Family therapy for attention‐deficit disorder or attention‐deficit/hyperactivity disorder in children
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:
To determine whether family therapy will help reduce symptoms of inattention, impulsivity and hyperactivity for children with ADHD or ADD as compared to no treatment or standard treatment.
Background
Nature of the Problem
Attention‐deficit hyperactivity disorder (ADHD) is one of the most frequently diagnosed psychological disorders in children. The major symptoms of this disorder are developmentally inconsistent and chronic levels of inattention, impulsivity, and hyperactivity (APA 2000, Barkley 1998). In some cases, particular symptoms are predominant. In those cases, subtypes of the diagnosis can be indicated: attention‐deficit/hyperactivity disorder, predominantly inattentive type or predominantly hyperactive‐impulsive type. Where neither subtype predominates, individuals can be diagnosed with attention‐deficit/hyperactivity disorder, combined type, which is the most common subtype of this disorder in children and adolescents (APA 2000). ADHD is diagnosed in approximately 3% to 7% of school‐age children (APA 2000). Indeed, the number of patients visiting physicians for ADHD seems to be increasing from year to year (Goldman 1998, Swanson 1995). In England and Wales, the prevalence has been estimated to be approximately 5% of children aged 6‐16 (NICE 2000). Adolescents with this disorder have been found to be more likely to have a comorbid oppositional defiant disorder or a comorbid conduct disorder than adolescents without a diagnosis of ADHD, and are more likely to self‐report more antisocial behaviour and poorer social competence than a control group (Barkley 1991). In addition, the majority of children who are diagnosed with ADHD through a rigorous set of criteria will continue to present with the core symptoms of ADHD into adolescence, and 43% will meet diagnostic criteria for conduct disorder at follow‐up (Barkley 1990).
Interventions for ADHD
ADHD is currently treated with a variety of either training interventions or psychotherapeutic interventions for parents, children, and teachers (NICE 2000). ADHD is most often treated with pharmacological interventions, sometimes in combination with other types of therapy. The medications most frequently prescribed for clients diagnosed with ADHD are stimulant medications such as methylphenidate or dexamphetamine (Wolraich 1990). Other medications such as antidepressants, antihypertensive medication, beta‐blockers, and anticonvulsants are also used, generally when stimulants are not found to be effective for clients, or when comorbid diagnoses indicate that alternative treatment methods may be more applicable to certain cases (Barkley 1998). In the United States, for example, stimulant medications are the most frequently prescribed forms of psychotropic medication for children (Wolraich 2003). While a large number of studies have indicated that stimulant medication is effective for reducing symptoms of inattentiveness, impulsivity and hyperactivity in children and adolescents with ADHD in the short term, the long‐term effectiveness of pharmacotherapy for ADHD is not known (Goldman 1998, Schachter 2001). One rigorous systematic review found that many studies lack a sufficiently long‐term follow‐up and tend to score low on measures of quality (Jadad 1999)There is also concern that stimulant medications are overprescribed or are prescribed without sufficiently using appropriate diagnostic criteria. For example, one longitudinal community study showed that the majority of children who had been prescribed stimulants had never met diagnostic criteria for any form of ADHD, and those who were diagnosed with ADHD‐Not Otherwise Specified (NOS) were more likely to be prescribed stimulants if they met diagnostic criteria for oppositional defiant disorder (ODD) than if they did not (Angold 2000). This finding gives weight to the argument that prescription of stimulants may, in some cases, be augmented by comorbid behaviour disorders, which in turn might be addressed by nonpharmacological behavioural interventions rather than stimulants. However, the effectiveness of such forms of therapy for children with ADHD and comorbid behaviour problems must be evaluated empirically to determine whether it is effective, and for which symptoms it is effective.
