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4 Attention deficit hyperactivity disorder

Margretta Nolan and Alan Carr

Definitions

Attention deficit hyperactivity disorder, attention deficit disorder, hyper- kinetic disorder, hyperkinesis and minimal brain dysfunction are some of the terms used for a syndrome characterized by persistent overactivity, impulsiv- ity and difficulties in sustaining attention (Barkley, 1990; Hinshaw, 1994; Taylor, 1994). Throughout this chapter preference will be given to the term attention deficit hyperactivity disorder (ADHD) since this is currently the most widely used term. In Figure 4.1 the DSM IV(APA, 1994) diagnostic criteria for ADHD and the lCD 10 (WHO, 1992) criteria for Hyperkinetic Disorder are presented. The most noteworthy feature of the syndromes described in the two widely used classification systems is their similarity. Historically, a narrow definition of ADHD has been used in the UK and defined in the lCD classification system, with great emphasis being placed on the stability of the overactivity problems across home and school con- texts. In contrast, in the US, this cross-situation stability has not been a core diagnostic criterion within previous editions of the DSM (Hinshaw, 1994). In view of this historical difference, it is particularly noteworthy that currently in both the North American DSM IV and the European lCD 10, it is stipulated that symptoms must be present in two or more settings such as home and school for a positive diagnosis to be made.

Historically the following features have been used to subtype ADHD:

• The pervasivness of the problem • Presence or absence of both inattention and hyperactivity • Co-morbidity with conduct disorder

The occurrence of the symptoms both within and outside the home, presence of both inattention and overactivity, and the presence of conduct disorder are all associated with a more serious condition which is less responsive to treatment and which has a poorer outcome (McArdle et al., 1995). Both DSM IV and lCD 10 distinguish between subtypes of ADHD depending upon the patterning of symptomatology or the presence of co-morbid conditions.

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Carr, A. (Ed.). (2001). What works with children and adolescents? : A critical review of psychological interventions with children, adolescents and their families. ProQuest Ebook Central <a onclick=window.open('http://ebookcentral.proquest.com','_blank') href='http://ebookcentral.proquest.com' target='_blank' style='cursor: pointer;'>http://ebookcentral.proquest.com</a> Created from latrobe on 2020-09-15 21:57:37.

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DSMIV Attention deOcit hyperactivity disorder

A. Either 1 or 2.

1. Six or more of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level.

Inattention a. Often fails to give close attention to details or makes careless mistakes in schoolwork, work or other activities b. Often has difficulty sustaining attention in tasks or play activities c. Often does not seem to listen when spoken to directly d. Often does not follow through on instructions and fails to finish schoolwork, chores or work duties e. Often has difficulty organizing tasks and activities f. Often avoids or dislikes tasks that require sustained mental effort g. Often loses things necessary for tasks or activities h. Is often easily distracted by extraneous stimuli i. Is often forgetful in daily activities

2. Six or more of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level.

Hyperactivity a. Often fidgets with hands or feet or squirms in seat b. Often leaves seat in classroom or in other situations in which remaining seated is expected c. Often runs about or climbs excessively in situations in which it is inappropriate d. Often has difficulty playing or engaging in leisure activities quietly e. Is often on the go or acts as if driven by a motor f. Often talks excessively

Impulsivity g. Often blurts out answer before questions have been completed h. Often has difficulty awaiting turn i. Often interrupts or intrudes on others

B. Some of these symptoms were present before the age of 7 years

C. Some impairment from the symptoms is present in two or more settings (e.g. home and school)

D. Clinically significant impairment in social , academic or occupational functioning

E. Not due to another disorder

Specify: Combined type if inattention and overactivity-impulsivity

are present;

Inattentive type if overactivity is absent;

Hyperactive-impulsive type if inattentivness is absent

lCD 10 Hyperkinetic disorders

The cardinal features are impaired attention and overactivity. Both are necessary for the diagnosis and should be evident in more than one situation (e.g. home or school).

Impaired attention is manifested by prematurely breaking off from tasks and leaving activities unfinished. The children change frequently from one activity to another, seemingly losing interest in one task because they become diverted to another. These deficits in persistence and attention should be diagnosed only if they are excessive for the child's age and IQ.

Overactivity implies excessive restlessness, especially in situations requiring relative calm. It may, depending upon the situation, involve the child running and jumping around, getting up from a seat when he or she was supposed to remain seated, excessive talkativeness and noisiness, or fidgeting and wriggling. The standard for judgement should be that the activity is excessive in the context of what is expected in the situation and by comparison with other children of the same age and 10. This behavioural feature is most evident in structured, organized situations that require a high degree of behavioural self-control.

The characteristic behaviour problems should be of early onset (before the age of 6 years) and long duration.

Associated features include disinhibition in social relationships, recklessness in situations involving some danger, impulsive flouting of social rules, learning disorders, and motor clumsiness.

Specify: Hyperkinetic disorder with disturbance

of activity and attention when antisocial features of conduct disorder are absent;

Hyperkinetic conduct disorder when criteria for both conduct disorder and hyperkinetic disorder are met

Figure 4.1 Diagnostic criteria for attention and hyperactivity syndromes in DSM IV and ICD 10.

Source Adapted from DSM IV (APA, 1994) and ICD 10 (WHO, 1992).

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Attention deficit hyperactivity disorder 67

In DSM IV the main distinctions are between cases where inattention and overactivity are present or absent whereas co-morbid conduct problems are the basis for subtyping in lCD 10.

Evidence summarized by Hinshaw (1994) indicates that the inattentive and overactive subtypes of ADHD have distinct profiles. Children with the inattentive subtype of ADHD are described clinically as sluggish, apathetic daydreamers who are easily distracted and have difficulty completing assigned tasks within school because of learning difficulties. Within their family history there is a preponderance of learning disorders and emotional disorders such as anxiety and depression. Those with the hyperactive- impulsive subtype of ADHD are characterized by extreme overactivity, oppositional and aggressive behaviours. Conduct problems are their most notable school-based difficulties and they have a high rate of school sus- pension and special educational placement. Within their family history they have a preponderance of antisocial problems such as drug abuse and criminality and children with the hyperactive-impulsive profile are at risk for long-term antisocial behaviour problems and poor social adjustment. Children with both the inattentive and hyperactive-impulsive subtypes of ADHD have significant relationship difficulties with peers, school staff and family members and both respond to psychostimulant treatment although the inattentive subtype tends to respond to a lower dosage.

The primary distinction made in the lCD 10 system is between hyperkinetic conduct disorder, where a co-morbid conduct disorder is present, and cases where such co-morbidity is absent. Hinshaw (1994) in a review of differ- ences between these two subgroups concluded that those children with co- morbid conduct disorder show greater academic problems and suffer more extreme relationship difficulties with peers, teachers and family members. While they show some response to psychostimulant treatment, they rarely respond to psychosocial individual and family interventions.

ADHD with co-morbid emotional disorders such as anxiety or depres- sion, is not subclassified as a distinct condition within either lCD 10 or DSM IV. Children with such co-morbid profiles have been found to have a later onset for the disorder, fewer learning and cognitive problems and to be less responsive to stimulant medication than youngsters without co-morbid anxiety (Taylor, 1994).

ADHD is a particularly serious problem because youngsters with the core difficulties of inattention, overactivity and impulsivity may develop a wide range of secondary academic and relationship problems (Cantwell, 1996; Gaub and Carlson, 1997; Hinshaw, 1994). Attentional difficulties may lead to poor attainment in school. Impulsivity and aggression may lead to diffi- culties making and maintaining appropriate peer relationships and devel- oping a supportive peer group. Inattention, impulsivity and overactivity make it difficult for youngsters with these attributes to conform to parental expectations and so children with ADHD often become embroiled in chronic conflictual relationships with their parents. In adolescence, impulsivity may

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68 Margretta Nolan and Alan Carr

lead to excessive risk taking with consequent complications such as drug abuse, road traffic accidents and dropping out of school. All of these risk- taking behaviours have knock-on effects and compromise later adjustment. As youngsters with ADHD become aware of their difficulties with regulat- ing attention, activity and impulsivity and the failure that these deficits lead to within the family, peer group and school, they may also develop low self-esteem and depression. In light of the primary problems and secondary difficulties that may evolve in cases of ADHD, it is not surprising that for some the prognosis is poor (Hinshaw, 1994). For two-thirds of cases, the primary problems of inattention, impulsivity and hyperactivity persist into late adolescence and for some of these the primary symptoms persist into adulthood. Roughly a third develop significant antisocial behaviour prob- lems in adolescence including conduct disorder and substance abuse and for most of this subgroup, these problems persist into adulthood leading to criminality. Occupational adjustment problems and suicide attempts occur in a small but significant minority of cases.

Epidemiology

Reviews of epidemiological studies of ADHD report overall prevalence rates varying from 1 to 19 per cent depending upon the stringency of the diagnostic criteria applied and the demographic characteristics of the populations studied (Cantwell, 1996; Cohen et al., 1993; Gaub and Carlson, 1997; Hinshaw, 1994; McArdle et al., 1995). Using DSM IV criteria a pre- valence rate of about 3-5 per cent has been obtained. The prevalence of ADHD varies with gender and age. ADHD is more prevalent in boys than girls and in preadolescents than in late adolescents. Co-morbidity for con- duct disorder and ADHD is about 20 per cent in community populations and possibly double this figure in clinic populations. Co-morbidity for emo- tional disorders, such as anxiety or depression, and ADHD is about 10 per cent in community populations. In clinical populations the co-morbidity rate may be twice this figure. Virtually all children with ADHD have attainment problems. However, co-morbid severe specific learning difficulties have been estimated to occur in 10 to 25 per cent of cases. A proportion of youngsters with ADHD have co-morbid developmental language delays and elimination problems although reliable epidemiological data are unavailable.

Previous reviews

Historically, individually oriented play therapy based on psychodynamic or client-centred theories was widely used as a treatment for children with ADHD. This tradition has yielded little empirical research and those studies that have been conducted, while promising, have not employed control groups. For example, Fonagy and Target (1994) found that of 69 per cent

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Attention deficit hyperactivity disorder 69

of 93 cases who had disruptive behaviour disorders, after a year of psycho- dynamic treatment showed clinically significant improvement. Children with oppositional defiant disorder were most likely to improve, those with con- duct disorder were least likely to improve and those with ADHD showed improvement rates that fell between these two groups.

