Reported Child Behavioural Checklist (CBCL; Achenbach, 2001) Conduct Disorder Problems Subscale
Haydicky et al. (2012) 1
Teacher
Reported n = 2
Teacher reported Disruptive Behavior Disorders Rating Scale (DBD; Pelham et al., 1992). CD subscale (Higher scores indicate more severe symptoms). Van der Oord used a Dutch adaptation (Oosterlaan, Scheres, Antrop, Roeyers,
van der Oord et al. (2007)
Waxmonsky et al. (2010) 2
222
Outcome
Category Source
Number of
Instruments Child Outcome Variable Study
Number
of Studies
Sergeant, 2000). Conners Teacher Rating Scale (CTRS; Goyette et al., 1978) Conduct
Problems Abikoff et al. (2004b)
Bloomquist et al. (1991) 2
Self/Child-
reported n = 1 Youth Self Report (YSR; Achenbach, 2001) Conduct Disorder Problems
Composite
Haydicky et al. (2012)
1
Externalizi
ng
symptoms
(Combined
ODD/CD)
Parent
reported
n = 4
Parent Child Behavior Checklist (CBCL; Achenbach, 1991 Externalizing
Subscale
Pfiffner & McBurnett
(1997) 1
Parent Reported Child Behavioural Checklist (CBCL; Achenbach, 2001) Externalizing Subscale
Haydicky et al. (2012) 1
Parent reported Externalizing Problems Scale (i.e., combined aggression, hyperactivity, conduct problems) from the Behavior Assessment Scale for Children (BASC-I; Kamphaus & Frick, 1996) (higher scores represent greater problems).
Molina et al. (2008)
1
Parent reported Oppositionality/Aggressive Subscale Swanson, Nolan, and Pelham Rating Scale (SNAP, Swanson et al. 1992)
MTA Cooperative (1999)
1
Teacher
reported
n = 2
Teacher reported Oppositionality/Aggressive Subscale Swanson, Nolan, and Pelham Rating Scale (SNAP, Swanson et al. 1992)
MTA Cooperative (1999) 1
Teacher Rating Form of the Teacher Report Form (TRF; Achenbach, 1991) Externalizing Subscale
Pfiffner & McBurnett
(1997) 1
Self Child-
reported
n = 2
Youth Self Report (YSR; Achenbach, 2001) Externalizing Subscale Haydicky et al. (2012)
1
The Aggression and Conduct Problems Scale (American Psychiatric Association, 1994) Total child-reported delinquency or conduct problems
scale was used. (Higher scores represent greater problems). Checklist that measures combined ODD, CD, and aggressive behaviors.
Molina et al. (2008)
1
Anxiety
symptoms
Parent
reported
n = 3
Conners' Parent Rating Scales Long Version (CPRS-R:L; Conners, 1997). Anxious/Shy Scale.
Jensen & Kenny (2004) 1
Conners' Parent Rating Scales Long Version (CPRS-R:L; Conners, 1997). Perfectionism Scale.
Jensen & Kenny (2004) 1
Conners' Parent Rating Scales Long Version (CPRS-R:L; Conners, 1997). Psychosomatic Scale.
Jensen & Kenny (2004) 1
Teacher n = 2 Conners' Teacher Rating Scales Long Version (CTRS-R:L; Conners, 1997). Anxious/Shy Scale.
Jensen & Kenny (2004) 1
223
Outcome
Category Source
Number of
Instruments Child Outcome Variable Study
Number
of Studies
reported Conners' Teacher Rating Scales Long Version (CTRS-R:L; Conners, 1997). Perfectionism Scale
Jensen & Kenny (2004) 1
Self/Child-
Reported
n = 5
Self-reported Child Trait Anxiety subscale from the State-Trait Anxiety Inventory for Children (STAIC-C; Spielberger, 1973). Child rated 20 items on a 3-point Likert scale from 1 (almost never) to 2(often), (higher scores indicate higher anxiety levels). Dutch adaptation. (August, Realmuto, MacDonald, Nugent, Crosby, 1996).
van der Oord et al. (2007)
1
Self-reported Child Trait Anxiety subscale from the State-Trait Anxiety Inventory for Children (STAIC-C; Spielberger, 1973; Korean Version Cho & Choi, 1989). Is a 20-iteam self-report measure using a 3-point Likert scale from 1 (rarely) to 3 (a lot) to assess children perceptions of tendencies to experience anxiety.
Choi & Lee (2015)
1
Child reported Anxiety on the Multidimensional Anxiety Scale for Children Total MASC Score (MASC, March et al., 1997)
MTA Cooperative (1999) 1
Youth Self Report (YSR; Achenbach, 2001) DSM Anxiety Subscale Haydicky et al. (2012) 1
Mood
Symptoms
Parent
reported
n = 2
Children’s Depression Inventory Total Score (CDI; Kovacs, 1992) Hechtman et al. (2004b)
1
Self-reported Child Depression Total from the Child Depression Inventory (CDI; Kovacs, 1985) Korean Version (Cho & Lee, 1990) Is a 27-item self-report measure where the child answers three statements regarding a particular depressive symptom (0= no depression to 2 =possible depression) in the past 2 weeks.
Choi & Lee (2015)
1
Self-
reported
n =1 Suicidal ideation from the Children’s Depression Rating Scale-Revised (CDRS-R; Poznanski & Mokros, 2007).
Waxmonsky et al., (2010)
1
Depression from the Children’s Depression Rating Scale-Revised (CDRS-R; Poznanski & Mokros, 2007).
Waxmonsky et al., (2010) 1
Internalizi
ng
Symptoms
Parent
reported n = 4
Parent Child Behavior Checklist (CBCL; Achenbach, 1991) Internalizing
Scale
Pfiffner & McBurnett
(1997) 1
Parent-reported Behavior Assessment Scale for Children (BASC-I; Kamphaus & Frick, 1996) Internalizing Problems Composite Scale (i.e., Combined Anxiety, Depression, and Somatization) Higher scores represents greater problems).
Molina et al. (2008)
1
224
Outcome
Category Source
Number of
Instruments Child Outcome Variable Study
Number
of Studies
(combined
anxiety
and
depression)
Parent reported Internalizing Symptoms (Anxiety and Depression Combined) Subscale of the Social Skills Rating Scale (SSRS, Gresham & Elliot,1998)
MTA Cooperative (1999) 1
Conners' Parent Rating Scales Long Version (CPRS-R:L; Conners, 1997). Global Index Emotional Lability Scale.
Jensen & Kenny (2004) 1
Teacher
reported
n= 3
Teacher reported Internalizing Symptoms (Anxiety and Depression Combined) Subscale of the Social Skills Rating Scale (SSRS, Gresham & Elliot,1998).
MTA Cooperative (1999)
1
Conners' Teacher Rating Scales Long Version (CTRS-R:L; Conners, 1997). Global Index Emotional Lability Scale.
Jensen & Kenny (2004) 1
Teacher Rating Form (TRF) of the Child Behavior Checklist (TRF; Achenbach, 1991) Internalizing subscale
Pfiffner & McBurnett
(1997) 1
Self/Child-
reported
n = 5
Self-reported Emotional Symptoms Behavior Assessment Scale for Children (BASC-I; Kamphaus & Frick, 1996) (i.e., Combined social stress, anxiety, depression, sense of inadequacy, interpersonal relationships, and self-esteem). (Higher scores represent greater problems).
Molina et al. (2008)
1
Youth Self Report (YSR; Achenbach, 2001) Anxious/Depressed Subscale
(mixed anxiety and mood measured together) Haydicky et al. (2012)
1
Poor Awareness Subscale of the Emotion Expression Scale for Children (EESC; Penza-Clyve & Zeman, 2002) is a self-report of child impaired ability to express emotion. Initially adapted from the 30-item Toronto Alexithymia Scale for Adults (Bagby, Taylor, & Ryan, 1986) the Korean version by Choi (2011) was used. 5 point Likert scale 1 (not at all true) to 5 (extremely true) to indicate how well each item described the child experience with these expressive difficulties. Higher scores indicate poorer emotion awareness.
Choi & Lee (2015)
1
Self-reported Expressive Reluctance Subscale of the Emotion Expression Scale for Children (EESC; Penza-Clyve & Zeman, 2002) is a self-report of child impaired ability to express emotion. Initially adapted from the 30-item Toronto Alexithymia Scale for Adults (Bagby, Taylor, & Ryan, 1986) the Korean version by Choi (2011).
Choi & Lee (2015)
1
Peer
relations/so
cial skills
Parent
reported n = 10
Parent reported Social Skills Total Score from the Social Skills Rating Scale (SSRS; Gresham & Elliot, 1998). (This scale consists of 30 items related to cooperation, assertion, responsibility, and self-control. High scores indicate more positive social skills).
Abikoff et al. (2004a),
MTA Cooperative (1999),
Pfiffner & McBurnett
(1997), van der Oord et
al. (2007), Waxmonsky et
5
225
Outcome
Category Source
Number of
Instruments Child Outcome Variable Study
Number
of Studies
al. (2010) Parent reported Cooperation Subscale (from Social Skills Scale) from the Social Skills Rating Scale (SSRS; Gresham & Elliot, 1998).
Antshel & Remer (2003) 1
Parent reported Assertion Subscale (from Social Skills Scale) from the Social Skills Rating Scale (SSRS; Gresham & Elliot, 1998).
Antshel & Remer (2003),
Frankel et al. (2007) 2
Parent reported Responsibility Subscale (from Social Skills Scale) from the Social Skills Rating Scale (SSRS; Gresham & Elliot, 1998).
Antshel & Remer (2003) 1
Parent reported Self-Control Subscale (from Social Skills Scale) from the Social Skills Rating Scale (SSRS; Gresham & Elliot, 1998).
Antshel & Remer (2003),
Frankel et al. (2007) 2
Parent reported Social Skills Rating System (SSRS; Greshman & Elliot, 1998) Problem Behavior Subscale
(consist of 18 items related to externalizing and internalizing problem domains; lower scores indicate fewer problems).
Pfiffner & McBurnett
(1997), Waxmonsky et al.
(2010) 2
Parent UCI (University of California, Irvine, Pfiffner & McBurnett, 1997) Social Skills Score Total Scale is a 10-item rating scale constructed for this study to measure the specific social behaviors that were taught in the children treatment groups (Group 1 & Group 2). Parents rated the extent to which their child follow game rules, stays with the game (maintains participation in group activity), says nice things to others (validates and compliments), follows directions, use assertive communication, ignores teasing, uses problem solving, recognizes others' feelings and deals with anger appropriately. Each skills is rated as never (1) to (5) most or all of the time.
Pfiffner & McBurnett
(1997)
1
Parent reported Peer/social Relationships scale Impairment Rating Scale (IRS; Fabiano et al., 2006). (The parent version contains seven domains (relationship with peers, relationship with siblings, relationship with parents, academic progress, self-esteem, influence on family functioning, and over- all impairment). Scored on a 7-point Likert scale ranging from 0 (No problem) to 6 (Extreme problem). IRS items assessing the degree to which children's impairments affect their peer relationships as reported by parent.
Evans et al. (2011),
Waxmonsky et al. (2010)
2
Parent Reported Child Behavioural Checklist (CBCL; Achenbach, 2001) Social Problems Subscale
Haydicky et al. (2012) 1
Conners' Parent Rating Scales Long Version (CPRS-R:L; Conners, 1997). Social Problems Scale.
Jensen & Kenny (2004) 1
Teacher
reported n = 8 Teacher reported Social Skills Total Score from the Social Skills Rating Scale (SSRS; Gresham & Elliot, 1998). Higher scores indicate better social skills.
MTA Cooperative (1999),
Pfiffner & McBurnett
(1997), van der Oord et
4
226
Outcome
Category Source
Number of
Instruments Child Outcome Variable Study
Number
of Studies
al. (2007), Waxmonsky et
al. (2010)
Teacher reported Social Skills Rating System (SSRS; Greshman & Elliot, 1998) Problem Behavior Subscale
(consist of 18 items related to externalizing and internalizing problem domains; lower scores indicate fewer problems).
Pfiffner & McBurnett
(1997)
Waxmonsky et al. (2010) 2
Teacher reported Peer Relationships scale Impairment Rating Scale (IRS; Fabiano et al., 2006). (The teacher version has six domains (relationship with peers, relationship with teacher, academic progress, self-esteem, influence on classroom functioning, and overall impairment). The instructions ask the rater to assess the severity of a child’s problem in each domain and the need for treatment and special services.)
Evans et al. (2011),
Waxmonsky et al. (2010)
2
Teacher reported Taxonomy of Problem Situations Total Score (Dodge et al., 1985). This measure differentiates socially rejected peers and accepted children.
Abikoff et al. (2004a) b
1
Teacher Reported Peer Preferred Social Behavior of the Walker-McConnell Scale of Social Competence and School Adjustment (Walker & McConnell, 1988) is a checklist that samples behaviour, social and academic competence domains according to three scales (teacher preferred social behavior, peer preferred social behavior, and school adjustment)
Bloomquist et al. (1991)
1
Conners' Teacher Rating Scales Long Version (CTRS-R:L; Conners, 1997). Social Problems Scale.
Jensen & Kenny (2004) 1
Teacher reported Self-control in a measure (Humphrey, 1982) poorly described. Only says that it is a 15-item instrument that measures children's self-control.
Brown et al. (1986)
1
Teacher ACTeRS reported ADD-H Comprehensive Teacher Ratings Scale (ACTeRS; Ullmann, 1991). Social Skills Subscale.
Brown et al. (1986) 1
Self/Child-
reported
n = 11
Self-report Version of the Social Skills Rating Scale were used to obtained Total Social Skills Total Score (SSRS; Gresham & Elliot, 1998)
Abikoff et al. (2004a) 1
Self-reported Cooperation Subscale (from Social Skills Scale) from the Social Skills Rating Scale (SSRS; Gresham & Elliot, 1990, 1998).
Antshel & Remer (2003) 1
Self-reported Assertion Subscale (from Social Skills Scale) from the Social Skills Rating Scale (SSRS; Gresham & Elliot, 1990, 1998).
Antshel & Remer (2003) 1
Self-reported Empathy Subscale (from Social Skills Scale) from the Social Skills Rating Scale (SSRS; Gresham & Elliot, 1990, 1998).
Antshel & Remer (2003) 1
Self-reported Self-Control Subscale (from Social Skills Scale) from the Antshel & Remer (2003) 1
227
Outcome
Category Source
Number of
Instruments Child Outcome Variable Study
Number
of Studies
Social Skills Rating Scale (SSRS; Gresham & Elliot, 1990, 1998). Youth Self Report (YSR; Achenbach, 2001) Social Problems Subscale Haydicky et al. (2012) 1
Child reported Test of Like Skill Knowledge (TOSLK; Pfiffner & Mikami, 2005) (e.g., what should you do if someone is teasing you?) to assess social and organizational skills taught in the child group (10 items scored on a 3-point Likert scale where 1=no or inaccurate response, 2= partial response, and 3=full accurate response).
Pfiffner et al. (2007)
1
Child self-reported Social Skills Knowledge Scale Total Score (Pfiffner & McBurnett, 1997). This criterion-based measure was designed to assess children’s knowledge about the specific social skills taught during the treatment groups (Group 1 & Group 2). It contains 6 questions pertaining to the skills taught in the 6 modules (e.g., what are some ways to deal with anger?). Ratings range from 1 = no or inaccurate to 15, full accurate response).
Pfiffner & McBurnett
(1997)
1
Self-reported Initiative. Peer Relational Skills Scale (Yang & Oh, 2005) is a child self-report measure consisting of 19 items, Total/Overall
Choi & Lee (2015) 1
Self-reported Cooperation/Empathy. Peer Relational Skills Scale (Yang & Oh, 2005) is a child self-report measure consisting of 19 items, Total/Overall
Choi & Lee (2015) 1
Self-reported Total Ability for Peer Relational Skills (Social skills total). Peer Relational Skills Scale (Yang & Oh, 2005) is a child self-report measure consisting of 19 items, Total/Overall
Choi & Lee (2015)
1
Family/
Parent-
Child
Relationshi
p
Parent
reported
n = 3
Parent reported regarding the parent-child relation on a Personal Closeness
Composite of the Parent-Child Relationship Questionnaire (PCRQ; Furman & Giberson, 1995)
MTA Cooperative (1999)
1
Parent reported Home Situations Questionnaire (HSQ) (Barkley, 1990) yields the Number of problematic home situations.
Abikoff et al. (2004b) 1
Parent reported Home Situations Questionnaire (HSQ) (Barkley, 1990) yields the Severity of the problematic home situations.
Abikoff et al. (2004b) 1
Parent reported Impairment Rating Scale (IRS; Waschbusch, & King, 2006) Family Relationships scale.
Antshel et al. (2014),
Waxmonsky et al. (2010) 2
Parent reported Impairment Rating Scale (IRS; Waschbusch, & King, 2006) Parent-Child Relationships Scale. Parent [(7 items) versions are score on a 7-point Likert scale ranging from 0 (No problem) to 6 (Extreme problem)].
Antshel et al. (2014),
Villodas et al. (2014),
Waxmonsky et al. (2010)
3
Parent reported Impairment Rating Scale (IRS; Waschbusch, & King, 2006) Sibling Relationships scale.
Antshel et al. (2014),
Waxmonsky et al. (2010) 2
228
Outcome
Category Source
Number of
Instruments Child Outcome Variable Study
Number
of Studies
Self/Child-
reported
n = 4
Children ratings of their mother’s positive parenting from the Parent Perception Inventory (Hazzard, Christenser, & Margolin, 1983). (5-point
scale from \"never\" to \"a lot).”
Hechtman et al. (2004a)
1
Children ratings of their mother’s negative parenting form the Parent Perception Inventory (Hazzard, Christenser, & Margolin, 1983). (5-point
scale from \"never\" to \"a lot).”
Hechtman et al. (2004a)
1
Children ratings of their father’s positive parenting from the Parent Perception Inventory (Hazzard, Christenser, & Margolin, 1983). (5-point
scale from \"never\" to \"a lot).”
Hechtman et al. (2004a)
1
Children ratings of their father’s negative parenting form the Parent Perception Inventory (Hazzard, Christenser, & Margolin, 1983). (5-point
scale from \"never\" to \"a lot).”
Hechtman et al. (2004a)
1
Note. Studies Abikoff et al. (2004b), Hechtman et al. (2004b), Hechtman et al. (2004a), Klein et al. (2004), and Abikoff et al. (2004a) are different publications of the same sample. Abikoff et al. (2004b) has 12 outcomes of interest, Hechtman et al. (2004b) only 1 outcome of interest, and Hechtman et al. (2004a) has 4, Klein et al. (2004) none, Abikoff et al. (2004a) has 6 outcomes of interest, so total of 23 outcomes for this same sample). Frankel et al. (2007) whenever is parent report, it is mother reported.
229
Appendix A. b) Within-subjects Design List of Child Outcome Instruments by Reporter
Outcome
Category
Source Number of
Instruments Child Outcome Variable
Study Number
of Studies
ADHD
symptoms
Parent reported
n = 7
Parent Total Score Conners Abbreviated Symptom
Questionnaire (ASQ-P; Conners, 1990) (composed of the ten items most frequently endorsed by parents of hyperactive children. The ASQ-P was originally developed in 1973; items were extracted from the full version of the Conners' Parent and Teacher Rating Scales, and are called the Hyperactivity Index)
Lufi & Parish-Plass
(2011), Harrison et al.
(2004) 2
Parent Conners-3rd Ed (Conners, 2008) Inattentive Subscale Haydicky et al. (2015) 1
Conners-3rd Ed (Conners, 2008) Hyperactivity/impulsivity
Subscale Haydicky et al. (2015)
1
Parent reported ADHD Symptom Severity Scale of the Child Symptom Inventory (CSI; Gadow & Sprafkin, 1994). (18 items) correspond to DSM-IV symptoms rated on a 4-point Likert scale ranging from 0 (Never) to 3 (Very Often).
Villodas et al. (2014)
1
Parent Reported Child Behavior Checklist (CBCL; Achenbach, 1991) Attention Problems Subscale
Lufi & Parish-Plass
(2011) 1
Mother Reported Child Behavior Checklist (CBCL; Achenbach, 1991) Attention Problems Subscale
van der Weijer-Bergsma
et al. (2012) 1
Father Reported Child Behavior Checklist (CBCL; Achenbach, 1991) Attention Problems Subscale
van der Weijer-Bergsma
et al. (2012) 1
Teacher
reported n =1
Teacher Report Form Attention Problems Subscale (TRF; Achenbach, 1991)
van der Weijer-Bergsma
et al. (2012) 1
Teacher reported ADHD Symptom Severity Scale of the Child Symptom Inventory (CSI; Gadow & Sprafkin, 1994). (18 items) correspond to DSM-IV symptoms rated on a 4-point Likert scale ranging from 0 (Never) to 3 (Very Often).
Villodas et al. (2014)
1
Self/Child-
reported
n = 5
Youth Self-Report (YSR; Achenbach, 1991). The YSR is a self-rating scale for children ages 5 to 18 (with norms for both sexes and for two age groups 5-11 and 12-18), answered on a 3-point Likert-type scale (0 not true, 1 somewhat true, 2 often true) describing behaviors during the past 6 months. Attention
Subscale.
Lufi & Parish-Plass
(2011), van der Weijer-
Bergsma et al. (2012) 2
Adolescent Self-report Conners-3SR (Conners, 2008) Inattention Subscale
Haydicky et al. (2015) 1
230
Outcome
Category
Source Number of
Instruments Child Outcome Variable
Study Number
of Studies
Adolescent Self-report Conners-3SR (Conners, 2008) Hyperactivity/impulsivity Subscale
Haydicky et al. (2015) 1
Self-reported Behavior Assessment System for Children-2nd Ed. (BASC-2; Reynolds & Kamphaus, 2006) Inattention Total
Score
Antshel et al., 2014e
1
Self-reported Behavior Assessment System for Children-2nd Ed. (BASC-2; Reynolds & Kamphaus, 2006) Hyperactivity
Total Score
Antshel et al., 2014 e
1
ODD
Symptoms
Parent reported
n =2
Parent Conners-3rd Ed (Conners, 2008) Oppositionality
Subscale Haydicky et al. (2015)
1
Parents reported ODD Symptom Severity Scale of the Child Symptom Inventory (CSI; Gadow & Sprafkin, 1994) (8 items) correspond to DSM-IV symptoms rated on a 4-point Likert scale ranging from 0 (Never) to 3 (Very Often)
Villodas et al. (2014)
1
Teacher reported
n =1
Teacher reported ODD Symptom Severity Scale of the Child Symptom Inventory (CSI; Gadow & Sprafkin, 1994) (8 items) correspond to DSM-IV symptoms rated on a 4-point Likert scale ranging from 0 (Never) to 3 (Very Often).
Villodas et al. (2014)
1
Self/Child-
reported
n = 1 Adolescent self-report Conners-3SR (Conners, 2008) Oppositionality Subscale
Haydicky et al. (2015)
1
CD Symptoms
Parent reported n =1
Parent Conners-3rd Ed (Conners, 2008) Conduct Disorder
Subscale Haydicky et al. (2015)
1
Self/Child-
Reported
n = 1 Adolescent self-report Conners-3SR (Conners, 2008) Conduct
Disorder Subscale
Haydicky et al. (2015)
1
231
Outcome
Category
Source Number of
Instruments Child Outcome Variable
Study Number
of Studies
Externalizing
Symptoms
(Combined)
ODD/CD)
Parent
Reported
n = 6
Parent Child Behavior Checklist (CBCL; Achenbach, 1991
Externalizing Subscale
Lufi & Parish-Plass
(2011) 1
Mother Reported Child Behavior Checklist Externalizing Scale (CBCL; Achenbach, 1991)
van der Weijer-Bergsma
et al. (2012) 1
Father Reported Child Behavior Checklist Externalizing Scale (CBCL; Achenbach, 1991)
van der Weijer-Bergsma
et al. (2012) 1
Parent Child Behavior Checklist (CBCL; Achenbach, 1991) Aggression Subscale
Lufi & Parish-Plass
(2011) 1
Parent Child Behavior Checklist (CBCL; Achenbach, 1991) Delinquency Subscale
Lufi & Parish-Plass
(2011) 1
Parent Reported Externalizing Problems Scale Behavior Assessment System for Children-2nd Ed. (BASC-2; Reynolds & Kamphaus, 2006)
Antshel et al. (2014) 1
Teacher
reported
n =2
Teacher Rating Form of the Teacher Report Form (TRF; Achenbach, 1991) Externalizing Subscale
van der Weijer-Bergsma
et al. (2012) 1
Teacher Version Behavior Assessment System for Children-2nd Ed. (BASC-2; Reynolds & Kamphaus, 2006) Externalizing
Total Score
Antshel et al. (2014) e
1
Self/Child-
reported
n = 3
Youth Self-Report (YSR; Achenbach, 1991). The YSR is a self-rating scale for children ages 5 to 18 (with norms for both sexes and for two age groups 5-11 and 12-18), answered on a 3-point Likert-type scale (0 not true, 1 somewhat true, 2 often true) describing behaviors during the past 6 months. Externalizing Subscale.
Lufi & Parish-Plass
(2011), van der Weijer-
Bergsma et al. (2012) 2
Youth Self-Report (YSR; Achenbach, 1991). Aggression
Subscale Lufi & Parish-Plass
(2011) 1
Youth Self-Report (YSR; Achenbach, 1991). Delinquency
Subscale
Lufi & Parish-Plass
(2011) 1
Anxiety
Symptoms
Parent
reported
n = 4
Parent Child Behavior Checklist (CBCL; Achenbach, 1991) Anxiety Symptoms
Lufi & Parish-Plass
(2011) 1
Parent Child Behavior Checklist (CBCL; Achenbach, 1991) Somatic Symptoms
Lufi & Parish-Plass
(2011) 1
Parent Child Behavior Checklist (CBCL; Achenbach, 1991) Thoughts Symptoms
Lufi & Parish-Plass
(2011) 1
Revised Children’s Anxiety and Depression Scale – Parent-Report (Chorpita, 2014). Anxiety Subscale
Haydicky et al. (2015) 1
Self/Child-
reported n = 1
Revised Children’s Anxiety and Depression Scale – Self-Report (Chorpita, 2014). Anxiety Subscale
Haydicky et al. (2015) 1
232
Outcome
Category
Source Number of
Instruments Child Outcome Variable
Study Number
of Studies
Mood
Symptoms
Parent
reported
n= 2
Parent Child Behavior Checklist (CBCL; Achenbach, 1991) Withdrawn Subscale
Lufi & Parish-Plass
(2011) 1
Revised Children’s Anxiety and Depression Scale – Parent-Report (Chorpita, 2014). Depression Subscale
Haydicky et al. (2015) 1
Self/Child-
reported n= 2
Youth Self-Report (YSR; Achenbach, 1991) Withdrawn
Subscale Lufi & Parish-Plass
(2011) 1
Revised Children’s Anxiety and Depression Scale – Self-Report (Chorpita, 2014). Depression Subscale
Haydicky et al. (2015) 1
Internalizing
Symptoms
(combined
anxiety and
depression)
Parent
reported
n= 3
Parent Child Behavior Checklist (CBCL; Achenbach, 1991) Internalizing Scale
Lufi & Parish-Plass
(2011) 1
Mother Reported Child Behavior Checklist Internalizing Scale (CBCL; Achenbach, 1991)
van der Weijer-Bergsma
et al. (2012) 1
Father Reported Child Behavior Checklist Internalizing Scale (CBCL; Achenbach, 1991)
van der Weijer-Bergsma
et al. (2012) 1
Parent-reported Behavior Assessment Scale for Children-2nd Ed. Internalizing Problems Composite Scale (BASC-2; Reynolds & Kamphaus, 2006)
Anstshel et al., 2014 e
1
Parent Revised Revised Children’s Anxiety and Depression Scale (Chorpita, 2014). Internalizing Composite
Haydicky et al. (2015) 1
Teacher reported
n=2
Teacher Rating Form (TRF) of the Child Behavior Checklist (TRF; Achenbach, 1991) Internalizing subscale
van der Weijer-Bergsma
et al. (2012), Antshel et al. (2014)
2
Teacher Version Behavior Assessment System for Children-2nd Ed. (BASC-2; Reynolds & Kamphaus, 2006) Internalizing
Total Score
Anstshel et al., 2014 e
1
Self/Child-
reported
n= 4
Self-reported Emotional Symptoms Behavior Assessment System for Children-2nd Ed. (BASC-2; Reynolds & Kamphaus, 2006)
Anstshel et al., 2014 e
1
Self-reported Behavior Assessment System for Children-2nd Ed. (BASC-2; Reynolds & Kamphaus, 2006) Internalizing
Total Score
Anstshel et al., 2014 e
1
Youth Self-Report Internalizing Scale (YSR; Achenbach, 1991)
van der Weijer-Bergsma
et al. (2012) 1
Adolescent Self-report Conners-3SR (Conners, 2008) Internalizing Composite
Haydicky et al. (2015) 1
Peer
Relations/
Social Skills
Parent
reported n= 6
Parent reported Social Skills Total Score from the Social Skills Rating Scale (SSRS; Gresham & Elliot, 1990, 1998). (This scale consists of 30 items related to cooperation, assertion,
Corkum et al. (2010) 1
233
Outcome
Category
Source Number of
Instruments Child Outcome Variable
Study Number
of Studies
responsibility, and self-control. High scores indicate more positive social skills).