In the current literature, there is some evidence for the efficacy of various forms of family therapy for the treatment of attentional disorders in children (Carr 2000b). Many of these forms of family therapy can be categorised as those focused on changing problem‐maintaining behaviour patterns and belief systems, and related mediating and moderating factors (Carr 2000a). Examples of these types of family therapy are: Mental Research Institute (MRI) brief therapy, strategic family therapy, structural family therapy, cognitive‐behavioural family therapy, and functional family therapy, all of which are described and categorised in a review of family therapy for behaviour patterns (Carr 2000a). These types of family therapy can be used to help families learn how to best support a child with this type of disability and how to avoid parenting practices, cycles of interactions, and other environmental factors that might exacerbate the problem.
Current Evidence for Family Therapy
Much of the evidence suggesting that family therapy is efficacious for children and adolescents with ADHD refers to multimodal forms of family therapy which include pharmacological components combined with family therapy or parent training, and sometimes individual therapy for children and school‐based interventions (Carr 2000b; MTA 1999), and do not conclusively show that these types of interventions are significantly more effective than pharmacological treatment alone (MTA 1999). Unfortunately, such conclusions do not benefit clients who do not respond to medication (10%‐13% of clients (Goldman 1998)), who suffer from unpleasant side effects from medication (e.g. decreased appetite, insomnia, anxiety, irritability, or tics (DuPaul 1998)), or who are taking medications that cannot be taken along with ADHD medication (e.g. monoamine oxidase inhibitors (DuPaul 1998)). In addition, the Technology Appraisal Guidance from the National Institute for Clinical Excellence limits the usage of stimulants by recommending that methylphenidate be used only with children ages six and older who do not have "marked anxiety, agitation or tension; symptoms or family history of tics or Tourette's syndrome; hyperthyroidism; severe angina or cardiac arrhythmia; glaucoma; or thyrotoxicosis" and recommends caution in treatment for children with "epilepsy, psychotic disorders, or a history of drug or alcohol dependence" (NICE 2000, p.1). In addition, client preference for nonpharmacological treatment is common. For example, it is reported that parents of children with ADHD tend to view parent training or support groups significantly more favourably than medication (Corkum 1999).
There is evidence of the potential effectiveness of family therapy without pharmacological components for various internalising and externalising problems in children and adolescents with ADHD. For example, one clinical trial yielded results showing that family therapy and two types of parent training (behaviour management training, problem‐solving and communication training, and structural family therapy) each predicted reductions in parent‐adolescent conflicts, improvement in communication between parents and adolescents, and reduced intensity of anger during conflicts over time, according to reports by mothers and their adolescents who had been diagnosed with ADHD (Barkley 1992). These three forms of treatment were also found to produce improvements in school adjustment as reported by mothers and in various externalising and internalising problems as reported by mothers and adolescents (Barkley 1992). However, a lack of a control group in this study prevents the researchers to draw conclusions about the effectiveness of these interventions relative to no treatment. In addition, information was not collected from schools to determine applicability of results across settings. Moreover, standard assessment questionnaires to measure changes in the core symptoms of ADHD were not used, as the researchers were not looking directly at treating ADHD symptoms, but rather other behavioural problems.
Non‐systematic reviews of the literature examining the effectiveness of family therapy for symptoms of inattention, hyperactivity, and impulsivity indicate that family therapy is effective when it helps parents understand and cope with their children's disorder, decreases family distress, and improves the structural aspects of the family such as the intergenerational hierarchy, rules and routines, and communication (Carr 2000a). However, these reviews have not been conducted systematically and the literature lacks meta‐analyses of controlled trials in this area which could clarify and consolidate the information about the effectiveness of family therapy for these symptoms. To address this problem, this review will evaluate the efficacy of selected family therapy interventions for symptoms of inattention, hyperactivity, and impulsivity in children with ADHD, independent of pharmacological treatments.
Objectives
To determine whether family therapy will help reduce symptoms of inattention, impulsivity and hyperactivity for children with ADHD or ADD as compared to no treatment or standard treatment.
Methods
Criteria for considering studies for this review
Types of studies
Studies will be included if they are randomised controlled trials investigating the efficacy of methods of family therapy excluding medication for children with ADHD or ADD or attentional and hyperactivity problems as defined by trialists. Studies will be evaluated for inclusion in the review based on methodological quality including randomisation, concealment of allocation, blinding, appropriateness of data analysis methods, and handling of missing data.