Working within the cognitive-behavioural tradition, Meichenbaum and Goodman (1971) developed an individual approach to treatment - self- instructional training- where children with ADHD were coached in the use of self-instructions to control the way in which they deployed their atten- tion and controlled their impulses to engage in high levels of activity. Researchers within this tradition have expanded Meichenbaum's original treatment package to include other elements, notably social as well as academic problem-solving skills training, and therapy-based contingency management. However, the development of self-control through training in the use of self-instructions remains the core feature of this treatment approach. Extensive reviews of this literature have concluded that while self-instructional training may have some effects on parent or teacher rated behaviour problems, these effects are minimal and do not constitute clinic- ally significant improvement (Abikoff, 1991; Hinshaw and Erhardt, 1991). From their meta-analysis of this literature, Baer and Nietzel (1991) con- cluded that self-instructional training is maximally effective if therapy focuses on both academic and social tasks and involves therapy-based contingency management.

Within the behavioural tradition, a contingency-management approach to the treatment of children with ADHD emerged from the seminal work of Patterson (1965). This involved therapy-based contingency management implemented directly by therapists within therapy sessions or laboratory- based specialist classrooms. Children with ADHD were reinforced for deploying their attention in a focused appropriate way and for reduced inappropriate activity levels. Response-cost systems were used where chil- dren lost points for engaging in inappropriate behaviour. Such systems have typically involved intensive schedules of reinforcement with therapists or teachers prompting children to engage in appropriate behaviours and administering reinforcement with high levels of frequency and immediacy. While such approaches had the potential to strongly influence children's behaviour, they ran the risk of leading to low generalizability (DuPaul and Eckert, 1997). That is, they entailed the possibility that treatment effects would be confined to treatment sessions or specialist classrooms.

Behavioural parent training and school-based contingency management were developed to deal with this problem (Braswell and Bloomquist, 1991). In these approaches parents or teachers were trained by therapists in con- tingency management procedures. They then implemented these contingency management programmes to modify and normalize the behaviour of children with ADHD in their home or classroom contexts. Typically parents and teachers were trained to prompt and reinforce appropriate target behaviours

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70 Margretta Nolan and Alan Carr

and to use response cost and time-out methods to reduce the frequency of target negative behaviours. Typically such training procedures have been referred to as behavioural parent training. While these programmes had the benefit of increasing the possibility of generalization of appropriate beha- viour to home and school contexts, they ran the risk of reduced potency since typically reinforcement was delivered with lower levels of frequency and immediacy than therapy or special class-based contingency management programmes. Parents and teachers, due to other demands, were unable to offer frequent prompts and to be available to administer reinforcement immediately and frequently. In a review of studies of contingency manage- ment approaches for the treatment of children with ADHD, Hinshaw eta/. (1998) concluded that programmes implemented by therapists in treatment sessions or specialist classrooms have profound immediate effects but these are short-lived and do not generalize beyond the classroom setting to the home or normal school context. Contingency management programmes implemented by parents and teachers, in contrast, have in a limited number of studies led to sustained clinically significant benefits.

Following the serendipitous discovery by Bradley (1937) of the positive effects of stimulants on the conduct and academic performance of disturbed children, more than a hundred controlled studies of the effects of stimu- lants on children with attention and hyperactivity problems have been con- ducted. Early studies examined the effects of dextroamphetamine, but the bulk of recent studies have focused on methylphenidate.

Following a thorough review of this literature, Greenhill (1998) con- cluded that stimulant therapy is effective in 70 per cent of cases in reducing the core symptoms of ADHD. Stimulants have a greater effect on behaviour than academic achievement. The effects of stimulants are short term and evidence for their long-term effectiveness has not been established.

The idea that combined psychological and pharmacological therapies might have synergistic effects has led to studies of the impact of combined treatment packages. Typically these studies have evaluated the effects of stimulant therapy combined with self-instructional training, behavioural parent training and school- or therapy-based contingency management. In these studies the effects of combined therapy packages have been compared with those of psychological treatments, stimulant therapy and/or various control conditions. Such control conditions have included placebo pills, psychological support groups for children which have acted as attention placebo conditions, and waiting list control groups. In a review of such studies Hinshaw et a/. (1998) concluded that the short-term effects of stimulant therapy are greater than those of behavioural parent training and contingency management programmes. While contingency management interventions add little incremental value to the short-term impact of high dosage (.6-.8 mg/kg body weight) stimulant therapy, they may reduce the requirement for high dosages by 50 per cent and they may lead to long- term maintenance of treatment gains.

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Attention deficit hyperactivity disorder 71

Method

The aim in this chapter was to review well-designed studies of the effects of psychological interventions or combined psychological and pharmacological interventions for children and adolescents with ADHD. A computer-based literature search of the PsychLit database was conducted. Terms that defined the disorder, such as attention deficit hyperactivity disorder, hyper- activity, impulsiveness, inattention and hyperkinesis were combined with terms that defined interventions such as treatment, therapy, intervention, con- tingency management, behavioural parent training, self-instructional train- ing, social skills training, behaviour therapy, cognitive-behaviour therapy, family therapy, methylphenidate and stimulant therapy. The search, which was confined to English language journals, covered the period 1977 to 1997 inclusively. A manual search through bibliographies of all recent re- view papers on psychological interventions for ADHD was also conducted. Treatment outcome studies were selected for inclusion in this review if they contained a psychological or psychological and pharmacological treatment condition or group and a control or comparison condition or group; if at least five cases were included in the active treatment group; and if reliable and valid pre- and post-treatment measures were included in the design of the study. Single-case designs and studies reported in dissertations or con- vention papers were not included in the review. Using these inclusion and exclusion criteria twenty studies were selected.

Characteristics of the studies

Characteristics of the studies are set out in Table 4.1. All of the studies were conducted between 1978 and 1993 and all were conducted in either the USA or Canada. Of the twenty studies eleven evaluated the effects of psychological interventions and nine examined the effects of combined psychological and pharmacological interventions. Eighteen studies employed comparative group designs and two used repeated measures designs where the same group of cases participated in two or more different treatment conditions sequentially. One thousand and ninety-six children were con- tained in the 66 treatment groups or conditions of the twenty studies. Of these 1096 children 862 were in treatment groups and 234 were in control conditions. Participants' ages ranged from three to eighteen years. For the sixteen studies where gender data were given, 87 per cent of cases were male and 13 per cent were female. Co-morbidity data were reported in only eight studies and for these, oppositional defiant disorder and conduct dis- order were the most commonly reported co-morbid conditions. For the ten studies where referral information was given, schools and physicians were the principal referring agents. Cognitive and/or behavioural treatment interventions were evaluated in all of the studies selected. All of the pro- grammes were conducted on an outpatient basis with two in community

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74 Margretta Nolan and Alan Carr

settings; five in hospitals, six in university outpatient clinics, six in schools and two in school-based summer treatment programmes. The number of sessions of treatment ranged from six to 40 sessions over three to sixteen weeks.

Methodological features

Methodological features of the twenty studies included in this review are presented in Table 4.2. All of the studies included in this review contained control or comparison groups or conditions. All studies contained diagnost- ically homogeneous groups which were assessed before and after treatment on reliable and valid measures. In 60 per cent of studies parent ratings of improvement were recorded and in 75 per cent of studies teacher ratings of behavioural changes were made. Parent- and teacher-rated symptomatic improvement after treatment and at follow-up were commonly assessed with the Conners Parent Rating Scale or the Conners Teacher Rating Scale (Conners, 1990), both of which contain a specific hyperactivity factor score. Researcher-rated improvements, which were conducted in sixteen studies, were based on observations of specific classroom behaviours such as on- task and off-task behaviour or disruptive behaviour. Improvements in rela- tionships within the child's family system and social network were conducted in only two of these twenty studies, but self-esteem was assessed in four studies, attentional deployment in eleven, and academic achievement in eight. The Piers-Harris Children's Self-Concept Scale (Piers and Harris, 1969) was commonly used to assess self-esteem and the Wide Range Achievement Test (Wilkinson, 1993) to assess academic performance. To assess children's capacity to deploy attention in a sustained manner a range of laboratory test were used and these included the Matching Familiar Figures Test (Kagan, 1966), the Continuous Performance Test (Conners, 1995) and the Porteus Mazes (Porteus, 1955). In 70 per cent of studies cases were randomly assigned to conditions. In 40 per cent of studies cases within conditions were matched for co-morbidity. In 75 per cent of studies, groups were demographically similar. In 50 per cent of studies follow-up assessments were conducted two or more months following the end of treatment. In 50 per cent of studies deterioration was assessed and in 80 per cent, drop-out rates were reported. In 20 per cent of studies information on engagement in further treatment was given. In 45 per cent of studies information on both statistical and clinical significance of treatment gains was reported. Experi- enced therapists were used in 50 per cent of studies and in eight of the four- teen studies (57 per cent) where two or more treatments were compared, information given in the reports suggested that treatments were equally valued by the research team. In 75 per cent of studies treatments were manualized but in only 35 per cent of studies was information on supervision given. In 55 per cent of studies treatment integrity was checked. Different treatments compared were equally valued. In 80 per cent of studies informa- tion on concurrent treatment was given but in only 10 per cent of studies

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76 Margretta Nolan and Alan Carr

was information on engagement in further treatment given. Overall this was a methodologically robust group of studies.

Substantive findings

Effect sizes and other outcome results of the eleven studies which focused exclusively on the effects of psychological treatments of ADHD are given in Table 4.3. Results of studies of combined psychological and pharmacolo- gical interventions are given in Table 4.4. A narrative summary of key findings from all twenty studies is presented in Table 4.5. What follows is a summary of these studies.

