By Charles Bankhead, Staff Writer, MedPage Today
Published: April 01, 2013
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco
· Parent behavior training topped medication and other interventions for preschool children at risk of attention-deficit/hyperactivity disorder (ADHD).
· Point out that separate analyses of outcomes related to parenting skills and child behavior also yielded moderate effects in favor of the intervention.
Parent behavior training (PBT) topped medication and other interventions for preschool children at risk of attention-deficit/hyperactivity disorder (ADHD), a systematic literature review showed.
Eight methodologically sound studies of PBT produced the best and most consistent strength of evidence for efficacy, with a standard mean difference (SMD) of -0.68, reported Alice Charach, MD, of the Hospital for Sick Children in Toronto, and colleagues online in Pediatrics.
However, the investigators found only one good study of medical treatment with methylphenidate, resulting in a low strength of evidence, while combined home and school/daycare interventions yielded inconsistent results.
"The evidence-based PBT interventions included in this review improve parenting skills and improve child disruptive behavior, including core symptoms of ADHD," the authors concluded. "Community physicians are in an excellent position to initiate the assessments required, guide parents to evidence-based programs where available, monitor these conditions over time, and advocate for increased resources in communities where they do not yet exist."
A variety of interventions for ADHD have been developed and evaluated in children and adolescents. However, no information about the comparative efficacy of PBT and other types of interventions has been reported.
Given the paucity of evidence to inform decision making, the Agency for Healthcare Research and Quality sponsored a review and critical examination of published studies involving interventions for ADHD. Specifically, the authors were charged with evaluating the comparative effectiveness of, and adverse events associated with, interventions for preschool children at high risk of ADHD.
To enhance the generalizability of the review, Charach and colleagues included studies of children who met criteria for clinically impairing symptoms of disruptive behavior, including ADHD symptoms.
A single key question guided the review: among children younger than 6 years with ADHD or disruptive behavior disorder, what are the effectiveness and adverse-event outcomes after treatment?
Charach and colleagues searched several databases for relevant studies reported from 1980 to Nov. 24, 2011. They limited the review to interventions for children younger than 6 with "clinically significant" disruptive behavior, as determined by:
· Referral for treatment
· Reliable and valid screening instruments
· A diagnosis of ADHD, oppositional defiant disorder, or conduct disorder (DSM III, IIIR, and IV or ICD 9 or 10 criteria)
Most of the studies included were randomized controlled trials. Interventions reviewed included pharmacologic and nonpharmacologic treatment. Alternative/complementary interventions were excluded.
The review identified 55 publications that met inclusion criteria: 34 described PBT interventions, 15 involved treatment with psychostimulants (primarily immediate-release methylphenidate), and six described combinations of PBT and day care- or school-based interventions.
The investigators included all 55 publications in a qualitative synthesis and 14 of the 55 in a meta-analysis.
Analysis of 13 good or fair-quality trials of PBT involving 558 children resulted in a moderate effect size (SMD -0.75) in favor of the intervention. An analysis limited to eight good-quality studies produced an SMD of -0.68 in favor of the intervention. The investigators found minimal heterogeneity among the studies.
Separate analyses of outcomes related to parenting skills and child behavior also yielded moderate effects in favor of the intervention. Five good- or fair-quality studies specifically evaluated effects of PBT on one or more ADHD core symptoms. A pooled analysis produced a moderate effect favoring the intervention (SMD -0.77).
The authors acknowledged that the PBT trials had some limitations in methodology including small sample sizes, use of wait-list controls, and reliance on parent report for child behavior outcomes, with minimal information about child behavior in classroom or daycare settings.
The 15 articles on psychostimulants involved 10 separate studies, the largest being the Preschool ADHD Treatment Study (PATS), which involved 165 patients. PATS was the only study that the authors considered high-quality evidence.
PATS evaluated several doses of methylphenidate with the objective of identifying the optimal dose. The best dose was associated with a small positive effect for teacher- but not parent-rated ADHD symptoms, no improvement in parental stress, and worsening of parent-rated child mood. Clinicians rated the children improved with a moderate to large effect.
Six publications represented five studies of multicomponent psychosocial or behavioral interventions. The authors found no consistency in the results reported from the trials.
"The evidence for PBT was rated high for the consistency of results with eight good-efficacy trials, supported by evidence of dose effect and continued benefit 6 months after baseline," the authors said in their summary of the strength of evidence.
"Methylphenidate use was given a low rating for strength of evidence," they stated. "There is only one good trial with findings supported by three small, within-subject trials of lesser quality. The evidence for combined home and school behavioral interventions was insufficient, as interventions were diverse and results contradictory."
The study was sponsored by the Agency for Healthcare Research and Quality.
The authors reported no conflicts of interest.
Primary source: Pediatrics
Charach A, et al "Interventions for preschool children at high risk for ADHD: a comparative effectiveness review" Pediatrics 2013; DOI: 10.1542/peds.2012-0974.