Types of participants
Children or adolescents as defined by trialists, with diagnoses of ADHD or ADD as determined by DSM‐III or DSM‐IV criteria, diagnoses of Hyperkinetic Disorder as determined by ICD‐9 or ICD‐10 criteria (WHO 1993) , or a cutoff score on a well‐validated assessment measure. Participants may have comorbid diagnoses, given the substantial prevalence of comorbid diagnoses with ADHD such as Oppositional‐Defiant Disorder or Conduct Disorder (APA 1994; APA 2000). Children must not be taking medication for their symptoms during the trials.
Types of interventions
Family therapy interventions which include functional family therapy, cognitive‐behavioural family therapy, or behavioural family therapy, all of which must include components with at least one parent and the child participating in some therapy sessions with therapist. These forms of family therapy were selected because they can be logically grouped together as they all contain a component of behavioural therapy in treatment (Carr 2000a). Treatment methods which involve interventions with parents exclusively will be excluded. Multisystemic family therapy will be excluded to avoid overlap with another ongoing review. Treatment methods will be considered if they also include components with teachers. Trials in which medication is administered to the intervention group will be excluded. Trials in which a separate group receives medication will be included, but analyses will focus on family therapy group versus control group only.
Types of outcome measures
Outcomes considered will be the incidence or severity of symptoms of inattention, impulsivity, and hyperactivity. Outcomes measures considered for inclusion will be ratings on standard, psychometrically sound and validated assessment questionnaires measuring changes in attentional, impulsive, and hyperactive symptoms over time, for example, the Conners' Rating Scale (Conners 1998). Included measures could assess attentional problems and impulsive or disruptive behaviour at home or at school, or both. Results from any assessments of participant satisfaction with treatment and adverse effects will be included.
Search methods for identification of studies
The following electronic databases will be searched, with no language restrictions:
The Cochrane Register of Controlled Trials (CENTRAL)
MEDLINE
PsycINFO
CINAHL
Biosis (Biological Abstracts)
Dissertation Abstracts
Sociological Abstracts (Sociofile)
The following search strategy will be used to search MEDLINE and adapted as necessary to other databases:
1. family therapy.mp. or exp Family Therapy/
2. (family adj based).mp. [mp=title, original title, abstract, name of substance, mesh subject heading]
3. family‐based.mp.
4. (family adj cent$).mp. [mp=title, original title, abstract, name of substance, mesh subject heading]
5. ((family adj focused) or focussed).mp. [mp=title, original title, abstract, name of substance, mesh subject heading]
6. family‐responsive.mp.
7. family‐relation$.mp.
8. (family adj3 relation$).mp. [mp=title, original title, abstract, name of substance, mesh subject heading]
9. (famil$ adj3 educat$).mp. [mp=title, original title, abstract, name of substance, mesh subject heading]
10. (famil$ adj3 program$).mp. [mp=title, original title, abstract, name of substance, mesh subject heading]
11. (famil$ adj3 therap$).mp. [mp=title, original title, abstract, name of substance, mesh subject heading]
12. (famil$ adj3 counsel$).mp. [mp=title, original title, abstract, name of substance, mesh subject heading]
13. (famil$ adj3 support$).mp. [mp=title, original title, abstract, name of substance, mesh subject heading]
14. (famil$ adj3 intervention$).mp. [mp=title, original title, abstract, name of substance, mesh subject heading]
15. (famil$ adj3 treatment$).mp. [mp=title, original title, abstract, name of substance, mesh subject heading]
16. (famil$ adj3 management$).mp. [mp=title, original title, abstract, name of substance, mesh subject heading]
17. (parent$ and (child$ adj3 therap$)).mp. [mp=title, original title, abstract, name of substance, mesh subject heading]
18. (parent$ and (child$ adj3 intervention$)).mp. [mp=title, original title, abstract, name of substance, mesh subject heading]
19. (parent$ and (child$ adj3 treatment$)).mp. [mp=title, original title, abstract, name of substance, mesh subject heading]
20. (mother$ and (child$ adj3 therap$)).mp. [mp=title, original title, abstract, name of substance, mesh subject heading]
21. (mother$ and (child$ adj3 intervention$)).mp. [mp=title, original title, abstract, name of substance, mesh subject heading]
22. (mother$ and (child$ adj3 treatment$)).mp. [mp=title, original title, abstract, name of substance, mesh subject heading]
23. (father$ and (child$ adj3 therap$)).mp. [mp=title, original title, abstract, name of substance, mesh subject heading]
24. (father$ and (child$ adj3 intervention$)).mp. [mp=title, original title, abstract, name of substance, mesh subject heading]
25. (father$ and (child$ adj3 treatment$)).mp. [mp=title, original title, abstract, name of substance, mesh subject heading]
26. (conjoint adj therapy).mp. [mp=title, original title, abstract, name of substance, mesh subject heading]
27. (famil$ adj3 communicat$).mp. [mp=title, original title, abstract, name of substance, mesh subject heading]
28. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27
29. exp Attention Deficit Disorder with Hyperactivity/ or adhd.mp.