Parent reported Peer/social Relationships scale Impairment Rating Scale (IRS; Fabiano et al., 2006). (The parent version contains seven domains (relationship with peers, relationship with siblings, relationship with parents, academic progress, self-esteem, influence on family functioning, and over- all impairment). Scored on a 7-point Likert scale ranging from 0 (No problem) to 6 (Extreme problem). IRS items assessing the degree to which children's impairments affect their peer relationships as reported by parent.
Anstshel et al. (2014),
Villodas et al. (2014)
2
Parent Child Behavior Checklist (CBCL; Achenbach, 1991) Social Problems Subscale
Lufi & Parish-Plass
(2011) 1
Parent Conners-3rd Ed (Conners, 2008) Peer relations
Subscale Haydicky et al. (2015)
1
Parent reported Social Skills Total Scale of the Social Skills Improvement System (SSIS; Gresham & Elliot, 2008), (46 items for parent versions). All items are scored on a 4-pony Likert scale from 0 (never) to 3 (Almost always)
Villodas et al. (2014)
1
Parents reported Total Problem Behaviors Scale of the Social Skills Improvement System (SSIS; Gresham & Elliot, 2008), (46 items for parent versions). All items are scored on a 4-pony Likert scale from 0 (never) to 3 (Almost always)
Villodas et al. (2014)
1
Teacher reported
n= 4
Teacher reported Social Skills Total Score from the Social Skills Rating Scale (SSRS; Gresham & Elliot, 1990, 1998). Higher scores indicate better social skills.
Corkum et al. (2010)
1
Teacher reported Peer Relationships scale Impairment Rating Scale (IRS; Fabiano et al.,, 2006). (The teacher version has six domains (relationship with peers, relationship with teacher, academic progress, self-esteem, influence on classroom functioning, and overall impairment). The instructions ask the rater to assess the severity of a child’s problem in each domain and the need for treatment and special services.)
Anstshel et al., 2014,
Villodas et al. (2014)
2
Teacher reported Social Skills Scale of the Social Skills
Improvement System (SSIS; Gresham & Elliot, 2008), (46 items for teacher versions). All items are scored on a 4-pony Likert scale from 0 (never) to 3 (Almost always)
Villodas et al. (2014)
1
Teacher reported Problem Behaviors Scale of the Social Skills
Improvement System (SSIS; Gresham & Elliot, 2008), (46 Villodas et al. (2014)
1
234
Outcome
Category
Source Number of
Instruments Child Outcome Variable
Study Number
of Studies
items for teacher versions). All items are scored on a 4-pony Likert scale from 0 (never) to 3 (Almost always)
Self/Child-
reported
n= 3
Self-report Version of the Social Skills Rating Scale were used to obtained Total Social Skills Total Score (SSRS; Gresham & Elliot, 1990)
Corkum et al. (2010)
1
Youth Self-Report (YSR; Achenbach, 1991) Social Problems
Subscale Lufi & Parish-Plass
(2011) 1
Child reported Test of Like Skill Knowledge (TOSLK; Pfiffner & Mikami, 2005) (e.g., what should you do if someone is teasing you?) to assess social and organizational skills taught in the child group (10 items scored on a 3-point Likert scale where 1=no or inaccurate response, 2= partial response, and 3=full accurate response).
Villodas et al. (2014)
1
Family/
Parent-Child
Relationship
Parent
reported
n= 10
Parent reported Impairment Rating Scale (IRS; Waschbusch, & King, 2006) Sibling Relationships scale.
Anstshel et al., 2014
1
Parent reported Impairment Rating Scale (IRS; Waschbusch, & King, 2006) Parent-Child Relationships Scale. Parent [(7 items) versions are score on a 7-point Likert scale ranging from 0 (No problem) to 6 (Extreme problem)].
Anstshel et al., 2014,
Villodas et al. (2014) 2
Parent reported Impairment Rating Scale (IRS; Waschbusch, & King, 2006) Family Relationships scale.
Anstshel et al., 2014 1
Parent Reported Quality of the Parent-Child Relationship. Completed a 30-item scale; adaptation from Pianta’s 1990 Student-Teacher Relationship Scale (Harrison, et al., 2003)
Harrison et al. (2004)
1
Parent Reported Warmth in the Child-Parent Relationship
Scale Completed a 30-item scale; adaptation from Pianta’s 1990 Student-Teacher Relationship Scale (Harrison, et al., 2003)
Harrison et al. (2004)
1
Parent Reported Conflict in the Child-Parent Relationship
Scale Completed a 30-item scale; adaptation from Pianta’s 1990 Student-Teacher Relationship Scale (Harrison, et al., 2003)
Harrison et al. (2004)
1
Parent Reported Open Communication in the Child-Parent
Relationship Scale Completed a 30-item scale; adaptation from Pianta’s 1990 Student-Teacher Relationship Scale (Harrison, et al., 2003)
Harrison et al. (2004)
1
Mother reported IC Number of conflicts with adolescent Parent version Issues Checklist (IC; Robin, 1975; Prinz et al.,
Haydicky et al. (2015) 1
235
Outcome
Category
Source Number of
Instruments Child Outcome Variable
Study Number
of Studies
1979) 44-item list of conflicts. Mother reported IC Mean Conflict intensity in the conflict between mother and adolescent. Parent version Issues Checklist (IC; Robin, 1975; Prinz et al., 1979) is a 44-item list of issues that may be areas of disagreement between parents and adolescents. The questionnaire was slightly changed to reflect current vocabulary and cultural trends, e.g., stereo was changed to music, and an internet/computer time was added. Participants identified the issues that had been discussed in the last month, and rated the intensity go the discussion on a Likert scale ranging from 1 (calm) to 5 (very angry)
Haydicky et al. (2015)
1
Parent reported Family Assessment Device (FAD; Epstein et al., 1983) General Functioning Subscale
Haydicky et al. (2015) d 1
Self/Child-
reported
n= 4
Adolescent self-report Conners-3SR (Conners, 2008) Family
Relations Subscale Haydicky et al. (2015)
1
Adolescent reported IC Number of conflicts with Mother
Adolescent version Issues Checklist (IC; Robin, 1975; Prinz et al., 1979) 44-item list of conflicts
Haydicky et al. (2015) d
1
Adolescent reported IC Conflict Mean Intensity with
Mother. Adolescent version Issues Checklist (IC; Robin, 1975; Prinz et al., 1979) is a 44-item list of issues that may be areas of disagreement between parents and adolescents. The questionnaire was slightly changed to reflect current vocabulary and cultural trends, e.g., stereo was changed to music, and an internet/computer time was added. Participants identified the issues that had been discussed in the last month, and rated the intensity go the discussion on a Likert scale ranging from 1 (calm) to 5 (very angry).
Haydicky et al. (2015)
1
Adolescent reported FAD General functioning. Family Assessment Device (FAD; Epstein et al., 1983) is based on the McMaster Model of Family Functioning which described the structure, organization, and relational patterns characteristics of healthy families. This is a self-report measure that describes emotional relationships and functioning within the family. Each family member rates 60 statements on a scale of 1 (Strongly Agree) to 4 (Strongly Disagree) yielding 7 sub scales scores. The General functioning was used here describing overall health of the family unit.
Haydicky et al. (2015)
1
236
[a) Dutch translation [b] Teachers only post-test data available. Parents’ post-test and follow-up data obtained. Parents Cohort 1 out of 5 did not complete this survey. [c] Anstshel et al., 2014 study BASC-2 scores provided in T-Scores. [d] Haydicky et al. (2015) study results were based on maternal report, with the exception of one father who was the primary caregiver.
237
Appendix B. Online Library Searches
a) ProQuest Platform Library searches
ProQuest platform searches were conducted from the earliest date possible until September 21, 2015. The following search terms were used:
Table 1. Syntax for Records identified in PsychINFO, ERIC, and ProQuest Dissertations and Theses Global: Aggression search
(ADHD OR "attention deficit hyperactivity disorder" OR "attention deficit hyperactivity" OR "attention deficit disorder" OR attention* NEAR/2 deficit* OR ADHD NEAR/2 diagnos* OR "at risk for ADHD" OR "at risk for attention deficit hyperactivity disorder" OR "at risk for attention deficit hyperactivity" OR "at risk for attention deficit" OR hyperactivity OR hyperkinesis OR "minimal brain dysfunction" OR attention NEAR/2 problem OR inattention NEAR/2 problem OR inattention OR impulsivity OR behavior* NEAR/2 problem* OR behaviour* NEAR/2 problem*) AND (Aggress* OR "Oppositional Defiant Disorder" OR "Conduct disorder" OR "Disruptive behaviour problems" OR "Disruptive behavior problems" OR "Disruptive behaviour" OR "Disruptive behavior" OR "Disruptive behaviours" OR "Disruptive behaviors" OR externali* OR oppositional behavi*) AND ("behavioral treatment" OR "behavioral therapy" OR "behavioral intervention" OR "behavioural treatment" OR "behavioural therapy" OR "behavioural intervention" OR "behavioral treatments" OR "behavioral therapies" OR "behavioral interventions" OR behavioural OR CBT OR "cognitive behavior therapy" OR "cognitive behaviour therapies" OR "cognitive behaviour therapies" OR "cognitive behaviour therapy" OR "cognitive behavioural therapy" OR "cognitive behavioral therapy" OR psychotherap* OR counseling OR counselling OR mindfulness OR "mindfulness-based intervention" OR "mindfulness based intervention" OR "mindfulness treatment" OR "mindfulness therapy" OR mindfulness OR psychodynamic OR psychoanalytic OR "psychodynamic treatment" OR "psychodynamic intervention" OR "psychodynamic therapy" OR "social skills training" OR "social skills intervention" OR "social skills group") AND (child* OR "children" OR "young adult" OR "young adults" OR preadolescen* OR pre-adolescen* OR adolescen* OR "early adolescents" OR "early adolescent" OR kid* OR youth* OR juvenile* OR teen* OR teenager* OR girl* OR boy* OR student*) AND (RCT OR randomi* OR "controlled trial" OR "controlled trials" OR "control trial" OR "control trials" OR "controlled clinical" OR "clinical trial" OR "clinical trials" OR "random assignment" OR "randomly assigned" OR "random allocation" OR "randomly allocated" OR "control group" OR "control groups" OR "controlled group" OR "controlled groups" OR "comparison group" OR "comparison groups" OR "treatment group" OR "treatment groups" OR "wait list" OR "wait lists" OR "waiting list" OR "waiting lists" OR wait-list OR wait-lists OR "control condition" OR "control conditions" OR "controlled condition" OR "controlled conditions" OR quasi-ex* OR quasiex* OR control* NEAR/3 interven* OR control* NEAR/3 treat* OR "program evaluation" OR pre-assess* OR post-assess* OR program* NEAR/3 evaluat* OR pre-treat* OR pre-interven* OR pre-evaluat* OR treat* NEAR/3 evaluat* OR interven* NEAR/3 evaluat* OR therap* NEAR/3 evaluat* OR post-treat* OR post-interven* OR treat* NEAR/3 program* OR compari* NEAR/3 interven* OR compari* NEAR/3 group* OR compari* NEAR/3 treat* OR compari* NEAR/3 condition* OR assess* NEAR/3 progress OR assess* NEAR/3 change* OR assess* NEAR/3 improv* OR treat* NEAR/3 outcome* OR measure* NEAR/3 outcome* OR follow-up)
238
Table 2. Syntax for Records identified in PsychINFO, ERIC, and ProQuest Dissertations and Theses Global: Anxiety Search
(ADHD OR "attention deficit hyperactivity disorder" OR "attention deficit hyperactivity" OR "attention deficit disorder" OR attention* NEAR/2 deficit* OR ADHD NEAR/2 diagnos* OR "at risk for ADHD" OR "at risk for attention deficit hyperactivity disorder" OR "at risk for attention deficit hyperactivity" OR "at risk for attention deficit" OR hyperactivity OR hyperkinesis OR "minimal brain dysfunction" OR attention NEAR/2 problem OR inattention NEAR/2 problem OR inattention OR impulsivity OR behavior* NEAR/2 problem* OR behaviour* NEAR/2 problem*) AND (Anxiet* OR "Anxiety Disorder" OR "Anxiety Disorders") AND ("behavioral treatment" OR "behavioral therapy" OR "behavioral intervention" OR "behavioural treatment" OR "behavioural therapy" OR "behavioural intervention" OR "behavioral treatments" OR "behavioral therapies" OR "behavioral interventions" OR behavioural OR CBT OR "cognitive behavior therapy" OR "cognitive behaviour therapies" OR "cognitive behaviour therapies" OR "cognitive behaviour therapy" OR "cognitive behavioural therapy" OR "cognitive behavioral therapy" OR psychotherap* OR counseling OR counselling OR mindfulness OR "mindfulness-based intervention" OR "mindfulness based intervention" OR "mindfulness treatment" OR "mindfulness therapy" OR mindfulness OR psychodynamic OR psychoanalytic OR "psychodynamic treatment" OR "psychodynamic intervention" OR "psychodynamic therapy" OR "social skills training" OR "social skills intervention" OR "social skills group") AND (child* OR "children" OR "young adult" OR "young adults" OR preadolescen* OR pre-adolescen* OR adolescen* OR "early adolescents" OR "early adolescent" OR kid* OR youth* OR juvenile* OR teen* OR teenager* OR girl* OR boy* OR student*) AND (RCT OR randomi* OR "controlled trial" OR "controlled trials" OR "control trial" OR "control trials" OR "controlled clinical" OR "clinical trial" OR "clinical trials" OR "random assignment" OR "randomly assigned" OR "random allocation" OR "randomly allocated" OR "control group" OR "control groups" OR "controlled group" OR "controlled groups" OR "comparison group" OR "comparison groups" OR "treatment group" OR "treatment groups" OR "wait list" OR "wait lists" OR "waiting list" OR "waiting lists" OR wait-list OR wait-lists OR "control condition" OR "control conditions" OR "controlled condition" OR "controlled conditions" OR quasi-ex* OR quasiex* OR control* NEAR/3 interven* OR control* NEAR/3 treat* OR "program evaluation" OR pre-assess* OR post-assess* OR program* NEAR/3 evaluat* OR pre-treat* OR pre-interven* OR pre-evaluat* OR treat* NEAR/3 evaluat* OR interven* NEAR/3 evaluat* OR therap* NEAR/3 evaluat* OR post-treat* OR post-interven* OR treat* NEAR/3 program* OR compari* NEAR/3 interven* OR compari* NEAR/3 group* OR compari* NEAR/3 treat* OR compari* NEAR/3 condition* OR assess* NEAR/3 progress OR assess* NEAR/3 change* OR assess* NEAR/3 improv* OR treat* NEAR/3 outcome* OR measure* NEAR/3 outcome* OR follow-up)
239
Table 3. Syntax for Records identified in PsychINFO, ERIC, and ProQuest Dissertations and Theses Global: Depression Search
((ADHD OR "attention deficit hyperactivity disorder" OR "attention deficit hyperactivity" OR "attention deficit disorder" OR attention* NEAR/2 deficit* OR ADHD NEAR/2 diagnos* OR "at risk for ADHD" OR "at risk for attention deficit hyperactivity disorder" OR "at risk for attention deficit hyperactivity" OR "at risk for attention deficit" OR hyperactivity OR hyperkinesis OR "minimal brain dysfunction" OR attention NEAR/2 problem OR inattention NEAR/2 problem OR inattention OR impulsivity OR behavior* NEAR/2 problem* OR behaviour* NEAR/2 problem*) AND (Depress* OR "Depressive Disorder" OR "Depressive Disorders") AND ("behavioral treatment" OR "behavioral therapy" OR "behavioral intervention" OR "behavioural treatment" OR "behavioural therapy" OR "behavioural intervention" OR "behavioral treatments" OR "behavioral therapies" OR "behavioral interventions" OR behavioural OR CBT OR "cognitive behavior therapy" OR "cognitive behaviour therapies" OR "cognitive behaviour therapies" OR "cognitive behaviour therapy" OR "cognitive behavioural therapy" OR "cognitive behavioral therapy" OR psychotherap* OR counseling OR counselling OR mindfulness OR "mindfulness-based intervention" OR "mindfulness based intervention" OR "mindfulness treatment" OR "mindfulness therapy" OR mindfulness OR psychodynamic OR psychoanalytic OR "psychodynamic treatment" OR "psychodynamic intervention" OR "psychodynamic therapy" OR "social skills training" OR "social skills intervention" OR "social skills group") AND (child* OR "children" OR "young adult" OR "young adults" OR preadolescen* OR pre-adolescen* OR adolescen* OR "early adolescents" OR "early adolescent" OR kid* OR youth* OR juvenile* OR teen* OR teenager* OR girl* OR boy* OR student*) AND (RCT OR randomi* OR "controlled trial" OR "controlled trials" OR "control trial" OR "control trials" OR "controlled clinical" OR "clinical trial" OR "clinical trials" OR "random assignment" OR "randomly assigned" OR "random allocation" OR "randomly allocated" OR "control group" OR "control groups" OR "controlled group" OR "controlled groups" OR "comparison group" OR "comparison groups" OR "treatment group" OR "treatment groups" OR "wait list" OR "wait lists" OR "waiting list" OR "waiting lists" OR wait-list OR wait-lists OR "control condition" OR "control conditions" OR "controlled condition" OR "controlled conditions" OR quasi-ex* OR quasiex* OR control* NEAR/3 interven* OR control* NEAR/3 treat* OR "program evaluation" OR pre-assess* OR post-assess* OR program* NEAR/3 evaluat* OR pre-treat* OR pre-interven* OR pre-evaluat* OR treat* NEAR/3 evaluat* OR interven* NEAR/3 evaluat* OR therap* NEAR/3 evaluat* OR post-treat* OR post-interven* OR treat* NEAR/3 program* OR compari* NEAR/3 interven* OR compari* NEAR/3 group* OR compari* NEAR/3 treat* OR compari* NEAR/3 condition* OR assess* NEAR/3 progress OR assess* NEAR/3 change* OR assess* NEAR/3 improv* OR treat* NEAR/3 outcome* OR measure* NEAR/3 outcome* OR follow-up))
240
Table 4. Syntax for Records identified in PsychINFO, ERIC, and ProQuest Dissertations and Theses Global: Parent-Child Relationships Search
(ADHD OR "attention deficit hyperactivity disorder" OR "attention deficit hyperactivity" OR "attention deficit disorder" OR attention* NEAR/2 deficit* OR ADHD NEAR/2 diagnos* OR "at risk for ADHD" OR "at risk for attention deficit hyperactivity disorder" OR "at risk for attention deficit hyperactivity" OR "at risk for attention deficit" OR hyperactivity OR hyperkinesis OR "minimal brain dysfunction" OR attention NEAR/2 problem OR inattention NEAR/2 problem OR inattention OR impulsivity OR behavior* NEAR/2 problem* OR behaviour* NEAR/2 problem*) AND ("parent-child relation" OR "parent-child relations" OR "parent-child relationship" OR "parent-child relationships" OR "parent-youth relation" OR "parent-youth relations" OR "parent-youth relationship" OR "parent-youth relationships" OR "parent-teen relation" OR "parent-teen relations" OR "parent-teen relationship" OR "parent-teen relationships" OR "caregiver-child relation" OR "caregiver-child relations" OR "caregiver-child relationship" OR "caregiver-child relationships" OR "parent-adolescent relation" OR "parent-adolescent relations" OR "parent-adolescent relationship" OR "parent-adolescent relationships" OR parent* NEAR/2 youth NEAR/2 conflict* OR "parent-youth conflict" OR "parent-youth conflicts" OR "parent-teen conflict" OR "parent-teen conflicts" OR parent* NEAR/2 teen NEAR/2 conflict* OR "parent-child conflict" OR "parent-child conflicts" OR parent* NEAR/2 child NEAR/2 conflict* OR "parent-adolescent conflict" OR "parent-adolescent conflicts" OR parent* NEAR/2 adolesc* NEAR/2 conflict* OR "caregiver-child conflict" OR "caregiver-child conflicts" OR caregive* NEAR/2 child NEAR/2 conflict* OR "family conflict" OR "family conflicts" OR family NEAR/2 conflict* OR "parent-child communication problem" OR parent-child* NEAR/2 communicatio* NEAR/2 problem* OR parent-child* NEAR/2 communicatio* NEAR/2 difficult* OR "parent-child communication problems" OR "parent-teen communication problem" OR "parent-teen communication problems") AND ("behavioral treatment" OR "behavioral therapy" OR "behavioral intervention" OR "behavioural treatment" OR "behavioural therapy" OR "behavioural intervention" OR "behavioral treatments" OR "behavioral therapies" OR "behavioral interventions" OR behavioural OR CBT OR "cognitive behavior therapy" OR "cognitive behaviour therapies" OR "cognitive behaviour therapies" OR "cognitive behaviour therapy" OR "cognitive behavioural therapy" OR "cognitive behavioral therapy" OR psychotherap* OR counseling OR counselling OR mindfulness OR "mindfulness-based intervention" OR "mindfulness based intervention" OR "mindfulness treatment" OR "mindfulness therapy" OR mindfulness OR psychodynamic OR psychoanalytic OR "psychodynamic treatment" OR "psychodynamic intervention" OR "psychodynamic therapy" OR "social skills training" OR "social skills intervention" OR "social skills group") AND (child* OR "children" OR "young adult" OR "young adults" OR preadolescen* OR pre-adolescen* OR adolescen* OR "early adolescents" OR "early adolescent" OR kid* OR youth* OR juvenile* OR teen* OR teenager* OR girl* OR boy* OR student*) AND (RCT OR randomi* OR "controlled trial" OR "controlled trials" OR "control trial" OR "control trials" OR "controlled clinical" OR "clinical trial" OR "clinical trials" OR "random assignment" OR "randomly assigned" OR "random allocation" OR "randomly allocated" OR "control group" OR "control groups" OR "controlled group" OR "controlled groups" OR "comparison group" OR "comparison groups" OR "treatment group" OR "treatment groups" OR "wait list" OR "wait lists" OR "waiting list" OR "waiting lists" OR wait-list OR wait-lists OR "control condition" OR "control conditions" OR "controlled condition" OR "controlled conditions" OR quasi-ex* OR quasiex* OR control* NEAR/3 interven* OR control* NEAR/3 treat* OR "program evaluation" OR pre-assess* OR post-assess* OR program* NEAR/3 evaluat* OR pre-treat* OR pre-interven* OR pre-evaluat* OR treat* NEAR/3 evaluat* OR interven* NEAR/3 evaluat* OR therap* NEAR/3 evaluat* OR post-treat* OR post-interven* OR treat* NEAR/3 program* OR compari* NEAR/3 interven* OR compari* NEAR/3 group* OR compari* NEAR/3 treat* OR compari* NEAR/3 condition* OR assess* NEAR/3 progress OR assess* NEAR/3 change* OR assess* NEAR/3 improv* OR treat* NEAR/3 outcome* OR measure* NEAR/3 outcome* OR follow-up)
241
Table 5. Syntax for Records identified in PsychINFO, ERIC, and ProQuest Dissertations and Theses Global: Peer Relationships Search
(ADHD OR "attention deficit hyperactivity disorder" OR "attention deficit hyperactivity" OR "attention deficit disorder" OR attention* NEAR/2 deficit* OR ADHD NEAR/2 diagnos* OR "at risk for ADHD" OR "at risk for attention deficit hyperactivity disorder" OR "at risk for attention deficit hyperactivity" OR "at risk for attention deficit" OR hyperactivity OR hyperkinesis OR "minimal brain dysfunction" OR attention NEAR/2 problem OR inattention NEAR/2 problem OR inattention OR impulsivity OR behavior* NEAR/2 problem* OR behaviour* NEAR/2 problem*) AND ("social relation" OR "social relations" OR "social relationship" OR "social relationships" OR "interpersonal competence" OR "interpersonal relation" OR "interpersonal relations" OR "interpersonal relationship" OR "interpersonal relationships" OR "peer acceptance" OR "peer relation" OR "peer relations" OR "peer relationship" OR "peer relationships" OR "prosocial behaviour" OR "prosocial behavior" OR "prosocial behaviours" OR "prosocial behaviors" OR peer* NEAR/2 relatio* OR prosocia* NEAR/2 behav*) AND ("behavioral treatment" OR "behavioral therapy" OR "behavioral intervention" OR "behavioural treatment" OR "behavioural therapy" OR "behavioural intervention" OR "behavioral treatments" OR "behavioral therapies" OR "behavioral interventions" OR behavioural OR CBT OR "cognitive behavior therapy" OR "cognitive behaviour therapies" OR "cognitive behaviour therapies" OR "cognitive behaviour therapy" OR "cognitive behavioural therapy" OR "cognitive behavioral therapy" OR psychotherap* OR counseling OR counselling OR mindfulness OR "mindfulness-based intervention" OR "mindfulness based intervention" OR "mindfulness treatment" OR "mindfulness therapy" OR mindfulness OR psychodynamic OR psychoanalytic OR "psychodynamic treatment" OR "psychodynamic intervention" OR "psychodynamic therapy" OR "social skills training" OR "social skills intervention" OR "social skills group") AND (child* OR "children" OR "young adult" OR "young adults" OR preadolescen* OR pre-adolescen* OR adolescen* OR "early adolescents" OR "early adolescent" OR kid* OR youth* OR juvenile* OR teen* OR teenager* OR girl* OR boy* OR student*) AND (RCT OR randomi* OR "controlled trial" OR "controlled trials" OR "control trial" OR "control trials" OR "controlled clinical" OR "clinical trial" OR "clinical trials" OR "random assignment" OR "randomly assigned" OR "random allocation" OR "randomly allocated" OR "control group" OR "control groups" OR "controlled group" OR "controlled groups" OR "comparison group" OR "comparison groups" OR "treatment group" OR "treatment groups" OR "wait list" OR "wait lists" OR "waiting list" OR "waiting lists" OR wait-list OR wait-lists OR "control condition" OR "control conditions" OR "controlled condition" OR "controlled conditions" OR quasi-ex* OR quasiex* OR control* NEAR/3 interven* OR control* NEAR/3 treat* OR "program evaluation" OR pre-assess* OR post-assess* OR program* NEAR/3 evaluat* OR pre-treat* OR pre-interven* OR pre-evaluat* OR treat* NEAR/3 evaluat* OR interven* NEAR/3 evaluat* OR therap* NEAR/3 evaluat* OR post-treat* OR post-interven* OR treat* NEAR/3 program* OR compari* NEAR/3 interven* OR compari* NEAR/3 group* OR compari* NEAR/3 treat* OR compari* NEAR/3 condition* OR assess* NEAR/3 progress OR assess* NEAR/3 change* OR assess* NEAR/3 improv* OR treat* NEAR/3 outcome* OR measure* NEAR/3 outcome* OR follow-up)
242
Appendix B. b) OVID Platform Library Searches
OVID platform searches: Embase searches were conducted from the earliest date possible until September 21, 2015, and Medline until October 21, 2015. The following search terms were used:
Table 6. Syntax for Records identified in Embase: Aggression Search
Set Search Statement
1. attention deficit disorder/ 2. minimal brain dysfunction.mp. 3. inattention problem*.mp. 4. adhd.mp. 5. attention deficit.mp. 6. hyperkinetic syndrome.mp. 7. Hyperkinesis.mp.