Psychological treatment

Eleven studies in this review examined the effects of psychological treat- ment on ADHD in children and adolescents. Three of these studies were concerned primarily with the effects of self-instructional training combined with therapy-based contingency management (Kendall and Braswell, 1982; Kendall and Finch, 1978; Kendall and Wilcox, 1980); one evaluated a social skills training programme (Frankel et a/., 1997); three assessed the effects of behavioural parent training (Anastopoulos eta/., 1993; Barkley et al., 1992; Pisterman et al., 1992); and four examined the effects of multicom- ponent programmes involving behavioural parent training, self-instructional training and school-based contingency management (Abikoff and Gittleman, 1984; Bloomquist et al., 1991; Horn et al., 1987, 1990).

Self-instructional training and social skills training

In Kendall's series of three investigations of self-instructional trammg, the first study (Kendall and Finch, 1978) evaluated the effects of routine self-instructional training. The six-session treatment programme involved Meichenbaum and Goodman's (1971) self-instructional approach com- bined with a response-cost procedure. In the self-instructional training the therapist demonstrated how to use increasingly covert self-instructions from speaking aloud to engaging in covert self-talk to guide completing particular tasks such as finishing a picture. There were five steps in this self- instructional protocol: problem definition, problem approach, focusing attention, selecting an answer and self-reinforcing for correct performance. For this training, a standard set of materials was used over the six sessions covering the areas of conceptual thinking, attention to detail, recognition of identities, sequential recognition, visual closure and visual reproduction. For example, with sequential recognition children had to work out what comes next in a sequence from an array of alternatives. For the response- cost procedure, children were given ten poker chips and informed that they could buy items from a reinforcement menu with the chips after the session

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Attention deficit hyperactivity disorder 77

but could lose chips for making mistakes during the session. Cases in the control group covered the six-session curriculum but did not receive self- instructional training or undergo response-cost procedures.

In Kendall's second study (Kendall and Wilcox, 1980), similar self- instructional and response-cost therapy techniques and teaching materials were used over twelve sessions, but for one group, concrete self-instructions which focused on the specific task at hand were used whereas for the second treatment condition, children were coached in using abstract self- instructions. For example, children in the concrete self-instructional training group were taught to use task-specific self-instructions such as 'I'm to find the picture that doesn't match; I must look at the pictures'. In contrast, children in the abstract self-instructional training programme used more general, conceptually based self-instructions such as 'My first step is to make sure that I know what I'm supposed to do; I should think about only what I am doing right now'.

In Kendall's third study (Kendall and Braswell, 1982) the self-instructional training procedure initially helped the child to develop concrete self- statements but later, more general abstract self-instructions were taught. In addition, a broader curriculum was used which covered social as well as academic problem solving. This treatment, combined with the response- cost procedure used in the other two studies, was compared with a pro- gramme that employed the use of response cost alone and a control condition where neither self-instruction nor response-cost procedures were used.

For the self-instructional training programmes combined with therapy- based response-cost procedures evaluated in these three studies, effect sizes based on teacher-reported improvements ranged from 0.8 to 1.3, with the highest effect size occurring in the group that received the abstract or con- ceptually based self-instructional training. This indicates that from teachers' perspective, the average child who participated in these programmes fared better after treatment than 79 to 90 per cent of cases in the control group. At four to twelve weeks' follow-up, excluding the group who received con- crete rather than abstract self-instructional training and who all relapsed, effect sizes based on teacher-reported improvements ranged from 0.7 to 1.3. Thus, four to twelve weeks following treatment, the average treated cases fared better than 76-90 per cent of cases in the control group on teacher- rated improvements.

Effect sizes for therapist-rated improvement following treatment ranged from 1.8 to 2.0 and at four to twelve weeks' follow-up in the third study the effect size based on therapists' ratings was 1.8. These results indicate that from therapists' perspective the average treated case fared better after treatment and at follow-up than 96 per cent of untreated cases.

Effect sizes for self-rated improvement, parent-rated improvement, self- esteem, and reading achievement both following treatment and at follow- up were small and ranged from -0.3 to 0.5. Effect sizes for performance on laboratory tests of vigilance and attentional deployment following treatment

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Sy st

em ic

a nd

c og

ni ti

ve i

m pr

ov em

en t

at f

ol lo

w -u

p Pa

re nt

-< :h

ild i

nt er

ac ti

C hi

ld re

n' s

se lf-

es te

Pe rf

or m

an ce

o n

Ia b

t es

- -

0 .9

2 -

-1 .0

0 0.

9 0.

4 R

ea di

n g

ac h

ie ve

m en

t -

- 0.

3 -0

- 0.

5 -0

-0 .5

3 0.

4 Po

si tiv

e cl

in ic

al o

ut co

m es

i m

pr ov

ed a

ft er

t re

at m

en t

- -

5 7

v 45

% i

m pr

ov ed

a t

fo llo

w -u

p 50

50 %

v 5

0 %

N eg

at iv

e cl

in ic

al o

ut co

m es

D et

er io

ra ti

% D

ro p-

ou t

- 0%

- 13

13 %

- -

18 %

ng ag

ed i

n fu

rt he

r tr

ea tm

en t

- -

- 85

K ey

B PT

= B

eh av

io ur

al p

a re

nt t

ra in

in g.

S IT

Sc lf

-i ns

rr uc

ri on

al t

ra in

in g.

S IT

-C O

N =

on cr

et e

se lf

-i n

st ru

ct io

n al

t ra

in in

SI T

-A B

S =

A b

st ra

ct s

el f-

in st

ru ct

io n

al t

ra in

in g.

T B

-C M

= T

h er

ap y-

b as

ed c

on ti

n ge

n cy

an ag

em en

t. SB

-C M

Sc ho

ol -b

as ed

c on

ti ng

en cy

m an

ag em

en t.

P S

C T

= P

ro b

le m

s ol

vi ng

a nd

c om

m un

ic at

io n

sk ill

s tr

ai ni

ng .

SS T

= S

oc ia

l sk

ill s

tr ai

n in

1- 1

= fa

m ily

t he

ra py

. ST

St im

ul an

t th

er ap

y w

it h

m et

hy lp

h en

id at

e be

tw ee

n 10

a nd

4 0

m g

pe r

da y

in a

d ivi

de d

do se

a nd

b as

ed o

n .3

-. 4

m g/

kg b

od y

w ei

gh t.

L o·

S T

= 0

.3 -0

.4 m

g/ kg

, bi

d of

m et

hy lp

he ni

da te

. H

i- ST

= 0

.6 -0

.8 m

g/ kg

, bi

d of

m et

hy lp

he ni

da te

. S

= Im

p ro

ve m

en t

w as

s ig

ni fi

ca nt

a t

p <

.0 5

b ut

i ns

uf fi

ci en

t da

ta w

er e

pr ov

id ed

t o

ca lc

u la

te .

C op

yr ig

ht ©

2 00

1. T

ay lo

r & F

ra nc

is G

ro up

. A ll

rig ht

s re

se rv

ed .

Ta bl

e 4.

5 S

um m

ar y

o f

m ai

n fi

nd in

gs o

f tw

en ty

t re

at m

en t

ou tc

om e

st ud

ie s

o f

A D

H D

St ud

y St

ud y

Au th

or s

Ye ar

p er

g p

N o.

o f

G ro

K ey

f in

di ng

s no

. ty

se ss

io n

s di

ffe re

nc es

K en

da ll

a nd

F in

19 78

S IT

+ T

B -C

M =

1 0

6 1

> 2

•

T he

S IT

+ T

B -C

M g

ro up

i m

pr ov

ed i

n te

ac he

r- ra

te d

2 . c

= 1

0 im

pu ls

iv it

y, M

F F

T ,

bu t

n o

t se

lf -r

ep or

te d

im pu

ls iv

it y

or t

ea ch

er -r

at ed

c on

fl ic

ts .

2 PI

en da

ll a

nd W

il co

x 19

1. S

IT -C

O N

+ T

B -C

M =

1 1

2 >

1 >

• B

ot h

SJ T

-A B

S an

d S

IT -C

O N

g ro

up s

im pr

ov ed

o n

2. S

IT -A

B S

+ T

B -C

M =

1 1

te ac

he r-

ra te

d im

pu ls

iv it

y bu

t th

e SI

T -A

B S

gr ou

p 3.

c =

1 1

sh ow

ed g

re at

es t

im pr

ov em

en t.

•

N o

im pr

ov em

en t

on s

el f-

re po

rt ed

i m

pu ls

iv it

y or

(' )

te st

s of

a tt

en ti

on al

d ep

lo ym

en t

(M F

F T

a nd

P or

te us

.g M

az es

) oc

cu rr

ed .

3 PI

en da

ll a

nd B

ra sw

el l

19 82

S IT

-A B

S +

T B

-C M

= 9

> 2

> 3

•

O ve

ra ll

t he

S IT

-A B

S tr

ea tm

en t

w as

s up

er io

r to

t he

'-<:

:: 2.

T B

-C M

= 9

B -C

M t

re at

m en

<2·

3. c

= 9

•

T ea

ch er

s' r

at in

gs o

f ch

il d'

s se

lf -c

on tr

ol p

os t-

::r- tr

ea tm

en t

w er

e hi

gh er

f or

t he

S IT

-A B

S +

T B

-C M

) 0.

. gr

ou p

bu t

th is

d if

fe re

nc e

w as

he d

ou t

at 1

m on

~ fo

ll ow

-u p.

•

T he

ra pi

st 's

r at

in gs

o f

im pr

ov em

en t

w er

e gr

ea te

.....

fo r

th e

S IT

-A B

S -

T B

-C M

g ro

up .

(! )

• B

ot h

tr ea

tm en

ts l

ed t

o im

pr ov

em en

ts i

n te

ac he

r- ~ . ~

ra te

d hy

pe ra

ct iv

it y

. •

P er

fo rm

an ce

o n

m at

ch in

g fa

m il

ia r

fi gu

re s

te st

; re

ad in

g, s

pe ll

in g

an d

ar it

hm et

ic s

ub te

st s

of th

e W

R A

T ;

se lf

-e st

ee m

a nd

p ar

en t-

ra te

d co

nt ro

l an

d hy

pe ra

ct iv

it y

fo r

bo th

c on

di ti

on s

w er

e th

e sa

m e

th os

e sh

ow n

by t

he c

on tr

ol g

ro up

. 4

F ra

nk el

e t a

l. 19

1. S

S T

= 4

9 12

> 2

•

C hi

ld re

n in

t he

S ST

g ro

up s

ho w

ed i

m pr

ov em

en ts

i n

2 . c

= 2

4 pa

re nt

-r ep

or te

d se

lf -c

on tr

ol a

nd a

ss er

ti on

a nd

ac he

r- ra

te d

w it

hd ra

w al

, li

ke ab

il it

y an

d ag

gr es

si on

. 5

P is

te rm

an e

t a l.