30. addh.mp. [mp=title, original title, abstract, name of substance, mesh subject heading]
31. (attention adj3 deficit).mp. [mp=title, original title, abstract, name of substance, mesh subject heading]
32. hyperactiv$.mp. [mp=title, original title, abstract, name of substance, mesh subject heading]
33. hyperkinesis$.mp. or exp HYPERKINESIS/
34. (minimal adj brain adj3 disorder$).mp. [mp=title, original title, abstract, name of substance, mesh subject heading]
35. (minimal adj brain adj3 dysfunction$).mp. [mp=title, original title, abstract, name of substance, mesh subject heading]
36. (minimal adj brain adj3 damage$).mp. [mp=title, original title, abstract, name of substance, mesh subject heading]
37. 29 or 31 or 32 or 33 or 34 or 35 or 36
38. 28 and 37
In addition, hand searches of relevant journals will be undertaken and bibliographies of reviews and trials will be scrutinised to identify further studies. Triallists and experts in the field (including representatives from relevant professional bodies, eg the International Family Therapy Association, as well as members of CHADD [Children and Adults with Attention Deficit/Hyperactivity Disorder]) will be contacted for information on ongoing or unpublished trials.
Data collection and analysis
Selection of trials:
The titles and abstracts obtained in the above search will be screened by the reviewers (GB and PM) for trials for possible inclusion. After trials are identified, fullt texts will be obtained and independently screened by the two reviewers to decide whether the studies meet the criteria for inclusion. If there is disagreement, advice may be sought from a third, independent adjudicator at the editorial base of the Cochrane Developmental, Psychosocial and Learning Problems Group. Additional information from the authors of the trials will be sought as necessary to resolve questions about the relevance/methodology of a trial. Information regarding this decision making process will be documented. Neither the reviewers nor the independent adjudicator will be blind to the authors, institutions, or the journals of publication of the articles.
Assessment of methodological quality:
Methodological quality will be assessed independently by each reviewer (GB, PM) and any disagreements will be resolved by discussion and, if necessary, advice from a third, independent adjudicator from the Cochrane editorial base. Assessment will be made of all included studies, to consider the following questions:
Was the assignment to treatment groups truly random?
Was allocation adequately concealed?
How complete was follow‐up?
How were the outcomes considered for people who withdrew?
Were they included in the analysis?
Were those assessing outcomes blind to the treatment allocation?
Randomisation
Randomisation will be judged as 'adequate' when computer‐generated random numbers, a random numbers table, or coin‐tossing have been used.
Allocation concealment
The reviewers will allocate the trials into quality categories as defined in the Cochrane Collaboration Handbook, where:
A=adequate allocation concealment,
B=unclear concealment,
C=inadequate allocation concealment, and
D=allocation concealment not used (Alderson 2004).
For the purposes of this review, only trials meeting categories "A" or "B" will be included.