8. hyperactive behavi* problem*.mp
9. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 10. (Aggress* or Oppositional Defiant Disorder* or Conduct disorder* or disruptive behavi* or externali* or oppositional behavi*).mp.
11. 9 and 10
12. therap*.mp.
13. intervention*.mp.
14. treatment*.mp.
15. psychotherap*.mp.
16. counsel*ing.mp.
17. social skills training.mp.
18. 12 or 13 or 14 or 15 or 16 or 17
19. 11 and 18 20. limit 19 to (human and english language and (school child <7 to 12 years> or adolescent <13 to 17 years>))
21.
(RCT or randomi* or control* trial* or control* clinical or clinical trial* or random* assign* or random* allocat* or control* group* or comparison group* or treat* group* or wait* list* or wait*-list* or waitlist or control* condition* or quasi-ex* or quasiex* or (control* adj3 interven*) or (control* adj3 treat*) or pre-assess* or post-assess* or (program* adj3 evaluat*) or pre-treat* or pre-interven* or pre-evaluat* or (treat* adj3 evaluat*) or (interven* adj3 evaluat*) or (therap* adj3 evaluat*) or post-treat* or post-interven* or (treat* adj3 program*) or (compari* adj3 interven*) or (compari* adj3 group*) or (compari* adj3 treat*) or (compari* adj3 condition*) or (assess* adj3 progress) or (assess* adj3 change*) or (assess* adj3 improv*) or (treat* adj3 outcome*) or (measure* adj3 outcome*) or follow-up).mp.
22. 20 and 21
243
Table 7. Syntax for Records identified in Embase: Anxiety Search
Set Search Statement
1. attention deficit disorder/ 2. minimal brain dysfunction.mp. 3. inattention problem*.mp.
4. adhd.mp.
5. attention deficit.mp.
6. hyperkinetic syndrome.mp.
7. Hyperkinesis.mp.
8. hyperactive behavi* problem*.mp
9. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8
10. (Anxiet* or Nervousness or hypervigilance or hyper-vigilance or hyper vigilance).mp.
11. 9 and 10
12. therap*.mp.
13. intervention*.mp.
14. treatment*.mp.
15. psychotherap*.mp.
16. counsel*ing.mp.
17. social skills training.mp.
18. 12 or 13 or 14 or 15 or 16 or 17
19. 11 and 18
20. limit 19 to (human and english language and (school child <7 to 12 years> or adolescent <13 to 17 years>))
21.
(RCT or randomi* or control* trial* or control* clinical or clinical trial* or random* assign* or random* allocat* or control* group* or comparison group* or treat* group* or wait* list* or wait*-list* or waitlist or control* condition* or quasi-ex* or quasiex* or (control* adj3 interven*) or (control* adj3 treat*) or pre-assess* or post-assess* or (program* adj3 evaluat*) or pre-treat* or pre-interven* or pre-evaluat* or (treat* adj3 evaluat*) or (interven* adj3 evaluat*) or (therap* adj3 evaluat*) or post-treat* or post-interven* or (treat* adj3 program*) or (compari* adj3 interven*) or (compari* adj3 group*) or (compari* adj3 treat*) or (compari* adj3 condition*) or (assess* adj3 progress) or (assess* adj3 change*) or (assess* adj3 improv*) or (treat* adj3 outcome*) or (measure* adj3 outcome*) or follow-up).mp.
22. 20 and 21
Table 8. Syntax for Records identified in Embase: Depression Search
Set Search Statement
1. attention deficit disorder/
244
2. minimal brain dysfunction.mp. 3. inattention problem*.mp.
4. adhd.mp.
5. attention deficit.mp.
6. hyperkinetic syndrome.mp.
7. Hyperkinesis.mp.
8. hyperactive behavi* problem*.mp
9. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8
10. Depress*.mp.
11. 9 and 10
12. therap*.mp.
13. intervention*.mp.
14. treatment*.mp.
15. psychotherap*.mp.
16. counsel*ing.mp.
17. social skills training.mp.
18. 12 or 13 or 14 or 15 or 16 or 17
19. 11 and 18
20. limit 19 to (human and english language and (school child <7 to 12 years> or adolescent <13 to 17 years>))
21.
(RCT or randomi* or control* trial* or control* clinical or clinical trial* or random* assign* or random* allocat* or control* group* or comparison group* or treat* group* or wait* list* or wait*-list* or waitlist or control* condition* or quasi-ex* or quasiex* or (control* adj3 interven*) or (control* adj3 treat*) or pre-assess* or post-assess* or (program* adj3 evaluat*) or pre-treat* or pre-interven* or pre-evaluat* or (treat* adj3 evaluat*) or (interven* adj3 evaluat*) or (therap* adj3 evaluat*) or post-treat* or post-interven* or (treat* adj3 program*) or (compari* adj3 interven*) or (compari* adj3 group*) or (compari* adj3 treat*) or (compari* adj3 condition*) or (assess* adj3 progress) or (assess* adj3 change*) or (assess* adj3 improv*) or (treat* adj3 outcome*) or (measure* adj3 outcome*) or follow-up).mp.
22. 20 and 21
Table 9. Syntax for Records identified in Embase: Peer Relationships Search
Set Search Statement 1. attention deficit disorder/ 2. minimal brain dysfunction.mp. 3. inattention problem*.mp.
4. adhd.mp.
5. attention deficit.mp.
245
6. hyperkinetic syndrome.mp.
7. Hyperkinesis.mp.
8. hyperactive behavi* problem*.mp
9. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8
10. (social relation* or interpersonal competence or interpersonal relation* or peer acceptance or peer relation* or prosocial behavio* or social interaction*).mp.
11. 9 and 10
12. therap*.mp.
13. intervention*.mp.
14. treatment*.mp.
15. psychotherap*.mp.
16. counsel*ing.mp.
17. social skills training.mp.
18. 12 or 13 or 14 or 15 or 16 or 17
19. 11 and 18
20. limit 19 to (human and english language and (school child <7 to 12 years> or adolescent <13 to 17 years>))
21.
(RCT or randomi* or control* trial* or control* clinical or clinical trial* or random* assign* or random* allocat* or control* group* or comparison group* or treat* group* or wait* list* or wait*-list* or waitlist or control* condition* or quasi-ex* or quasiex* or (control* adj3 interven*) or (control* adj3 treat*) or pre-assess* or post-assess* or (program* adj3 evaluat*) or pre-treat* or pre-interven* or pre-evaluat* or (treat* adj3 evaluat*) or (interven* adj3 evaluat*) or (therap* adj3 evaluat*) or post-treat* or post-interven* or (treat* adj3 program*) or (compari* adj3 interven*) or (compari* adj3 group*) or (compari* adj3 treat*) or (compari* adj3 condition*) or (assess* adj3 progress) or (assess* adj3 change*) or (assess* adj3 improv*) or (treat* adj3 outcome*) or (measure* adj3 outcome*) or follow-up).mp.
22. 20 and 21
Table 10. Syntax for Records identified in Embase: Parent-Child Relationships Search
Set Search Statement
1. attention deficit disorder/ 2. minimal brain dysfunction.mp. 3. inattention problem*.mp.
4. adhd.mp.
5. attention deficit.mp.
6. hyperkinetic syndrome.mp.
7. Hyperkinesis.mp.
8. hyperactive behavi* problem*.mp
9. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8
246
10. ((caregiver* adj2 child* adj2 relation*) or (caregiver adj2 child adj2 conflict*) or (parent* adj2 child* adj2 relation*) or (parent* adj2 youth* adj2 relation*) or (parent* adj2 teen* adj2 relation*) or (parent* adj2 youth* adj2 conflict*) or (parent* adj2 teen* adj2 conflict*) or (parent* adj2 child* adj2 conflict*) or (parent* adj2 adolescen* adj2 relation*) or (parent* adj2 adolescen* adj2 conflict*) or (famil* adj2 conflict*)).mp.
11. 9 and 10
12. therap*.mp.
13. intervention*.mp.
14. treatment*.mp.
15. psychotherap*.mp.
16. counsel*ing.mp.
17. social skills training.mp.
18. 12 or 13 or 14 or 15 or 16 or 17
19. 11 and 18
20. limit 19 to (human and english language and (school child <7 to 12 years> or adolescent <13 to 17 years>))
21.
(RCT or randomi* or control* trial* or control* clinical or clinical trial* or random* assign* or random* allocat* or control* group* or comparison group* or treat* group* or wait* list* or wait*-list* or waitlist or control* condition* or quasi-ex* or quasiex* or (control* adj3 interven*) or (control* adj3 treat*) or pre-assess* or post-assess* or (program* adj3 evaluat*) or pre-treat* or pre-interven* or pre-evaluat* or (treat* adj3 evaluat*) or (interven* adj3 evaluat*) or (therap* adj3 evaluat*) or post-treat* or post-interven* or (treat* adj3 program*) or (compari* adj3 interven*) or (compari* adj3 group*) or (compari* adj3 treat*) or (compari* adj3 condition*) or (assess* adj3 progress) or (assess* adj3 change*) or (assess* adj3 improv*) or (treat* adj3 outcome*) or (measure* adj3 outcome*) or follow-up).mp.
22. 20 and 21
Table 11. Syntax for Records identified in Medline: Aggression Search
Set Search Statement
1. exp Attention Deficit Disorder with Hyperactivity/ 2. minimal brain dysfunction.mp. 3. Hyperkinesis.mp.
4. inattention problem*.mp.
5. adhd.mp.
6. attention deficit hyperactivity disorder.mp.
7. hyperkinetic syndrome.mp.
8. attention deficit disorder*.mp.
9. hyperactive behavi* problem*.mp.
10. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9
11. Aggress* or Oppositional Defiant Disorder* or Conduct disorder* or disruptive behavi* or externali* or oppositional behavi*).mp.
247
12. 10 and 11
13. therap*.mp.
14. intervention*.mp.
15. treatment*.mp.
16. psychotherap*.mp.
17. counsel*ing.mp.
18. social skills training.mp.
19. 13 or 14 or 15 or 16 or 17 or 18
20. 12 and 19
21. limit 20 to (english language and humans and ("child (6 to 12 years)" or "adolescent (13 to 18 years)"))
22.
(RCT or randomi* or control* trial* or control* clinical or clinical trial* or random* assign* or random* allocat* or control* group* or comparison group* or treat* group* or wait* list* or wait*-list* or waitlist or control* condition* or quasi-ex* or quasiex* or (control* adj3 interven*) or (control* adj3 treat*) or pre-assess* or post-assess* or (program* adj3 evaluat*) or pre-treat* or pre-interven* or pre-evaluat* or (treat* adj3 evaluat*) or (interven* adj3 evaluat*) or (therap* adj3 evaluat*) or post-treat* or post-interven* or (treat* adj3 program*) or (compari* adj3 interven*) or (compari* adj3 group*) or (compari* adj3 treat*) or (compari* adj3 condition*) or (assess* adj3 progress) or (assess* adj3 change*) or (assess* adj3 improv*) or (treat* adj3 outcome*) or (measure* adj3 outcome*) or follow-up).mp.
23. 21 and 22
Table 12. Syntax for Records identified in Medline: Anxiety Search
Set Search Statement
1. exp Attention Deficit Disorder with Hyperactivity/ 2. minimal brain dysfunction.mp. 3. Hyperkinesis.mp.
4. inattention problem*.mp.
5. adhd.mp.
6. attention deficit hyperactivity disorder.mp.
7. hyperkinetic syndrome.mp.
8. attention deficit disorder*.mp.
9. hyperactive behavi* problem*.mp.
10. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9
11. (Anxiet* or Nervousness or hypervigilance or hyper-vigilance or hyper vigilance).mp.
12. 10 and 11
13. therap*.mp.
14. intervention*.mp.
248
15. treatment*.mp.
16. psychotherap*.mp.
17. counsel*ing.mp.
18. social skills training.mp.
19. 13 or 14 or 15 or 16 or 17 or 18
20. 12 and 19
21. limit 20 to (english language and humans and ("child (6 to 12 years)" or "adolescent (13 to 18 years)"))
22.
(RCT or randomi* or control* trial* or control* clinical or clinical trial* or random* assign* or random* allocat* or control* group* or comparison group* or treat* group* or wait* list* or wait*-list* or waitlist or control* condition* or quasi-ex* or quasiex* or (control* adj3 interven*) or (control* adj3 treat*) or pre-assess* or post-assess* or (program* adj3 evaluat*) or pre-treat* or pre-interven* or pre-evaluat* or (treat* adj3 evaluat*) or (interven* adj3 evaluat*) or (therap* adj3 evaluat*) or post-treat* or post-interven* or (treat* adj3 program*) or (compari* adj3 interven*) or (compari* adj3 group*) or (compari* adj3 treat*) or (compari* adj3 condition*) or (assess* adj3 progress) or (assess* adj3 change*) or (assess* adj3 improv*) or (treat* adj3 outcome*) or (measure* adj3 outcome*) or follow-up).mp.
23. 21 and 22
Table 13. Syntax for Records identified in Medline: Depression Search
Set Search Statement
1. exp Attention Deficit Disorder with Hyperactivity/ 2. minimal brain dysfunction.mp. 3. Hyperkinesis.mp.
4. inattention problem*.mp.
5. adhd.mp.
6. attention deficit hyperactivity disorder.mp.
7. hyperkinetic syndrome.mp.
8. attention deficit disorder*.mp.
9. hyperactive behavi* problem*.mp.
10. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9
11. Depress*.mp.
12. 10 and 11
13. therap*.mp.
14. intervention*.mp.
15. treatment*.mp.
16. psychotherap*.mp.
17. counsel*ing.mp.
249
18. social skills training.mp.
19. 13 or 14 or 15 or 16 or 17 or 18
20. 12 and 19
21. limit 20 to (english language and humans and ("child (6 to 12 years)" or "adolescent (13 to 18 years)"))
22.
(RCT or randomi* or control* trial* or control* clinical or clinical trial* or random* assign* or random* allocat* or control* group* or comparison group* or treat* group* or wait* list* or wait*-list* or waitlist or control* condition* or quasi-ex* or quasiex* or (control* adj3 interven*) or (control* adj3 treat*) or pre-assess* or post-assess* or (program* adj3 evaluat*) or pre-treat* or pre-interven* or pre-evaluat* or (treat* adj3 evaluat*) or (interven* adj3 evaluat*) or (therap* adj3 evaluat*) or post-treat* or post-interven* or (treat* adj3 program*) or (compari* adj3 interven*) or (compari* adj3 group*) or (compari* adj3 treat*) or (compari* adj3 condition*) or (assess* adj3 progress) or (assess* adj3 change*) or (assess* adj3 improv*) or (treat* adj3 outcome*) or (measure* adj3 outcome*) or follow-up).mp.
23. 21 and 22
Table 14. Syntax for Records identified in Medline: Peer Relationships Search
Set Search Statement
1. exp Attention Deficit Disorder with Hyperactivity/ 2. minimal brain dysfunction.mp. 3. Hyperkinesis.mp.
4. inattention problem*.mp.
5. adhd.mp.
6. attention deficit hyperactivity disorder.mp.
7. hyperkinetic syndrome.mp.
8. attention deficit disorder*.mp.
9. hyperactive behavi* problem*.mp.
10. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9
11. (social relation* or interpersonal competence or interpersonal relation* or peer acceptance or peer relation* or prosocial behavio* or social interaction*).mp.
12. 10 and 11
13. therap*.mp.
14. intervention*.mp.
15. treatment*.mp.
16. psychotherap*.mp.
17. counsel*ing.mp.
18. social skills training.mp.
19. 13 or 14 or 15 or 16 or 17 or 18
20. 12 and 19
250
21. limit 20 to (english language and humans and ("child (6 to 12 years)" or "adolescent (13 to 18 years)"))
22.
(RCT or randomi* or control* trial* or control* clinical or clinical trial* or random* assign* or random* allocat* or control* group* or comparison group* or treat* group* or wait* list* or wait*-list* or waitlist or control* condition* or quasi-ex* or quasiex* or (control* adj3 interven*) or (control* adj3 treat*) or pre-assess* or post-assess* or (program* adj3 evaluat*) or pre-treat* or pre-interven* or pre-evaluat* or (treat* adj3 evaluat*) or (interven* adj3 evaluat*) or (therap* adj3 evaluat*) or post-treat* or post-interven* or (treat* adj3 program*) or (compari* adj3 interven*) or (compari* adj3 group*) or (compari* adj3 treat*) or (compari* adj3 condition*) or (assess* adj3 progress) or (assess* adj3 change*) or (assess* adj3 improv*) or (treat* adj3 outcome*) or (measure* adj3 outcome*) or follow-up).mp.
23. 21 and 22
Table 15. Syntax for Records identified in Medline: Parent-Child Relationships Search
Set Search Statement
1. exp Attention Deficit Disorder with Hyperactivity/ 2. minimal brain dysfunction.mp. 3. Hyperkinesis.mp.
4. inattention problem*.mp.
5. adhd.mp.
6. attention deficit hyperactivity disorder.mp.
7. hyperkinetic syndrome.mp.
8. attention deficit disorder*.mp.
9. hyperactive behavi* problem*.mp.
10. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9
11. caregiver* adj2 child* adj2 relation*) or (caregiver adj2 child adj2 conflict*) or (parent* adj2 child* adj2 relation*) or (parent* adj2 youth* adj2 relation*) or (parent* adj2 teen* adj2 relation*) or (parent* adj2 youth* adj2 conflict*) or (parent* adj2 teen* adj2 conflict*) or (parent* adj2 child* adj2 conflict*) or (parent* adj2 adolescen* adj2 relation*) or (parent* adj2 adolescen* adj2 conflict*) or (famil* adj2 conflict*)).mp.
12. 10 and 11
13. therap*.mp.
14. intervention*.mp.
15. treatment*.mp.
16. psychotherap*.mp.
17. counsel*ing.mp.
18. social skills training.mp.
19. 13 or 14 or 15 or 16 or 17 or 18
20. 12 and 19
21. limit 20 to (english language and humans and ("child (6 to 12 years)" or "adolescent (13 to 18 years)"))
251
22.
(RCT or randomi* or control* trial* or control* clinical or clinical trial* or random* assign* or random* allocat* or control* group* or comparison group* or treat* group* or wait* list* or wait*-list* or waitlist or control* condition* or quasi-ex* or quasiex* or (control* adj3 interven*) or (control* adj3 treat*) or pre-assess* or post-assess* or (program* adj3 evaluat*) or pre-treat* or pre-interven* or pre-evaluat* or (treat* adj3 evaluat*) or (interven* adj3 evaluat*) or (therap* adj3 evaluat*) or post-treat* or post-interven* or (treat* adj3 program*) or (compari* adj3 interven*) or (compari* adj3 group*) or (compari* adj3 treat*) or (compari* adj3 condition*) or (assess* adj3 progress) or (assess* adj3 change*) or (assess* adj3 improv*) or (treat* adj3 outcome*) or (measure* adj3 outcome*) or follow-up).mp.
23. 21 and 22
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Appendix C. Coding Forms.
Part I: Study Level Descriptors
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1. Study ID Number
2. Bibliographic Reference
3. Publication Type (Please select the type of publication of the most comprehensive report
consulted for this study. Be careful with MTA studies). Please select one of the following:
Journal article
Book chapter
Conference paper
Other unpublished data (hospital report or governmental setting report)
Thesis or doctoral dissertation
4. Publication year
5. Indicate if published online to date
Please select one of the following:
Yes
No
Don't know
6. Is this an MTA Study?
Please select one of the following:
Yes
No
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7. Country were study was conducted
Please select one of the following:
US
Canada
Europe
Australia
Israel
Other
8. Who were the treatment targets? I.e., who received treatment during this study? Please check all that apply. Please select all that apply:
Children only
Children and parents
Children, parents, and teachers (multimodal treatment)
Children and teachers
9. Theoretical orientation used in study. Select all that apply.
Please select all that apply:
Behavioural
Cognitive
Cognitive-Behavioural
Mindfulness
Social Learning
Psychodynamic/psychoanalytic
Pharmacological (meds)
Can't tell
Behavioural Parent training (only
when parents were treatment receivers)
Other
10. Confidence in your judgement of theoretical orientation.
Please select one of the following:
80-100% (Very confident)
60-79% (Somewhat confident)
Less than 60% (Not very confident)
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11. Intervention types used. (Please check all that apply).
Please select all that apply:
Behavioural
Cognitive
Cognitive-Behavioural
Mindfulness
Social Skills Training
Psychodynamic/psychoanalytic
Pharmacological
Summer Treatment Program
Other
12. Intervention name (e.g., A modified version of the Social Skills Training (SST) of Milich et al. (1995)).
13. Only if a pharmacological component incorporated, indicate meds name (e.g.,
Methylphenidate). If groups were divided by dosage, please indicate the dosage given
14. Only if a parent component incorporated, indicate which type. 15. Only if a teacher component incorporated, indicate which type. 16. How many treatment groups or conditions were used in the study?
Please number and a brief description. (E.g., 2: a behavioural intervention and a wait- list control group). Be very detailed in your reply.
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Part II: Sample Characteristics
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1. Study ID
2. Inclusion criteria: Please select all that apply:
Child's diagnosis of ADHD by licensed
psychiatrist, psychologist, or pediatric neurologist
Child MEAN age falls somewhere between 6-18 years, or 72 and 216
months
Child enrolled in school - necessary for inclusion
Child's ADHD clinically significant scale scores on at least one
standardized child assessment
instrument on referral to the study
Other (Not relevant for this review (e.g., parent high ratings of parenting
stress) necessary for inclusion
Presence of other child's comorbidity
(e.g., ODD/CD) necessary for inclusion
Presence of other associated problem
(e.g., social skills deficits, high family conflict) necessary for inclusion
3. Child's ADHD screening at referral to study was by: Please select all that apply:
Psychologists
Social workers
Graduate degrees in psychology
(does not specify whether MA or Phd level)
Graduate students in psychology or
other disciplines
Undergraduate research assistants
Psychiatrists or physicians
Others
4. Child's ADHD screening at referral to study was made via: Please select all that apply:
Diagnostic interview (e.g., DICA-R-P, K-SADS, DISC, etc)
Parent Questionnaire(s) (e.g., Conners, DBDRS, CBCL, etc)
Teacher Questionare(s) (e.g.,
Conners, DBDRS, CBCL, etc)
Child Questionnaire(s) (e.g., YSR)
Other
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5. Name(s) of ADHD screening instrument(s) used. (If only certain modules or subscales of the measure/interview used, indicate which ones):
6. ADHD or "ADD" symptoms screening according to: Please select one of the following:
DSM-III
DSM-III-R
DSM-IV
Can't tell
7. Exclusion criteria (Select all that apply) for children Note. DSM-5 (May 2013) has actually discarded the multiaxial system of diagnosis (Axis I, Axis II, Axis III), listing all disorders in Section II. It has replaced Axis IV with significant psychosocial and contextual features and dropped Axis V (Global Assessment of Functioning, known as GAF). Please select all that apply:
Axis I Disorders (e.g., Substance
abuse, OCD, Bipolar Disorder,
Schizophrenia)
Axis II Disorders (e.g., Autism, intellectual disability, and Personality
disorders)
IQ of less than 80
Major Depressive Disorder (Current or
past history: Self-harm or suicidal ideation) requiring immediate treatment
Seizures (Current or past history)
Child abuse (Current or past history)
Physical conditions precluding ADHD meds administration
Child NOT on stimulant meds (and
has ADHD)
Parents currently separated or divorce or child experienced significant losses
(Current or Recent)
Placement in a self-contained special education classroom
Child with sensory impairment (not having normal hearing or normal or
corrected vision)
Child being in the same school classroom as another participant
Child having a sibling who was
already enrolled in the study
Other
Not specified
Child currently in hospital
Child currently in another study
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259
Child received neuroleptic (antipsychotics) meds in previous 6
months
Major neurological or medical illness
Child missed 1/4 of school days in the previous 2 months
Parental stimulant abuse in the
previous 2 years
Non-English speaking primary caretaker
No telephone (so, inability to participate in ongoing contacts)
8. If "Other" inclusion/exclusion criteria. Please specify (e.g., additional inclusion criteria was that the child had to be living with at least one parent for the past year)
9. Total Sample n
10. Group 1 n
11. Group 2 n
12. Group 3 n
13. Group 4 n
14. Group 5 n
15. Group 6 n
16. Attrition Total. % of children who left the study (I.e., from the total pool of participants starting the study, which % left. E.g., n=22 started the study, but only 18 treatment completers, this means that if 22 is 100%, and 4 left, which is 18.18%).
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260
17. Reasons about attrition from study provided? Please select one of the following:
Yes
No
No, because there was no attrition (no participants left the study)
18. If attrition reasons provided, please describe. 19. Attrition Group 1. % of children who left
20. Attrition group 2. % of children who left
21. Attrition group 3. % of children who left
22. Attrition group 4. % of children who left
23. Attrition group 5. % of children who left
24. Attrition group 6. % of children who left
25. Child Age info page number
26. Child MEAN age (in months) Total Sample
27. Child SD age (in months) Total Sample 28. Child RANGE age (in months) Total Sample
29. Child MEAN age (in months) Group 1
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30. Child MEAN age (in months) Group 2
31. Child MEAN age (in months) Group 3
32. Child MEAN age (in months) Group 4
33. Child MEAN age (in months) Group 5
34. Child MEAN age (in months) Group 6
35. Child SD age (in months) Group 1
36. Child SD age (in months) Group 2
37. Child SD age (in months) Group 3
38. Child SD age (in months) Group 4
39. Child SD age (in months) Group 5
40. Child SD age (in months) Group 6
41. Child RANGE age (in months) Group 1
42. Child RANGE age (in months) Group 2
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43. Child RANGE age (in months) Group 3
44. Child RANGE age (in months) Group 4
45. Child RANGE age (in months) Group 5
46. Child RANGE age (in months) Group 6
47. Child gender Total sample Male n
48. Child gender Total sample Female n
49. Child gender Total sample Male %
50. Child gender Total sample Female %
51. Child gender Group 1 Male n
52. Child gender Group 2 Male n
53. Child gender Group 3 Male n
54. Child gender Group 4 Male n
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55. Child gender Group 5 Male n
56. Child gender Group 6 Male n
57. Child gender Group 1 Male %
58. Child gender Group 2 Male %
59. Child gender Group 3 Male %
60. Child gender Group 4 Male %
61. Child gender Group 5 Male %
62. Child gender Group 6 Male %
63. Child Ethnicity Please select all that apply:
Caucasian
African American
Northeast Asian (Chinese, Filipino, Vietnamese, Korean, Japanese,
Tawianese)
South Asian (India, Pakistan, Bangladesh, Nepal, Bhutan, Maldives,
and Sri Lanka)
Hispanic (Latin American)
Other
Not specified
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64. n of Caucasian children in the Total sample
65. n of African American children in the Total sample
66. n of Northeast Asian (e.g., Chinese) children in the Total sample
67. n of South Asian (e.g., Indian) children in the Total sample
68. n of Hispanic children in the Total sample
69. n of Other ethnicity children in the Total
70. Percentage (%) of Caucasian children in the Total sample
71. Percentage (%) of African American children in the Total sample
72. Percentage (%) of Northeast Asian children in the Total sample
73. Percentage (%) of Southeast Asian (e.g., Indian) children in the Total sample
74. Percentage (%) of Hispanic children in the Total sample
75. Percentage (%) of Other children in the Total sample
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265
76. Children's first language in total sample (take your best guess, e.g., if the study was in US assume it was English)
Please select one of the following:
English
Other
Not specified
77. If "other" than English language is the first language of the total sample was indicated, please indicate which language.