19 92

B PT

= 2

3 12

> 2

•

F or

p re

sc ho

ol er

s w

it h

A D

H D

c hi

ld re

n w

ho se

c =

2 2

pa re

nt s

re ce

iv ed

g ro

up -b

as ed

B PT

i nc

re as

co m

pl ia

nc e

w it

h pa

re nt

al r

eq ue

st s

an d

pa re

nt -c

hi ld

te ra

ct io

n al

so i

m pr

ov ed

. •

65 %

o f

ca se

s im

pr ov

ed c

li ni

ca ll

y an

d re

m ai

ne d

im pr

ov ed

a t

3- m

on th

f ol

lo w

u p.

A na

st op

ou lo

s et

a l.

19 93

B P

T =

1 9

9 1

2 •

C hi

ld re

n in

t he

B PT

g ro

up i

m pr

ov ed

o n

th e

A D

H D

c =

1 5

ra ti

ng s

ca le

C op

yr ig

ht ©

2 00

1. T

ay lo

r & F

ra nc

is G

ro up

. A ll

rig ht

s re

se rv

ed .

• A

t a

sy st

em ic

l ev

el t

he B

PT g

ro up

i m

pr ov

ed o

n th

e pa

re nt

a nd

c hi

ld d

om ai

ns o

f th

e pa

re nt

in g

st re

in de

x an

d th

e pa

re nt

s al

so i

m pr

ov ed

o n

an i

nd ex

o f

pa re

nt in

g se

lf -e

ff ic

ac y

. 7

B ar

kl ey

e t a

/. 19

1. B

PT =

2 0

1 =

2 >

• F

or a

do le

sc en

ts w

it h

A D

H D

, B

PT w

as a

s ef

fe ct

iv e

2 . P

S +

C T

= 2

1 as

P S

+ C

T a

nd a

l itt

le b

et te

r th

an F

T w

it h

ab ou

t 3.

F T

= 2

0 20

% s

ho w

in g

cl in

ic al

ly s

ig ni

fi ca

nt i

m pr

ov em

en t.

o rn

et a

/. 19

1. B

PT +

S IT

= 7

> 1

= 2

•

O ve

ra ll

t he

o ut

co m

e fo

r ch

il dr

en r

ec ei

vi ng

S IT

w as

B PT

= 6

ig ht

ly s

up er

io r

to t

ha t

of c

hi ld

re n

re ce

iv in

g B

3. S

IT =

or a

c om

bi ne

d tr

ea tm

en t

pa ck

ag e

w hi

ch i

nc lu

de d

bo th

t re

at m

en ts

. •

A t

on e-

m on

th f

ol lo

w -u

p ch

il dr

en i

n th

e SI

T g

ro up

ta in

ed l

ow er

h yp

er ac

ti vi

ty s

co re

s on

t he

C PR

S an

d in

t hi

s w

ay S

IT w

as s

up er

io r

to t

he o

th er

t w

o ap

pr oa

ch es

. •

T he

o ut

co m

e fo

r ca

se s

re ce

iv in

g SI

T ,

B PT

a nd

t he

) co

m bi

ne d

pa ck

ag e

w as

s im

il ar

a ft

er t

re at

m en

t an

.g at

o ne

-m on

th f

ol lo

w -u

p on

a ll

ot he

r pa

re nt

- an

""' te

ac he

r- ra

te d

sy m

pt om

s, c

hi ld

s el

f- co

nc ep

t, ch

il d

<2·

pe rf

or m

an ce

o n

la b

te st

s w

hi ch

a ss

es se

d at

te nt

io na

::r- de

pl oy

m en

t (M

FF T

) an

d ac

hi ev

em en

t te

st s

(i )

(W R

A T

0. .

• Im

pr ov

em en

t w

as a

ss oc

ia te

d w

it h

th e

fo ll

ow in

~ fa

ct or

s: l

ev el

o f

so ci

al s

up po

rt a

va il

ab le

f or

p ar

en ts

; ch

il dr

en 's

c ap

ac it

y to

r ef

le ct

o n

th ei

r pr

ob le

m s

an d

.....

ch il

dr en

's l

oc us

o f

co nt

ro l.

) ~ .

9 PI

bi ko

ff a

19 84

B PT

+ S

B -C

M =

2 8

15 w

> 2

•

C hi

ld re

n w

ho r

ec ei

ve d

th e

B PT

+ S

B -C

M p

ac ka

G it

tl em

2. c

= 2

8 sh

ow ed

s ig

ni fi

ca nt

r ed

uc ti

on s

in a

gg re

ss io

n, b

ut n

o t

hy pe

ra ct

iv it

y an

d in

at te

nt io

H o

rn et

a /.

19 90

B PT

+ S

IT +

S B

-C M

= 1

1 27

> 2

= 3

•

W he

n ca

se s

w er

e cl

as si

fi ed

o n

th e

C B

C L

B PT

= 1

2 ex

te rn

al iz

in g

sc al

e as

i m

pr ov

ed o

r no

t 3.

S IT

= 1

1 fo

ll ow

in g

tr ea

tm en

t, t

he c

om bi

ne d

tr ea

tm en

t (B

PT +

S IT

+ S

B -C

M )

le d

to m

or e

im pr

ov em

en t

th an

e it

he r

B PT

o r

SI T

. •

A ll

th re

e tr

ea tm

en ts

l ed

t o

pa re

nt -

an d

te ac

he r-

ra te

d im

pr ov

em en

ts i

n be

ha vi

ou r

fr om

p re

- to

p os

t- te

on t

he C

B C

L a

nd t

he C

T R

• N

on e

of th

e tr

ea tm

en ts

l ed

t o

t ea

ch er

-r at

im pr

ov em

en ts

o n

th e

C T

R S

a t

fo ll

ow -u

• N

on e

of th

e tr

ea tm

en ts

h ad

a s

ig ni

fi ca

nt e

ff ec

t on

hi ev

em en

t te

st (

W R

A T

) sc

or es

, la

b te

st s

o f

at te

nt io

na l

de pl

oy m

en t

(C PT

), o

r se

lf -c

on ce

pt .

C op

yr ig

ht ©

2 00

1. T

ay lo

r & F

ra nc

is G

ro up

. A ll

rig ht

s re

se rv

ed .

Ta bl

e 4.

5 (c

on t'd

)

St ud

y St

ud y

A ut

ho rs

N p

er g

p N

o. o

f G

ro up

ey f

in di

ng s

no .

ty pe

ss io

n s

di ffe

re nc

B lo

om qu

is t

et a

/. 19

1. B

PT +

S B

-C M

+ S

IT =

1 1

1 >

2 >

3 •

T he

m ul

ti co

m po

ne nt

p ro

gr am

m e

2. S

B -C

M =

1 2

( B PT

+ S

B -C

M +

S IT

) w

as m

or e

ef fe

ct iv

e th

an t

3. c

= 1

3 SB

-C M

p ro

gr am

m e

in i

m pr

ov in

g on

-t as

k be

ha vi

ou r

( )

in s

ch oo

l bu

t at

o ne

-m on

th f

ol lo

w -u

p th

is e

ff ec

t w

as he

d ou

~ •

T he

p ro

gr am

m es

h ad

n o

ef fe

ct s

on t

ea ch

er o

r ch

il d

ra ti

ng s

of a

dj us

tm en

<2 ·

PI -S

C oh

en e

ta /.

1. S

IT +

S T

6 20

= 2

= 3

= 4

•

F or

k in

de rg

ar te

n ch

il dr

en w

it h

A H

D a

ll th

re e

:::r

2. S

IT =

tr ea

tm en

t pa

ck ag

es w

er e

no m

or e

ef fe

ct iv

e th

Ci>

3. S

T =

no t

re at

m en

t on

p ar

en t

an d

te ac

he r

ra ti

ng s

on t

Q .

4. C

= 4

on ne

rs ' s

ca le

s, l

ab t

es ts

o f

at te

nt io

na l

de pl

oy m

en t

s: (M

F F

T ),

a nd

s el

f- co

nc ep

t. Q

) 13

-S T

ro w

n et

a/ .

19 85

S IT

+ S

T =

1 0

1 =

2 >

3 >

• F

or p

re -a

do le

sc en

t bo

ys w

it h

A D

H D

, co

m bi

ne d

..... .

2 .S

IT =

1 0

T a

nd S

T t

re at

m en

t w

as n

o be

tt er

t ha

n ST

a lo

~ 3.

S T

= 1

0 an

d bo

th w

er e

be tt

er t

ha n

SI T

. 4

. c =

1 0

• Im

pr ov

em en

ts f

or p

ar en

t an

d te

ac he

r ra

ti ng

s on

t he

on ne

rs s

ca le

s oc

cu rr

ed f

or t

he S

IT +

S T

a nd

S T

ou ps

. •

SI T

+ S

T a

nd S

T g

ro up

s im

pr ov

ed t

he ir

s co

re s

la b

te st

s of

a tt

en ti

on al

d ep

lo ym

en t

(M FF

T ).

•

N on

e of

th e

gr ou

ps i

m pr

ov ed

o n

m ea

su re

s of

ad em

ic a

ch ie

ve m

en t

(W R

A T

PI -S

H in

sh aw

e ta

19 84

S IT

+ S

T =

1 1

6 1

> 2

•

T he

S IT

+ S

T p

ac ka

ge p

ro du

ce d

op ti

m al

e ff

ec ts

. 2.

