Social skills training for Attention Deficit Hyperactivity Disorder (ADHD) in children aged 5 to 18 years

Ole Jakob Storebø; Maria Skoog; Dorte Damm; Per Hove Thomsen; Erik Simonsen; Christian Gluud

doi:10.1002/14651858.CD008223.pub2

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Figure 1

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study

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Figure 3

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies

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Figure 4

TSA 1

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Figure 5

TSA 2

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Figure 6

TSA 2

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Analysis 1.1

Comparison 1 Social skills (SSRS), Outcome 1 Primary analysis: Social skills competences.

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Analysis 1.2

Comparison 1 Social skills (SSRS), Outcome 2 Teacher‐rated social skills (Mean Difference).

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Analysis 1.3

Comparison 1 Social skills (SSRS), Outcome 3 Parent‐rated social skills competences (Mean Difference).

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Analysis 1.4

Comparison 1 Social skills (SSRS), Outcome 4 Walker‐McConnel Social skills.

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Analysis 1.5

Comparison 1 Social skills (SSRS), Outcome 5 Social skills scale (UCI) parent‐rated.

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Analysis 1.6

Comparison 1 Social skills (SSRS), Outcome 6 Child social skills knowledge scale.

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Analysis 1.7

Comparison 1 Social skills (SSRS), Outcome 7 Social interaction observation ‐ negative behaviour.

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Analysis 2.1

Comparison 2 General behaviour, Outcome 1 Primary analysis: Teacher‐rated general behaviour.

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Analysis 3.1

Comparison 3 ADHD symptoms, Outcome 1 Teacher‐rated ADHD symptoms.

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Analysis 4.1

Comparison 4 Subgroup analysis 1: trials with social skills training without parental training compared to social skills training combined with parental training, Outcome 1 Teacher‐rated.

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Analysis 5.1

Comparison 5 Subgroup analysis 2: trials with ADHD including comorbidity compared to trials with ADHD and no comorbidity, Outcome 1 Parent‐rated ADHD symptoms at end of treatment.

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Analysis 6.1

Comparison 6 Subgroup analysis 3: trials with social skills training, parental training and medication compared to trials with social skills training and parental training without medication, Outcome 1 Social skills training, parent training, teacher consultations with and without medication.

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Summary of findings for the main comparison. Social skills training compared to no intervention

Social skills training compared to no intervention
Patient or population: Children aged 5 to 18 years with ADHD Settings: All Intervention: Social skills training Comparison: No intervention
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
		Social skills training
Teacher‐rated social skills competences at end of treatment ‐ all eligible trials (SSRS)		The mean score for teacher‐rated social skills competences at end of treatment in the intervention groups was 0.16 standard deviations higher (0.04 lower to 0.36 higher)		392 (5 studies)	⊕⊕⊝⊝ low
Teacher‐rated general behaviour at end of treatment ‐ all eligible trials		The difference in mean scores for teacher‐rated general behaviour at end of treatment between the intervention and control groups was 0.00 standard deviations (‐0.21 lower to 0.21 higher)		358 (3 studies)	⊕⊕⊝⊝ low
Teacher‐rated ADHD symptoms ‐ all eligible trials		The mean score for teacher‐rated ADHD symptoms at end of treatment in the intervention groups was 0.02 standard deviations lower (0.19 lower to 0.16 higher)		515 (6 studies)	⊕⊕⊝⊝ low
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% confidence interval).
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.

Summary of findings for the main comparison. Social skills training compared to no intervention

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Table 1. Differences between protocol and review

