A systematic review shows that simple classroom measures may reduce the impact of ADHD (but no recipes)

Next September, within a month, a lot of children who used to go to special education in Flanders, will be able to attend regular schools from now on. This does bring feelings of uncertainty to school leaders and teachers, as they have the impression that their classes already can be quite diverse and often unclear how to deal with it. One of the more phenomena who have been a theme for a longer period in education is ADHD and a new review study shows that simple classroom measures – without the need of taking drugs – can help, but at the same time warns to not to get the hopes up too high, as more (robust) research is needed and if you’re looking for clear recipes? I’m afraid you won’t find it here… yet.

From the press release (bold by me):

A systematic review was led by the University of Exeter Medical School funded by NIHR’s Health Research Technology Assessment programme and supported by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula (PenCLAHRC). The review has concluded that non-drug interventions in schools may be effective in improving outcomes such as performance in standardised tests for children with ADHD.

The team found 54 studies (39 randomised controlled trials and 15 non randomised studies) that tested many different ways of supporting these children, such as having daily report cards filled in by teachers and parents to give consistent and regular feedback, or study and organisational skills training, which can help children achieve better attainment levels, reduce hyperactive behaviour and increase attention.

However, the research, published in the journal Health Technology Assessment on July 1, also found so many different types of strategies, often combined in different ways and so many different ways of measuring whether they worked, that it was that it was impossible to clearly identify what works best. The researchers have called for more standardised assessment to make future research outcomes more meaningful.

The systematic review, which involved collaborators at Kings College London and the Hong Kong Institute of Education, looked at all available and relevant research published between 1980 and 2013. They examined the following different areas that are important to supporting children with ADHD in schools:- the effectiveness and cost-effectiveness of school-based interventions for children with or at risk of ADHD; and research investigating the attitudes and experiences of children, teachers, parents and others using ADHD interventions in school settings; as well as the experience of ADHD in school among pupils, their parents and teachers more generally.

The research team could find no studies of cost-effectiveness, which need to be conducted in future. The studies of attitudes and experience suggest that differences in beliefs about ADHD can create tensions in relationships between teachers, pupils and parents that may be significant barriers to its effective treatment. The review concluded that education of school staff as well as the public around ADHD would help to break down preconceptions and stigma, and that classroom / school culture as well as individualised support for children with ADHD may make the support offered more or less effective.

Professor Tamsin Ford, from the University of Exeter Medical School, led the study, which involved collaborators from Kings College London and the Hong Kong Institute for Education. She said: “There is strong evidence for the effectiveness of drugs for children with ADHD, but not all children can tolerate them or want to take them. ADHD can be disruptive to affected children as well as the classroom overall, but our study shows that effective psychological and behavioural management may make a significant improvement to children’s ability to cope with school. While this is encouraging, it’s not possible to give definitive guidance on what works because of variations between the strategies tested, and the design and analysis of the studies that we found. We now need more rigorous evaluation, with a focus on what works, for whom and in which contexts. Gaps in current research present opportunities to develop and test standardised interventions and research tools, and agree on gold standard outcome measure to provide answers to both schools and families.”

Abstract of the study:

Background:  Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterised by age-inappropriate levels of inattention, impulsivity and hyperactivity. School can be particularly challenging for children with ADHD. Few reviews have considered non-pharmacological interventions in school settings.
Objectives: To assess the effectiveness of non-pharmacological interventions delivered in school settings for pupils with, or at risk of, ADHD and to explore the factors that may enhance, or limit, their delivery.
Data sources: Twenty electronic databases (including PsycINFO, MEDLINE, EMBASE, Education Resources Information Centre, The Cochrane Library and Education Research Complete) were searched from 1980 to February–August 2013. Three separate searches were conducted for four systematic reviews; they were supplemented with forward and backwards citation chasing, website searching, author recommendations and hand-searches of key journals.
Review methods: The systematic reviews focused on (1) the effectiveness of school-based interventions for children with or at risk of ADHD; (2) quantitative research that explores attitudes towards school-based non-pharmacological interventions for pupils with ADHD; (3) qualitative research investigating the attitudes and experiences of children, teachers, parents and others using ADHD interventions in school settings; and (4) qualitative research exploring the experience of ADHD in school among pupils, their parents and teachers more generally. Methods of synthesis included a random-effects meta-analysis, meta-regression and narrative synthesis for review 1, narrative synthesis for review 2 and meta-ethnography and thematic analysis for reviews 3 and 4.
Results:  For review 1, 54 controlled trials met the inclusion criteria. For the 36 meta-analysed randomised controlled trials, beneficial effects (p < 0.05) were observed for several symptom and scholastic outcomes. Mean weighted effect sizes ranged from very small (d+ < 0.20) to large (d+ ≥ 0.80), but substantial heterogeneity in effect size estimates across studies was reported. Moderator analyses were not able to clarify which intervention features were linked with effectiveness. For review 2, 28 included studies revealed that educators’ attitudes towards interventions ranged in positivity. Most interventions were rated positively or neutrally across different studies. The only intervention that consistently recorded positive attitudes from educators was daily report cards. For review 3, 33 studies met the inclusion criteria. Key findings included tensions regarding the preferred format of interventions, particularly how structured interventions were and the extent to which they are tailored to the child with ADHD. There were mixed views about the impact of interventions, although it was clear that interventions both influence and are influenced by the relationships held by children with ADHD and participants’ attitudes towards school and ADHD. For review 4, 34 studies met the inclusion criteria. Key findings included the importance of causal attributions that teachers, parents and pupils made about ADHD symptoms, the decisions teachers made about treatment, the self-perceptions pupils developed about themselves, the role of the classroom environment and stigma in aggravating ADHD symptoms, and the significant barrier to treatment posed by the common presence of conflict in relationships between pupils–teachers, parents–teachers and pupils–peers in relation to ADHD. An overarching synthesis of the four reviews highlighted the importance of the context affecting interventions. It suggested that ADHD psychoeducation and relationship-building skills are potential implications for interventions.
Limitations: The breadth of both interventions and outcomes in the reviewed studies presented a challenge for categorisation, analysis and interpretation in reviews 1–3. Across reviews, relatively few studies were conducted in the UK, limiting the applicability of findings to UK education. In reviews 1 and 2, the poor methodological quality of some included studies was identified as a barrier to establishing effectiveness or comparing attitudes. In review 3 the descriptive analysis used by the majority of studies constrained theorising during synthesis. Studies in review 4 lacked detail regarding important issues like gender, pupil maturity and school level.
Conclusion:  Findings suggest some beneficial effects of non-pharmacological interventions for ADHD used in school settings, but substantial heterogeneity in effect sizes was seen across studies. The qualitative reviews demonstrate the importance of the context in which interventions are used. Future work should consider more rigorous evaluation of interventions, as well as focus on what works, for whom and in which contexts. Gaps in current research present opportunities for the development and testing of standardised tools to describe interventions, agreement on gold-standard outcome measures assessing ADHD behaviour and testing a range of potential moderators alongside intervention trials.

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