S IT

+ P

= 1

0 D

ec re

as es

i n

th e

in te

ns it

y of

b eh

av io

ur w

he n

pr ov

ok ed

o cc

ur re

d as

a r

es ul

t of

th e

ST c

om po

ne nt

d in

cr ea

se s

in t

he u

se o

f se

lf -c

on tr

ol s

tr at

eg ie

s w

he n

pr ov

ok ed

o cc

ur re

d as

a r

es ul

t of

S IT

. 15

-S T

bi ko

ff a

19 85

S IT

+ S

T =

2 1

1 =

2 =

• F

ol lo

w in

g tr

ea tm

en t

th er

e w

er e

no d

if fe

re nc

G it

tl em

2. S

T +

S U

P =

1 4

be tw

ee n

th e

th re

e co

nd it

io ns

o n

pa re

nt o

r te

ac he

r 3.

S T

= 1

5 be

ha vi

ou r

ra ti

ng s,

l ab

t es

ts o

f at

te nt

io na

l de

pl oy

m en

t (M

FF T

) or

a ch

ie ve

m en

t te

st s

(W R

A T

C op

yr ig

ht ©

2 00

1. T

ay lo

r & F

ra nc

is G

ro up

. A ll

rig ht

s re

se rv

ed .

<2 ·

:::r

Q . ~ CD ~

PI -S

B ro

w n

et a

/. 19

PI -S

F ir

es to

ne e

ta /.

PI -S

C ar

ls on

e t a

/. 19

1. S

IT +

S T

= 9

. S IT

+ P

= 1

0 3.

S T

+ S

U P

= 8

S U

P +

P =

1. B

PT +

S T

= 3

0 2.

B PT

+ P

= 2

1 3.

S T

= 2

1. S

B -C

M +

H i-

S T

= 2

4 2.

S B

-C M

+ L

o- ST

= 2

4 3.

S B

-C M

+ P

= 2

4. H

i- S

T =

2 4

5. L

o- S

T =

2 4

6. p

= 2

4 R

ep ea

te d

m ea

su re

s de

si gn

2 2

9 40

1 =

2 =

3 =

1 =

3 >

F or

c la

ss b

eh av

io ur

= 2

= 4

= 5

> 3

= 6

or o

n- ta

sk b

eh av

io ur

= 2

= 4

> 3

= 5

> 6

or a

ch ie

ve m

en t

1 =

2 =

4 =

5 >

3 =

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t SI

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. •

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hi ev

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it h

SB -C

M a

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m or

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or a

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il dr

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f- re

po rt

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us tm

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in vo

lv in

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l ed

t o

m or

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an t

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ha m

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S B

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+ H

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T =

3 1

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B -C

M +

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B -C

M +

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3 1

4 . H

i- S

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3 1

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3 1

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a 1.

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+ S

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6 Ia

lo ng

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19 93

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+ S

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S B

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+ l

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1 6

3. B

PT +

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M +

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1 6

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4 >

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> 3

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fi nd

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• T

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th is

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a nd

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p er

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pa ct

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at o

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t he

l ow

S T

c on

di ti

on t

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to .

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it h

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as n

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d os

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t o

SB -C

M m

ad e

a su

bs ta

nt ia

l di

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t o

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sr oo

m b

eh av

io ur

a nd

ad em

ic p

er fo

rm an

ce .

• A

ft er

t re

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c as

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l ow

d os

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it h

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a nd

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w er

e as

i m

pr ov

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s th

os e

th at

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d hi

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ST a

lo ne

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(b ut

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w as

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bi ne

d w

it h

ps yc

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m ad

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pr ov

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ts o

n re

se ar

ch er

- ra

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of f-

ta sk

b eh

av io

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se lf

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to ry

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of a

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PT ),

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(W R

A T

-R r

ea di

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ca le

• A

t ni

ne -m

on th

f ol

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-u p

so m

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f th

es e

ga in

s w

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ta bl

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at in

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la bo

ra to

ry m

ea su

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of a

tt en

ti on

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ep lo

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ro m

p os

t- te

st t

o ni

ne -m

on th

f ol

lo w

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ca se

s th

re ce

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c om

bi ne

d ST

a nd

S B

-C M

t re

at m

en ts

m ad

e im

pr ov

em en

ts o

n pa

re nt

-r at

ed b

eh av

io ur

w he

re as

os e

th at

r ec

ei ve

d ST

o nl

y di

d no

K ey

= A

stu

dy o

f ps

yc h

ol og

ic al

i nt

er ve

nt io

n on

ly .

PJ -S

T =

stu

dy o

f co

m bi

ne d

ps yc

ho lo

gi ca

l in

te rv

en ti

on a

nd s

ti m

ul an

t tr

ea tm

en t.

B PT

B eh

av io

ur al

p ar

en t

tr ai

ni ng

. SI

T =

S el

f- in

st ru

ct io

na l

tr ai

n- in

g. S

IT -C

O N

::: :

C on

cr et

e se

lf -i

ns tr

uc ti

on al

t ra

in in

g. S

IT -A

B S

= A

b st

ra ct

s el

f- in

st ru

ct io

na l

tr ai

ni ng

. T

B -C

M =

T he

ra py

-b as

ed c

on ti

n ge

n cy

m an

ag em

en t.

S B

-C M

= S

ch oo

l- b

as ed

c on

ti ng

en cy

m an

ag em

en t.

& C

T =

P ro

b le

m s

ol vi

n g

an d

co m

m u

n ic

at io

n s

ki lls

t ra

in in

g. S

S T

= S

oc ia

l sk

ill s

tr ai

ni ng

. IT

= F

am ily

t he

ra py

. ST

= S

ti m

u la

n t

th er

ap y

w it

h m

et hy

lp he

ni da

te b

et w

ee n

10 a

nd 4

0 m

g pe

r da

y in

a d

iv id

ed d

os e

an d

ba se

d on

. 3-

.4 m

g/ kg

b od

y w

ei gh

t. L o - S T ~ 0

.3 -{

). 4

m g/

kg ,

bi d

of m

et hy

lp he

ni da

te .

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ST ~ 0

.6 -{

). 8

m g/

kg ,

bi d

o f

m et

hy lp

he ni

da te

. C

~C o n t r o l g

ro up

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Attention deficit hyperactivity disorder 87

ranged from 0.1 to 0.5 and at follow-up from 0.1 to 1.3. The high level of variability in these results makes it difficult to draw firm conclusions about the impact of treatment on attentional deployment.

Frankel et a/. (1997) examined the effects of social skills training on children with ADHD. In the training sessions children were taught conversa- tion and telephone skills; group entry skills for joining in peer activities; procedures for managing play-dates where children visit a youngster's home; skills for the management of peer rejection or teasing; negotiation skills for managing conflicts of interest; and skills for managing confrontations with adults. Didactic input, modelling, rehearsal and therapy-based contingency management were used throughout this social skills training programme. Children were also directly coached in play skills. In dyads, therapists used prompting and contingency management to facilitate the development of rule-following and turn-taking behaviours. Concurrently, parents received psychoeducation on the development of social skills in children. Following treatment, effect sizes for parent- and teacher-rated improvement were 1.1 and 1.0 indicating that the average treated child fared better after treatment than 84 to 86 per cent of untreated cases.

The results of these four studies of child-focused psychological interven- tions for ADHD allow a number of conclusions to be drawn. First, both self-instructional training and social skills training have positive effects on pre-adolescent school-aged children with ADHD. Self-instructional training where children learn both specific and general self-instructions combined with therapy-based contingency management over six to twelve sessions is probably effective in reducing school- and clinic-based behaviour problems, but not achievement problems, behavioural problems in the home or atten- tion deployment as assessed by laboratory tests of vigilance. However, cau- tion in drawing these conclusions is warranted because Kendall's studies on which these conclusions are based were conducted before the introduc- tion of stringent criteria for the diagnosis of ADHD were routinely used in selecting cases for inclusion in treatment trials. A second conclusion is that social skills training conducted over twelve sessions supplemented with therapy-based contingency management and parental psychoeducation is probably effective in reducing home- and school-based behaviour prob- lems. The studies reviewed in this section provide evidence for the short- term effectiveness of self-instructional and social skills training, but do not address the issue of long-term improvement.

Behavioural parent training

Three studies included in this review examined the effects of behavioural parent training offered as a self-contained treatment package (Anastopoulos et al., 1993; Barkley eta/., 1992; Pisterman et al., 1992). Pisterman eta/. (ibid.) evaluated the effects of a twelve-session behavioural parent training programme for preschool children with ADHD. The programme offered

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88 Margretta Nolan and Alan Carr

parents training in shaping and reinforcing compliance with parental requests and on-task behaviour, and using time-out procedures for dealing with non-compliance (Forehand and McMahon, 1981). Psychoeducation, modelling, rehearsal and video-feedback were used in parent training. Anastopoulos et a/. ( 199 3) examined the effects of a similar nine-session parent training programme for pre-adolescent school-age children (Barkley, 1987, 1990). Following treatment, in Pisterman's programme 65 per cent of cases showed clinically significant change on researcher ratings of on- task behaviour and in Anoustopoulos' study 64 per cent of cases showed clinically significant change on the ADHD rating scale (DuPaul, 1991). At follow-up in both studies these gains were maintained. In Pisterman's study there were substantial improvements in parent-child interaction. Treated cases fared better than 88 per cent of untreated cases following therapy and at follow-up. In Anastopoulos' study the parent-child system of the average treated case fared better than those 73 per cent of untreated cases. Combined deterioration and drop-out rates for both studies ranged from 20 to 21 per cent. These two studies provide evidence for the efficacy of behavioural parent training in leading to improvements in behaviour and parent-child relationships for preschoolers and pre-adolescent children with ADHD.

In contrast to Pisterman and Anastopoulos, who were concerned with children under twelve years of age, Barkley eta/. (1992) studied the impact of behavioural parent training with adolescents. They compared the effect- iveness of behavioural parent training with a programme of problem solving and communication skills training and a programme of structural family therapy. In each programme, ten sessions of therapy were offered. Clinically significant gains were made by 20 per cent of cases receiving behavioural parent training; nineteen of cases in the problem solving and communica- tion skills training programme; and only 5 per cent of cases who engaged in structural family therapy. Deterioration occurred in 10 per cent of the behavioural parent training cases but not in the other two conditions.