Protocol	Review
Outcomes: In the protocol we stated that we would measure the two primary and the first two of secondary outcomes at short term (up to six months), medium term (six to 12 months), and long term (more than 12 months). In the protocol we did not prespecify the most important comparisons for the 'Summary of findings' table.	In the review this has been changed to at the end of treatment and at the longest follow‐up. We have added definition of adverse outcomes according to the International Committee of Harmonization guidelines (ICH 1996). In the review we used our two primary outcomes (teacher‐rated social‐skills and general behaviour) and the first secondary outcome (ADHD symptoms) in the 'Summary of findings' table.
Subgroup analysis: In the protocol we planned to perform subgroup analysis according to the following categories: 1. Children aged five to 11 years compared to children aged 12 to 18 years. 2. Social skills training in a group setting compared to individual social skills training. 3. Trials with social skills training only compared to trials with social skills training supported by parental training or supporting efforts focused on parents/teachers. 4. Children with ADHD compared to children with ADHD and comorbid behavioural disorders (conduct disorder, oppositional disorder). 5. Children with ADHD plus depression, attachment disorder, or anxiety disorders compared to children with ADHD without these comorbidities. 6. Trials with low risk of bias compared to trials with high risk	In the review it was not possible to perform subgroup analysis 1, 2, 5, and 6 due to lack of sufficient data in the included trials.
Risk of bias: In the protocol we had not planned to evaluate blinding of participants and personnel. In the protocol we stated that we would only use trials with low risk (or lower risk) of bias in the meta‐analysis.	In the review we also assessed the blinding of participants and personnel. In the review we changed this decision to restrict meta‐analysis to trials with comparable risk of bias (for example, all low risk, all unclear, or all the trials are at high risk of bias), and perform sensitivity analyses accordingly.
Sensitivity analysis: In the protocol we stated that we would repeat the analysis taking different methods used to handle the missing data into consideration.	In the review we did not perform this due to lack of necessary data. We have analysed the data 'as reported'.

Table 1. Differences between protocol and review

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Comparison 1. Social skills (SSRS)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Primary analysis: Social skills competences Show forest plot	7		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1 Primary analysis: Teacher‐rated social skills competences at end of treatment ‐ all eligible trials	5	392	Std. Mean Difference (IV, Random, 95% CI)	0.16 [‐0.04, 0.36]
1.2 Sensitivity analysis:Teacher‐rated social skills competences ‐ excluding the trial with longest intervention duration (also largest trial)	4	185	Std. Mean Difference (IV, Random, 95% CI)	0.19 [‐0.10, 0.48]
1.3 Teacher‐rated social skills competences ‐ longest follow‐up	1	18	Std. Mean Difference (IV, Random, 95% CI)	0.06 [‐0.86, 0.98]
1.4 Secondary analysis: Parent‐rated social skills competences at end of treatment ‐ all eligible trials	7	628	Std. Mean Difference (IV, Random, 95% CI)	0.22 [0.04, 0.40]
1.5 Secondary analysis: Participant‐rated social skills competences at end of treatment ‐ all eligible trials	2	188	Std. Mean Difference (IV, Random, 95% CI)	0.21 [‐0.09, 0.51]
2 Teacher‐rated social skills (Mean Difference) Show forest plot	4	185	Mean Difference (IV, Random, 95% CI)	1.81 [‐1.02, 4.64]

3 Parent‐rated social skills competences (Mean Difference) Show forest plot	5	313	Mean Difference (IV, Random, 95% CI)	2.82 [‐0.92, 6.56]

4 Walker‐McConnel Social skills Show forest plot	1	46	Mean Difference (IV, Fixed, 95% CI)	1.06 [‐0.47, 2.59]

5 Social skills scale (UCI) parent‐rated Show forest plot	1	18	Mean Difference (IV, Fixed, 95% CI)	9.70 [6.07, 13.33]

6 Child social skills knowledge scale Show forest plot	1	18	Mean Difference (IV, Fixed, 95% CI)	4.20 [1.99, 6.41]

7 Social interaction observation ‐ negative behaviour Show forest plot	1	68	Mean Difference (IV, Fixed, 95% CI)	0.20 [‐0.11, 0.51]

Comparison 1. Social skills (SSRS)

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Comparison 2. General behaviour

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Primary analysis: Teacher‐rated general behaviour Show forest plot	3		Std. Mean Difference (IV, Fixed, 95% CI)	Subtotals only

1.1 Primary analysis: Teacher‐rated general behaviour at end of treatment ‐ all eligible trials	3	358	Std. Mean Difference (IV, Fixed, 95% CI)	0.00 [‐0.21, 0.21]
1.2 Sensitivity analysis: Teacher‐rated general behaviour excluding the trial with longest intervention duration	2	290	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.04 [‐0.27, 0.19]
1.3 Sensitivity analysis: Teacher‐rated general behaviour excluding the largest trial	2	104	Std. Mean Difference (IV, Fixed, 95% CI)	0.15 [‐0.24, 0.53]
1.4 Teacher‐rated general behaviour ‐ longest follow‐up	2	256	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.23 [‐0.48, 0.01]
1.5 Secondary analysis: Parent‐rated general behaviour at end of treatment	1	254	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.26 [‐0.51, ‐0.01]