Please select one of the following:
French
Spanish
Chinese
Dutch
German
Japanese
Other
78. Percentage of children in the total sample who had English as a first language
79. Percentage of children in the total sample for whom English was not the first language (but "other") was
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80. Presenting problems in child (Total Sample). Select all that apply. Make sure you are as accurate as possible, avoiding to use the "other" category as much as you can.
Please select all that apply:
ADHD diagnosis - Type not specified
ADHD diagnosis - Predominantly Inattentive Type
ADHD diagnosis - Predominantly Hyperactive Type
ADHD diagnosis - Combined Type
ADD diagnosis
Inattentive Symptoms
Hyperactive Symptoms
Inattentive and Hyperactive Symptoms
Aggression (type not specified)
ODD diagnosis
CD diagnosis
ODD symptoms
CD symptoms
Anxiety disorders
Mood disorders (e.g., Depression)
LD
Sleep Problems
Social/peer problems
parent-child conflict
Academic problems
Tic Disorders
Other
81. ODD/CD symptoms/diagnoses in Total Sample n
82. ODD/CD symptoms/diagnoses in Group 1 n
83. ODD/CD symptoms/diagnoses in Group 2 n
84. ODD/CD symptoms/diagnoses in Group 3 n
85. ODD/CD symptoms/diagnoses in Group 4 n
86. ODD/CD symptoms/diagnoses in Group 5 n
87. ODD/CD symptoms/diagnoses in Group 6 n
267
88. Anxiety symptoms/diagnoses in Total Sample n
89. Anxiety symptoms/diagnoses in Group 1 n
90. Anxiety symptoms/diagnoses in Group 2 n
91. Anxiety symptoms/diagnoses in Group 3 n
92. Anxiety symptoms/diagnoses in Group 4 n
93. Anxiety symptoms/diagnoses in Group 5 n
94. Anxiety symptoms/diagnoses in Group 6 n
95. Mood symptoms/diagnoses in Total Sample n
96. Mood symptoms/diagnoses in Group 1 n
97. Mood symptoms/diagnoses in Group 2 n
98. Mood symptoms/diagnoses in Group 3 n
99. Mood symptoms/diagnoses in Group 4 n
100. Mood symptoms/diagnoses in Group 5 n
101. Mood symptoms/diagnoses in Group 6 n
102. Child IQ Mean in Total Sample
268
103. Child IQ SD in Total Sample
104. Child IQ Range in total sample
105. n of children in the Total Sample who had received prior mental health treatment
106. n of children in Group 1 who had received PRIOR mental health treatment
107. n of children in Group 2 who had received PRIOR mental health treatment
108. n of children in Group 3 who had received PRIOR mental health treatment
109. n of children in Group 4 who had received PRIOR mental health treatment
110. n of children in Group 5 who had received PRIOR mental health treatment
111. n of children in Group 6 who had received PRIOR mental health treatment
112. Percentage (%) of children in the Total Sample who had received prior mental health treatment
113. Percentage (%) of children in Group 1 who had received prior mental health treatment
114. Percentage (%) of children in Group 2 who had received prior mental health treatment
115. Percentage (%) of children in Group 3 who had received prior mental health treatment
116. Percentage (%) of children in Group 4 who had received prior mental health treatment
117. Percentage (%) of children in Group 5 who had received prior mental health treatment
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118. Percentage (%) of children in Group 6 who had received prior mental health treatment
119. n of children in the Total Sample who were taking medications during the study
120. n of children in Group 1 taking medications during the study
121. n of children in Group 2 taking medications during the study
122. n of children in Group 3 taking medications during the study
123. n of children in Group 4 taking medications during the study
124. n of children in Group 5 taking medications during the study
125. n of children in Group 6 taking medications during the study
126. Percentage (%) of children in the Total Sample who were taking medications during the study
127. Percentage (%) of children in Group 1 who were taking medications during the study
128. Percentage (%) of children in Group 2 who were taking medications during the study
129. Percentage (%) of children in Group 3 who were taking medications during the study
130. Percentage (%) of children in Group 4 who were taking medications during the study
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131. Percentage (%) of children in Group 5 who were taking medications during the study
132. Percentage (%) of children in Group 6 who were taking medications during the study
133. Other (parallel) intervention children received during the study was:
134. Percentage (%) of children in Total Sample who were receiving other (parallel) intervention during the study
135. Percentage (%) of children in Group 1 who were receiving other (parallel) intervention during the study
136. Percentage (%) of children in Group 2 who were receiving other (parallel) intervention during the study
137. Percentage (%) of children in Group 3 who were receiving other (parallel) intervention during the study
138. Percentage (%) of children in Group 4 who were receiving other (parallel) intervention during the study
139. Percentage (%) of children in Group 5 who were receiving other (parallel) intervention during the study
140. Percentage (%) of children in Group 6 who were receiving other (parallel) intervention during the study
141. Parent demographics info. Page number
142. Parent age Mean, if indicated in the Total sample
271
143. Parent age SD, if indicated in the Total sample
144. Parent age Range, if indicated in the Total sample
145. Maternal psychopathology Please select all that apply:
No response
ADHD
Anxiety
Depression
Parenting stress
Other
146. Father psychopathology Please select all that apply:
No response
ADHD
Anxiety
Depression
Parenting stress
Other
147. Parental (mother + father) psychopathology
Please select all that apply:
No response
ADHD
Anxiety
Depression
Parenting stress
Other
148. If reported, Family SES index's (measure/scale) name used
149. Family SES Total Sample Mean
272
150. Family SES Total Sample SD
151. Family SES Total Sample Range
152. Family SES Group 1 Mean
153. Family SES Group 2 Mean
154. Family SES Group 3 Mean
155. Family SES Group 4 Mean
156. Family SES Group 5 Mean
157. Family SES Group 6 Mean
158. Family SES Group 1 SD
159. Family SES Group 2 SD
160. Family SES Group 3 SD
161. Family SES Group 4 SD
162. Family SES Group 5 SD
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163. Family SES Group 6 SD
164. Family SES Group 1 Range
165. Family SES Group 2 Range
166. Family SES Group 3 Range
167. Family SES Group 4 Range
168. Family SES Group 5 Range
169. Family SES Group 6 Range
170. Family income Mean of total sample
171. Family income SD of total sample
172. Family income Range of total sample
173. n of single parent households in the Total Sample
174. n of married/partnered parents (1 household) in the Total Sample
175. n of separated/divorced parents (2 households) in the Total Sample
176. Percentage of single parent households in the Total Sample
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177. Percentage of married/partnered parents (one household) in the Total Sample
178. Percentage of divorced/separated parents (2 households) in the Total Sample
179. Education level of participating parent (if not reported separately for mothers and fathers). Total Sample n of high school education or below
180. Education level of participating parent. Total Sample n of Community college or undergraduate education
181. Education level of participating parent. Total Sample n of graduate education or professional trained (e.g., law or dentist school)
182. Mother Education Level. Total Sample n of high school education or below
183. Mother Education Level. Total Sample n of Community college or undergraduate education
184. Mother Education Level. Total Sample n of Graduate education of professional training (e.g., law or dentist school)
185. Father Education Level. Total Sample n of high school education or below
186. Father Education Level. Total Sample n of Community College or undergraduate education
275
187. Father Education Level. Total Sample n of Graduate education of professional training (e.g., law or dentist school)
188. Family SES Total Sample Range
276
Part III: Intervention Characteristics
277
1. Psychosocial Treatment components provided. (Could be more than one. Please check all that apply).
Please select all that apply:
2. If you selected "Other" on the previous question, please specify treatment component provided.
3. Were pharmacological treatment (medications for ADHD) administered to a comparison group in the study?
Please select one of the following:
Yes
No
4. If "yes" to medications used. Please indicate which one(s).
5. Targets of intervention. Indicate page number where this information can be found in the paper.
6. Targets of intervention. Indicate who receive the treatment.
Please select all that apply:
Individual child alone
Group of children
Individual child alone with separate parent component
Group of children with separate parent component
Individual child alone with separate teacher component
Group of children with separate teacher component
Cognitive tools
Behavioural techniques
Mindfulness tools
Social skills training
Psychodynamic Tools
Other
278
Varies on stage
Other format
7. If you selected "varies by stage" or "Other" on the previous qs regarding intervention targets, please specify here.
8. Did the intervention have an additional parent component?
Please select one of the following:
Yes
No
9. If the intervention had an additional parent component, please specify which type (e.g., mindfulness based, parent training, etc)
10. Recruitment of the participants info. Page number.
11. Recruitment. Select all that applies.
Please select all that apply:
Mental health clinic
Hospital
School
Referral by Psychologists or Paediatricians/physicians
Community/newspaper postings
Other
12. Mode of intervention delivery.
Please select one of the following:
Direct (face to face)
Indirect (self directed by reading psychoeducational tools) or on-line
A combination of direct and indirect with 60% or more of direct contact
A combination of direct and indirect with less than 60% of direct contact
13. Setting in which treatment was conducted (e.g., hospital, university, etc). Page number.
14. Setting in which treatment was conducted (e.g., hospital, university, etc). Select all that apply.
279
Please select all that apply:
Clinic or hospital
School
Home (e.g., intervention homework)
Other
Cannot tell
15. If "other" in the previous question. Please specify. Also, if more than one setting was selected in the previous question, please write an estimation of the % spent in each setting. (E.g., 80% at clinic and 20% at home doing homework exercises).
16. Treatment was manualized?
Please select one of the following:
Yes
No
17. Page number regarding the manual reference information.
18. Treatment fidelity was considered?
Please select one of the following:
Yes
No
19. Page number of treatment fidelity info
20. Duration and Frequency of intervention page number(s)
21. Frequency of intervention
Please select one of the following:
Daily
Twice a week
Weekly
Every other week
Monthly
Other
22. Number of planned sessions
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23. (Number of planned) Duration of each session in minutes (e.g., 30 mins, 60mins, or 90 mins, etc.)
24. Actual number of sessions attended: Average
25. Minimum Actual number of sessions attended
26. Maximum Actual number of sessions attended
27. Total direct contact with each participant in minutes: Average
28. Minimum total direct contact with each participant in minutes
29. Maximum total direct contact with each participant in minutes
30. Length of follow-up. (Circle ALL time points that apply) If "Other", please notify Clarisa right away in order to incorporate that option in Survey Wizard.
Please select all that apply:
Pre-post testing
2 months follow-up
3 months follow-up
4 months follow-up
5 months follow-up
6 months follow-up
7 months follow-up
12 months follow-up
24 months follow-up
36 months follow-up
Other
31. Qualification of the individual delivering the psycho-social intervention of interest (e.g.,
281
not the pharmacological treatment).
Please select one of the following:
University professionals or psychologist with unspecified case load or centre staff (e.g., an OISE prof)
Community mental health professional (psychologist, psychiatrist, nurse, social worker, physician, other) with a clinical case load
Graduate student (psychology, med school, etc)
Paraprofessional (e.g., teacher)
Undergraduate students (psychology, nursing school, etc)
Cannot tell (e.g., refers to "therapist" but doesn't specifies their education level)
32. Amount of training therapists received for the specified intervention. Circle ALL that apply. (Make sure you select the most appropriate one and avoid "Cannot tell" as much as possible)
Please select all that apply:
None
Previous generic training (e.g., what is a psycho-social intervention, but not about THAT specific intervention to be delivered to children)
Previous program specific training
Received supervision throughout
Completion of session checklist
Reporting of checklist scores
Report of treatment integrity
Cannot tell (e.g., refers to "therapists were trained" but doesn't specifies how)
282
Part IV: Outcome
Measurement Scales
283
1. Study ID
2. OUTCOMES MEASURED. Please SELECT all the outcomes that were measured in this study.
Please select all that apply:
ADHD
ODD/CD (disruptive symptoms)
Anxiety
Depression
Social Skills
Family/Parent-Child Relations
Treatment Acceptability
Overall/global (child) improvement
3. ADHD Symptomatology was only measured for the purpose of screening participant eligibility/study entry criteria (i.e., no ADHD outcome measures reported).
Please select one of the following:
Yes
No
4. Additional notes on Outcomes measured.
5. ADHD Measurement (symptoms or diagnosis). Select all that apply.
Please select all that apply:
Assessed by qualified health
professional (e.g., psychologist, family physician, paediatrician, psychiatrist)
Diagnostic interview (e.g., DICA-R-P, K-SADS, DISC, etc)
Parent Questionnaire(s) (e.g., Conners, DBDRS, CBCL, etc)
Teacher Questionare(s) (e.g., Conners, DBDRS, CBCL, etc)
Child Questionnaire(s) (e.g., YSR)
Other
6. ODD, CD (Disruptive behaviours/externalizing when is clearly not just ADHD) Measurement (symptoms or diagnosis). Select all that apply.
Please select all that apply:
Assessed by qualified health
professional (e.g., psychologist, family physician, paediatrician, psychiatrist)
Diagnostic interview (e.g., DICA-R-P, K-SADS, DISC, etc)
284
Parent Questionnaire(s) (e.g., Conners, DBDRS, CBCL, etc)
Teacher Questionare(s) (e.g., Conners, DBDRS, CBCL, etc)
Child Questionnaire(s) (e.g., YSR)
Other
7. Anxiety Measurement (symptoms or diagnosis). Select all that apply. Please select all that apply:
Assessed by qualified health
professional (e.g., psychologist, family physician, paediatrician, psychiatrist)
Diagnostic interview (e.g., DICA-R-P,
K-SADS, DISC, etc)
Parent Questionnaire(s) (e.g., Conners, CBCL, RCADS, etc)
Teacher Questionare(s) (e.g., Conners, CBCL, etc)
Child Questionnaire(s) (e.g., YSR, RCADS)
Other
8. Depression Measurement (symptoms or diagnosis). Select all that apply. Please select all that apply:
Assessed by qualified health
professional (e.g., psychologist, family physician, paediatrician, psychiatrist)
Diagnostic interview (e.g., DICA-R-P,
K-SADS, DISC, etc)
Parent Questionnaire(s) (e.g., Conners, CBCL, RCADS, etc)
Teacher Questionare(s) (e.g., Conners, CBCL, etc)
Child Questionnaire(s) (e.g., YSR,
RCADS)
Other
9. Social Peer Difficulties Measurement (symptoms or diagnosis). Select all that apply. Please select all that apply:
Assessed by qualified health
professional (e.g., psychologist, family physician, paediatrician, psychiatrist)
Diagnostic interview (e.g., K-SADS, DISC, etc)
Parent Questionnaire(s) (e.g., SSRS, Conners, Third Edition, CBCL, etc)
Teacher Questionare(s) (e.g., Conners, CBCL, etc)
Other (e.g., peer nomination or peer
rating of social skills, or adult observer of social skills)
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10. Family/Parent-Child Relations Measurement. Select all that apply. Please select all that apply:
Assessed by qualified health professional (e.g., psychologist, family
physician, paediatrician, psychiatrist)
Diagnostic interview (e.g., K-SADS, DISC, etc)
Parent Questionnaire(s) (e.g., Issues
Checklist, etc)
Teacher Questionare(s) (e.g., Conners, CBCL, etc)
Other (e.g., adult observer of relationship)
Child Questionnaire(s) (e.g., FAD, Issues Checklist)
11. Treatment Acceptability Measurement. Select all that apply. None, leave blank.
Please select all that apply:
Assessed by child's parent measure (e.g., Parent Consultation Evaluation
Scale, etc)
Assessed by child's teacher measure (e.g., Parent Consultation Evaluation
Scale, etc)
Assessed by self-report -youth measure
Informal parent interview/survey
Informal teacher survey
Informal child survey
12. Overall/global child's improvement outcome instrument used? (E.g., a measure of how the overall child's quality of life improve after treatment; or the treatment effect on daily activities such as as absence from school) Please select all that apply:
Child reported (e.g.,xxx )
Child's parent measure (e.g., Clinical
Global Impressions-Improvement)
Child's teacher measured (e.g.,
Clinical Global Impressions- Improvement)
Child Questionnaire(s) (e.g., SSRS,YSR)
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13. ADHD scale name Exact name of the instrument(s) and specific scale(s) used to measure ADHD. (E.g., Parent Conners-3, Hyperactivity Scale, and CBCL (Achenbach, 1991) Attention Problems Scale)
14. ODD/CD scale name Exact name of the instrument(s) and specific scale(s) used to measure it, (e.g., Conners-3-P aggression and oppositonality scales)
15. Anxiety scale name
Exact name of the instrument(s) and specific scale(s) used to measure it, (e.g., Revised Child Anxiety and Depression Scale- Youth and Parent Report (RCADS; Chorpita et al, 2000) Total internalizing scale, total anxiety scale, and 6 subscales: Separation Anxiety disorder, etc).
16. Depression scale name
Exact name of the instrument(s) and specific scale(s) used to measure it. (E.g., Revised Child Anxiety and Depression Scale- Youth and Parent Report (RCADS; Chorpita et al, 2000) Total internalizing scale, and Major Depressive Disorder subscale, etc.).
17. Social Skills/Peer Relations scale name
Exact name of the instrument(s) and specific scale(s) used to measure it, (e.g., Conners-R, Social problems scale; and Social Skills Rating System (SSRS; Greshman & Elliot, 1999) Parent and child versions, Cooperation, Assertion, Responsibility, and Self-Control scales).
18. Family/Parent-Child Relations measure name
Exact name of the instrument(s) and specific scale(s) used to measure it, (e.g.,
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Issues Check-list (Robin, 1975; Printz et al., 1979) parent and youth versions, and Family Assessment Device Youth version, Family relations composite created, of which of the 7 subscales, e.g., Problem Solving, roles, etc).
19. Treatment Acceptability measure name
Exact name of the instrument(s) and specific scale(s) used to measure it, (e.g.,Overall/global child's improvement outcome instrument name
20. Unintended intervention outcome(s) reported?
Please select one of the following:
Yes. Positive unintended outcome
Yes. Negative unintended outcome
No. None specified
21. Positive Unintended effects. Please indicate which was the unintended intervention outcome(s) (e.g., a treatment designed to improve ADHD and aggression symptoms also had an unintended effect on improving social peer relations) and how was it measured (e.g., interview by whom, or which questionnaire was used).
22. Negative Unintended effects.
Please indicate which was the unintended intervention outcome(s) (e.g., a treatment designed to improve social skills had an unintended effect of worsening these skills) and how was it measured (e.g., interview by whom, or which questionnaire was used).
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Part V. Effect Sizes: Group
Comparisons
289
2. Page number(s) of stats info
3. Total N (sample size of all groups combined)
4. Type of data effect size was based on (report the analyses done, but extract data only for Means, SD, and n in the upcoming questions)
Please select all that apply:
Means and SD t-test ANOVAS (F) Regressions Other
5. If other, please specify
6. How many outcomes (O1, O2...) were measured in this report?
(If ADHD was reported as Parent Conners Hyperactivity, and Parent Conners Inattention, and Teacher Conners Hyperactivity, and Teacher Conners Inattention, these are = 4 outcomes, and all their Means, SD, and sample size (n) needs to be reported separately for each in the Qs to follow). Please select one of the following:
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
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16 17 18 19 20 21 22 23 24 25 26
7. Outcome 1 - Complete with it stands for (e.g., ADHD, ODD, CD, Anxiety, Depression, social skills, etc.)
8. Outcome 1 - Measured with: (Instrument name: e.g., CBCL, PArent Conners)
9. O1 Group 1 Pre Mean
10. O1 Group 2 Pre Mean
11. O1 Group 3 Pre Mean
12. O1 Group 4 Pre Mean
13. O1 Group 5 Pre Mean
14. O1 Group 6 Pre Mean
15. O1 Group 1 Mid Mean
16. O1 Group 2 Mid Mean
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18. O1 Group 4 Mid Mean
19. O1 Group 5 Mid Mean
20. O1 Group 6 Mid Mean
21. O1 Group 1 Post Mean
22. O1 Group 2 Post Mean
23. O1 Group 3 Post Mean
24. O1 Group 4 Post Mean
25. O1 Group 5 Post Mean
26. O1 Group 6 Post Mean
27. O1 Group 1 FU1 Mean
28. O1 Group 2 FU1 Mean
29. O1 Group 3 FU1 Mean
30. O1 Group 4 FU1 Mean
31. O1 Group 5 FU1 Mean
292
35. O1 Group 3 FU2 Mean
36. O1 Group 4 FU2 Mean
37. O1 Group 5 FU2 Mean
38. O1 Group 6 FU2 Mean
39. O1 Group 1 FU3 Mean
40. O1 Group 2 FU3 Mean
41. O1 Group 3 FU3 Mean
42. O1 Group 4 FU3 Mean
43. O1 Group 5 FU3 Mean
44. O1 Group 6 FU3 Mean
45. O1 Group 1 Pre SD
46. O1 Group 2 Pre SD
293
50. O1 Group 6 Pre SD
51. O1 Group 1 Mid SD
52. O1 Group 2 Mid SD
53. O1 Group 3 Mid SD
54. O1 Group 4 Mid SD
55. O1 Group 5 Mid SD
56. O1 Group 6 Mid SD
57. O1 Group 1 Post SD
294
65. O1 Group 3 FU1 SD
66. O1 Group 4 FU1 SD
67. O1 Group 5 FU1 SD
68. O1 Group 6 FU1 SD
69. O1 Group 1 FU2 SD
70. O1 Group 2 FU2 SD
71. O1 Group 3 FU2 SD
72. O1 Group 4 FU2 SD
295
80. O1 Group 6 FU3 SD
81. O1 Group 1 Pre n
82. O1 Group 2 Pre n
83. O1 Group 3 Pre n
84. O1 Group 4 Pre n
85. O1 Group 5 Pre n
86. O1 Group 6 Pre n
87. O1 Group 1 Mid n
296
95. O1 Group 3 Post n
96. O1 Group 4 Post n
97. O1 Group 5 Post n
98. O1 Group 6 Post n
99. O1 Group 1 FU1 n
100. O1 Group 2 FU1 n
101. O1 Group 3 FU1 n
102. O1 Group 4 FU1 n
103. O1 Group 5 FU1 n
104. O1 Group 6 FU1 n
105. O1 Group 1 FU2 n
106. O1 Group 2 FU2 n
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297
110. O1 Group 6 FU2 n
111. O1 Group 1 FU3 n
112. O1 Group 2 FU3 n
113. O1 Group 3 FU3 n
114. O1 Group 4 FU3 n
115. O1 Group 5 FU3 n
116. O1 Group 6 FU3 n
This form continues similarly to the above items for outcome 1 all the way to outcome 2 up to outcome 26.
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298
EPHPP Study Quality Tool
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299
1. Study ID
2. Selection Bias: Are the individuals selected to participate in the study likely to be representative of the target population?
Please select one of the following:
Very likely
Somewhat likely
Not likely
Can't tell
3. What percentage of selected individuals agreed to participate? Please select one of the following:
80-100% agreement
60-79% agreement
Less than 60% agreement
Not applicable
Can't tell
4. Rate this section "A" (See EPHPP Dictionary) Please select one of the following:
Strong
Moderate
Weak
5. Study design. Please select one of the following:
Randomized control trial
Controlled clinical trial
Cohort analytic (2 groups pre-post)
Case control
Cohort (1 group pre-post)
Interrupted time series
Other
Can't tell
6. If "other" in the previous question, please specify. 7. Was the study described as randomized? (If "no" skip next 2 Qs)
Please select one of the following:
Yes
No
300
300
8. If 'yes' was the method of randomization described? Please select one of the following:
Yes
No
9. If 'yes' was the method appropriate? Please select one of the following:
Yes
No
10. Rate this section "B" (See EPHPP Dictionary) Please select one of the following:
Strong
Moderate
Weak
11. Cofounders: Were there any important differences between groups prior to the intervention?
( E.g.: race, sex, marital status, age, SES, education, health status, or pre-intervention scores on outcome measure) 12. Confounders: If "yes" indicate which ones.
13. Confounders: If "yes" indicate the percentage of the relevant cofounders that were controlled (either in the design by stratification or matching or in the analyses)
Please select one of the following:
80-100% (most)
60-79% (somewhat)
Less than 60% (few or more)
Can't tell
14. Rate this section "C" (See EPHPP Dictionary) Please select one of the following:
Strong
Moderate
Weak
15. Blinding. Was/were the outcome assessor(s) aware of the intervention or exposure status of participants?
Please select one of the following:
Yes
No
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301
16. Blinding. Was/were the study participants aware of the research question? Please select one of the following:
Yes
No
Can't tell
17. Rate this section "D" (See EPHPP Dictionary) Please select one of the following:
Strong
Moderate
Weak
18. Data collection methods. Were data collection methods shown to be valid? Please select one of the following:
Yes
No
Can't tell
19. Data collection methods. Were data collection methods shown to be reliable? Please select one of the following:
Yes
No
Can't tell
20. Rate this section "E" (See EPHPP Dictionary) Please select one of the following:
Strong
Moderate
Weak
21. Intervention integrity. (Section "G"). Was the consistency of the intervention measured? Please select one of the following:
Yes
No
Can't tell
22. Withdrawals and drop-outs. Were withdrawals and drop outs reported in terms of numbers and/or reasons per group?
(Note that this study doesn't include one time surveys). Please select one of the following:
Yes
No
Can't tell
Can't tell
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302
23. Withdrawals. Indicate the PERCENTAGE of participants COMPLETING the study (if the % differs by groups, record the lowest) Please select one of the following:
80-100%
60-79%
Less than 60%
Can't tell
Not applicable (retrospective case control)
24. Rate this section "F" (See EPHPP Dictionary) Please select one of the following:
Strong
Moderate
Weak
25. Intervention integrity. (Section "G") What percentage of participants received the allocated intervention or exposure of interest?
Please select one of the following:
80-100% (most)
60-79% (somewhat)
Less than 60% (few or more)
Can't tell
26. Intervention integrity. (Section "G"). Was the consistency of the intervention measured? Please select one of the following:
Yes
No
Can't tell
27. Intervention integrity. (Section "G"). Is it likely that subjects received an unintended intervention (contamination or co-intervention) that may influence the results?