From these three studies it may be concluded that nine to twelve sessions of behavioural parent training is an effective treatment for a proportion of children and adolescents from three to eighteen years old with ADHD. Behavioural parent training leads to short-term positive changes in home- based behavioural problems and parent-child relationships. These studies provide no evidence for the long-term effectiveness of behavioural parent training or its impact on attentional deployment, academic performance or school-based behaviour.

Multicomponent treatment packages

In four studies the effects of behavioural parent training combined with self-instructional training and/or school-based contingency management were examined (Abikoff and Gittleman, 1984; Bloomquist eta/., 1991; Horn eta/., 1987; Hornet a/., 1990). Hornet a/. (1987) compared the effects of

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Attention deficit hyperactivity disorder 89

combined behavioural parent training and self-instructional training with self-instructional training alone and behavioural parent training alone. The behavioural parent training programme was similar to those described earlier in this section and was based on Patterson's (1976) approach. The self-instructional training programme was similar to those described in the previous section and was based on the approaches developed by Meichenbaum (1977) and Camp and Bash (1981). In all there were nine- teen treatment sessions: eight for behavioural parent training, eight for self- instructional training and three for school-based contingency management. Abikoff and Gittleman (1984) evaluated the effects of a combined beha- vioural parent training programme (Becker, 1971; Patterson, 1975) and school-based contingency management programme (O'Leary and O'Leary, 1972) in normalizing hyperactive children's behaviour. In all there were approximately fifteen sessions in this programme with eight devoted to parent training and several devoted to school-based contingency manage- ment. Horn et al. (1990) compared the efficacy of combined behavioural parent training, self-instructional training and a school-based contingency management programme with a behavioural parent training programme and a self-instructional training programme. The behavioural parent training programme was based on Barkley (1981), Patterson (1976) and Forehand and McMahon's (1981) manuals. The self-instructional training programme was based on the clinical practices outlined in Camp and Bash (1981), Kendall and Braswell (1985) and Meichenbaum's (1977) texts. The school- based contingency management programme involved consultations with teachers and the use of a daily report card system (Ayllon et al., 1975). In all there were 27 sessions: twelve for behavioural parent training, twelve for self-instructional training and three for school-based contingency management. Bloomquist et al. (1991) compared the effects of a combined programme of behavioural parent training, self-instructional training and school-based contingency management with a school-based contingency management programme alone using treatment procedures detailed in Braswell and Bloomquist (1991). In all there were 29 treatment sessions: seven for behavioural parent training, twenty for self-instructional training and two for school-based contingency management.

Across these four studies, for improvements in parent-reported behaviour following treatment, effect sizes ranged from 0.2 to 0.6 and at follow-up they ranged from -0.1 to 0.7. The largest sustained effects occurred in Horn et al.'s (1990) study where the multicomponent treatment package, when compared with the behavioural parent training and the self-instructional training programmes after treatment and at follow-up yielded effect sizes that ranged from 0.6 to 0. 7, indicating that the average case receiving the combined package fared better than 73-76 per cent of cases who received single component treatments. The worst results for combined treatments compared to single component treatments occurred in Horn et al.'s earlier ( 1987) study where they found an effect size of -1.0 at one-month follow-up

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90 Margretta Nolan and Alan Carr

on parent-rated behaviour. This showed that the average case receiving a combined behavioural parent training and self-instructional training pack- age was worse off than 84 per cent of cases who received self-instructional training alone.

For teacher-rated behavioural improvement comparing combined treat- ments with single treatments, effect sizes ranged from -0.6 to -0.1 follow- ing treatment across the four studies. These results show that none of the combined treatment packages were any better than single component approaches in modifying school-based behaviour in the period immediately following treatment. In fact they were marginally worse. At four to twelve weeks' follow-up, effect sizes for teacher-rated behaviour ranged from -0.5 to 0.5, with the worst and the best results occurring in Horn et al.'s later (1990) study. The average case in the multicomponent programme fared better at follow-up than 69 per cent of cases in the self-instructional train- ing programme and worse than 69 per cent of cases in the behavioural parent training programme.

Across the four studies, effect sizes for researcher ratings of children's behaviour ranged from 0.7 to above 2.0, with the largest effect sizes occur- ring in Bloomquist's (1991) study. The average case receiving a combined programme of behavioural parent training, self-instructional training and school-based contingency management fared better than 98 per cent of untreated controls.

For children's self-esteem, effect sizes across the four studies concerned with the impact of combined treatments ranged from -0.2 to 0.9 following treatment and from -1.0 to 1.1 at follow-up. Both the largest and smallest effect sizes occurred in studies where a combined treatment package was compared with self-instructional training. In Horn et al.'s earlier (1987) study, effect sizes of 0.9 and 1.1 were obtained post-treatment and at follow- up from a comparison of a combined progamme of behavioural parent training and self-instructional training with self-instructional training alone. In contrast, in Hornet al.'s later (1990) study, an effect size of -1.0 was obtained after treatment and at follow-up from a comparison of a com- bined programme of behavioural parent training, self-instructional training and school-based contingency management with self-instructional training alone. These conflicting findings make it difficult to draw firm conclusions in this domain.

For laboratory tests of attentional deployment, effect sizes across the four studies concerned with the impact of combined treatments after therapy and at follow-up ranged from -0.7 to 0.4. These results suggest that, com- pared with single component treatments, combined treatments did not enhance attentional deployment and vigilance for children with ADHD.

For academic achievement tests of reading skills, effect sizes across the four studies concerned with the impact of multicomponent programmes after therapy and at follow-up ranged from -0.5 to 0.7. Both the largest and smallest effect sizes occurred in studies where a multicomponent treatment

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Attention deficit hyperactivity disorder 91

package was compared with behavioural parent training. In Horn et al.'s earlier (1987) study, effect sizes of 0.5 and 0.7 were obtained after therapy and at follow-up from a comparison of a multicomponent programme with behavioural parent training alone. In contrast, in Horn et al.'s later (1990) study, effect sizes of -0.5 and -0.3 were obtained after treatment and at follow-up from a comparison of a multicomponent programme with behavioural parent training alone. These conflicting findings make it diffi- cult to draw firm conclusions in this domain.

In studies of multicomponent treatment programmes after therapy 36- 51 per cent of cases were classified as having made clinically significant improvements or being indistinguishable from children without ADHD and at follow-up these figures improved to 73 per cent. Caution is required in interpreting this follow-up figure since it is based on a single study. In com- parison, 9-25 per cent of cases who received single component treatments made clinically significant improvements. The drop-out rate for combined treatment packages was 23 per cent and for single component treatments, drop-out rates ranged from 15-20 per cent.

In summary, the studies reviewed in this section suggest that multicom- ponent treatment packages may be more effective than single component packages in reducing home-based behaviour problems and researcher- rated behaviour problems. For school-based behavioural and achievement problems, self-esteem and attentional deployment as assessed by laboratory tests of vigilance there was no compelling evidence that multicomponent treatment packages were any better than single component treatments. Effective multicomponent treatment packages included behavioural parent training, self-instructional training and in some instances school-based con- tingency management and spanned 17 to 29 sessions over eight to twelve weeks.

Combined psychological and pharmacological treatment

Nine studies in this review examined the effects of combined psychological and pharmacological treatments. Five of these involved self-instructional training combined with stimulant therapy (Abikoff and Gittleman, 1985; Brown et al., 1985, 1986; Cohen et al., 1981; Hinshaw et al., 1984). Four involved stimulant therapy combined with either behavioural parent train- ing, or school-based contingency management or multicomponent psy- chological interventions (Carlson et al., 1992; Firestone et al., 1986; Horn et al., 1991; Pelham et al., 1993).

Self-instructional training and stimulant therapy

Cohen et al. (1981) compared the outcome for kindergarten children with ADHD who received self-instructional training combined with stimulant therapy to that of children who received either of the treatment components

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alone and a control group. The self-instructional training was based on the protocols of Meichenbaum and Goodman (1971), Camp and Bash (1981) and Douglas et al. (1976). Stimulant therapy involved 10-20 mgs per day of methylphenidate. Children began medication one to two weeks before the first assessment and remained on medication for the post-treatment assessment. Brown et al. (1985), using a similar four-group research design to that of Cohen et a/. (1981), examined the effects of self-instructional training combined with stimulant therapy with school-aged children. The self-instructional training programme was based on the work of Meichenbaum and Goodman (1971) and Douglas et al. (1976). Stimulant therapy involved 5-15 mgs per day of methylphenidate administered in a divided dose and children remained on medication for post-treatment assessment. Hinshaw et al. (1984) compared the effects of self-instructional training combined with stimulant therapy to that of the same psychological treatment combined with a pill placebo. The self-instructional training addressed the management of academic problems and socially provocative situations (Meichenbaum, 1977; Spivack and Shure, 1974; Douglas et al., 1976; Kendall and Braswell, 1985). Stimulant therapy dosages of methyl- phenidate ranged from 4-40 mgs. Abikoff and Gittleman (1985) compared the effects of self-instructional training combined with stimulant therapy to those of stimulant therapy alone or in combination with an attention placebo psychological support treatment. The self-instructional training addressed the management of academic and social problems (Douglas et al., 1976; Meichenbaum, 1977; Spivack and Shure, 1974). Stimulant therapy included up to 80 mgs of methylphenidate, 50 mgs of dextroamphetamine or 50 mgs of pemoline per day given in a divided dose. Following sixteen weeks of treatment, all cases on stimulant medication alone and 50 per cent of those in the combined treatment group were placed on placebo pills and subsequently, their requirement for further stimulant treatment assessed regularly for a one-month period. Brown's team in a four-group design compared the effects of combined self-instructional training and stimulant therapy with those of stimulant therapy combined with an attention placebo psychological support treatment; self-instructional training combined with a pill placebo; and a placebo control group (Brown eta/., 1985; Brown, Borden et al., 1986; Brown, Wynne et al., 1986).

Self-instructional training followed Meichenbaum and Goodman's (1971) protocol and stimulant treatment involved 10-40 mgs of methylphenidate per day in a divided dose.

Across these five studies, for combined self-instructional training and stimulant therapy compared with self-instructional training alone or with a placebo pill, effect sizes for improvements in parent-rated behaviour ranged from 0.2 to 1.4 after treatment and the average effect size was 0.8, indicat- ing that for parent-rated behaviour problems the average case receiving the combined treatment fared better than 79 per cent of cases treated with self- instructional training alone. However, these parent-rated behavioural gains

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were not maintained at three months' follow-up in all studies, where effect sizes ranged from -0.5 to 0.8.

