ADHD: Training Interventions Don't Have to Be Completed to Work

Degree of compliance with an effective ADHD intervention varied.

An assessment of outcomes from an intensive training intervention (TI) in middle school children with attention-deficit/hyperactivity disorder (ADHD) found improvement regardless of incomplete participation. That suggested to researchers that the level of kids' involvement was commensurate with their need for the program.

Intensive TIs to improve the coping skills of children with ADHD are conducted over many months to years in an effort to attain cumulative benefits over time. But the burden on families to provide transportation and for the children to attend multiple sessions each week inevitably affects compliance with the program.

Brandon Schultz, EdD, (picture) Department of Psychology, East Carolina University and colleagues sought to examine the effectiveness of one TI program by comparing participants to a control group receiving customary community care, as well as by distinguishing between those with varied levels of participation.

"Researchers most often examine the overall effect of an intervention based on original group assignment," Schultz and colleagues explain. "It is equally important to determine whether compliance leads to the benefits that treatment developers anticipate."

ITT

The researchers applied both an intent-to-treat () analysis of program effects on program participants and those likely to have completed participation except for obstacles, and a complier-average-causal-effect (CACE) analysis to compare those in compliance with the program to similar individuals in the control group who, they describe, "most likely would have complied had treatment been offered."

Schultz and colleagues explain that their use of statistical models to account for varied levels of compliance reflects their recognition that treatment compliers are an unusual subset of participants, who may be more motivated than their peers, or possibly in less need of the treatment.

The study randomized 216 public middle school students with ADHD to either the TI group (N=112) or the community care control group (N=104). There were no significant differences in group demographics, and in each, boys outnumbered girls in an approximate 3:1 ratio, consistent with prevalence surveys. Compliance was defined as 80% or greater attendance in the two sessions per week, each lasting a little over two hours, throughout the school year.

DBD

The TI sessions targeted development of what the researchers referred to as "academic enablers", including organization, study skills, assignment tracking, and social problem solving. Outcomes included school grades; and the parent-rated behavior measures: Children's Organizational Skills Scale (COSS), Disruptive Behavior Disorders Rating Scale (), Homework Problems Checklist. These were assessed five times during the school year, and in a follow-up 6 months after the school year and TI ended. In addition, examiners applied the Social Skills Improvement System (SSIS) scale at baseline, end of the TI, and at follow-up.

The researchers report that the TI compliers demonstrated medium to large gains in the parent rating scales of academic functioning and in grade point compared to similar participants in the control group. There were also gains in some social skills, although not as large as the academic ratings. They note the treatment effect size is comparable to that of medication effect.

They also report finding little difference between treatment compliers and outcomes for the treatment group overall, and that the benefits persisted through the six month follow-up. "TIs enable adolescents to master ADHD coping skills when attendance is commensurate with need," Schultz and colleagues conclude.

The assessment of outcomes of a treatment intervention for children with ADHD relative to their level of participation in the program, " Outcomes for Adolescents Who Comply with Long-term Psychosocial Treatment for ADHD," is in the March issue of the Journal of Consulting and Clinical Psychology.

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