Please select one of the following:
Yes
No
Can't tell
28. Global Ratings: Selection Bias (SECTION "A" copy answer from item #4) Please select one of the following:
Strong
Moderate
Weak
29. Study design (SECTION "B" copy answer from item #8)
Not applicable (one time surveys orinterviews)
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303
Please select one of the following:
Strong
Moderate
Weak
30. Confounders (SECTION "C" copy answer from item #12) Please select one of the following:
Strong
Moderate
Weak
31. Blinding (SECTION "D" copy answer from item #14) Please select one of the following:
Strong
Moderate
Weak
32. Data collection method (SECTION "E" copy answer from item #16) Please select one of the following:
Strong
Moderate
Weak
33. Withdrawals/dropouts (SECTION "F" copy answer from item #19) Please select one of the following:
Strong
Moderate
Weak
34. Global rating for this paper (calculate from the above ratings). STRONG: No Weak ratings. MODERATE: 1 Weak rating. WEAK: 2 or more Weak ratings. Please select one of the following:
Strong
Moderate
Weak
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304
Quality Assessment Tool
for Quantitative Studies
Dictionary
The purpose of this dictionary is to describe items in the tool thereby assisting raters to score study quality. Due to
under-reporting or lack of clarity in the primary study, raters will need to make judgements about the extent that bias
may be present. When making judgements about each component, raters should form their opinion based upon
information contained in the study rather than making inferences about what the authors intended.
A) SELECTION BIAS
(Q1) Participants are more likely to be representative of the target population if they are randomly selected from a
comprehensive list of individuals in the target population (score very likely). They may not be representative if they are
referred from a source (e.g. clinic) in a systematic manner (score somewhat likely) or self-referred (score not likely).
(Q2) Refers to the % of subjects in the control and intervention groups that agreed to participate in the study before
they were assigned to intervention or control groups.
B) STUDY DESIGN
In this section, raters assess the likelihood of bias due to the allocation process in an experimental study. For
observational studies, raters assess the extent that assessments of exposure and outcome are likely to be independent.
Generally, the type of design is a good indicator of the extent of bias. In stronger designs, an equivalent control group
is present and the allocation process is such that the investigators are unable to predict the sequence.
Randomized Controlled Trial (RCT)
An experimental design where investigators randomly allocate eligible people to an intervention or control group. A
rater should describe a study as an RCT if the randomization sequence allows each study participant to have the same
chance of receiving each intervention and the investigators could not predict which intervention was next. If the
investigators do not describe the allocation process and only use the words ‘random’ or ‘randomly’, the study is
described as a controlled clinical trial.
See below for more details.
Was the study described as randomized?
Score YES, if the authors used words such as random allocation, randomly assigned, and random assignment.
Score NO, if no mention of randomization is made.
Was the method of randomization described?
Score YES, if the authors describe any method used to generate a random allocation sequence.
Score NO, if the authors do not describe the allocation method or describe methods of allocation such as alternation,
case record numbers, dates of birth, day of the week, and any allocation procedure that is entirely transparent before
assignment, such as an open list of random numbers of assignments.
If NO is scored, then the study is a controlled clinical trial.
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Was the method appropriate?
Score YES, if the randomization sequence allowed each study participant to have the same chance of receiving each
intervention and the investigators could not predict which intervention was next. Examples of appropriate approaches
include assignment of subjects by a central office unaware of subject characteristics, or sequentially numbered, sealed,
opaque envelopes.
Score NO, if the randomization sequence is open to the individuals responsible for recruiting and allocating participants
or providing the intervention, since those individuals can influence the allocation process, either knowingly or
unknowingly.
If NO is scored, then the study is a controlled clinical trial.
Controlled Clinical Trial (CCT)
An experimental study design where the method of allocating study subjects to intervention or control groups is open
to individuals responsible for recruiting subjects or providing the intervention. The method of allocation is transparent
before assignment, e.g. an open list of random numbers or allocation by date of birth, etc.
Cohort analytic (two group pre and post)
An observational study design where groups are assembled according to whether or not exposure to the intervention
has occurred. Exposure to the intervention is not under the control of the investigators. Study groups might be non-
equivalent or not comparable on some feature that affects outcome.
Case control study
A retrospective study design where the investigators gather ‘cases’ of people who already have the outcome of interest
and ‘controls’ who do not. Both groups are then questioned or their records examined about whether they received the
intervention exposure of interest.
Cohort (one group pre + post (before and after)
The same group is pretested, given an intervention, and tested immediately after the intervention. The intervention
group, by means of the pretest, act as their own control group.
Interrupted time series
A time series consists of multiple observations over time. Observations can be on the same units (e.g. individuals over
time) or on different but similar units (e.g. student achievement scores for particular grade and school). Interrupted
time series analysis requires knowing the specific point in the series when an intervention occurred.
C) CONFOUNDERS
By definition, a confounder is a variable that is associated with the intervention or exposure and causally related to the
outcome of interest. Even in a robust study design, groups may not be balanced with respect to important variables
prior to the intervention. The authors should indicate if confounders were controlled in the design (by stratification or
matching) or in the analysis. If the allocation to intervention and control groups is randomized, the authors must report
that the groups were balanced at baseline with respect to confounders (either in the text or a table).
D) BLINDING
(Q1) Assessors should be described as blinded to which participants were in the control and intervention groups. The
purpose of blinding the outcome assessors (who might also be the care providers) is to protect against detection bias.
(Q2) Study participants should not be aware of (i.e. blinded to) the research question. The purpose of blinding the
participants is to protect against reporting bias.
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E) DATA COLLECTION METHODS
Tools for primary outcome measures must be described as reliable and valid. If ‘face’ validity or ‘content’ validity has
been demonstrated, this is acceptable. Some sources from which data may be collected are described below:
Self reported data includes data that is collected from participants in the study (e.g. completing a questionnaire,
survey, answering questions during an interview, etc.).
Assessment/Screening includes objective data that is retrieved by the researchers. (e.g. observations by
investigators).
Medical Records/Vital Statistics refers to the types of formal records used for the extraction of the data.
Reliability and validity can be reported in the study or in a separate study. For example, some
standard assessment tools have known reliability and validity.
F) WITHDRAWALS AND DROP-OUTS
Score YES if the authors describe BOTH the numbers and reasons for withdrawals and drop-outs.
Score NO if either the numbers or reasons for withdrawals and drop-outs are not reported.
The percentage of participants completing the study refers to the % of subjects remaining in the study at the final data
collection period in all groups (i.e. control and intervention groups).
G) INTERVENTION INTEGRITY
The number of participants receiving the intended intervention should be noted (consider both frequency and intensity).
For example, the authors may have reported that at least 80 percent of the participants received the complete
intervention. The authors should describe a method of measuring if the intervention was provided to all participants
the same way. As well, the authors should indicate if subjects received an unintended intervention that may have
influenced the outcomes. For example, co-intervention occurs when the study group receives an additional intervention
(other than that intended). In this case, it is possible that the effect of the intervention may be over-estimated.
Contamination refers to situations where the control group accidentally receives the study intervention. This could
result in an under-estimation of the impact of the intervention.
H) ANALYSIS APPROPRIATE TO QUESTION
Was the quantitative analysis appropriate to the research question being asked?
An intention-to-treat analysis is one in which all the participants in a trial are analyzed according to the intervention to
which they were allocated, whether they received it or not. Intention-to-treat analyses are favoured in assessments of
effectiveness as they mirror the noncompliance and treatment changes that are likely to occur when the intervention is
used in practice, and because of the risk of attrition bias when participants are excluded from the analysis.
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Component Ratings of Study:
For each of the six components A – F, use the following descriptions as a roadmap.
A) SELECTION BIAS
Strong: The selected individuals are very likely to be representative of the target population (Q1 is 1) and there is
greater than 80% participation (Q2 is 1).
Moderate: The selected individuals are at least somewhat likely to be representative of the target population (Q1 is 1
or 2); and there is 60 - 79% participation (Q2 is 2). ‘Moderate’ may also be assigned if Q1 is 1 or 2 and Q2 is 5 (can’t
tell).
Weak: The selected individuals are not likely to be representative of the target population (Q1 is 3); or there is less than
60% participation (Q2 is 3) or selection is not described (Q1 is 4); and the level of participation is not described (Q2 is 5).
B) DESIGN
Strong: will be assigned to those articles that described RCTs and CCTs.
Moderate: will be assigned to those that described a cohort analytic study, a case control study, a cohort design, or
an interrupted time series.
Weak: will be assigned to those that used any other method or did not state the method used.
C) CONFOUNDERS
Strong: will be assigned to those articles that controlled for at least 80% of relevant confounders (Q1 is 2); or (Q2 is 1).
Moderate: will be given to those studies that controlled for 60 – 79% of relevant confounders (Q1 is 1) and (Q2 is 2).
Weak: will be assigned when less than 60% of relevant confounders were controlled (Q1 is 1) and (Q2 is 3) or
control of confounders was not described (Q1 is 3) and (Q2 is 4).
D) BLINDING
Strong: The outcome assessor is not aware of the intervention status of participants (Q1 is 2); and the study
participants are not aware of the research question (Q2 is 2).
Moderate: The outcome assessor is not aware of the intervention status of participants (Q1 is 2); or the study
participants are not aware of the research question (Q2 is 2); or blinding is not described (Q1 is 3 and Q2 is 3).
Weak: The outcome assessor is aware of the intervention status of participants (Q1 is 1); and the study participants
are aware of the research question (Q2 is 1).
E) DATA COLLECTION METHODS
Strong: The data collection tools have been shown to be valid (Q1 is 1); and the data collection tools have been
shown to be reliable (Q2 is 1).
Moderate: The data collection tools have been shown to be valid (Q1 is 1); and the data collection tools have not
been shown to be reliable (Q2 is 2) or reliability is not described (Q2 is 3).
Weak: The data collection tools have not been shown to be valid (Q1 is 2) or both reliability and validity are not
described (Q1 is 3 and Q2 is 3).
F) WITHDRAWALS AND DROP-OUTS - a rating of:
Strong: will be assigned when the follow-up rate is 80% or greater (Q2 is 1).
Moderate: will be assigned when the follow-up rate is 60 – 79% (Q2 is 2) OR Q2 is 5 (N/A).
Weak: will be assigned when a follow-up rate is less than 60% (Q2 is 3) or if the withdrawals and drop-outs were not
described (Q2 is 4).
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QUALITY ASSESSMENT TOOL FOR
QUANTITATIVE STUDIES
COMPONENT RATINGS
A) SELECTION BIAS
(Q1) Are the individuals selected to participate in the study likely to be representative of the target population?
1 Very likely
2 Somewhat likely
3 Not likely
4 Can’t tell
(Q2) What percentage of selected individuals agreed to participate?
1 80 - 100% agreement
2 60 – 79% agreement
3 less than 60% agreement
4 Not applicable
5 Can’t tell
RATE THIS SECTION STRONG MODERATE WEAK
See dictionary 1 2 3
B) STUDY DESIGN
Indicate the study design
1 Randomized controlled trial
2 Controlled clinical trial
3 Cohort analytic (two group pre + post)
4 Case-control
5 Cohort (one group pre + post (before and after))
6 Interrupted time series
7 Other specify
8 Can’t tell
Was the study described as randomized? If NO, go to Component C.
No Yes
If Yes, was the method of randomization described? (See dictionary)
No Yes
If Yes, was the method appropriate? (See dictionary)
No Yes
RATE THIS SECTION STRONG MODERATE WEAK
See dictionary 1 2 3
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C) CONFOUNDERS
(Q1) Were there important differences between groups prior to the intervention?
1 Yes
2 No
3 Can’t tell
The following are examples of confounders:
1 Race
2 Sex
3 Marital status/family
4 Age
5 SES (income or class)
6 Education
7 Health status
8 Pre-intervention score on outcome measure
(Q2) If yes, indicate the percentage of relevant confounders that were controlled (either in the design (e.g.
stratification, matching) or analysis)?
1 80 – 100% (most)
2 60 – 79% (some)
3 Less than 60% (few or
none) 4 Can’t Tell
RATE THIS SECTION STRONG MODERATE WEAK
See dictionary 1 2 3
D) BLINDING
(Q1) Was (were) the outcome assessor(s) aware of the intervention or exposure status of participants?
1 Yes
2 No
3 Can’t tell
(Q2) Were the study participants aware of the research question?
1 Yes
2 No
3 Can’t tell
RATE THIS SECTION STRONG MODERATE WEAK
See dictionary 1 2 3
E) DATA COLLECTION METHODS
(Q1) Were data collection tools shown to be valid?
1 Yes
2 No
3 Can’t tell
(Q2) Were data collection tools shown to be reliable?
1 Yes
2 No
3 Can’t tell
RATE THIS SECTION STRONG MODERATE WEAK
See dictionary 1 2 3
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F) WITHDRAWALS AND DROP-OUTS
(Q1) Were withdrawals and drop-outs reported in terms of numbers and/or reasons per group?
1 Yes
2 No
3 Can’t tell
4 Not Applicable (i.e. one time surveys or interviews)
(Q2) Indicate the percentage of participants completing the study. (If the percentage differs by groups, record the
lowest).
1 80 -100%
2 60 - 79%
3 less than 60%
4 Can’t tell
5 Not Applicable (i.e. Retrospective case-control)
RATE THIS SECTION STRONG MODERATE WEAK
See dictionary 1 2 3 Not Applicable
G) INTERVENTION INTEGRITY
(Q1) What percentage of participants received the allocated intervention or exposure of interest?
1 80 -100%
2 60 - 79%
3 less than 60%
4 Can’t tell
(Q2) Was the consistency of the intervention measured?
1 Yes
2 No
3 Can’t tell
(Q3) Is it likely that subjects received an unintended intervention (contamination or co-intervention) that may
influence the results?
4 Yes
5 No
6 Can’t tell
H) ANALYSES
(Q1) Indicate the unit of allocation (circle one)?
Community organization/institution practice/office indvidual
(Q2) Indicate the unit of analysis (circle one)?
Community organization/institution practice/office indvidual
(Q3) Are the statistical methods appropriate for the study design?
1 Yes
2 No
3 Can’t tell
(Q4) Is the analysis performed by intervention allocation status (i.e. intention to treat) rather than the actual
intervention received?
1 Yes
2 No
3 Can’t tell
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GLOBAL RATING
COMPONENT RATINGS
Please transcribe the information from the gray boxes on pages 1-4 onto this page. See dictionary on how to rate this section.
A SELECTION BIAS STRONG MODERATE WEAK
1 2 3
B STUDY DESIGN STRONG MODERATE WEAK
1 2 3
C CONFOUNDERS STRONG MODERATE WEAK
1 2 3
D BLINDING STRONG MODERATE WEAK
1 2 3
E DATA COLLECTION
STRONG
MODERATE
WEAK
METHOD 1 2 3
F WITHDRAWALS AND DROPOUTS
STRONG MODERATE WEAK
1 2 3 Not Applicable
GLOBAL RATING FOR THIS PAPER (circle one):
1 STRONG (no WEAK ratings)
2 MODERATE (one WEAK rating)
3 WEAK (two or more WEAK ratings)
With both reviewers discussing the ratings:
Is there a discrepancy between the two reviewers with respect to the component (A-F) ratings?
No Yes
If yes, indicate the reason for the discrepancy
1 Oversight
2 Differences in interpretation of criteria
3 Differences in interpretation of study
Final decision of both reviewers (circle one): 1 STRONG
2 MODERATE
3 WEAK
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Appendix D. Results of t-tests for Between Groups Design Studies.
Study Name
Control group SST group Outcome t p
M SD n M SD n
Pfiffner et al., 2007 13.70 2.60 16 14.90 2.90 21 Child Social Skills Knowledge -1.32 .194
Pfiffner & McBurnett, 1997 6.10 0.90 9 6.00 1.20 9 Child Social Skills Knowledge 0.20 .844
Antshel, & Remer, 2003 8.10 1.40 40 8.00 1.20 80 Parent Assertion Social Skills 0.39 .700 Frankel et al., 1997 12.00 2.86 12 12.11 3.21 35 Parent Assertion Social Skills -0.11 .912
Molina et al., 2008 71.22 19.72 9 69.73 22.02 11 Parent Externalizing 0.16 .875
Pfiffner & McBurnett, 1997 70.80 8.70 9 59.40 8.20 9 Parent Externalizing 2.86 .011 Waxmonsky et al., 2010 19.58 5.62 27 21.25 5.32 29 Parent Behaviour Problems -1.14 .259
Pfiffner & McBurnett, 1997 128.20 13.70 9 123.40 8.90 9 Parent Behaviour Problems 0.88 .391
Waxmonsky et al., 2010 1.81 0.59 27 1.64 0.63 29 Parent Hyperactivity/Impulsivity 1.04 .302 The MTA Cooperative Group, 1999 1.89 0.62 140 1.91 0.69 140 Parent Hyperactivity/Impulsivity -0.26 .799 The MTA Cooperative Group, 1999 1.95 0.67 142 1.89 0.64 140 Parent Hyperactivity/Impulsivity 0.77 .443
Evans et al., 2011 12.80 5.40 18 14.50 4.40 31 Parent Hyperactivity/Impulsivity -1.13 .262 Waxmonsky et al., 2010 2.15 0.58 27 2.05 0.63 29 Parent Inattention 0.62 .539 The MTA Cooperative Group, 1999 2.03 0.64 140 2.07 0.61 140 Parent Inattention -0.54 .593 The MTA Cooperative Group, 1999 2.05 0.65 142 1.99 0.63 139 Parent Inattention 0.79 .433 Evans et al., 2011 19.10 4.90 18 20.40 4.00 31 Parent Inattention -0.96 .344
Molina et al., 2008 60.33 11.91 9 59.91 12.80 11 Parent Internalizing 0.08 .940 The MTA Cooperative Group, 1999 0.97 0.37 137 0.98 0.37 138 Parent Internalizing -0.22 .823 The MTA Cooperative Group, 1999 0.97 0.35 137 0.93 0.43 133 Parent Internalizing 0.84 .403
Pfiffner & McBurnett, 1997 63.40 12.60 9 59.30 16.70 9 Parent Internalizing 0.59 .565
Waxmonsky et al., 2010 1.26 0.57 27 1.35 0.69 29 Parent ODD -0.53 .596
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Appendix D. Results of t-tests for Between Groups Design Studies (continued).
Study Name
Control group SST group Outcome t p
M SD n M SD n
The MTA Cooperative Group, 1999 1.45 0.80 139 1.39 0.71 140 Parent ODD 0.66 .508 The MTA Cooperative Group, 1999 1.49 0.70 142 1.37 0.70 140 Parent ODD 1.44 .151
Waxmonsky et al., 2010 3.41 1.74 27 3.62 1.86 29 Parent Peer Relations -0.44 .664 Evans et al., 2011 2.90 2.10 18 3.60 1.80 31 Parent Peer Relations -1.18 .242
Antshel, & Remer, 2003 5.00 1.00 40 5.10 1.00 80 Parent Self-Control Social Skills -0.52 .607
Frankel et al., 1997 6.67 2.53 12 8.60 4.46 35 Parent Self-Control Social Skills -1.84 .073 Waxmonsky et al., 2010 42.04 9.11 27 40.64 13.01 29 Parent Social Skills Total 0.47 .641 The MTA Cooperative Group, 1999 1.01 0.24 137 1.04 0.23 138 Parent Social Skills Total -1.06 .291 The MTA Cooperative Group, 1999 1.03 0.23 137 1.02 0.22 133 Parent Social Skills Total 0.37 .715 Pfiffner & McBurnett, 1997 75.80 11.10 9 70.20 9.10 9 Parent Social Skills Total 1.17 .259
Klein et al., 2004 78.10 16.10 34 75.70 20.40 34 Parent Social Skills Total 0.54 .592
Waxmonsky et al., 2010 0.26 0.27 27 0.22 0.22 29 Teacher CD 0.61 .548 Abikoff et al., 2004a 1.20 0.60 34 1.20 0.60 34 Teacher CD 0.00 1.000
Waxmonsky et al., 2010 16.81 6.32 27 16.83 6.84 29 Teacher Behaviour Problems -0.01 .991
Pfiffner & McBurnett, 1997 118.90 11.40 9 112.20 12.30 9 Teacher Behaviour Problems 1.20 .248 Waxmonsky et al., 2010 1.31 0.67 27 1.42 0.88 29 Teacher Hyperactivity/Impulsivity -0.53 .599 The MTA Cooperative Group, 1999 2.08 0.71 135 1.89 0.77 137 Teacher Hyperactivity/Impulsivity 2.12 .035 The MTA Cooperative Group, 1999 1.93 0.81 135 2.05 0.75 136 Teacher Hyperactivity/Impulsivity -1.27 .207 Evans et al., 2011 6.70 6.70 18 9.00 7.00 31 Teacher Hyperactivity/Impulsivity -1.14 .260
Waxmonsky et al., 2010 1.82 0.68 27 1.79 0.91 29 Teacher Inattention 0.14 .889 The MTA Cooperative Group, 1999 2.27 0.61 135 2.16 0.67 137 Teacher Inattention 1.42 .158
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Appendix D. Results of t-tests for Between Groups Design Studies (continued).
Study Name
Control group SST group Outcome t p
M SD n M SD n
The MTA Cooperative Group, 1999 2.19 0.69 135 2.28 0.64 136 Teacher Inattention -1.11 .267 Evans et al., 2011 13.10 7.70 18 14.70 7.70 31 Teacher Inattention -0.70 .487
Pfiffner & McBurnett, 1997 60.30 10.60 9 59.70 10.60 9 Teacher Internalizing 0.12 .906
Waxmonsky et al., 2010 0.89 0.69 27 1.18 0.89 29 Teacher ODD -1.37 .177 The MTA Cooperative Group, 1999 1.39 0.92 120 1.29 0.91 137 Teacher ODD 0.87 .383 The MTA Cooperative Group, 1999 1.35 0.88 135 1.43 0.86 136 Teacher ODD -0.76 .450
Waxmonsky et al., 2010 3.56 2.08 27 3.66 2.07 29 Teacher Peer Relations -0.18 .858 Evans et al., 2011 1.80 1.90 18 2.30 2.00 31 Teacher Peer Relations -0.87 .388
Waxmonsky et al., 2010 27.26 8.15 27 25.45 11.13 29 Teacher Social Skills Total 0.70 .488 The MTA Cooperative Group, 1999 0.83 0.31 117 0.84 0.29 113 Teacher Social Skills Total -0.25 .801 The MTA Cooperative Group, 1999 0.87 0.29 115 0.80 0.25 115 Teacher Social Skills Total 1.96 .051
Pfiffner & McBurnett, 1997 85.30 8.20 9 81.00 16.80 9 Teacher Social Skills Total 0.69 .500 Note. SST= Social Skills Training Level of significance was established as p ≤ .01.
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Appendix E. Hedge’s g Formulas
Effect Size for Between-Groups Design
Calculating Hedges’ g from means, standard deviations and sample size:
� = �� −������ � × � � − 3� − 2.25� × �� − 2�
���� � = ���������� − 1� + ��� ���� − 1���� + � � − 2
where N - total sample size n - sample size in a particular group M – mean Subscripts C - comparison group Subscripts I - intervention group SD - standard deviation df - degrees of freedom Effect Size for Within-Subjects Design
� = ! × "
! = 1 − 34"$ − 1
" = ��%& −�' �()&*)+
�()&*)+ = ��),,-2�1 − .� where SDdiff – standard deviation of the different scores at pre- and post-measurements r – correlation between pre and post scores Mpost – mean of the post-scores Mpre – mean of the pre-scores df – degrees of freedom
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Appendix F. Excluded Studies.
Study Reason for exclusion Abikoff (1991) This article does not provide sufficient information from which effect sizes could be calculated. It
is a review of the literature. Abikoff (1987) Unavailable full text publication. Failed attempts to retrieve the publication. Last communication
with the University of Toronto librarian regarding this article on Oct 6, 2015. Abikoff & Gittelman (1984) There was no child-focused intervention. Study described a classroom intervention, where the
teachers were the treatment providers. No direct child-therapist contact. Abikoff & Gittelman (1985) Does not provide sufficient information from which effect sizes could be calculated. No readily
available Means and Standard Deviation of outcomes of interest. Abikoff et al. (2013) Child-focused intervention was not eligible. Study compared the efficacy of two behavioural
interventions to improve organization, time management, and planning. Academic/organizational outcomes not of interest to me.
Abramowtiz et al. (1987) There was no child-focused intervention. Teachers were the treatment providers, no measurement of comorbidities. Only observational measures used. Additionally, different research design and measures than the ones I am interested.
Al-Ansari & Hafeedh (1998) Sample too small (N= 8) to be informative. Alfano et al. (2009) Sample too diverse to be informative. The participants were not diagnosed with ADHD or with
clinical symptoms of ADHD. Study describes a Cognitive Behavioural Therapy for anxiety disorders only.
Algozzine (1991) This article does not provide sufficient information from which effect sizes could be calculated. This article is a review of the literature, and it does not present original empirical data.
Allen (1990) There was no child-focused intervention. Intervention described evaluated teacher implementation of treatment within their classrooms. Not a child focused treatment for children with externalizing symptoms. Additionally, sample too small (n=3) to be informative.
Almeida-Rosenberg (1998) Does not provide sufficient information from which effect sizes could be calculated. The study has no quantitative presentation of data. It describes an intervention (named Pygmalion) aimed at reducing acting out behaviours and increasing social skills for 8-12 year-old children and their parents, but no data is presented.
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Almeida (1985) There was no child-focused intervention. This study compared a parent training approach to a medication only treatment.
Amatea et al. (2010) Sample too small (n=3) to be informative. Additionally, it does not provide sufficient information from which effect sizes could be calculated. Study reports only BASC T-scores, and no statistics were calculated.
Amon & Campbell (2008) There was no child-focused intervention. This study evaluated Biofeedback through a computer program. Additionally, the study employed a non-standardized ADHD questionnaire created by the authors with no reliability calculations reported.
Arnold et al. (1997) Archives of General Psychiatry
Study does not provide sufficient information from which effect sizes could be calculated. This article is a publication of the MTA study describing its rationale and methods. Describes the investigators and co-investigators from the six sites and the investigators in the NIHM. Also it provides some detail on what the psychosocial behaviour treatment involved and describes how treatment fidelity was achieved cross-site.
Arnold et al. (1997) Journal of Attention Disorders
Study does not provide sufficient information from which effect sizes could be calculated. This article is a publication of the MTA study further describing the sample, the recruitment and the four treatment conditions (actually 3 treatments and one no treatment- community care condition) in some detail, and about treatment fidelity across sites.
Arnold et al. (2004) Study does not provide sufficient information from which effect sizes could be calculated. Publication of the MTA study describing the results of five potential outcome of interest at 9 months (mid treatment). Composites (aggregation of variables) were used at this time-point making it non-eligible for inclusion.
Arnold et al. (2003) Study does not provide sufficient information from which effect sizes could be calculated. This article is a publication of the MTA study further describing results, however, composites were created (no raw data on outcome of interest, but composites, e.g., ODD symptoms overall parent rating (all the measures aggregated together) to compare treatment response within the MTA sample divided by ethnicity/race: Caucasians, African Americans, and Latino. Findings are examined in this way. No new data presented.
Atamanoff (2007) Sample too small to be informative. In the abstract the sample was described as n= 50, however, in the article the sample for which statistics are provided is too small to be informative. Three treatment groups: child group training-only, child group training and parent
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group training, or child group training, parent group training, and home- and school-based behavioural consultation. However, stats analyses conducted only with n = 2, 4, and 5 respectively. Sample size too small for inclusion.
August et al. (2001) Sample too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Inclusion criteria for the study was “aggressive”. Additionally, the sample age is not eligible as the sample is too young (kindergartens) to be informative.
Augustyniak et al. (2009) Sample too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The inclusion criterion of this study was very vague and consisted of any child "in need". The intervention was aimed at targeting emotional regulation intended for any child.
Bachmann et al. (2010) Study does not provide sufficient information from which effect sizes could be calculated. It is a naturalistic observational study. Additionally, the sample is too diverse to be informative. Total sample (n =306) and with Attention-deficit/hyperactivity disorder (n = 94), however, results are not presented separately for the subset of children with ADHD.