For combined self-instructional training and stimulant therapy compared with self-instructional training alone or with a placebo pill, effect sizes for improvements in teacher-rated behaviour ranged from 0.2 to 0.9 after treat- ment and the average effect size was 0.6, indicating that for teacher-rated behaviour problems the average case receiving the combined treatment fared better than 73 per cent of cases treated with self-instructional training alone. These teacher-rated behavioural gains, however, were not maintained at three months' follow-up in all studies, where effect sizes ranged from -0.3 to 0.7.

For combined self-instructional training and stimulant therapy compared with self-instructional training alone or with a placebo pill, effect sizes for improvements in self-rated behaviour ranged from 0.1 to 0.3 after treat- ment and from 0.3 to 2.4 at follow-up. Cases treated with the combined treatment made negligible progress compared with cases treated with self- instructional training alone over the course of treatment, but in one study at follow-up substantial gains were made. However, the variability in re- sults precludes firm conclusions being drawn in this domain.

For combined self-instructional training and stimulant therapy compared with self-instructional training alone or with a placebo pill, effect sizes for improvements in attentional deployment as assessed by laboratory tests range from -0.9 to 1.0 after treatment and from -1.0 to 0.9 at follow-up. Once again, as with the results on self-reported behavioural improvements, those for attentional deployment have such a wide variability that drawing firm conclusions about the benefits of combined self-instructional training and stimulant therapy compared with self-instructional training alone in this domain is not possible.

For combined self-instructional training and stimulant therapy compared with self-instructional training alone or with a placebo pill, effect sizes for improvements in academic achievement as assessed by standardized reading tests ranged from 0.1 to 0.2 after treatment and from -0.3 to -0.1 at follow-up. These results suggest that combined self-instructional training and stimulant therapy probably have few advantages over self-instructional training alone in this domain.

In one study (Hinshaw et a/., 1984) compared with self-instructional training alone or with a placebo pill, combined self-instructional training and stimulant therapy led to significant gains in researcher-rated behaviour when faced with interpersonal provocations in a laboratory situation.

Let us now consider the combined self-instructional training and stimu- lant therapy compared with stimulant therapy alone or with an attention placebo psychological support intervention. Across the four studies that made such comparisons effect sizes for parent-rated, teacher-rated and self- rated behavioural improvements ranged from -0.9 to 0.4 after treatment and at follow-up. These results suggest that combined self-instructional

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training and stimulant therapy probably has few advantages over stimulant therapy alone in facilitating behavioural improvements at home or at school. Effect sizes for attentional deployment and academic achievement ranged from -0.5 to 0.6 after treatment and at follow-up. These results suggest that combined self-instructional training and stimulant therapy probably have few advantages over stimulant therapy alone in facilitating improved attention and academic achievement.

In summary, compared with self-instructional training alone or with a placebo pill, combined self-instructional training and stimulant therapy led to short-term improvements in parent- and teacher-rated behaviour, but such gains were not always maintained at follow-up. For self-reported behavioural improvement, attentional deployment as assessed by laborat- ory tasks requiring sustained vigilance, and for academic achievement as assessed by standardized reading test, there was no firm evidence that combined self-instructional training and stimulant therapy were routinely more effective than self-instructional training alone or with a placebo pill. Combined self-instructional training and stimulant therapy probably had few advantages over stimulant therapy alone in facilitating behavioural improvements at home or school or in facilitating improved attention and academic achievement. Self-instructional training programmes examined in these studies involved six to 32 sessions over three to sixteen weeks and were offered on an outpatient basis. Stimulant therapy commonly involved a daily divided dose of 5-40 mgs of methylphenidate.

Behavioural parent training, school-based contingency management and stimulant therapy

Four studies included in this review investigated the effects of stimulant therapy combined with either behavioural parent training, or school-based contingency management or multicomponent psychological intervention programmes (Carlson et al., 1992; Firestone et al., 1986; Hornet al., 1991; Pelham et al., 1993 ). Firestone et a/. (ibid.) compared the effects of nine sessions of behavioural parent training based on Patterson's (1975) ap- proach combined with stimulant therapy, with behavioural parent training combined with a placebo pill. Children receiving stimulant treatment were given 10-30 mgs of methylphenidate per day in a divided dose.

For combined behavioural parent training and stimulant therapy com- pared with behavioural parent training plus a placebo pill, effect sizes for improvements in parent- and teacher-rated behaviour were 0.7 and 0.8 after treatment, indicating that the average case receiving the combined treat- ment fared better than 76 per cent of cases treated with behavioural parent training and a placebo at home and better than 79 per cent at school. However, these gains were not maintained when cases were followed up three months later and effect sizes of -0.4 and 0.0 were obtained for sus- tained improvements in parent- and teacher-rated behaviour respectively.

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For attentional deployment on laboratory tests of vigilance an effect size of 0.6 was obtained following treatment and this increased to 0.9 at three months' follow-up. Thus, the average case receiving combined behavioural parent training and stimulant therapy fared better on tests of attentional deployment three months after treatment than 82 per cent of cases who received behavioural parent training plus a placebo pill. Effect sizes for performance on academic reading achievement tests following treatment and three months later were 0.1 and 0.3, indicating that the differences between groups were negligible. At two years' follow-up, differences be- tween cases who received combined behavioural parent training and stimu- lant therapy and cases who received behavioural parent training plus a placebo pill were negligible on all variables. Following treatment and at three months' and two years' follow-up, differences between cases who received combined behavioural parent training and stimulant therapy and cases who received stimulant therapy only were negligible on all variables. Thus it may be concluded from Firestone's study that combined behavioural parent training and stimulant therapy were more effective than behavioural parent training without stimulant therapy in reducing parent- and teacher- rated behaviour problems and in improving attentional deployment in the short term but not the long term. However, the combined therapy was no more effective in the short term than stimulant therapy alone and neither had a significant impact on academic performance.

Carlson et al. (1992) compared the effects of school-based contingency management combined with high and low doses of stimulant therapy, with school-based contingency management combined with a placebo pill. In addition, groups that received high and low doses of stimulant therapy and a group that received a placebo pill without contingency management were included in the six condition repeated measures design. Children received treatment within the context of a summer day programme with 40 daily sessions conducted over an eight-week period. There were twelve children per class. The contingency management programme included a high level of classroom structure, rules posted on classroom walls and teacher feed- back on performance; a token and social reinforcement system; time out; an honour roll system; and a daily home-school report card. High dose methylphenidate stimulant therapy was based on 0.6 mg per kg body weight and low dose therapy was based on 0.6 mg per kg body weight. Stimulant therapy was given in a divided daily dose and the first dose was given within two hours of the treatment sessions. Pelham et a/. (1993) used a similar design, contingency management treatment procedures and stimulant medication dosages for their study. They report that the for low stimulant therapy the range was 5-15 mgs and for the high dose condition the range was 10-23 mgs.

In these two studies, for researcher ratings of on-task behaviour and disruptive behaviour three conditions produced the best results: the high stimulant therapy condition alone and in combination with school-based

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contingency management and the low stimulant therapy condition in combination with school-based contingency management. When these three conditions were compared with the low stimulant therapy condition and the school-based contingency management plus placebo conditions, the average effect size of 0.55 indicated that the average case in the top three conditions fared better than approximately 70 per cent of cases in the other two conditions. In Pelham et al.'s study (1993) 57 per cent of cases in the high stimulant therapy condition alone and in combination with school- based contingency management and the low stimulant therapy condition in combination with school-based contingency management showed clinic- ally significant improvement. In contrast only 46 per cent of cases in a low stimulant therapy condition and the school-based contingency manage- ment plus placebo conditions made such improvements. Thus, it may be concluded that the addition of school-based contingency management to a low dose of stimulant therapy made it as effective in improving classroom behaviour as a high dose of stimulant therapy.

Hornet al. (1991) compared the effects of a multicomponent treatment package containing behavioural parent training, self-instructional training and school-based contingency management combined with high and low doses of stimulant therapy, and the multicomponent treatment package combined with a placebo pill. In addition, groups that received high and low doses of stimulant therapy and a group that received a placebo pill without the contingency management programme were included in the six-group design. The behavioural parent training was based on manuals by Patterson (1976), Forehand and McMahon (1981), Barkley (1981) and Becker (1971). The self-instructional training component was based on protocols developed by Kendall and Braswell (1985), Camp and Bash (1991) and Meichenbaum (1977). The school-based contingency management programme involved a daily home-school report card system such as that described by Ayllon et al. (1975). In all there were 27 treatment sessions: twelve of behavioural parent training, twelve of self-instructional training and three of school-based contingency management. High dose methyl- phenidate stimulant therapy was based on 0.8 mg per kg body weight and low dose therapy was based on 0.4 mg per kg body weight. Nine-month follow-up data following the withdrawal of stimulant medication was published in a second paper (lalongo et al., 1993).

In this study, for teacher-rated behavioural improvement following treatment, three conditions produced the best results: the high-stimulant therapy condition alone and in combination with multicomponent treat- ment package and the low-stimulant therapy condition in combination with the multicomponent treatment package. When these three conditions were compared with the low-stimulant therapy condition and the multicomponent treatment package plus placebo conditions, the average effect size of 0.6 indicated that the average case in the top three conditions fared better than approximately 73 per cent of cases in the other two conditions. From

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post-test to nine-month follow-up, cases that received combined treatments made improvements on parent-rated behaviour whereas those that received stimulant treatment only did not.

In summary, the following conclusions may be drawn from the four studies addressed in this section. Combined behavioural parent training and stimulant therapy was more effective than behavioural parent training without stimulant therapy in reducing parent- and teacher-rated behaviour problems and in improving attentional deployment in the short term but not the long term. However, the combined therapy was no more effective in the short term than stimulant therapy alone and neither had a significant impact on academic performance. The addition of school-based contingency management or a multicomponent psychological intervention package to a low dose of stimulant therapy made it as effective in improving classroom behaviour as a high dose of stimulant therapy in the short term. Combined stimulant therapy and a multicomponent psychological intervention treat- ment package was more effective in leading to sustained improvements over a nine-month period in home-based behaviour problems than stimulant therapy alone.

