Also in this Issue:
 What
Works Best for ADHD Children? 
Klassen, A., Miller, A.,
Raina, P., Lee, S.K., & Olsen, L. (1999). Attention-deficit hyperactivity
disorder in children and youth: A quantitative systematic review of the
efficacy of different management strategies. Canadian Journal of Psychiatry,
44, 1007-1016.
Attention
deficit hyperactivity disorder (ADHD) is the most frequently diagnosed
behaviour disorder in North America. About 3-5% of school-aged children
in North America meet the diagnostic criteria for ADHD.
Some
of the current strategies for managing ADHD include:
- Medicating the child to
reduce the frequency and intensity of problematic behaviours and to
allow the child to achieve better self control and better regulation
of attention to tasks.
- Educating the parents and
teachers about the nature of ADHD, thereby allowing them to have realistic
expectations of the child, providing simple strategies to modify the
child's environment to reduce behaviour problems, and training them
to acquire effective behaviour-managment skills.
- Using psychological therapy
to teach the child self- control and self-monitoring skills.
There
has been concern that ADHD may be over diagnosed and that prescriptions
for psychostimulants may be over prescribed in North America as the diagnosis
of ADHD is made less often and medication is prescribed less frequently
in other regions such as Europe and Australia.
Some
concerns around the prescription of psychostimulants for ADHD include:
- the safety of medication
for individual patients and possible adverse effects
- the potential for illicit
use and abuse of psychostimulants
- the economic impact of increasing
prescriptions
- the relative effectiveness
and safety of nondrug interventions
In
this paper, three treatment strategies for ADHD were examined to determine
their relative effectiveness. An extensive literature review lead to 26
studies that met the criteria of the researchers. Diagnoses of ADHD were
based on parents' and teachers' completed questionnaires on the child's
behaviour (the Hyperactivity Index of Conners' Teacher Rating Scale and
Conners' Parent Rating Scale are two widely used measures). The three
treatment conditions were tested against either a no treatment condition
or a placebo condition. In the majority of the studies (22 of 26), children
were randomly assigned to these conditions.
Results
- Medication-only therapy
was effective in reducing the symptoms of ADHD
- Behavioural therapies
used alone appeared not to be effective
[However,
it should be noted that only two studies were analysed in this category
and they had small samples and poor methodological quality].
- Combination therapy
was:
- more effective than
placebo or no treatment (for parent but not for teacher ratings)
- not more effective
than drug therapy alone
- more effective than
behavioural treatments alone (based on parent but not teacher
ratings)
[Since
drug therapy alone was found to be beneficial, we would then expect that
the addition of another mode of therapy would as least be as effective
as drug therapy alone. However, there were only three studies that examined
combined medication and behaviour therapy with small samples and mixed
methodological quality.]
The
authors suggest that medication may be more effective in reducing the
main symptoms of ADHD while behavioural therapies may be more effective
with other components of ADHD, such as confictual relationships with peers
and poor academic performance. However, because behavioural ratings are
used to measure the effect of treatment in most studies rather than other
measures such as direct observations of the student or measures on individual
treatment, the effects of modes of therapy other than medication may be
hard to assess.
The
authors discuss the other problems with testing the effects of behavioural
treatments in controlled experimental studies. As children with ADHD present
a different array of problems to clinicians, parents, teachers, and peers,
they cannot be categorized into one group. In this regard, these children
cannot be given one standard form of behaviour therapy as the treatment
must be in tune with the individual needs and differences of the child.
The effects of medication therapy on the other hand, lend themselves well
to controlled experimental studies.
Although
the results of this study suggest that medical therapy is more effective
than behavioural therapy alone or in combination with medical therapy,
there is a lack a quality research in the two latter areas. Therefore,
no conclusive statements about the relative effectiveness of these types
of therapies can be made.
Preventing the Development
of Antisocial Behaviour
Ialongo,
N.S., Werthamer, L., Kellam, S.G. Brown, C.H., Wang, S., & Lin, Y.
(1999). Proximal impact of two first-grade preventive interventions on
the early risk behaviors for later substance abuse, depression, and antisocial
behavior. American Journal of Community Psychology, 27, 599-641.
There
is considerable evidence suggesting that preventative interventions are
more cost effective than the treatment of antisocial behaviour after it
has become an established pattern of behaviour. In this study, 678 first-grade
children in nine Baltimore City public schools were randomly assigned
to three intervention conditions:
- Classroom Centered Intervention
- Family- School Partnership
Intervention
- A control group that received
no intervention
Classroom
Centered Intervention (CC)
The
three components included: curriculum enhancement, improved behaviour
management practices, and backup strategies for children who failed to
respond adequately to the intervention.
Family-School
Partnership Intervention (FSP)
This
intervention was designed to improve achievement and reduce early aggressive
behaviour, shy behaviour, and concentration problems by enhancing parent
teacher communication and providing parents with effective teaching and
child behaviour management strategies.
The
interventions were provided over the first-grade year, after pretest assessment
in the early Fall. Intervention impact was assessed in the Spring of the
first and second grades.
Results
- Children who underwent the
CC and FSP interventions did better in math and reading than children
in the control group. The improvement was most pronouced for those children
who were doing poorly before the intervention.
- Children who received the
CC intervention demonstrated significantly fewer behaviour problems
as rated by teachers both at the end of first and second grade. For
children who received the FSP intervention, their behaviour also improved
by the end of first grade but the improvement did not reach a statictically
significant level until the follow up at the end of the second grade.
- Significantly fewer boys
in the CC group were nominated as aggressive by peers in the Spring
of first grade than boys in control group. No significant effects were
found for CC girls or FSP girls or boys. [Although fewer boys in FSP
group were nominated by peers as aggressive compared to the control
group, the difference was not statisically significant.]
Comment
This
is yet another study showing that early intervention can reduce aggressive
behaviour and improve academic achievement. Although the follow-up in
this study was under two years, there are many studies showing that the
results of early intervention last through adolescence and adulthood.
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Institute
for the study of Antisocial behaviour in Youth (lAY) 
