NIHR Signal Schools can provide valuable help for children with attention deficit hyperactivity disorder

Published on 14 September 2015

This series of NIHR-funded systematic reviews found that some things schools do (interventions) can help children with attention deficit hyperactivity disorder. These were grouped into 15 main approaches including reward and punishment, skills training and self-management, creative-based therapies, such as music therapy, and structured physical activity. These reviews covered different strategies to change behaviour other than giving children medication. Most showed positive effects. Due to substantial variation in the effect on symptoms, behaviour or educational achievement across the included studies, the reviews were not able to specify the best programme, or determine which elements were most closely linked with success. The reviews indicate that success was influenced by pupils’ relationships with their peers or teachers and the school context. Those designing programmes need to be sensitive to the school’s culture and organisation and should aim to minimise the stigma of this condition.

No UK-based studies were identified for the effectiveness review, making it harder to apply any findings to UK schools. The insights from this study are likely to help inform the design of future UK trials.

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Why was this study needed?

A 2003 UK survey of over 10,000 children aged five to 15 years found that 3.62% of boys and 0.85% of girls had attention deficit hyperactivity disorder (ADHD). Many studies have shown increases in the prevalence of clinically diagnosed ADHD in the last couple of decades, especially in the US, but there are differences in how ADHD is diagnosed between countries. However, a small 2009 UK survey found there is still controversy about ADHD with half of GPs and 1 in 5 special education needs coordinators, believing that ADHD was not “a real neurological condition”.

The NIHR funded this series of systematic reviews to find out whether school-based interventions without drugs improve ADHD symptoms in children, and to investigate factors – like attitudes and beliefs – that enhance or limit delivery of such interventions.

What did this study do?

This study reported on four systematic reviews of non-drug programmes and interventions for ADHD delivered in schools. One measured effectiveness and cost effectiveness. Three looked into attitudes and experiences.

The effectiveness and cost-effectiveness review looked at studies of children with, or at risk of, ADHD. Fifty-four controlled trials were included, 39 of which were randomised controlled trials. The included trials evaluated interventions over a period of 32 years, which were grouped into 15 types of intervention packages including reward and punishment, skills training and self-management, creative-based therapies, such as music therapy, and structured physical activity. Few studies used similar combinations of packages. The results of the RCTs and the non-RCTs were analysed separately using meta-analysis.

Three reviews summarised qualitative research from 95 studies examining the attitudes and experiences of school practitioners, pupils, teachers and parents related to non-drug interventions for ADHD in schools.

No UK-based studies were included in the effectiveness review and there were only nine in the other reviews. Most of the RCTs were conducted in the US which limits the applicability of the findings to UK schools which have different educational systems. Other limitations included the breadth of the interventions and outcomes, and the poor quality of many of the included studies, for example, those assessing outcomes or rating children were often aware of the treatments received.

What did it find?

  • Pooling the results of 36 randomised trials using any type of non-drug intervention showed improvements were possible in several outcomes, including core ADHD symptoms such as independently assessed inattention and hyperactivity/impulsivity (medium effect sizes: d+ = 0.44 and d+ = 0.33 respectively).
  • The effects for teacher-rated inattention, externalising symptoms and educational outcomes ranged from medium to small (d+ = 0.60, d+ = 0.20 and d+ = 0.26).
  • Substantial differences in effect sizes (from very small to large) were seen across studies. This was partly due to the lack of standardised interventions and outcome measures.
  • Economic outcomes were not included in any studies so cost-effectiveness could not be assessed.
  • The qualitative reviews highlighted the importance of context in terms of particular school and national education policies. They suggested that negative attitudes toward ADHD, and the relationships of pupils with their teachers and peers, could influence how well interventions worked.

What does current guidance say on this issue?

The 2008 NICE guideline on diagnosis and management of ADHD recommends non-drug interventions as the first-line treatment for children of school age with ADHD and moderate impairment. Outside of the school the recommended interventions include group parent training/education programmes, and/or group psychological treatment such as cognitive behavioural therapy, or social skills training for younger child. For older children, individual psychological treatment is an option. Drug treatment should be offered to children with persisting symptoms. The 2008 guideline recommends drugs as a first-line treatment for children with severe ADHD.

This guideline also recommends that teachers who have received training about ADHD and its management should provide behavioural interventions in the classroom to help children and young people with ADHD. However, the guideline says that teachers in England are not systematically trained to use classroom management and teaching strategies for children with ADHD.