Blinding of assessors
It is not possible to blind either those who deliver family therapy or those who receive it to the nature of the intervention. It is a criterion for this review that assessors be blinded. Quality of blinding will be determined primarily by whether those who assess and code outcome measures are blind to condition, and by categorizing the quality of blinding where:
Adequate=assessor blind to condition,
Unclear=blinding of assessor not reported and information not available from researchers, and
Inadequate=assessor not blind to condition
Loss to follow‐up
Loss to follow‐up will be assessed by categorizing the studies by method of response to loss to follow‐up where:
Adequate=losses to follow up are equally distributed between treatment and comparison groups,
Unclear=information about losses to follow up unavailable,
and Inadequate=losses to follow‐up in excess of 30% or unevenly distributed between treatment and comparison groups.
Intention to treat
Assessment will also take into account whether researchers used intention‐to‐treat analyses by including measures from all participants, even those that did not participate fully in the treatment protocol, and by replacing missing data for each participant with the last available data from that participant (i.e. using pretest scores at pretest and posttest if participant did not provide posttest data) The researchers will categorise studies such that:
Adequate=intention‐to‐treat analyses performed or can be performed using available data;
Unclear=information about whether intention‐to‐treat analyses were performed is not available and cannot be acquired by contacting the researchers of the study; and Inadequate=intention‐to‐treat analyses were not performed and cannot be done using available data.
Data extraction:
Data will be extracted by the reviewers using a data extraction sheet including information about methods, interventions, and outcomes. Attempts will be made to contact authors where data presented in articles is insufficient. This extraction will include a critical appraisal of methodological quality including information about allocation, blinding, follow‐up, and inclusion of participants lost during the study. This information will also be used in the table of included studies in the review. Data will be entered in to RevMan by one reviewer (GB) and checked by the second reviewer (PM).
Data synthesis:
1. Meta‐analysis: Meta‐analysis will only be performed where studies report similar interventions and where data are available and sufficiently clinically and statistically homogeneous. Analyses will be conducted using both a fixed effect and a random effects model.
2. Incomplete data:
Where data are not available for more than 1/3 of the allocated participants authors will contacted to supply the missing data. If missing data cannot be obtained in this way, data will not be used due to potential bias.
3. Dichotomous data:
Where dichotomous data are presented, a relative risk ratio with a 95% confidence interval will be calculated for each trial (Alderson 2004).
4. Continuous data:
Continuous data will be analysed when means and standard deviations are available and where the data are not skewed. Where outcomes are measured using the same scale, a weighted mean difference will be calculated to determine the differences in mean scores between groups. Where the same outcomes are measured using different scales, a standardized mean difference will be calculated.
5. Qualitative data:
Qualitative data will not be included in the analyses.
6. Heterogeneity:
To examine the possibility of heterogeneity among included studies, inconsistency will be determined by visual assessment of the results and through the use of the I2 statistic (Higgins 2002), which will determine the percentage of variability that is due to heterogeneity rather than sampling error or chance, where a value greater than 50% indicates heterogeneity. A test of homogeneity will also be carried out to confirm the results of the heterogeneity analyses. In addition, the reviewers will discuss the possible reasons for any heterogeneity and conduct sub‐group analyses accordingly, where data permit.
7. Subgroup analyses will be carried out when it is possible to separate the following subgroups:
Children with ADD, ADHD, or specific subtypes of ADHD
Children of different developmental levels, i.e. children vs. adolescents
Children with various comorbid diagnoses
Gender
Ethnic group
Subgroups of family therapy with and without teacher participation will be analysed separately to compare the effectiveness of treatment with and without teacher involvement.
8. Assessment of bias:
A funnel plot will be used where possible to determine the likelihood of publication bias. Asymmetry of the funnel plot will indicate possible publication bias in this review, but also may indicate other methodological or sample size issues within the trials. If asymmetry of the funnel plot is found, the clinical diversity of the studies will be examined (Egger 1997).
9. Sensitivity analyses:
Sensitivity analyses will be performed if required depending on the descriptions of methodology available in identified studies. Possible issues may include analysis of studies reporting blinding of assessor; studies reporting adherence to a treatment protocol, and studies reporting that participants met ICD‐10 (WHO 1993) or DSM‐IV (APA 1994) diagnostic criteria for ADHD.