Comparison 2. General behaviour

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Comparison 3. ADHD symptoms

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Teacher‐rated ADHD symptoms Show forest plot	8		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1 Primary analysis: Teacher‐rated ADHD symptoms at end of treatment ‐all eligible trials	6	515	Std. Mean Difference (IV, Random, 95% CI)	‐0.02 [‐0.19, 0.16]
1.2 Sensitivity analysis:Teacher‐rated ADHD symptoms excluding the trial with the longest treatment intervention	5	447	Std. Mean Difference (IV, Random, 95% CI)	‐0.06 [‐0.25, 0.12]
1.3 Sensitivity analysis: Teacher‐rated ADHD symptoms at end of treatment excluding the largest trial	5	261	Std. Mean Difference (IV, Random, 95% CI)	0.07 [‐0.18, 0.31]
1.4 Teacher‐rated ADHD symptoms ‐ longest follow‐up	2	79	Std. Mean Difference (IV, Random, 95% CI)	‐0.24 [‐0.90, 0.41]
1.5 Teacher‐rated ADHD symptoms ‐ MTA inattention outcome	1	254	Std. Mean Difference (IV, Random, 95% CI)	0.01 [‐0.23, 0.26]
1.6 Teacher‐rated Sluggish cognitive tempo end of treatment	1	66	Std. Mean Difference (IV, Random, 95% CI)	‐0.29 [‐0.78, 0.20]
1.7 Secondary analysis: Parent‐rated ADHD symptoms at end of treatment ‐ all eligible trials	7	654	Std. Mean Difference (IV, Random, 95% CI)	‐0.49 [‐0.79, ‐0.19]

Comparison 3. ADHD symptoms

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Comparison 4. Subgroup analysis 1: trials with social skills training without parental training compared to social skills training combined with parental training

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Teacher‐rated Show forest plot	1	36	Mean Difference (IV, Fixed, 95% CI)	7.42 [‐1.42, 16.25]

1.1 Teacher‐rated social skills training with parent training	1	18	Mean Difference (IV, Fixed, 95% CI)	5.60 [‐6.78, 17.98]
1.2 Teacher‐rated social skills training without parent training	1	18	Mean Difference (IV, Fixed, 95% CI)	9.30 [‐3.31, 21.91]

Comparison 4. Subgroup analysis 1: trials with social skills training without parental training compared to social skills training combined with parental training

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Comparison 5. Subgroup analysis 2: trials with ADHD including comorbidity compared to trials with ADHD and no comorbidity

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Parent‐rated ADHD symptoms at end of treatment Show forest plot	7		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1 Parent‐rated ADHD symptoms at end of treatment without comorbidity	1	97	Std. Mean Difference (IV, Random, 95% CI)	‐0.78 [‐1.19, ‐0.36]
1.2 Parent‐rated ADHD symptoms at end of treatment ‐ with comorbidity	6	557	Std. Mean Difference (IV, Random, 95% CI)	‐0.44 [‐0.76, ‐0.11]

Comparison 5. Subgroup analysis 2: trials with ADHD including comorbidity compared to trials with ADHD and no comorbidity

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Comparison 6. Subgroup analysis 3: trials with social skills training, parental training and medication compared to trials with social skills training and parental training without medication

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Social skills training, parent training, teacher consultations with and without medication Show forest plot	5	331	Std. Mean Difference (IV, Random, 95% CI)	0.26 [‐0.04, 0.56]

1.1 Social skills training and parent training with medication	3	244	Std. Mean Difference (IV, Random, 95% CI)	0.19 [‐0.10, 0.48]
1.2 Social skills training, parent training without medication	2	87	Std. Mean Difference (IV, Random, 95% CI)	0.64 [‐0.48, 1.76]

Comparison 6. Subgroup analysis 3: trials with social skills training, parental training and medication compared to trials with social skills training and parental training without medication

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