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Nonpharmacological interventions for ADHD beneficial in school setting

Although gaps in standardized interventions warrant further research, nonpharmacological interventions showed positive outcomes for attention-deficit/hyperactivity disorder in school settings, according to a synthesis of systematic reviews recently published in Health Technology Assessment.

“We now need more rigorous evaluation, with a focus on what works, for whom and in which contexts,” Tamsin J. Ford, PhD, from the University of Exeter Medical School, said in a press release. “Gaps in current research present opportunities to develop and test standardized interventions and research tools, and agree on gold standard outcome measures to provide answers to both schools and families.”

Ford and colleagues from the University of Exeter Medical School, Kings College London and Hong Kong Institute of Education extracted 54 studies (39 randomized controlled trials [RCTs], 15 nonrandomized) from 20 databases published between 1980 and 2013. They sought to determine the effectiveness of psychological and behavioral interventions among patients with or at risk for ADHD in the classroom. Participants were aged 4 to 18 years.

Four systematic reviews were performed observing:

• the effectiveness and cost-effectiveness of nonpharmacological interventions;
• quantitative studies evaluating the attitudes toward such interventions;
• the overall attitude of interventions among students, teachers and parents; and
• school-related experiences with ADHD among students, parents and teachers.

In the first review, a meta-analysis of 36 RCTs showed that nonpharmacological outcomes had a positive effect on symptoms of ADHD (P < .05), including inattention and hyperactivity/impulsivity (P = .001 for both). Teachers also reported improvements in inattention among students (P = .001), as well as expression (P = .03) and scholastic behaviors, including perception of school adjustment and standardized achievement (P = .02 for both).

“Although overall the evidence indicates the beneficial effects of nondrug intervention, the heterogeneity in effect sizes points to the lack of standardized interventions and shared outcome measures across the included studies,” the researchers wrote.

No studies calculated the cost of the interventions; thus, the economic effects were not assessed.

The researchers wrote that analyses related to attitudes toward nonpharmacological interventions were inadequate and prone to bias. The only intervention consistent in yielding favorable outcomes was daily report cards. Most studies, however, concluded that interventions had positive or neutral effects on relationships, attitudes and how participants perceived ADHD and school.

In the final review, the researchers suggested that stigma and expectations in the school setting could exacerbate ADHD symptoms and form relationship barriers between students, teachers and parents. Therefore, approaches concerning student adaptation are critical.

“The qualitative reviews suggest that stigma and marginalization may be increased through intervention,” the researchers wrote. “This is an important consideration for implementation. The findings from reviews 3 and 4 suggest that psychoeducation about ADHD could usefully be provided to school staff, pupils with ADHD and their peers as an adjunct to any intervention that targets children with or at risk of ADHD.” – by Stephanie Viguers

Disclosure: Richardson reports no relevant financial disclosures. Please see the full study for a list of all other authors’ relevant financial disclosures.