What are the implications?

Fifteen types of non-drug intervention packages were identified during this research but few studies used similar combinations of packages. This research showed that non-drug interventions in schools could improve ADHD symptoms and educational outcomes, but given the lack of standardised interventions and common outcome measures it was not possible to recommend which strategies worked best. This limits the immediate implications for UK practice.

There are also implications for the training of teachers if these programmes are to be implemented at scale.

Childhood ADHD results in considerable cost for society. A 2013 study found that in the UK the mean cost per adolescent for NHS, social care and education resources was £5,493 per year in 2010 prices with education resources accounting for three times the costs of healthcare. The total annual cost for adolescents with ADHD in the UK was around £670 million.

Citation

Richardson M, Moore DA, Gwernan-Jones R, et al. Non-pharmacological interventions for attention-deficit/hyperactivity disorder (ADHD) delivered in school settings: systematic reviews of quantitative and qualitative research. Health Technol Assess. 2015 Jun;19(45):1-470.

This project was funded by the National Institute for Health Research Health Technology Assessment programme. The study is registered as PROSPERO CRD42011001716.

Bibliography

Ford T, Goodman R, Meltzer H. The British Child and Adolescent Mental Health Survey 1999: the prevalence of DSM-IV disorders. J Am Acad Child Adolesc Psychiatry. 2003;42(10):1203-11.

NICE. Attention deficit hyperactivity disorder: Diagnosis and management of ADHD in children, young people and adults. [CG 72] London: National Institute for Health and Care Excellence; 2008.

O’Regan F. A review of SENCo and GP attitudes towards ADHD. ADHD in Practice. 2009;1:4–7.

Sayal K, Ford T, Goodman R. Trends in recognition of and service use for attention-deficit hyperactivity disorder in Britain, 1999–2004. Psychiatr Serv 2010;61:803–10.

Telford C, Green C, Logan S, et al. Estimating the costs of ongoing care for adolescents with attention-deficit hyperactivity disorder. Soc Psychiatry Psychiatr Epidemiol 2013;48:337–44.

Why was this study needed?

A 2003 UK survey of over 10,000 children aged five to 15 years found that 3.62% of boys and 0.85% of girls had attention deficit hyperactivity disorder (ADHD). Many studies have shown increases in the prevalence of clinically diagnosed ADHD in the last couple of decades, especially in the US, but there are differences in how ADHD is diagnosed between countries. However, a small 2009 UK survey found there is still controversy about ADHD with half of GPs and 1 in 5 special education needs coordinators, believing that ADHD was not “a real neurological condition”.

The NIHR funded this series of systematic reviews to find out whether school-based interventions without drugs improve ADHD symptoms in children, and to investigate factors – like attitudes and beliefs – that enhance or limit delivery of such interventions.

What did this study do?

This study reported on four systematic reviews of non-drug programmes and interventions for ADHD delivered in schools. One measured effectiveness and cost effectiveness. Three looked into attitudes and experiences.

The effectiveness and cost-effectiveness review looked at studies of children with, or at risk of, ADHD. Fifty-four controlled trials were included, 39 of which were randomised controlled trials. The included trials evaluated interventions over a period of 32 years, which were grouped into 15 types of intervention packages including reward and punishment, skills training and self-management, creative-based therapies, such as music therapy, and structured physical activity. Few studies used similar combinations of packages. The results of the RCTs and the non-RCTs were analysed separately using meta-analysis.

Three reviews summarised qualitative research from 95 studies examining the attitudes and experiences of school practitioners, pupils, teachers and parents related to non-drug interventions for ADHD in schools.

No UK-based studies were included in the effectiveness review and there were only nine in the other reviews. Most of the RCTs were conducted in the US which limits the applicability of the findings to UK schools which have different educational systems. Other limitations included the breadth of the interventions and outcomes, and the poor quality of many of the included studies, for example, those assessing outcomes or rating children were often aware of the treatments received.

What did it find?

  • Pooling the results of 36 randomised trials using any type of non-drug intervention showed improvements were possible in several outcomes, including core ADHD symptoms such as independently assessed inattention and hyperactivity/impulsivity (medium effect sizes: d+ = 0.44 and d+ = 0.33 respectively).
  • The effects for teacher-rated inattention, externalising symptoms and educational outcomes ranged from medium to small (d+ = 0.60, d+ = 0.20 and d+ = 0.26).
  • Substantial differences in effect sizes (from very small to large) were seen across studies. This was partly due to the lack of standardised interventions and outcome measures.
  • Economic outcomes were not included in any studies so cost-effectiveness could not be assessed.
  • The qualitative reviews highlighted the importance of context in terms of particular school and national education policies. They suggested that negative attitudes toward ADHD, and the relationships of pupils with their teachers and peers, could influence how well interventions worked.