Conclusions

From this review of twenty well-conducted studies, two broad conclusions may be drawn about the effectiveness of psychological treatments alone or in combination with pharmacological treatments for ADHD. First, a range of psychological interventions have positive short-term effects on ADHD symptomatology and related problems. These psychological treatments include child-focused interventions (social skills training, self-instructional training, therapy-based contingency management), family-based interven- tions (behavioural parent training, problem solving and communications training, family therapy), school-based interventions (school-based con- tingency management), and multisystemic interventions where child, family and school-focused interventions are combined into a multicomponent treat- ment package. Second, the effects of these interventions may be enhanced when they are combined with stimulant therapy. In addition to these broad conclusions, a series of specific conclusions may be drawn from this review about the effectiveness of particular interventions on particular features of ADHD symptomatology and related clinical features. A consideration of these follows.

Social skills training and self-instructional training were the principal child-focused psychological interventions for ADHD addressed in this review and the following conclusions concern these interventions. First, social skills training conducted over twelve sessions supplemented with therapy-based contingency management and parental psychoeducation is probably effective in reducing home- and school-based behaviour problems in the short term. Second, self-instructional, where children learn both specific and general

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self-instructions combined with therapy-based contingency management over six to twelve sessions is probably effective in reducing school- and clinic-based behaviour problems, but not home-based behaviour problems, achievement problems or attention deployment problems. Third, combined self-instructional training spanning six to 32 sessions over three to sixteen weeks and stimulant therapy involving a daily divided dose of 5-40 mgs of methylphenidate is probably more effective than self-instructional training alone in leading to short-term improvements in home- and school-based behaviour problems but no more effective than self-instructional training alone in improving achievement problems and attention deployment diffi- culties. Fourth, combined self-instructional training and stimulant therapy probably have few advantages over stimulant therapy alone in facilitating behavioural improvements at home or school.

Behavioural parent training was the principal family-based psychological intervention for ADHD addressed in this review and the following con- clusions concern these interventions. First, behavioural parent training conducted over nine to twelve sessions probably leads to short-term positive changes in home-based behavioural problems and parent-child relation- ships for children and adolescents from age three to eighteen with ADHD. Second, behavioural parent training has little impact on attentional deploy- ment, academic performance or school-based behaviour. Third, behavioural parent training is probably as effective as problem solving and communica- tion skills training and structural family therapy with adolescents. Fourth, combined behavioural parent training and stimulant therapy is probably more effective than behavioural parent training without stimulant therapy in reducing home- and school-based behaviour problems and in improving attentional deployment in the short term. Fifth, combined behavioural parent training and stimulant therapy are probably no more effective than stimulant therapy alone.

From this review, the following conclusions about the effectiveness of multicomponent treatment packages may be drawn. First, multicompon- ent treatment packages that include behavioural parent training, self- instructional training and school-based contingency management and span seventeen to 29 sessions over eight to twelve weeks are probably more effect- ive than single component packages in reducing home-based behaviour prob- lems in the short term. Second, multicomponent psychological intervention packages combined with a low dose (0.3 mglkg) of methylphenidate stimu- lant therapy are probably as effective as a high dose therapy (0.6 mglkg) alone in improving school-based behaviour problems in the short term. Third, multicomponent psychological intervention treatment packages combined with stimulant therapy are probably more effective in leading to sustained improvements in home-based behaviour over a nine-month period than stimulant therapy alone.

In drawing out the implications of these conclusions for clinical practice, service development and further research, it is important to keep in mind

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the risks associated with psychological and pharmacological interventions. Currently there are no sound reasons to suspect that any of the psycholo- gical interventions addressed in this review have serious short- or long-term negative effects on children's health or development. In contrast stimulant therapy has a number of well-documented side-effects, but unfortunately there is little information on the long-term negative effects of protracted stimulant therapy. In the short term methylphenidate may lead to insomnia (59 per cent), decreased appetite (55 per cent), stomach aches (33 per cent), headaches (30 per cent), and dizziness (12 per cent), motor and vocal tics (1 per cent) and there is also some evidence that stimulant therapy may lead to a reduction in growth velocity (Greenhill, 1998). These negative effects of stimulant therapy warrant a cautious approach to the routine use of high dosages.

The conclusions of this review suggest that in clinical practice for effect- ive short-term treatment of ADHD, multisystemic interventions involving multicomponent treatment packages combined with low dose stimulant therapy are the treatments of choice. Multicomponent treatment packages should include behavioural parent training, self-instructional training and school-based contingency management elements and span seventeen to 29 sessions over eight to twelve weeks. Low dose methylphenidate stimulant therapy should be based on 0.3 mg/kg body weight.

For effective long-term treatment, it is probable that a chronic care model of service delivery is required. Children with ADHD and their families, within such a model of service delivery, would be offered the option of infrequent but sustained contact with a psychological and paediatric service over the course of childhood and adolescence. It is likely that at transitional points within each yearly cycle (such as entering new school classes each autumn) and at transitional points within the life cycle (such as entering adolescence, changing school, or moving house) increased service contact would be required. Two of the studies reviewed in this chapter (Carlson et al., 1992; Pelham et al., 1993) underscore the value of intensive summer school day programmes as an option for service delivery and such annual programmes could well form part of a chronic care model of service delivery.

This review highlights the need for well-controlled large-scale long-term studies to examine the effectiveness of multicomponent treatment packages alone and in combination with low dose stimulant therapy offered within the context of a chronic care model. Of course it would be essential for such studies to take account of the design features outlined in Chapter 1 and in addition to include measures of classroom behaviour, academic achievement, attention deployment and stimulant therapy side-effects. Within the context of such studies there is also a need to examine the effects of withdrawing stimulant therapy following normalization of behaviour and achievement. Currently two such studies are nearing completion (Hechtman and Abikoff, 1995; Richters et al., 1995) but more are required.

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ASSESSMENT

Atkins, M., Pelham, W. and Licht, M. (1988). The development and validation of objective classroom measures for the assessment of conduct and attention deficit disorders. In R. Prinz (ed.), Advances In Behavioural Assessment Of Children And Families (Vol. 4, pp. 3-33). New York: Guilford.

Cairns, E. and Cammock, T. (1978). Development of a more reliable version of the Matching Familiar Figures Test. Developmental Psychology, 18, 555-60.

Conners, C. (1990). The Conners' Rating Scales. North Tonawanda, NY: Multi- Health Systems.

Conners, C. (1995). The Conners' Continuous Performance Test. North Tonawanda, NY: Multi-Health Systems.

Conners, C. (1996a). Conners' Abbreviated Symptom Questionnaire. Odessa, FL: PAR. Available from PAR, PO Box 998, Odessa, Florida, USA. Phone +1-800- 331-8378.

Conners, C. (1996b). Conners' Rating Scales Computer Programme. Available from PAR, PO Box 998, Odessa, Florida, USA. Phone +1-800-331-8378.

DuPaul, G. (1991). Parent and teacher ratings of ADHD symptoms: Psychometric properties in a community based sample. Journal of Clinical Child Psychology, 20, 245-53.

DuPaul, G. and Barkley, R. (1992). Situational variability of attention problems: Psychometric properties of the revised Home and School Situations Question- naires. Journal of Clinical Child Psychology, 21, 178-88.

Gilliam, J. (1996). Attention Deficit Hyperactivity Disorder Test. Odessa, FL: PAR. Available from PAR, PO Box 998, Odessa, Florida, USA. Phone+ 1-800-331-8378.

Ullmann, R., Sleator, E. and Sprague, R. (1984). A new rating scale for diagnosis and monitoring of ADD children. Psychopharmacology Bulletin, 20, 160-4.

Wilkinson, G. (1993). WRAT-3: Wide Range Achievement Test (Third Edition). Wilmington, Delaware: Wide Range Inc.

TREATMENT MANUALS AND RESOURCES

American Academy of Child and Adolescent Psychiatry (1991). Practice parameters for the assessment and treatment of ADHD. Journal of the American Academy of Child and Adolescent Psychiatry, 30, i-iii.

Barkley, R. (1987). Defiant Children: A Clinician's Manual for Parent Training. New York: Guilford.

Barkley, R. (1990). Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment (Second Edition). New York: Guilford.

Becker, W. (1971). Parents are Teachers: A Child Management Programme. Champaign, Ill: Research Press.

Braswell, L. and Bloomquist, M. (1991). Cognitive Behavioural Therapy for ADHD Children: Child, Family and School Interventions. New York: Guilford.

Camp, B. and Bash, M. (1981). Think Aloud: Increasing Social and Cognitive Skills: A Problem Solving Program for Children. Champaign, Ill: Research Press.

Cantwell, D.P. (1994). Therapeutic Management of Attention Deficit Disorder: Par- ticipant Workbook. New York: Guilford.

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Feindler, E. and Ecton, R. (1985). Adolescent Anger Control: Cognitive-Behavioural Techniques. New York: Pergamon.

Forehand, R. and McMahon, R. (1981). Helping the Non-compliant Child: A Clinician's Guide to Parent Training. New York: Guilford.

Gordon, M. (1995). How to Operate an ADHD Clinic or Subspecialty Practice. Odessa, FL: PAR.

Kendall, P. and Braswell, L. (1985). Cognitive Behavioural Therapy for Impulsive Children. New York: Guilford.

Meichenbaum, D. (1977). Cognitive Behaviour Modification. An Integrative Ap- proach. New York: Plenum.

O'Leary, K. and O'Leary, S. (1972). Classroom Management: The Successful Use of Behaviour Modification. New York: Pergamon.

Patterson, G. (1975). Families: Applications of Social Learning to Family Life. Champaign, Ill: Research Press.

Patterson, G. (1976). Living with Children: New Methods for Parents and Teachers. Champaign Ill: Research Press.

Pelham, W. (1994) . Attention Deficit Hyperactivity Disorder: A Clinician's Guide. New York: Plenum.

Robin, A. and Foster, S. (1989). Negotiating Parent-Adolescent Conflict. New York: Guilford.