Bailey (2001) This study does not provide sufficient information from which effect sizes could be calculated. This article is a review of Cognitive Behavioural Therapy interventions for different disorders, including ADHD, but does not present original data.
Baker et al. (2009) Sample too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The intervention was aimed at any child to improve their social skills. Additionally, no outcomes of interest.
Banathy (1976) Study does not provide sufficient information from which effect sizes could be calculated. The article describes an intervention but does not present quantitative comparisons.
Barkley et al. (2001) Study does not provide sufficient information from which effect sizes could be calculated. There was no-psychosocial intervention control group in this study. Both groups received therapy.
Barkley et al. (1992) Study does not provide sufficient information from which effect sizes could be calculated. There was no-psychosocial intervention (waitlist, or medication only) control group in this study. The two groups of interest received a form of family therapy.
Barkley et al. (1996) Sample too young (ages 4.5 - 6 years old) to be informative. Additionally, the interventions evaluated were not of interest. (Children were subdivided into four-treatment groups no-treatment control, parent training only, classroom only, and parent training, combined with special classroom.
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Barreras (2008) Sample too small (n =10) to be informative. Additionally, the study does not provide sufficient information from which effect sizes could be calculated, study uses a multiple baseline design.
Baty et al. (2000) Sample too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Intervention was aimed at improving the social skills of every child Additionally; the study does not provide sufficient information from which effect sizes could be calculated.
Beauchaine & Gartner (2003) The study does not provide sufficient information from which effect sizes could be calculated. There was no control group. In this study, behavioural and rating scale data were compared among CD (n = 13), ADHD (n = 20), and CD/ADHD (n = 45) preadolescents during one-month of multimodal inpatient treatment that included methylphenidate administration. But the treatments (meds versus psychosocial) were not compared. The goal of this paper was to describe differences among the sample of children, all receiving the same treatment type.
Beck & McDonnell (1980) The study does not provide sufficient information from which effect sizes could be calculated. This article consists of the presentation of a theoretical model of working with challenging students for the school counsellor.
Behan et al. (2001) There was no child-focused intervention. Participants in the study were 50 parents whose children, aged 3-12 years have been referred to outpatient child psychiatry clinics. Additionally, the sample was too diverse to be informative. The children of the participants were not diagnosed with ADHD or with clinical symptoms of ADHD; a child could have ODD and LD, for example, without any ADHD symptoms.
Belsher et al. (1995) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The intervention was aimed at improving exclusively depression (i.e., not ADHD and comorbid depression).
Benner et al. (2012) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Additionally, there was no child-focused intervention; the intervention was facilitated by teachers to any student with "externalizing" symptoms.
Berg et al. (2012) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Additionally, there was no child-focused intervention; the intervention was facilitated by teachers to any student in his or her class.
Bienert & Schneider (1995) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or
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with clinical symptoms of ADHD. The study compared social skills training in Grade 6 students. (N= 78), who were either categorized as either "aggressive" or "sensitive-isolated" and results are provided in these terms.
Bierman et al. (2004) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The study refers to children at “high risk for behaviour problems". Additionally, sample too young to be informative. JK children invited to participate in a longitudinal study, in the summer preceding Grade 1 matriculation.
Bleeker et al. (2012) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The study describes a school-based intervention to decrease conflict and aggression for every student in a given class.
Bodiford (1989) The sample was too young to be informative, N =30 (2-7yrs old), 24 attending preschool, mean age does not fall into 6-18 years old.
Bögels et al. (2008) The sample was too small (n =14) and too diverse to be informative. Study described a mindfulness training that was evaluated as a new treatment for attention and impulsivity problems in adolescents with a variety of different externalizing disorders: attention deficit/hyperactivity disorder, oppositional-defiant and/or conduct disorder, including autism spectrum disorder.
Bower (1976) The sample was too small (n = 5) and too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The study described an assertiveness training intervention for school children ("five fourth grade girls were selected for the program"). Also, no ADHD or externalizing measurement. The five participants were selected for inclusion because they were "shy, bullied, and not assertive, only talking in above whisper level".
Brammer & Sandorsky (2000) The study does not provide sufficient information from which effect sizes could be calculated. Although CBCL is used as pre and post outcome measure of ADHD and ODD treatment, there is no specification of which scale is used. Stats provided are vague.
Brown & Greenspan (1983) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Students (N = 32) of a school in an impoverished area considered "high risk". Abstentism and discipline issues were considered upon deciding eligibility criteria). Additionally, no outcome measurement reported.
Brown et al. (1985) Outcomes limited to core ADHD symptom outcomes. Brownsmith (1976) The sample was too small (N = 6) and too diverse (nominated by teachers because of behaviour
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problems) to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD.
Bunke & Edwards (1997) Sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Additionally, study did not have any of the outcome measures of interest. Study described children in two categories, namely: "Does little", or "stubborn".
Burrows (2000) The study does not provide sufficient information from which effect sizes could be calculated. Comparison of conditions not in the scope of interest. This study compared 23 children with ADHD to 19 children without ADHD across two treatment conditions: social skills only, and social skills combined with parent training. Treatment gains were assessed across pre- and post-testing periods.
Bushman & Peacock (2010) Sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. This study evaluated two interventions (parent training and child-focused CBT) for children with ODD. CBCL "externalizing" was the pre-and post-measure used to measured ODD.
Cabiya et al. (2008) The study does not provide sufficient information from which effect sizes could be calculated. When contacted by email, the first author provided the raw data on SPSS and Excel formats that unfortunately had no variable description and it was not impossible to know which variable refer to which outcome of interest. Study described a CBT intervention aimed at reducing disruptive behaviours and depression; participants (n = 355) had to fulfilled the diagnostic criteria for one or more of the disruptive behaviours disorders, ADHD, ODD, or CD. The study results were presented by group (intervention versus control) but participants in both groups are mixed. As it was not clear what works specifically for ADHD and ODD, or ADHD and CD, author was contacted for data.
Canu, W. H., & Bearman (2011) There was no child-focused intervention. The study evaluated a Behavioural Parent Training intervention, a shorter version of the Defiant Children manual by Barkley.
Carlson et al. (1992) Outcome measured are not relevant. This study had only academic measures, observational data of students, and self-rating on qualitative questionnaires across the six conditions evaluated in the described Summer treatment program.
Carrigan & Aberdeen (1970) Sample too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Study is described as evaluating "white versus black" kids
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performance in school. Casey (2012) The study does not provide sufficient information from which effect sizes could be calculated. This
article is a review on interventions for "Emotional Behavioural Disorders (EBD)" children. Chambers et al. (2008) Sample too diverse to be informative. The participants were not diagnosed with ADHD or with
clinical symptoms of ADHD. Chan et al. (2013) Not a child-focused intervention of interest. The study goal was to evaluate the mentoring
relationship quality is associated with youth outcomes (none of them being ADHD). Intervention offered to every student. Additionally, the sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD.
Chang et al. (2014) The sample was too small (N = 10) and too diverse to be informative. In this study, children received social skills training at a local clinic for developmentally delayed children in northern Taiwan.
Chapman (2004) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD.
Cheney et al. (2009) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Participants had severe behaviour problems, including both the externalizing and internalizing behavioural characteristics.
Cholewa et al. (2010) The study does not provide sufficient information from which effect sizes could be calculated. This article is a review of four evidence-based programs for school counsellors (including incredible years) but no empirical data is presented.
Chronis et al. (2004) The study does not provide sufficient information from which effect sizes could be calculated. No control group. Evaluation of Summer treatment program for children with ADHD. Point system is a different study design to the one I am interested. Point system is based on measuring the same child on multiple occasions, rather than having two or more treatments evaluated pre-post.
Clark & Jerrott (2012) The study does not provide sufficient information from which effect sizes could be calculated. No control group. This study is a follow-up of an intervention Jerrot (2010) that used a control group. This follow-up does not have a control group. Additionally, the sample was too diverse to be informative. Eligibility criteria was that children had to have Disruptive Behaviour Disorders: ADHD, CD, or ODD. Results are presented together for all children, so it is not clear what works best for ADHD or for CD or ODD groups.
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Coard et al. (2007) Not a child-focused intervention. This study described a Parent behavioural training for black parents of 5 and 6 year-olds. Additionally, the sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD.
Coker & Thyer (1990) The study does not provide sufficient information from which effect sizes could be calculated. This article is a review of the literature.
Coles et al. (2005) The sample was too small (n= 4) to be informative. Colton & Sheridan (1998) The sample too small (n =3) to be informative. This study described a behavioural social skills
intervention that was delivered in the context of CBC to enhance the cooperative peer interactions of 3 boys (aged 8–9 years) with ADHD.
Conduct Problems Prevention Research Group (2002)
The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Study eligibility criterion consisted in administering the 10-item Authority Acceptance scale of the Teacher Observation of Classroom Adaptation-Revised (TOCA-R; Werthamer-Larsson, Kellam, & Wheeler, 1991), which describes aggressive and oppositional behaviours (i.e., fighting, teasing, disobedience). If children were high on this scale, they were included in the study.
Conners et al. (2001) Study does not provide sufficient information from which effect sizes could be calculated. Publication of the MTA study describing the utility of using a different statistical approach to the understanding of the MTA findings, using a single composite measure of treatment outcome at 14 months (post treatment). Different statistics are reported, but not new data presented. In this publication, outcomes were aggregated together to create composites, and total scores were created, giving equal weight to whether the outcome was reported by parents or teachers.
Conway (2004) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The study evaluated a social skills training directed at youth with LD and included diagnoses of ADHD, but also of Asperger’s Syndrome, specific types of language or nonverbal learning disabilities, anxiety disorders, and Obsessive- Compulsive disorder as secondary diagnoses. Results are presented for all youth together. Additionally, the sample is too old to be informative, with a mean of 16 years old and including many 20 year-old adults.
Cook & Rudin (1997) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Additionally, the outcome measured were informal surveys completed by teachers reporting, e.g., following discipline.
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Cope (2006) Not a child-focused intervention of interest. The study evaluated the wraparound process, which is an intensive, individualized care management process for youths with serious or complex needs including formal services and interventions, together with community services and interpersonal support and assistance provided by friends and other people drawn from the family’s social networks.
Cordier et al. (2009) The study does not provide sufficient information from which effect sizes could be calculated. The study describes a theoretical model to depict the interactive process between the characteristics of ADHD and factors that promote play.
Corrin (2003) The study does not provide sufficient information from which effect sizes could be calculated. No control group. Families in both groups received a psychosocial treatment. Families with an ADHD child were randomly assigned to either child group training or combined parent and child group training.
Costin et al. (2002) The sample was too small (n=5) to be informative. Study describes a pilot study designed to explore the suitability of a cognitive-behavioural family-based intervention for use in a child mental health services.
Cousins & Weiss (1993) The study does not provide sufficient information from which effect sizes could be calculated. The article describes a review of literature.
Craven & Lee (2006) The study does not provide sufficient information from which effect sizes could be calculated. The article describes a review of interventions for foster children.
Cressey (2010) The study does not provide sufficient information from which effect sizes could be calculated. The article describes the development of an instrument/scale.
Cuccaro & Geitner (2007) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Participants in the study were identified through discipline referrals, teacher recommendation, and lunchroom monitor referrals as having persistent and significant difficulties with aggression, disrespect, self- control, and accepting responsibility for their actions.
Curtis & Norgate (2007) No child-focused intervention. Intervention directed at entire schools. Not only at children at risk, Additionally, educational psychologists trained school staff.
Curtis (2010) The study does not provide sufficient information from which effect sizes could be calculated. The article describes pilot investigation employed a single group, A-B research design comparing post
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treatment behavioural symptoms to baseline functioning. Curtis et al. (2013) No outcomes of interest. This study described pre- and post-treatment teacher ratings of ADHD
symptoms were compared. Davis (2011) The sample was too small to be informative. Participants (N =11) ages 6-13 participated in two
emotional and social skills groups. Dawczak et al. (2000) No child-focused intervention. In this study, the intervention was directed at entire schools in an
impoverished area, and school staff was trained. Deakin, & Tiellet (2009) No child-focused intervention of interest. The intervention was provided to any child whose parents
thought might benefit from therapy. Not specifically for ADHD. Additionally, the sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD.
Denisco et al. (2005) The study does not provide sufficient information from which effect sizes could be calculated. This article is a review of the literature on treatments for ADHD.
DeRosier & Gilliom (2007) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Study only used BASC internalizing and externalizing scales for inclusion criteria.
Desbiens & Royer (2003) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Eligibility criteria consisted of identified “behavioural problems”. Study evaluated the effect of a program for elementary school students with behaviour problems integrated into the regular classroom. The programme combined in-class social skills training and specific educational activities with peers.
DiCesare (1982) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The study evaluated an intervention for children with behaviour problems according to teacher report.
Dopfner et al. (2004) Not a child-focused intervention of interest. There was not a standard treatment protocol for all the participants; therefore, the experiences of children in this study are not uniform. At different stages of treatment participants received psycho-education, behavioural treatment, then meds. It is not an efficacy trial and it is not comparable with my eligible studies.
Döpfner et al. (2015) Not a child-focused intervention of interest In this study, an intervention for a given participant could be terminated, complimented with other, or replaced by other treatment option, but results are
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all presented together despite the fact that is not possible to tell who received which intervention. Driskill (1999) The study does not provide sufficient information from which effect sizes could be calculated. No
control group. The three groups received one type of psychosocial therapy Additionally, sample demographics are poorly described.
Drugli et al. (2010) The study does not provide sufficient information from which effect sizes could be calculated. No control group. This study is follow-up of the Incredible Years parent training program (PT), or combined parent training and child treatment (PTCT). This publication no longer has a group of untreated children.
Drugli et al. (2007) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Study entry criteria was that child met criteria for DSM-IV ODD and/or CD. Only 35% of the sample had ADHD, but results are presented together for all children, and not separately for children diagnosed with ADHD. The study compared Incredible years parent training program to combined parent training + child treatment to a wait-list control group.
Ducharme, & Harris (2005) The study does not provide sufficient information from which effect sizes could be calculated. Time series design. Additionally, sample too small (n =5) and diverse (only 1 of the 5 with ADHD diagnosis) to be informative.
DuPaul & Weyandt (2006) The study does not provide sufficient information from which effect sizes could be calculated. This study is a review of three classroom interventions for children with ADHD.
Duvall et al. (1997) No child-focused intervention of interest. In this study, the intervention was directed at entire schools to increase pro-social behaviours; and school staff was trained.
Eisenstadt et al. (1993) Sample too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Additionally, the sample was too young. 2.5-7 years old.
Ekornås et al. (2011) The study does not provide sufficient information from which effect sizes could be calculated. Not a treatment evaluation study. This article is based on another study that investigated self-perception of social acceptance in children with emotional or behavioural disorders, and whether their perceptions were in line with parent/teacher reports of peer relationship problems.
Elkins & Izard (1992) Not a child-focused intervention of interest. The intervention described was directed at the entire school. Additionally, the sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD.
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Ellis (1985) The study does not provide sufficient information from which effect sizes could be calculated. No quantitative representation of the data. The article is a proposal of how a school intervention would potentially work best.
Emmons (2002) The sample was too small (N = 6) to be informative. The authors explained that the research design for this study was an exploratory case study using multiple cases within an embedded design.
Eresund (2007) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. A total of 9 boys received treatment, and a few of them had ADHD. Then, the subsample of children with ADHD is too small to be informative.
Evans & Owens (2010) The study does not provide sufficient information from which effect sizes could be calculated. This article is a review- commentary of aspects in different treatments.
Evans et al. (2005) The study does not provide sufficient information from which effect sizes could be calculated. No Means and SD provided either pre or post. Only already analyzed data provided. Failed attempts to obtained missing information from authors.
Evans et al. (2007) The study does not provide sufficient information from which effect sizes could be calculated. No Means and SDs provided. Only regression analyses data reported. Failed attempts to obtained missing information from authors.
Fabiano (2014) The study does not provide sufficient information from which effect sizes could be calculated. No quantitative representation of the data. The article is a review of literature.
Fabiano et al. (2010) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The intervention was provided to every child with an IEP, some of who had ADHD. Results of the intervention were not presented separately for children with ADHD.
Fabiano et al. (2009) No child-focused intervention. It is a comparison of two Behaviour Parent Training programs. Fabiano et al. (2008) No child-focused intervention of interest. This study evaluated an intervention aimed for all the
students in a school cafeteria. Additionally, the sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD.
Fabiano et al. (2007) The study does not provide sufficient information from which effect sizes could be calculated. Different study design to the one I am interested. Point system is based on measuring the same child on multiple occasions, rather than having two or more treatments evaluated pre-post.
Falissard et al. (2010) The study does not provide sufficient information from which effect sizes could be calculated. This
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article described an ongoing, 2-year, prospective, non-interventional, observational study that was conducted in 10 European countries. The study described actual practice across Europe rather than a clinical trial designed to demonstrate efficacy.
Fehlings et al. (1991) Outcome measured not relevant. Study evaluated children’s self-concept. Feighner & Feighner (1974) The study does not provide sufficient information from which effect sizes could be calculated.
This article is a review of the literature on treatments for ADHD. Feinfield & Baker (2004) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or
with clinical symptoms of ADHD. The study inclusion criteria was “aggression”. Fenstermacher et al. (2006) The sample was too small (n=4) to be informative. Fields (1989) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or
with clinical symptoms of ADHD. Inclusion criteria were solely peer ratings of social competence. Filipczak (1979) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or
with clinical symptoms of ADHD. Inclusion criteria were solely peer ratings of social competence. Finch (1998) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or
with clinical symptoms of ADHD. The study inclusion criteria was whether students had three or more referrals to the principal's office.
Flahive (2005) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Study entry criteria, children with social relationships issues, including anxiety and withdrawal. Study examined the effectiveness of group sand-tray therapy at school with preadolescents identified with behavioural difficulties.
Flannery-Schroeder et al. (2004) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Participants were children with anxiety disorders, some of who had ADHD, but not all of them, and results were not presented separately for the children with ADHD.
Flax (1998) Not a child-focused intervention of interest. The intervention was aimed at entire schools, and not exclusively for children with ADHD. Additionally, the sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD.
Fonagy & Target (1994) The study does not provide sufficient information from which effect sizes could be calculated. No treatment being compared to a control group. The article is a review of clinical files of children with emotional disorders before admission and after treatment in a psychodynamic clinic.
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Forness et al. (2006) The study does not provide sufficient information from which effect sizes could be calculated. The article is a review.
Forster et al. (2012) Not a child-focused intervention. In this study, teachers received training to facilitate intervention to the classroom.
Franklin et al. (2008) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Study entry criteria consisted of a child with a behavioural referral from a classroom teacher, including tardiness or social phobia.
Fraser et al. (2004) No child-focused intervention of interest. This study described a prevention intervention designed to increase prosocial behaviour, social involvement, and reducing aggressive behaviours in children at risk of serious conduct problems. Additionally, the sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD.
Frazier et al. (2012) The study does not provide sufficient information from which effect sizes could be calculated. The article is a descriptive paper about an after-school program for community children.
Froehlich et al. (2002) The study does not provide sufficient information from which effect sizes could be calculated. Time series design.
Fujiwara & Sanders (2011) No child-focused intervention. Study described a parent treatment. Additionally, the sample was too young (mean age 3 years old) to be informative.
Fung & Tsang (2007) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Participants were children high on aggression and treatment was aimed at reducing aggression levels.
Fung & Tsang (2006) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Participants were children high on aggression and treatment was aimed at reducing aggression levels.
Gadow et al. (2004) The study does not provide sufficient information from which effect sizes could be calculated. The article is a descriptive paper about the diagnosis of ADHD.
Galgana (2010) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The author asked the parents of adolescents, who were already taking part in martial arts classes, to fill in questionnaires. There is no information about eligibility criteria other than to belong to these programs. Additionally, there is no control group. Study compared parent rated measures of externalizing disorders in two different kinds of martial arts
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programs. Garthe et al. (1998) No child-focused intervention of interest. This study described an intervention that was facilitated
by teachers to any student in a given classroom. Additionally, the sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD.
Garza & Bratton (2005) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Participants were Hispanic children referred for school counselling due to behaviour problems.
Gau et al. (2010) The study does not provide sufficient information from which effect sizes could be calculated. The article is a descriptive paper about different ADHD presentations.
Glass et al. (2000) The study does not provide sufficient information from which effect sizes could be calculated. There was no quantitative presentation of data. Additionally, the sample was too small (n = 7) and diverse to be informative. Participants were 1 child with Asperger’s Syndrome, three with Non Verbal LD, and only three with ADHD.
Goldbeck & Schmid (2003) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Participants were described as "mildly disturbed outpatient population of children and adolescents with mostly internalizing symptoms, and/or some aggressive, impulsive, or attention deficit symptoms".
Goldston et al. (2007) The study does not provide sufficient information from which effect sizes could be calculated. The study goal was to examine psychiatric morbidity and functional impairment of adolescents with and without poor reading skills during mid- to late adolescence.
Gonzalez & Sellers (2002) Not a child-focused intervention of interest. The purpose of this study was to examine the effectiveness of a stress-management program on self-concept, locus of control orientation, and acquisition of coping strategies in school-age children diagnosed with ADHD. Additionally, outcomes measured not relevant. Study evaluated self-concept and stress management.
Gooding (2010) The sample was too diverse to be informative. The participants were not solely diagnosed with ADHD or with clinical symptoms of ADHD. Participants were children with a variety of clinical presentations including autism spectrum disorders, ADHD, Specific Learning Disabilities, PTSD, CD and ODD. Results were not presented separately for participants with ADHD.
Greenhill et al. (1996) The study does not provide sufficient information from which effect sizes could be calculated.
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This article described rationale and methods of the medication treatment in the MTA study. Greif (1978) The study does not provide sufficient information from which effect sizes could be calculated.
There was no control group. The two groups (individual versus group parent-child interaction training) in the study received a psychosocial intervention. Additionally, the sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Participant children had “behavioural problems”.
Gresham & Cook (2006) The sample was too small (n = 4) and too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Participants were children presenting social skills deficits.
Griggs & Mikami (2011) No child-focused intervention. The study described an intervention called parent friendship coaching (PFC) aimed at building parents’ skills in coaching their children toward forming friendships, there was no child treatment component nor did children attend PFC sessions.
Grizenko (1997) The sample was too diverse to be informative. The participants were not solely diagnosed with ADHD or with clinical symptoms of ADHD. Participants had ADHD, CD or ODD and participated in family therapy. Results for the children with ADHD were not presented separately.
Grizenko & Sayegh (1990) The sample was too diverse to be informative. The participants were not solely diagnosed with ADHD or with clinical symptoms of ADHD. Participants had ADHD, CD or ODD and participated in family therapy. Results for the children with ADHD were not presented separately.
Grizenko et al. (1993) The sample was too diverse to be informative. The participants were not solely diagnosed with ADHD or with clinical symptoms of ADHD. Results for the children with ADHD were not presented separately.
Gulck (1992) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Participants were students K-grade 6 who had disruptive behaviour or absenteeism. Referral to the study was done based on school staff reports on disruptive behaviour or absenteeism.
Guli et al. (2013) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Participants were children diagnosed with ASD, nonverbal learning disability and/or ADHD. Results for children with ADHD were not presented separately.
Gundersen & Svartdal (2006) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Participants were children who had social skills deficits.
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Gunn et al. (2006) The sample was too young (3 to 5-year-olds) and too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD.
Hahn (2001) The study does not provide sufficient information from which effect sizes could be calculated. It is a case study design.
Harper (1996) The study does not provide sufficient information from which effect sizes could be calculated. Pre and Post Means and SDs of depression and hyperactivity (the 2 outcomes of interest) are not available in the thesis. Additionally, the sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD.
Harrison et al. (1999) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Study entry criteria was that children were “troubled”. Intervention aimed at improving family relationships and conflict.
Hauch (2005) The study does not provide sufficient information from which effect sizes could be calculated. There was no control group. The three groups of children received a psychosocial intervention. Additionally, the sample was too young to be informative. Thirty-seven percent of the participants were 4 and 5 year-olds.
Hautmann et al. (2011) No child-focused intervention. The study evaluated a parent-based intervention. Hautmann et al. (2008) No child-focused intervention. The study evaluated a parent-based intervention. Hayduk (1978) The sample was too small to be informative (n= 8). Additionally no child-focused intervention. The
teacher implemented intervention in the classroom, there was no child-therapist contact. Hellenthal (2009) No child-focused intervention. The study evaluated a parent behavioural training program; there
was no child-therapist contact. Helseth et al. (2015) Outcomes measured not relevant. Only measure used was an observation measure the study authors
created. Additionally, the sample was too diverse to be informative. Not all the participants were diagnosed with ADHD or with clinical symptoms of ADHD. From the 222 participants, 151 children had a diagnosis of ADHD, and results were not presented separately for this group.
Hemphill & Littlefield (2006) The study does not provide sufficient information from which effect sizes could be calculated. There was no control group. Participants in the three groups received a psychosocial treatment. Additionally, the sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The study entry criteria was children with "externalizing" symptoms vaguely described.
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Hemphill & Littlefield (2001) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The study entry criteria was children with "externalizing" symptoms vaguely described. This study investigated the effectiveness of a cognitive behavioural program for school-aged children referred with externalizing behaviour problems and their parents, compared with children and their parents on a wait-list.
Herman et al. (2011) The sample was too young (Mean participant age = 5.91, children were 4-8 years old, and about 50% of them were 4 and 5 yrs old) and too diverse to be informative. The study entry criteria was ODD. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD.
Hinshaw (2007) The study does not provide sufficient information from which effect sizes could be calculated. This study is a description of the terms moderator and mediator and implications for them in clinical trials such as the MTA Study.
Hinshaw (1983) Outcomes measures were not relevant. This dissertation described three studies with observational outcome measures.
Hinshaw et al. (2015) The study does not provide sufficient information from which effect sizes could be calculated. This article is the latest MTA study published article and summarizes the core MTA study findings. No new empirical data presented.
Hinshaw et al. (1993) The study does not provide sufficient information from which effect sizes could be calculated. This article is a commentary of a previous study (1992). No original data presented.
Hinshaw et al. (1992) The study does not provide sufficient information from which effect sizes could be calculated. Relevant outcomes measures, but no available Means and SD on CBCL and Conners ratings. Only p values on already analyzed data presented comparing children with ADHD in a Summer Treatment Program with children receiving medications.
Hinshaw et al. (1984) No child-focused intervention of interest. This study described a cognitive training intervention. Additionally, the outcomes measured are not relevant. Only observation measure study authors created is employed.
Hinshaw, March, et al. (1997) The study does not provide sufficient information from which effect sizes could be calculated. This study describes MTA study sample recruitment, inclusion/exclusion criteria table, screening for ADHD diagnosis, and the cross-battery assessment battery used to predict and monitor treatment response.
Hinshaw, Zupan, et al. (1997) Not eligible study design. No pre-post design.
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Hinshaw et al. (2000) The study does not provide sufficient information from which effect sizes could be calculated. This article examined what mediators and moderators might have served to explain the treatment effects in the MTA study, particularly looking at parenting practices.
Hoffman (1987) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Study entry criteria was too vaguely described as children who their teacher thought were displaying aggressive tendencies in the classroom.
Holsen et al. (2008) The study does not provide sufficient information from which effect sizes could be calculated. This study describes the MTA Study rationale and methods. Describes sample recruitment, inclusion/exclusion criteria table, screening for ADHD, diagnosis, and the cross-battery assessment battery used to predict and monitor treatment response. No new data presented.
Hops et al. (1978) Not a child-focused intervention. This study described a classroom intervention, where teachers were the treatment providers. Additionally, the outcomes measured were not relevant.