What does current guidance say on this issue?

The 2008 NICE guideline on diagnosis and management of ADHD recommends non-drug interventions as the first-line treatment for children of school age with ADHD and moderate impairment. Outside of the school the recommended interventions include group parent training/education programmes, and/or group psychological treatment such as cognitive behavioural therapy, or social skills training for younger child. For older children, individual psychological treatment is an option. Drug treatment should be offered to children with persisting symptoms. The 2008 guideline recommends drugs as a first-line treatment for children with severe ADHD.

This guideline also recommends that teachers who have received training about ADHD and its management should provide behavioural interventions in the classroom to help children and young people with ADHD. However, the guideline says that teachers in England are not systematically trained to use classroom management and teaching strategies for children with ADHD.

What are the implications?

Fifteen types of non-drug intervention packages were identified during this research but few studies used similar combinations of packages. This research showed that non-drug interventions in schools could improve ADHD symptoms and educational outcomes, but given the lack of standardised interventions and common outcome measures it was not possible to recommend which strategies worked best. This limits the immediate implications for UK practice.

There are also implications for the training of teachers if these programmes are to be implemented at scale.

Childhood ADHD results in considerable cost for society. A 2013 study found that in the UK the mean cost per adolescent for NHS, social care and education resources was £5,493 per year in 2010 prices with education resources accounting for three times the costs of healthcare. The total annual cost for adolescents with ADHD in the UK was around £670 million.

Citation

Richardson M, Moore DA, Gwernan-Jones R, et al. Non-pharmacological interventions for attention-deficit/hyperactivity disorder (ADHD) delivered in school settings: systematic reviews of quantitative and qualitative research. Health Technol Assess. 2015 Jun;19(45):1-470.

This project was funded by the National Institute for Health Research Health Technology Assessment programme. The study is registered as PROSPERO CRD42011001716.

Bibliography

Ford T, Goodman R, Meltzer H. The British Child and Adolescent Mental Health Survey 1999: the prevalence of DSM-IV disorders. J Am Acad Child Adolesc Psychiatry. 2003;42(10):1203-11.

NICE. Attention deficit hyperactivity disorder: Diagnosis and management of ADHD in children, young people and adults. [CG 72] London: National Institute for Health and Care Excellence; 2008.

O’Regan F. A review of SENCo and GP attitudes towards ADHD. ADHD in Practice. 2009;1:4–7.

Sayal K, Ford T, Goodman R. Trends in recognition of and service use for attention-deficit hyperactivity disorder in Britain, 1999–2004. Psychiatr Serv 2010;61:803–10.

Telford C, Green C, Logan S, et al. Estimating the costs of ongoing care for adolescents with attention-deficit hyperactivity disorder. Soc Psychiatry Psychiatr Epidemiol 2013;48:337–44.

Non-pharmacological interventions for attention-deficit/hyperactivity disorder (ADHD) delivered in school settings: systematic reviews of quantitative and qualitative research

Published on 2 July 2015

Richardson, M.,Moore, D. A.,Gwernan-Jones, R.,Thompson-Coon, J.,Ukoumunne, O.,Rogers, M.,Whear, R.,Newlove-Delgado, T. V.,Logan, S.,Morris, C.,Taylor, E.,Cooper, P.,Stein, K.,Garside, R.,Ford, T. J.

Health Technol Assess Volume 19 , 2015

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterised by age-inappropriate levels of inattention, impulsivity and hyperactivity. School can be particularly challenging for children with ADHD. Few reviews have considered non-pharmacological interventions in school settings. OBJECTIVES: To assess the effectiveness of non-pharmacological interventions delivered in school settings for pupils with, or at risk of, ADHD and to explore the factors that may enhance, or limit, their delivery. DATA SOURCES: Twenty electronic databases (including PsycINFO, MEDLINE, EMBASE, Education Resources Information Centre, The Cochrane Library and Education Research Complete) were searched from 1980 to February-August 2013. Three separate searches were conducted for four systematic reviews; they were supplemented with forward and backwards citation chasing, website searching, author recommendations and hand-searches of key journals. REVIEW METHODS: The systematic reviews focused on (1) the effectiveness of school-based interventions for children with or at risk of ADHD; (2) quantitative research that explores attitudes towards school-based non-pharmacological interventions for pupils with ADHD; (3) qualitative research investigating the attitudes and experiences of children, teachers, parents and others using ADHD interventions in school settings; and (4) qualitative research exploring the experience of ADHD in school among pupils, their parents and teachers more generally. Methods of synthesis included a random-effects meta-analysis, meta-regression and narrative synthesis for review 1, narrative synthesis for review 2 and meta-ethnography and thematic analysis for reviews 3 and 4. RESULTS: For review 1, 54 controlled trials met the inclusion criteria. For the 36 meta-analysed randomised controlled trials, beneficial effects (p < 0.05) were observed for several symptom and scholastic outcomes. Mean weighted effect sizes ranged from very small (d + < 0.20) to large (d + >/= 0.80), but substantial heterogeneity in effect size estimates across studies was reported. Moderator analyses were not able to clarify which intervention features were linked with effectiveness. For review 2, 28 included studies revealed that educators' attitudes towards interventions ranged in positivity. Most interventions were rated positively or neutrally across different studies. The only intervention that consistently recorded positive attitudes from educators was daily report cards. For review 3, 33 studies met the inclusion criteria. Key findings included tensions regarding the preferred format of interventions, particularly how structured interventions were and the extent to which they are tailored to the child with ADHD. There were mixed views about the impact of interventions, although it was clear that interventions both influence and are influenced by the relationships held by children with ADHD and participants' attitudes towards school and ADHD. For review 4, 34 studies met the inclusion criteria. Key findings included the importance of causal attributions that teachers, parents and pupils made about ADHD symptoms, the decisions teachers made about treatment, the self-perceptions pupils developed about themselves, the role of the classroom environment and stigma in aggravating ADHD symptoms, and the significant barrier to treatment posed by the common presence of conflict in relationships between pupils-teachers, parents-teachers and pupils-peers in relation to ADHD. An overarching synthesis of the four reviews highlighted the importance of the context affecting interventions. It suggested that ADHD psychoeducation and relationship-building skills are potential implications for interventions. LIMITATIONS: The breadth of both interventions and outcomes in the reviewed studies presented a challenge for categorisation, analysis and interpretation in reviews 1-3. Across reviews, relatively few studies were conducted in the UK, limiting the applicability of findings to UK education. In reviews 1 and 2, the poor methodological quality of some included studies was identified as a barrier to establishing effectiveness or comparing attitudes. In review 3 the descriptive analysis used by the majority of studies constrained theorising during synthesis. Studies in review 4 lacked detail regarding important issues like gender, pupil maturity and school level. CONCLUSION: Findings suggest some beneficial effects of non-pharmacological interventions for ADHD used in school settings, but substantial heterogeneity in effect sizes was seen across studies. The qualitative reviews demonstrate the importance of the context in which interventions are used. Future work should consider more rigorous evaluation of interventions, as well as focus on what works, for whom and in which contexts. Gaps in current research present opportunities for the development and testing of standardised tools to describe interventions, agreement on gold-standard outcome measures assessing ADHD behaviour and testing a range of potential moderators alongside intervention trials. STUDY REGISTRATION: This study is registered as PROSPERO CRD42011001716. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Of the 15 packages identified here some were more commonly used than others. Contingency management, a package of rewards and/or punishments to change, alter or redirect the child’s behaviour, was identified as the most frequently used intervention in these school–based programmes. This was followed by things like academic skills training, emotional skills training and self-regulation training. This last example aims to teach the child to self-monitor and record their behaviour, to assess the factors that lead to problem behaviour and then identify solutions to overcome them (‘problem solving’). Other interventions including adaptation to the learning environment, music therapy, play therapy and providing ‘information only’ were less frequently part of these programmes.

Author commentary

Children with ADHD are often impaired in school – in both learning and socialising. There are several ways of helping them, and this comprehensive review shows that some health interventions (even without drugs) can indeed be valuable.

The review also highlights that the effectiveness of psychological ways of helping depends on the context as well as the pupils. The treatments need to be adapted in a way that is sensitive to the school’s culture and organisation and that does not exaggerate stigma. School and health professionals should work effectively together. The children need better and better-evaluated programmes.

Professor Eric Taylor, King's College London