Horn et al. (1991) The study does not provide sufficient information from which effect sizes could be calculated. Relevant intervention and outcomes, however, it lacks statistics (e.g., no results table). The author and co-authors responded after being contacted to request the missing information, but unfortunately, the missing statistics remained unavailable.
Horn et al. (1990) The study does not provide sufficient information from which effect sizes could be calculated. There was no control group. The children in the three groups received a psychosocial treatment.
Horn et al. (1987) The study does not provide sufficient information from which effect sizes could be calculated. There was no control group. The children in the three groups received a psychosocial treatment. Additionally, the sample was too small to be informative (n = 7, 6, and 6, respectively).
Houck et al. (2002) The study does not provide sufficient information from which effect sizes could be calculated. No quantitative comparison of interventions presented.
Hoza et al. (2005) The study does not provide sufficient information from which effect sizes could be calculated. This article is an MTA study publication describing social skills outcomes at 14 months (post-test) only. There is no pre-test data presented.
Hoza et al. (2003) The study does not provide sufficient information from which effect sizes could be calculated. No Means and SD provided for any of the outcomes of interest. Failed attempts to obtain the missing data from first author.
Huang et al. (2015) The study does not provide sufficient information from which effect sizes could be calculated. No
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Means and SD provided for any of the outcomes of interest. Failed attempts to obtain the missing data from first author.
Huddleston (1973) Not a child-focused intervention of interest. The intervention was directed at all children in given classrooms and it was aimed at improving their social skills. Additionally, the sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD.
Hughes et al. (1988) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The study entry was the presentation of CD symptoms and behaviours. Additionally, no outcomes of interest measured.
Hupp & Reitman (1999) The sample was too small (N =5) to be informative. Hupp et al. (2002) The sample was too small (N =5) to be informative. Hussey & Guo (2003) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with
clinical symptoms of ADHD. Study entry criteria was referral was described as: “documented evidence from parents, teachers, or school administrators that mental health issues are adversely affecting a child’s social-behavioural functioning, school attendance, or academic performance”.
Iaboni et al. (1995) Not a child-focused intervention of interest. The study described a cognitive training intervention being compared in children with and without ADHD.
Ialongo et al. (1993) The study does not provide sufficient information from which effect sizes could be calculated. No Means and SD available for any of the outcomes of interest.
Iovannone et al. (2009) Not a child-focused intervention. Trained teachers facilitated intervention. Additionally, the sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The study entry criteria was children with "externalizing symptoms".
Israel (1970) The sample was too small (n = 4) to be informative. Jacobsen (2003) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with
clinical symptoms of ADHD. Jason (1983) The sample was too diverse and too young to be informative; 4 and 5-year olds in daycare setting
received an intervention aimed at improving their social skills. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD.
Jensen (1994) Not a child-focused intervention of interest. The study described an intervention aimed at
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improving children’s social skills. Additionally, the sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD.
Jensen et al. (2007) No outcomes measured of interest. This article is a publication of the MTA Study presenting data for a 3-year follow-up where composites were created.
Jensen, Hinshaw, Kraemer et al. (2001)
The study does not provide sufficient information from which effect sizes could be calculated. This article is a publication of the MTA Study describing the different treatment response of the children according to their comorbidities.
Jensen, Hinshaw, Swanson, et al. (2001)
The study does not provide sufficient information from which effect sizes could be calculated. This article is a publication of the MTA Study summarizing the study’s main statistical findings aimed at informing the primary care providers.
Jent & Niec (2009) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The study entry criteria was that children were referred for mentoring services.
Johnson et al. (2012) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Sample included children with Asperger syndrome.
Johnson (1994) No child-focused intervention. The study described a parent and teacher training components. Jones et al. (2010) Not a child-focused intervention of interest. The study described an intervention directed to entire
school. Jurecska et al. (2011) The study does not provide sufficient information from which effect sizes could be calculated.
Does not have any means or SD on Aggression, Anxiety, Depression, Peer or Parent Problems. Study evaluated the Coping Power Program, an evidence-based group intervention for at-risk students identified with hyperactive and disruptive classroom behaviours.
Kamps et al. (2011) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The study evaluated an intervention aimed at all the students with disruptive behaviours who are at risk for emotional behavioural disorders.
Kamps, Kravits, et al. (2000) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Cognitive disabilities were not exclusionary criteria. The study evaluated an intervention aimed at all children with emotional disturbance.
Kamps, Tankersley et al. (2000) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The study evaluated an intervention aimed at all students whose
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teachers rated them as high on aggression or social impairment subscales and were then considered at risk for behavioural problems.
Kanagy-Borofka (2013) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The study evaluated an intervention for all 5th grade children in a regular classroom.
Kang et al. (2011) The study does not provide sufficient information from which effect sizes could be calculated. This study does not present post-test data. Failed attempts to obtained the missing data from the first author.
Kapalka (2005) Not a child-focused intervention. The participants of this study were teachers (kindergarten through fourth grade) from public schools who had at least one student in his/her class that was previously diagnosed with ADHD.
Kats-Gold et al. (2007) The study does not provide sufficient information from which effect sizes could be calculated. This article described children at risk for ADHD. No intervention study presented.
Kazdin (1987) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The study participants were children with acute disorders, e.g., highly aggressive and destructive behaviour, suicidal or homicidal ideation or behaviour, and deteriorating family conditions.
Kazdin et al. (1992) The sample was too diverse to be informative. Not all the participants were diagnosed with ADHD or with clinical symptoms of ADHD. Forty participants with ADHD, however, the results were provided for all the sample together, not separately for this group of children. The intervention aimed at improving antisocial behaviour in children.
Keeler (1999) The sample was too diverse to be informative. Not all the participants were diagnosed with ADHD or with clinical symptoms of ADHD. This study evaluated an intervention for all students "experiencing problems” in school. ADHD was not exclusionary, but the results are presented for all children together.
Kendall et al. (1990) The sample was too diverse to be informative. Not all the participants were diagnosed with ADHD or with clinical symptoms of ADHD. From the twenty-nine participants in the program only five had a concurrent diagnosis of ADHD. Results of study were presented together, not by separately for the group of children with ADHD; in any case, sample would have been too small (n = 5) to be informative.
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Kendrick (1994) No child-focused intervention. In this study the teacher administered intervention to fifty-four (9-13 year-old) children with ADHD. There was no child-clinician contact.
Kern et al. (2007) The sample was too young (3 to 5 years-old) to be informative. Kilian & Kilian (2011) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with
clinical symptoms of ADHD. Additionally, no outcomes measured of interest (e.g., report cards). Kiluk et al. (2009) The study does not provide sufficient information from which effect sizes could be calculated.
This is not an intervention study. This article is a review. King (2011) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with
clinical symptoms of ADHD. Participants were children with a wide range of academic abilities from the academically advanced, gifted and talented center class to the inclusion classes that are more heterogeneous in nature.
Klein & Abikoff (1997) Not a child-focused intervention. The participants of this behavioural intervention were the parents. Kolko & Pardini (2010) The sample was too diverse to be informative. Not all participants were diagnosed with ADHD or
with clinical symptoms of ADHD. This study evaluated the predictive validity of pre-treatment ODD ADHD, and callous–unemotional traits in relation to several treatment outcomes in children diagnosed with ODD or CD.
Kolko et al. (1990) The sample was too diverse to be informative. Not all the participants were diagnosed with ADHD or with clinical symptoms of ADHD. Additionally, a developmental disability was not an exclusionary criteria.
Koroloff (1991) No child-focused intervention of interest. This study described an intervention directed at entire school to increase prosocial behaviour and problem-solving skills; and school staff was trained. Additionally, there was no direct child-therapist contact, so potentially not a child-focused intervention altogether.
Koth et al. (2009) The study does not provide sufficient information from which effect sizes could be calculated. There was no treatment presented. The results of two previous studies examining the validity and factor structure of an instrument used to evaluate school-based programs are reviewed.
Kratochvil et al. (2009) No child-focused intervention of interest. Study described an intervention for children with depression, some who had ADHD, and the conditions compared are medications for depression to CBT treatment for depression alone. Not an intervention for children with ADHD. Additionally, sample too diverse to be informative. Not all the participants were diagnosed with ADHD or with
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clinical symptoms of ADHD. Kratochwill et al. (1984) The study does not provide sufficient information from which effect sizes could be calculated.
This is not an intervention study. This article is a review of social skills training diagnosis, assessment, and intervention for socially withdrawn children.
Kuhn et al. (2010) Sample too small (n = 2) and too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Cognitive disability was not an exclusionary criteria.
Laezer (2015) The study does not provide sufficient information from which effect sizes could be calculated. There is no control group. The two groups of children received a psychosocial treatment. Additionally, the sample was too diverse to be informative. Not all participants were diagnosed with ADHD or with clinical symptoms of ADHD.
Landazabal (2002) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Additionally, not a child-focused intervention of interest. The study described an intervention aimed at increasing prosocial skills and self-concept of all the adolescents in a school.
Lane (1999) Not a child-focused intervention. Trained teachers facilitated the intervention. Additionally, the sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The study entry criteria was children with "problem behaviour" at risk for antisocial behaviour.
Langberg et al. (2012) Not a child-focused intervention of interest. The study compared an organization intervention, namely, the Homework, Organization, and Planning Skills intervention to a waitlist control. Additionally, the outcomes were not of interest. Organizational skills and grade point academic are the outcomes presented.
Langberg et al. (2006) Not a child-focused intervention of interest. The study compared an organization intervention Outcome measured not relevant. Additionally, the outcomes were not of interest. Study measured general impairment, an academic composite, and organization skills as rated by parents and teachers, respectively.
Larson et al. (1998) The study does not provide sufficient information from which effect sizes could be calculated. No quantitative presentation of the data. Additionally, the sample was too diverse to be informative. Not all participants were diagnosed with ADHD or with clinical symptoms of ADHD. All participants had disruptive behaviours or attention deficit diagnosis in their clinical record.
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Lay et al. (2001) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Entry criteria was described as "patients with psychiatric disorders severe enough to warrant hospitalization, aged between 6 and 16 years, and with at least average cognitive abilities (IQ ≥ 85) were considered for enrolment". Results for a subgroup of children with ADHD were not presented separately.
Lee et al. (2004) The sample was too diverse to be informative. Not all the participants were diagnosed with ADHD or with clinical symptoms of ADHD. The study entry criteria was very broad, that children had at least average cognitive abilities (IQ ≥ 85), and results for a subgroup of children with ADHD were not presented separately.
Lee (2006) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The study evaluated an intervention for all English-speaking children who were between the ages of 9 and 12, or in grades four to six and enrolled in the Reading Specialist Program at the Center for Educational and Psychological Services.
Leffler (2004) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Participants were children referred for outpatient services through a hospital’s mental health program and their caregivers. The sample was described as children diagnosed with internalizing (17%), externalizing (60%), or comorbid (23%) disorders, and results for children with ADHD were not presented separately.
Leung et al. (2009) No child-focused intervention. This study evaluated a parent training intervention. The participants were parents of 2 to 8-year-old children who were referred because of concerns about their behaviour.
Link (1968) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Additionally, the study did not measured any of the outcome of interest, as this study only measured, without standardized instruments, "feelings, instructions, positive reinforcement, and non-responding” as measurement of treatment change.
Littlefield (2008) The study does not provide sufficient information from which effect sizes could be calculated. No quantitative presentation of the data. This article describes school programs for community children in Australia.
Lochman & Wells (2002) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Participants were children identified as being at risk on the basis of
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4th grade teachers’ ratings of children’s aggressive and disruptive behaviours, and interventions were delivered during the 5th- and 6th-grade years.
Lochman, Baden, et al. (2013) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Children’s eligibility for participation in this study was determined by 4th grade teachers’ ratings of 6 items assessing overt proactive and reactive aggressive behaviour.
Lochman, Wells, et al. (2013) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The study evaluated efficacy of the Coping Power, a program for at-risk aggressive preadolescent children.
Lochman et al. (2009) The study does not provide sufficient information from which effect sizes could be calculated. No quantitative presentation of the data. This article describes how an evidence-based aggression prevention strategy (Coping Power) was disseminated for real-world use in community schools.
Lochman et al. (1989) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The participants were selected for the study by asking teachers at six public elementary schools in Durham County to identify the most aggressive and disruptive boys in their classroom.
Lochman et al. (1981) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The participants. The study evaluated an anger-control treatment program for aggressive elementary school children. The treatment program integrated cognitive behavioural and social problem- solving strategies, and was based on a systematic model of anger arousal.
Lock (1996) The sample was too small (n = 5) to be informative. Loitz (1999) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with
clinical symptoms of ADHD. The participants were preschoolers with externalizing or internalizing problems. Additionally, the sample was too young to be informative, as the sample average age was 4 years, 4 months.
Loney et al. (1979) Not a child-focused intervention. This study evaluated a classroom intervention where the teachers were the treatment providers. Additionally, the study has no outcome of interest measured.
Long (1969) The study does not provide sufficient information from which effect sizes could be calculated. No quantitative presentation of the data. This study describes an intervention as counselling to a
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student who lacks discipline, including smoking in school. Additionally, the sample was too small to be informative, and too diverse, as participants were not diagnosed with ADHD or with clinical symptoms of ADHD.
Lopez et al. (2005) The sample was too diverse to be informative. Not all the participants had ADHD or clinical symptoms of ADHD, some had a diagnosis of exclusively depression, and the results are not presented separately for the subgroup with ADHD. This study described a pilot study of the Children’s Medication Algorithm Project, which incorporated a psycho-educational program into the medication algorithm created to improve treatment of children with ADHD and/or depression.
Love et al. (1972) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The participants were children referred for emotional and behavioural problems from elementary schools. Additionally, there was no control group as participants in the three groups received one psychosocial intervention (child therapy, parent counselling, and information feedback). No outcomes of interest as treatment change were measured in terms of changes in school grades and ratings of school behaviour (not in standardized instruments).
Lovering et al. (2006) The sample was too diverse to be informative. Not all the participants had ADHD or clinical symptoms of ADHD, only 1.2% of the sample had an ADHD diagnosis.
Macdonald at al. (2003) The study does not provide sufficient information from which effect sizes could be calculated. This study had a time series design. Additionally, the sample was the sample was too diverse to be informative. Not all the participants were diagnosed with ADHD or with clinical symptoms of ADHD. From the five participants, only one child had an ADHD diagnosis.
MacDonald (1990) The sample was too small (n = 3) to be informative. The study described a cognitive-behavioural social skills training approach to increase attention span, and to decrease impulsivity, and hyperactivity in three elementary aged school children. Additionally, the sample was the sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD.
Maddern et al. (2004) The sample too small (n = 8) to be informative. The study described a social skills program run in one primary school designed to promote children’s cooperative skills and anger management. Additionally, the sample was the sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD.
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Maestas & Gaillot (2010) Not a child-focused intervention. In this study trained teachers facilitated the intervention to rhe entire classroom.
Maestas & Gaillot (2008) The sample was the sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The study evaluated an after-school program for children aged 6-14 in different schools aimed at increasing prosocial behaviours while decreasing antisocial behaviours.
Malti et al. (2011) The sample was the sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD This study evaluated an intervention aimed at entire school, and not exclusively for children with ADHD.
Manderson & McCune (2003) The study does not provide sufficient information from which effect sizes could be calculated. This article examined how an instrument named Honosca was used in a mental health centre.
March et al. (2000) The study does not provide sufficient information from which effect sizes could be calculated. This article was an MTA study publication describing statistical analyses using anxiety as a predictor and outcome variable. No new raw data is added to the primary MTA study.
Masters (1991) The study does not provide sufficient information from which effect sizes could be calculated. The full text of this manuscript was unattainable. Several failed attempts to contact the author and the university would not lend the dissertation.
Mautone et al. (2012) The sample was too young to be informative. Participants were children in kindergarten (77.6% of them) and grade 1, aged 5 years.
McCarthy et al. (2006) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. In this study, participants were children aged 8 to 11 years with behavioural difficulties with no history of psychosis, debilitating physical impairment, or marked intellectual deficit.
McConaughy et al. (1999) Not a child-focused intervention. Children received social skills instruction from their classroom teachers. Additionally, the sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. In this study, the participants were emotionally disturbed children.
McConaughy et al. (1998) Not a child-focused intervention. Children received social skills instruction from their classroom teachers. Additionally, the sample was too diverse to be informative. Not all the participants were diagnosed with ADHD or with clinical symptoms of ADHD. From the 36 participating children,
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only three had an ADHD diagnosis. In this study, the participants were emotionally disturbed children.
McDaniel et al. (2011) Not a child-focused intervention of interest. This study described an intervention for foster care parents aimed at improve behaviour of foster care children.
McDonald et al. (1997) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. In this study, the participants were children with behavioural problems.
McGilloway et al. (2012) Not a child-focused intervention. This study described a parent training intervention, the Incredible Years BASIC parent-training program (IYBP) for children with behavioural problems. Children did not receive any treatment.
McKay et al. (1999) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. In this study, the participants had behavioural problems. The study evaluated a type of family therapy involving adult caregivers and all the children in the family.
McKee et al. (2004) Not a child-focused intervention. This study described a parent training program for mothers and fathers.
McLoughlin (2009) Not a child-focused intervention of interest. The intervention goals were to increase social skills and adolescents' relationship to their communities for entire school. Additionally, the sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD.
McQuade & Hoza (2008) The study does not provide sufficient information from which effect sizes could be calculated. This article is a review of literature.
Meany-Walen (2010) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. In this study, the participants were children whose teachers reported had disruptive behaviour –further described by the authors as crying, immaturity, aggression, attention seeking.
Mikami et al. (2013) Not a child-focused intervention. Doctoral students trained teachers who carried out the intervention at school. Teachers received 8 hours of training in their intervention condition prior to the summer program.
Mikami, Calhoun, et al. (2010) No outcomes of interest. Participants in this study were children with ADHD enrolled in a Summer Treatment Program. The treatment goal was to improve functioning inattention and hyperactivity-
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impulsivity, aggression, defiance, peer problems, depressive symptoms, and academic difficulties. However, the outcomes measured were not eligible, and more related to the positive illusory bias in relation to symptom improvement.
Mikami, Lerner, et al. (2010) Not a child-focused intervention. Parent training for social skills in children with ADHD. Miller et al. (2005) Not a child-focused intervention. The teachers were trained and carried out the intervention in the
school. Additionally, the sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The school where the intervention took place is a special needs school mainly for children with Autism and other severe disorders, aged 6 to 21 years.
Miller (2008) The sample too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The participants were children diagnosed with ADHD or Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS). Additionally, the sample was too small (n = 3) to be informative.
Miranda et al. (2002) Not a child-focused intervention. In this study the teachers were trained and carried out the intervention in the school.
Misener (1991) The sample too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The participants were children for whom the school staff had reported difficulty relating to peers, being the last one to be included in a team.
Molina et al (2001) The study does not provide sufficient information from which effect sizes could be calculated. This article was an MTA study publication describing results after 6 and 8 years of post-test.
Moodi et al. (2015) The study does not provide sufficient information from which effect sizes could be calculated. The full text of this manuscript was unattainable. Several failed attempts to contact the author and the full text was not available through the University of Toronto libraries or their lending partners.
Moore (2002) The sample too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The participants were children who have been identified by their teachers as needing help in solving classroom-related behaviour problems and who had more than one referral for behaviour problem to the principals' office.
Mowat (2011) The study does not provide sufficient information from which effect sizes could be calculated. There is o quantitative presentation of the data. Additionally, the sample was too small to be informative (n = 6), and the sample too diverse to be informative. Participants were not diagnosed
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with ADHD or with clinical symptoms of ADHD. Mrug et al. (2012) The study does not provide sufficient information from which effect sizes could be calculated. This
article was an MTA study publication describing the intervention portion of the sample at a 8-years follow-up. The article describes the predictive power of peer rejection and having dyadic friendships in late adolescence.
MTA Cooperative Group (2004) The study does not provide sufficient information from which effect sizes could be calculated. This article was an MTA study publication describing the 10-month follow-up. Means and SD are only available for three outcomes of interest (total ADHD, total ODD, and total social skills), which have been aggregated across reporters. These outcomes combined parent and teacher reports and are no longer comparable to the pre-post-test outcomes.
MTA Cooperative Group (1999) The study does not provide sufficient information from which effect sizes could be calculated. This article was an MTA study publication based on the same raw data of the original study and present a different statistical analyses of the data (i.e., random effects regressions adding factors defined by moderators mediators.
Muris et al. (2005) The sample too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The participants were children with ODD and aggression, and the intervention evaluated the effects of a social-cognitive group program.
Murray et al. (2008) Not a child-focused intervention. This study compared to a control group with a combination of parent training and a teacher classroom treatment from a co-joint theoretical orientation.
Muscott et al. (2009) The sample too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The participants were children with challenging behaviour (widely defined). Additionally, the program described was applied in early childhood programs settings, so the sample was too young to be informative.
Napoli et al. (2005) Not a child-focused intervention, as teachers were trained to conduct the intervention in the school for the entire classroom. Additionally, the sample too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The participants were students in first, second, and third grade.
Nardone (1982) The sample too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. The inclusion criteria of the 12 children included were not described.
Nestler & Goldbeck (2011) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with
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clinical symptoms of ADHD. This study evaluated the efficacy of the Social Competence Training for Adolescents with Borderline Intelligence (SCT-ABI), a multidimensional Cognitive Behavioural Therapy for increasing social competence in children with borderline intelligence.
Newcomb (1995) The sample was too diverse to be informative. Not all the participants were diagnosed with ADHD or with clinical symptoms of ADHD. Participants had ODD, CD, or ADHD, and results of the subgroup of children with ADHD were not presented separately. Additionally, the sample was too young (3 to 7 years old) to be informative.
Newman (1999) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD.
Nova (1989) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Additionally, the sample was too small (N =17) to be informative as a between-group design.
O'Callaghan et al. (2003) The study does not provide sufficient information from which effect sizes could be calculated. This study described a multiple-baseline design (N = 4) to evaluate the generalization of social skills in a sports context.
O'Leary et al. (1976) No outcomes of interest measured. Additionally, the sample was too small (N =17) to be informative as a between-group design.
O'Leary & Pelham (1978) The sample was too small (N = 7) to be informative. Additionally, the sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD.
O’Connor et al. (2014) No outcomes of interest measured. This study evaluated the efficacy of the intervention by measuring sports skills athletic competence variables (e.g., kicking accuracy).
Odhammar et al. (2011) The sample was too diverse to be informative. Not all the participants were diagnosed with ADHD or with clinical symptoms of ADHD; only 15 of 33 participants had ADHD. The results for the subgroup of children with ADHD were not presented separately.
Ooi & Ang (2004) The study does not provide sufficient information from which effect sizes could be calculated. This article is a review of a social skills training intervention and their effectiveness for Asian children.
Orchard (2007) Not a child-focused intervention. This study evaluated a parenting intervention (without a child component). Additionally, the sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. This intervention was aimed at
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improving mathematics, reading, spelling, social skills, and self-esteem, and was given to any parent of the students in a given classroom.
Oruche (2011) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. This study evaluated general features of functioning in adolescents. This study inclusion criterion was poorly described.
Owens et al. (2005) Not a child-focused intervention. This study described a treatment including a daily report card procedure, a teacher consultation, and parenting sessions. Additionally, the sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. Similarly, no limits on IQ were established at study entry.
Owens et al. (2003) Study does not provide sufficient information from which effect sizes could be calculated. This article is a publication of the MTA study further describing results. This study examined outcome predictors (variables associated with outcome regardless of treatment) and moderators (variables identifying subgroups with differential treatment effectiveness).
Panayiotopoulos (2004) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. This study described an intervention aimed at children who experience emotional and behavioural problems, including inappropriate sexual behaviour.
Parish-Plass & Lufi (1997) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. In this study forty-three boys with various disruptive behaviour disorders participated in group therapy.
Pelham Jr. et al. (2000) The study does not provide sufficient information from which effect sizes could be calculated. In this study, a point system research design is employed. Different research design that the ones I am interested.
Pelham, Jr. & Gnagy, (1998) The study does not provide sufficient information from which effect sizes could be calculated. This article is a review of other studies.
Pelham (1977) The study does not provide sufficient information from which effect sizes could be calculated. This study used a case study, a different research design and outcomes measures that the ones I am interested.
Pelham et al. (in press) The study does not provide sufficient information from which effect sizes could be calculated. Failed attempts to contact first author to obtain the manuscript. Other authors replied but unfortunately did not have the copy of the manuscript.
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Pelham et al. (2005) The study does not provide sufficient information from which effect sizes could be calculated. This study used a point system (i.e., collecting data everyday for a period of time), a different research design and outcomes measures that the ones I am interested (e.g., no pre-post-test data). Additionally, no outcomes of interest, given that the outcome measures are all observational to inform the point system.
Pelham et al. (1993) The study does not provide sufficient information from which effect sizes could be calculated. This study used a point system (i.e., collecting data everyday for a period of time), a different research design and outcomes measures that the ones I am interested (e.g., no pre-post-test data). Additionally, no outcomes of interest, given that the outcome measures are all observational to inform the point system.
Pelham et al. (2002) Not a child-focused intervention. This study evaluated the effects of methylphenidate (ADHD medications). Additionally, the study does not provide sufficient information from which effect sizes could be calculated. This study used a point system not a pre-post design.
Pelham Jr., & Hoza (1996) Outcome measures were not relevant. Observational measures used. Pelham et al. (1990) Not a child-focused intervention of interest. Study evaluated basketball performance in a 4-day
study while kids were on ADHD medications. Pelham et al. (1987) Outcome measures were not relevant. This study measured peer negative nominations and negative
behaviours, which were not comparable to other outcome measures used by other studies. Also, when the N = 22 children are divided into five treatment groups, sample was too small (n < 9) to be informative.
Pelham, Schnedler, et al. (1987) The sample was too small (N = 5) to be informative. Additionally, no outcomes of interest measured.
Pelham et al. (1980) The sample was too small (N = 8) to be informative. Additionally, no outcomes of interest measured.
Pepler et al. (1995) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. In this study children were admitted to the program based on four criteria, that their teachers identified them as having aggressive behaviour problems, rated them as above the mid-point on a five-point scale for aggression, disruption, and noncompliance, that the school principal concurred with the referral for aggressive behaviour problems, and that parents consented to treatment.
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Perera et al. (2012) Not a child-focused intervention of interest. This study compared the effects of medications with a placebo condition. There was no psychosocial treatment implemented.
Pfiffner & O'Leary (1987) The sample was too small (N = 7) to be informative. Additionally, the outcome measures were not relevant, as the study used exclusively observational measures.
Pfiffner et al. (2014) The study does not provide sufficient information from which effect sizes could be calculated. The study was otherwise eligible, however, it lack statistics. Several failed attempts to obtained pre-test Means and SD from the first author.
Pfiffner et al. (2013) No outcomes of interest. This article is another publication of the same sample as one of the included studies (Villodas et al. 2014), however, this publication presented the results for academic and organizational outcomes.
Pollock (1996) The sample was too young (mean age 4 years, 9 months) to be informative. This study evaluated the effectiveness of a Head Start parent-child interaction therapy. Additionally, the sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD.
Powell et al. (2008) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. This study evaluated an intervention on children with special educational needs, emotional, behavioural, and learning difficulties who were on the boundaries of being excluded from school.
Power et al. (2001) Not a child-focused intervention of interest. This study described an intervention aimed at improving homework in children with ADHD.
Power et al. (2012) Not a child-focused intervention of interest. This study described an intervention an academic intervention for children with ADHD.
Prasad et al. (2007) Not a child-focused intervention of interest. The study compared a behaviour therapy with a medications condition. However, the intervention description of the behaviour therapy was vague (i.e., “clinicians were able to prescribe any pharmacotherapy, or combination thereof, that was felt to be most appropriate for that particular patient, in conjunction with simple behavioural counselling"). Not clear what kind of treatment was offered to the participants.
Preece & Mellor (2009) The sample was too diverse to be informative. Not all the participants were diagnosed with ADHD or with clinical symptoms of ADHD. In this study, the participants were children selected by their case manager based on a diagnosis of a disruptive behaviour disorders, described as having ADHD,
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ODD, or CD. Results for the subgroup of children with ADHD were not presented separately. Preuss et al. (2006) The study does not provide sufficient information from which effect sizes could be calculated. This
article described an ongoing, 2-year non-interventional, observational study that was conducted in 10 European countries.
Prince et al. (2010) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. This study examined the effects of the Living Skills school-based intervention program as a method of improving school adjustment and the social lives of at-risk elementary school students. Youth participants were referred to the program by teachers or school counsellors based on perceptions of risk due to rejection and isolation, aggressive and disruptive behaviours, attention problems, high impulsivity, poor school bonding and poor academic performance.
Purdom (1979) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. This study evaluated a school intervention directed at children with "repeated suspension from school" or "non-compliance".
Quinn (2001) Not a child-focused intervention of interest. The intervention was aimed at the entire school and aimed at improving lack of respect, and answering back to school staff. Additionally, the study does not provide sufficient information from which effect sizes could be calculated. This article does not present a quantitative comparison.
Ray et al. (2009) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. In this study, the teachers were asked to identify the participants on the basis of showing CBCL "aggressive" behaviours. The intervention was aimed at decreasing aggressive behaviours.
Reddy et al. (2001) The study does not provide sufficient information from which effect sizes could be calculated. This article does not present a quantitative comparison, instead is a treatment description.
Reid (1989) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. This study evaluated an intervention for children who were observed to have aggressive behaviours by their teachers.
Rey et al. (1998) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical symptoms of ADHD. This study described the participants as “those admitted to the day program were disruptive at school and at home, so much so that many had been suspended or
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expelled". Richters et al. (1995) Study does not provide sufficient information from which effect sizes could be calculated. This
article is a publication of the MTA study describing its rationale and it is a literature review of ADHD terms, comorbidities, and existing treatments, and sets the context to show the need for the MTA study.
Rickson & Watkins (2003) The sample was too diverse to be informative. Not all the participants were diagnosed with ADHD or with clinical significant symptoms of ADHD. Twelve of the 15 children had a diagnosis of ADHD. Additionally, four children also had general developmental delay. Results were presented together.
Riddle et al. (2013) The sample was too young to be informative. This study is a follow-up of a treatment provided to children from the original PATS, assessed at baseline (mean age, 4.4 years, when they all met criteria for ADHD).
Rieppi et al. (2002) Study does not provide sufficient information from which effect sizes could be calculated. This article is a publication of the MTA study describing another version of the study’s intent-to-treat analyses, which now were repeated covarying for composite Hollingshead SES, education, occupation, income, and marital status. It does not provide new raw data.
Robertson & Lane (2007) Not a child-focused intervention. In this study trained teachers provided the intervention to the entre classroom. Additionally, no outcome measures of interest, as the outcome measured were GPA, and detention referrals, and sample too diverse to be informative. The participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD.
Robin (1981) The sample too diverse to be informative. The participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD. The participants were children who had parent-adolescent conflict.
Robin (1979) Study does not provide sufficient information from which effect sizes could be calculated. There is no quantitative presentation of the data. This study is a descriptive paper about a parent-youth problem solving intervention.
Robin (1975) The sample too diverse to be informative. The participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD. The participants were typical developing adolescents who had conflict with their parents.
Robinson (1983) Not a child-focused intervention. This study described an intervention aimed at training the parents
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of children with conduct disorder problems. Robinson (2000) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or
with clinical significant symptoms of ADHD. Robinson et al. (2002) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or
with clinical significant symptoms of ADHD. The participants were students with emotional or behavioural disorders.
Robinson et al (1981) Not a child-focused intervention of interest. The intervention aimed at changing reading and vocabulary performance. Additionally, different research design than the ones I am interested. This study used a BAB design and a token system requiring cooperative interaction.
Rodgers (2005) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD. The participants were with behavioural and emotional disorders.
Rose & Jones (2007) Not a child-focused intervention of interest. Mentoring intervention aimed at improving “pupil attendance, exclusions and school sanctions“. Additionally, the sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD.
Ruttledge & Petrides (2012) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD. This study evaluated an intervention for 22 youth five which were described as having special educational needs such as Dyslexia and Autistic Spectrum Disorder. The results presented for all the participants together.
Rynczak (2012) The study does not provide sufficient information from which effect sizes could be calculated. The full text of this manuscript was unattainable. Several failed attempts to contact the author and the university would not lend the dissertation.
Salvador (1982) Not a child-focused intervention of interest. This study evaluated a residential treatment. Additionally, the sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD.
Sanders (2007) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD. Additionally, The study does not provide sufficient information from which effect sizes could be calculated, as the study does not report any quantitative comparison. Similarly, the outcome measures were not relevant, as these were informal
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surveys (not standardized instruments) completed by teachers reporting on children's self-perception.
Sanz Martinez et al. (2008) The study does not provide sufficient information from which effect sizes could be calculated. This article is a theoretical description of an anger management intervention in Cuba.
Satterfield et al. (1981) Not a child-focused intervention of interest. Additionally, The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD.
Satterfield et al. (1980) Not a child-focused intervention of interest. Additionally, The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD.
Satterfield et al. (1979) Not a child-focused intervention of interest. Additionally, The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD.
Schiffer (1967) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD. In this study participants were children with "neurotic symptoms" and "school or learning problems".
Schmelzer Benisz (2002) The sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD. One participant was in a preschool handicap classroom, four were concurrently receiving OT services, one was receiving oral motor therapy and four others physical therapy. Similarly, Autism or developmental delay was not exclusionary criteria.
Schroeder et al. (2000) Not a child-focused intervention. The intervention was aimed at the entire school to improve No students’ lack of respect, and answering back to school staff.
Schuhmann et al. (1998) The sample was too young to be informative, aged 3 to 6-years. Schumann (2004) Not a child-focused intervention. This study evaluated an intervention for all students who were
referred for school counselling services through their school by their parents, teacher, or from the student discipline board aimed at reducing aggression. Additionally, the sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD.
Scott et al. (2010) This article does not provide sufficient information from which effect sizes could be calculated.
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This article is a review of a school-based intervention on tertiary level for individual students is presented through the lens of functional behaviour assessment.
Seeley et al. (2009) No child-focused intervention. In this study the coaches trained parents and teachers to provide the intervention aimed at improving interactions with the child through a token economy.
Seita & Brendtro (2003) This article does not provide sufficient information from which effect sizes could be calculated. This article is an opinion-based article about how to make schools better environments.
Semple (2010) The sample was too diverse and too old to be informative. The participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD. In this study adults were randomly assigned to one of treatment groups.
Semple (2005) Not a child-focused intervention of interest. This study evaluated a reading remedial program. Additionally, the sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD.
Semple et al. (2010) Not a child-focused intervention of interest. This study evaluated a reading remedial program. Additionally, the sample was too diverse to be informative. The participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD. Children were referred by the clinic’s educational psychologist as having significant reading difficulties. Most displayed some indicators of associated stress or anxiety. There were no other initial screening at study entry.
Semple et al. (2005) The sample was too diverse and too small (N = 5) to be informative. The participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD. Children had anxiety symptoms at study entry.
Semrud-Clikeman et al. (1999) Outcome measured not relevant. Outcomes measured were visual and auditory attention; no behavioural or social outcome measurement.
Shaffer et al. (2013) The sample was too diverse and too small (N = 5) to be informative. Not all the participants were diagnosed with ADHD or with clinical significant symptoms of ADHD. Participants were parent-child dyads where children had early-onset ODD or CD. The treatment aimed at improving parenting and reducing child externalizing behaviour problems. Despite the fact that 76% of the participants met DSM-IV criteria for comorbid ADHD, the results are presented together, not separated but the children who had the comorbidities, ADHD and ODD or ADHD and CD.
Shaffer et al. (2001) Not a child-focused intervention of interest. This study evaluated a cognitive training intervention, “Metromone”, aimed at improving motor and cognitive skills in a group of children with ADHD.
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Shelby (1986) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD. Participants were "problematic students". Additionally, not a child-focused intervention as the treatment was directed to the entire school by trained teachers.
Shelton et al. (2000) Not a child-focused intervention. The study compared a no-treatment group with parent-training only, teacher-based treatment only, and the combination of parent training with the teacher-based treatment.
Sheridan et al. (2012) Not child-focused intervention. This study described Co-joint Behavioural Consultation, where parents and teachers together participate in the consultation process. Problems are treated through collaborative interactions between parents and teachers with the guidance and assistance of an educational consultant, and there is no contact between children a therapist.
Sheridan et al. (2009) Not child-focused intervention. This study described Co-joint Behavioural Consultation, where parents and teachers together participate in the consultation process. Problems are treated through collaborative interactions between parents and teachers with the guidance and assistance of an educational consultant, and there is no contact between children a therapist.
Sheridan et al. (1996) The sample was too small (N = 5) to be informative. This study investigated the efficacy of a combined medication and social skills intervention program implemented for 5 boys (aged 8–10 years) ADHD and their parents.
Sherrod et al. (2009) Not a child-focused intervention of interest. This study evaluated a school-wide intervention approach named PRIDE. Additionally, the sample was too small (N = 5) and diverse to be informative. Participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD.
Sibley (2009) Not a child-focused intervention. Participants were the 60 parents who met the inclusion criteria of borderline to clinically significant relationship disturbance and child emotional and behavioural problems. They were randomly allocated into Pathways parent training or a wait-list control group.
Sibley et al. (2014) Not a child-focused intervention of interest. This study evaluated an academic and organizational intervention. Additionally, it has a different research design and measures than the ones I am interested.
Sibley, Pelham, et al. (2013) Not a child-focused intervention of interest. This study evaluated an academic intervention. Sibley, Ross, et al. (2013) This study does not provide sufficient information from which effect sizes could be calculated.
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There were four Issues Check list outcomes that were relevant but no post scores were available and several failed attempts to obtain this data from the authors. The rest of the outcomes measured were not relevant.
Sibley, Pelham, et al. (2012) This study does not provide sufficient information from which effect sizes could be calculated. Case study design.
Sibley, Smith, et al. (2012) Outcome measured were not relevant. In this study 19 adolescents with ADHD (aged 11 to16 years) participated in an 8-week pilot study of the intensive Summer Treatment Program–Adolescent.
Sibley et al. (2011) Outcome measured were not relevant. This study used observational measures. Simpson et al. (2011) This article does not provide sufficient information from which effect sizes could be calculated.
This is an opinion-based article describing a school program for emotional and behavioural disorders. No quantitative data is presented.
Singh et al. (2007) The sample was too small (N = 3) to be informative. Smith et al. (2013) Sample too small to be informative. N= 14 in both conditions. Smith (2002) This article does not provide sufficient information from which effect sizes could be calculated.
This article was an opinion-based on cognitive behavioural interventions in the schools. Smith (1996) This article does not provide sufficient information from which effect sizes could be calculated.
There was no treatment being evaluated. This article used archival data to examine relationships between variables at pre and post-treatment on children who had been provided therapy at a university clinic.
Smokowski et al. (2004) Not a child-focused intervention. This study evaluated a school-based prevention program called Making Choices, which was designed to decrease childhood aggression and peer rejection by teaching children social problem solving and relationship enhancement skills. The intervention was facilitated by teachers. Additionally, the sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD.
Sotnikova et al. (2012) This study does not provide sufficient information from which effect sizes could be calculated. The full text of this manuscript was unattainable. Several failed attempts to contact the authors. From the abstract it was discernible that nine children received a behavioural intervention and one of the outcome measures used was a cognitive measure (MRIs). It is possible that this study would have been excluded anyway, however that cannot be confirmed 100%.
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Sprague et al. (2011) Not a child-focused intervention. This was a pilot study on training teachers in managing behavioural problems in the classroom.
Springer (2012) Not a child-focused intervention. This study evaluated a school-based program facilitated by teachers. Additionally, the sample was too small (N = 5) to be informative.
Springer et al. (2010) This study does not provide sufficient information from which effect sizes could be calculated. There was no control group. The children in the three groups received a psychosocial treatment. All children participated in a 10-week cognitive behavioural child training group with skill sets focusing on social skills, impulsivity, and stress and anger management.
Squires & Caddick (2012) No outcome measured of interest. Only core ADHD symptoms measured. Stebbins (2012) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with
clinical significant symptoms of ADHD. Participants were students receiving special education services at a separate special education facility due to identification as emotionally disturbed.
Steinmann et al. (2011) This study does not provide sufficient information from which effect sizes could be calculated. The complete description of this conference abstract was unattainable. Several failed attempts to contact the authors. From the abstract it was discernible that children with ADHD received an intervention and that several of the outcomes measured were executive functioning outcomes (e.g., working memory). It is possible that this study would have been excluded anyway, however that cannot be confirmed 100%.
Stokes (2005) This study does not provide sufficient information from which effect sizes could be calculated. The study described employed a qualitative methodology. There were no quantitative comparisons reported. Additionally, the sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD.
Storebo et al. (2011) This study does not provide sufficient information from which effect sizes could be calculated. The article described the opinion of its authors in regards to how an intervention, named SOSTRA, could be best implemented.
Stout-Harris et al. (1999) Not a child-focused intervention. This study described an intervention directed to the entire school to increase prosocial behaviours and problem-solving skills and and school staff were trained and facilitated it. Additionally, the sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD.
Stumpf & Holman (1985) Not a child-focused intervention. This study described a classroom programme for disruptive
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behaviour disordered students. Additionally, the sample was too diverse and too small (N = 8) to be informative. Participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD.
Sutherland (2010) This article does not provide sufficient information from which effect sizes could be calculated. There was no treatment program evaluation study. The article described the importance of preventing bullying in children’s development.
Swan (1996) Not a child-focused intervention. This study described an intervention involving medications exclusively. No other psychosocial intervention provided to the children with ADHD.
Swanson et al. (2001) Study does not provide sufficient information from which effect sizes could be calculated. This article is a publication of the MTA study describing secondary statistical analyses to supplement the primary analyses. No new raw data is presented.
Tamaki (1996) Not a child-focused intervention. This study evaluated an intervention directed at entire school aimed at teaching anger management skills and facilitated by trained school staff.
Tamaki (1994) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD. In this study, the inclusion criteria were vaguely described as children "at risk for getting angry easily".
Tamm et al. (2013) Not a child-focused intervention of interest. This study evaluated a cognitive training intervention examining at executive functioning outcomes.
Teeter et al. (2000) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD. In this study, 81% participants showed elevated scores on the externalizing problem scale of the Behaviour Assessment Scale for Children (BASC). The study evaluated whether a cognitive-behavioural and social problem solving therapy was effective for a group of impulsive adolescents.
Treadaway (1996) The sample was too diverse to be informative. Not all the participants were diagnosed with ADHD or with clinical significant symptoms of ADHD. In this study children (aged 7-12 years old) with diverse presentations, one of them including ADHD. Results are not presented separately for the subgroup of children with ADHD. Additionally, there was no control group. The children in the two groups received a social skills training intervention, one with and one without a concurrent parent involvement component.
Tremblay et al. (1991) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with
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clinical significant symptoms of ADHD. Children had disruptive disorder and results of the study were presented together for the entire sample.
Treuting & Hinshaw (2001) Not a child-focused intervention. This study evaluated whether boys with ADHD who were divided by their aggressive status would show higher rates of depressive symptomatology and lower levels of self-esteem than would comparison boys. The study also explored attributional mechanisms in a subsample of the children.
Trinder et al. (2008) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD. Children eligible for the study were those who engage in impulsive, aggressive or bullying behaviour, who are withdrawn, anxious, or depressed, and/or those who have problematic peer relationships. The study evaluated an intervention named Confident Kids, which was aimed at developing children’s social skills and reducing their problematic behaviour.
Trotter et al. (2008) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD. Children eligible for the study were "students with serious behavioural issues, learning difficulties, or social adjustment concerns".
Tsai & Ray (2011) This study does not provide sufficient information from which effect sizes could be calculated. This article presents archival data from cases of children served through a university-based play therapy clinic. No treatment evaluation study. Sample described is also too diverse to be informative. Participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD.
Turnuklu et al. (2010) Not a child-focused intervention. This study evaluated an intervention aimed at entire schools, which reported an increased number of conflicts and higher incidence of interpersonal violence among their students. Additionally, the sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD
Tutty et al. (2003) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD. Additionally, no relevant outcome measures. Only measured ADHD core symptoms and teacher reported discipline.
Tynan et al. (2004) The sample was too diverse to be informative. Not all the participants were diagnosed with ADHD or with clinical significant symptoms of ADHD; ADHD or ODD was the inclusion criteria. Results of the study were presented together and not separately for the subgroup of children with ADHD.
Tynan et al. (1999) This study does not provide sufficient information from which effect sizes could be calculated. This
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article presents a review of other intervention studies by the authors with children with ADHD and ODD.
Ubinger (2006) This study does not provide sufficient information from which effect sizes could be calculated. This study employs a case study design and describes two clinical cases.
van den Hoofdakker et al. (2010)
Not a child-focused intervention. This publication described results of the same sample as Van den Hoofdakker et al. (2007).
van den Hoofdakker et al. (2007)
Not a child-focused intervention. This was double-checked by successful contact with the first author. In the intervention described parents and children could contact their child psychiatrist face to face or by telephone for advise, consultation or counselling. However, for the vast majority of the face-to-face appointments with the child psychiatrist the parents would come alone, without the child. Thus, interventions could be directly targeting the child (e.g., medication, psycho-education, counselling) or the parents (e.g., counselling, psycho-education, advise) or any combination. The intervention was not restricted and the child psychiatrists were free in their choice of interventions and techniques.
van der Oord, Bögels, et al. (2012)
This article does not provide sufficient information from which effect sizes could be calculated. Eligible study lacking means and standard deviations of outcomes of interest. The study reported statistical analyses and the raw data was missing. Contacted the first author but she was unfortunately unable to provide the missing data. The study evaluated the effectiveness of an 8-week mindfulness training for children with ADHD.
van der Oord, Prins, et al. (2012)
This article does not provide sufficient information from which effect sizes could be calculated. This publication described results of the same sample as van der Oord, S et al. (2007), and it is a naturalistic 4.5 to 7.5 years follow-up. The timeframe of the follow-up is too long since post-test. Additionally, the sample is not directly comparable in number or in outcomes as it has dramatically changed from the original study.
van der Oord et al. (2008) This article does not provide sufficient information from which effect sizes could be calculated. This publication described results of the same sample as van der Oord, S et al. (2007), an included study. After communications with the first author, the post-test means and standard deviations for the depression outcome of interest were unfortunately not available. The first author explained that depressed mood was only measured at pre-test to examine its predictor value.
van Lier et al. (2004) Not a child-focused intervention. The intervention was directed at the entire school to prevent
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disruptive behaviour, including attention-deficit/hyperactivity problems, oppositional defiant problems, and conduct problems. Additionally, the sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD.
van Manen et al. (2004) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD. A diagnosis of ADHD was set as exclusionary criteria.
van Vugt et al. (2013) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD. To be included in this study children had to score within the clinical range on any of the following variables: social anxiety, social problems, internalizing problems, externalizing problems, school skills, social acceptance, sporting skills, physical appearance, behavioural conduct and/or self-worth". Results are presented together for all children.
Van (2002) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD. Students were included if teachers rated them as having different types of social skills deficits.
Vaughn et al. (1984) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD. Additionally, the sample was too young (all preschoolers) to be informative. In this study teachers selected the participating preschoolers by filling in measures of aggressiveness, items examples: hits”, “kicks”, “pushes”, “threatens” and “bosses”.
Velazquez (2001) This article does not provide sufficient information from which effect sizes could be calculated. This publication described the Development of Emotional Regulation (DOER) program, aimed at improving executive functioning skills and improving child-parent interactions, and reducing ODD and ODD symptoms. There is no quantitative data presented.
Verduyn (1990) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD. In this study participants were children "who were observed to have behaviour problems and/or experience difficulties in social interactions, by teacher or peer report".
Vidal et al. (2015) This sample was too old to be informative. The sample age range was 15 to 21 years old, with a mean age of 17 years.
Waahlstedt et al. (2009) This article does not provide sufficient information from which effect sizes could be calculated. This publication described children with ADHD who completed neuropsychological tasks designed to measure executive function, state regulation and delay aversion. There was no intervention being
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evaluated. Wagner (2011) The sample was too small (N = 4) to be informative. Additionally, the sample was too young to be
informative and consisted of 5 and 6 year olds. Walker et al. (2009) Not a child-focused intervention. This study evaluated a school-based intervention facilitated by
teachers aiming at were the parent training to decrease children’s externalizing symptoms. Additionally, the sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD.
Walsh et al. (2002). The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD. Participants were students with disruptive behaviours The intervention targeted aimed at girls displaying aggressive behaviours due to multiple reasons, including sexual and other types of child abuse.
Ware (2004) The sample was too diverse to be informative. Not all the participants were diagnosed with ADHD or with clinical significant symptoms of ADHD, some had only bipolar disorder, or depression, and results were presented together and not separately for the subgroup of children with ADHD.
Waxmonsky et al. (2008) Not a child-focused intervention. The study described the effects of different medication dosages on children’s behaviours.
Webster-Stratton & Herman (2008)
Not a child-focused intervention. The study described parent training intervention.
Webster-Stratton & Reid (2003) This article does not provide sufficient information from which effect sizes could be calculated. This article reviews two other randomized control clinical trials that evaluated this parent-behavioural training with a child component, called the dinosaur program, aimed at improving symptoms for children with ODD/CD but also included a percentage of the sample who had a diagnosis of ADHD.
Webster-Stratton et al. (2013) The sample was too young to be informative, with a mean age of 5.34 years old. Children with ADHD who were treated with the Incredible Years.
Webster-Stratton et al. (2011) The sample was too young to be informative, with a mean age of 5.34 years old.
Webster-Stratton et al. (2004) The sample was too diverse to be informative. Not all the participants were diagnosed with ADHD or with clinical significant symptoms of ADHD, only 18% of the sample had ADHD, and the only requirement for study entry was that the child met criteria for ODD.
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Webster-Stratton et al. (2001) The sample was too diverse to be informative. Not all the participants were diagnosed with ADHD or with clinical significant symptoms of ADHD. Participants were children with early-onset CD, randomly assigned to a child training treatment group using the Incredible Years Dinosaur Social skills and problem solving curriculum program and a wait-list control group. The differential treatment response was evaluated according to child comorbidity with ADHD, parenting discipline practices, and family risk factors. Results were not presented separately for the subgroup of children diagnosed with ADHD.
Weiss & Weisz (1995) This article does not provide sufficient information from which effect sizes could be calculated. This article is a review of literature. No original intervention study.
Weiss et al. (2003) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD. Any child at least one standard deviation above the mean on the internalizing, externalizing, and overall psychopathology scores for two of three informants was eligible for project enrolment. This study evaluated the Reaching Educators, Children and Parents program, designed for children experiencing concurrent internalizing and externalizing problems, aiming at reducing psychological problems, but it also is a prevention program in that it focuses on preventing development of more serious problems among non-referred children.
Weissberg (1981) Not a child-focused intervention. This study evaluated an intervention directed at the entire school - to increase problem-solving skills and school staff facilitated it. Additionally, the sample too diverse to be informative. Participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD.
Welch et al. (2006) The sample was too diverse to be informative. Participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD. The inclusion criteria is vaguely described and it only mentions that children had ADHD and ODD symptoms and a total problem CBCL score was used. Additionally, no outcomes measured of interest.
Welkowitz & Fox (2001) Not a child-focused intervention. This study evaluated an intervention directed at students with "emotional disturbance" and the term is not defined.
Wells et al. (2006) Study does not provide sufficient information from which effect sizes could be calculated. This article is a publication of the MTA study describing parenting behaviours.
Wells et al. (2000) Study does not provide sufficient information from which effect sizes could be calculated. This article is a publication of the MTA study describing its rationale and methods. It describes attrition
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rates and a detailed description of the psychosocial treatment components. Wenz-Gross & Upshur (2012) Not a child-focused intervention. This study evaluated teacher acceptance and implementation of
treatment within their classrooms. Wiener, & Harris (1997) The sample too diverse to be informative. Participants were not diagnosed with ADHD or with
clinical significant symptoms of ADHD. The study entry criteria was a diagnosis of a learning disability.
Wignall (2006) The sample too diverse to be informative. Participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD. Participants were children with mainly depression and a high score on the Youth self-report on externalizing, but not specifically for ADHD.
Wilhite & Bullock (2012) The sample too diverse to be informative. Participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD. Participants were children with ADHD, learning disability, and Asperger’s syndrome. Results presented altogether, not separated for the subgroup of children with ADHD.
Wilkinson (1997) The study does not provide sufficient information from which effect sizes could be calculated. This is a time series design. Additionally, the sample was too small (N = 3) to be informative, and it is not a child-focused intervention either, as it is a behavioural consultation conducted by teachers.
Wilkinson (2005) The study does not provide sufficient information from which effect sizes could be calculated. This is a time series design. Additionally, the sample was too small (N = 2) to be informative and not a child-focused intervention either, as it is a Conjoint behavioural consultation, in which parents and teachers collaborate to meet the academic, social, and behavioural needs of children.
Wolraich wt al. (1978) The sample too diverse to be informative. Participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD. Additionally, the outcomes measured are not relevant.
Wu et al., (2010) The study does not provide sufficient information from which effect sizes could be calculated. This is a time series design. Additionally, the sample was too small (N = 2) to be informative.
Wyman et al. (2010) The sample too diverse to be informative. Participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD. Study evaluated an intervention for children with behaviour problems according to teacher report. No outcome measures of interest, as it disciplinary referrals and decrease in suspensions were the main treatment targets.
Yamashita et al. (2010) The sample too diverse to be informative. Not all the participants were diagnosed with ADHD or with clinical significant symptoms of ADHD. From 36, 30 children had ADHD, and 6 children had
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a diagnosis of ADHD comorbid with a pervasive developmental disorder. Results of the study were presented together and not separately for the subgroup of typically developing children with ADHD (i.e., without a pervasive developmental disorder).
Yeo & Choi (2011) The sample too diverse to be informative. Participants were not diagnosed with ADHD or with clinical significant symptoms of ADHD. Inclusion criteria consisted in teachers nominations of students based on overtly disruptive (e.g. arguing, fighting) or covertly disruptive in class (e.g. day dreaming, reading comics during lessons, average cognitive and academic functioning, and able to understand and communicate in English. Additionally, no outcomes measured were relevant.
Yeo et al. (2005) The sample too diverse to be informative. Not all the participants were diagnosed with ADHD or with clinical significant symptoms of ADHD. The most prevalent primary diagnoses were ADHD (n = 7, 54%) and there was one child with Autism. Results of the study are presented together gor all children and not separately for the subgroup of typically developing children (i.e., without autism) with ADHD.
Young & Amarasinghe (2010) The study does not provide sufficient information from which effect sizes could be calculated. This article reviews non-pharmacological interventions that are available for preschoolers, school-age children, adolescents and adults.
Zylowska et al. (2008) The sample was too old to be informative. Twenty-four adults and eight adolescents with ADHD were enrolled in a feasibility study of an 8-week mindfulness training program. Mean age of adults= 48.5 year old. The results of the intervention are presented together and not divided by age group.