Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterised by persistent inattention, impulsivity and hyperactivity.
School is a major part of children’s lives but children with ADHD may struggle to concentrate in class and/or behave in ways that can be disruptive in the classroom.
A recent health technology assessment report aims to summarise the literature on non-pharmacological school interventions for children with ADHD (Richardson et al, 2015). The authors conducted four systematic reviews focussing on effectiveness, attitudes and experiences.
Two independent reviewers completed a broad and systematic search of the literature for each review. Studies were then quality appraised according to standard criteria (the Cochrane risk of bias tool).
Review 1: Effectiveness
Fifty-four studies were included. These examined the effectiveness of school interventions on core ADHD symptoms, ‘ADHD-related symptoms’ (i.e. externalising symptoms, internalising symptoms and social skills) and/or academic outcomes. The 39 randomised controlled trials (RCTs) were collectively analysed using a technique called meta-analysis.
- Improvement on neurocognitive assessments of inattention and hyperactivity/impulsivity
- No differences on child-, parent-, teacher- or observer-ratings of core ADHD symptoms, except for an improvement in teacher-ratings of inattention
- No differences on child-, parent-, or teacher-ratings of ADHD-related symptoms, except for a significant improvement in teacher-ratings of externalising symptoms
- Improvement on standardised measures of academic achievement but not curriculum achievement
- Improvement on teacher-ratings of school adjustment, but not child- or parent-ratings
Several limitations are apparent in this review:
- First, the quality of studies was low: only eight studies attempted to control for the placebo effect and most studies did not report blinding of outcome assessors. This is problematic because previous studies have demonstrated non-blinded assessors are biased in favour of psychological interventions for ADHD (Sonuga-Barke et al., 2013)
- Second, the analysis of ‘ADHD-related symptoms’ was underpowered, and therefore unreliable, because there were only two to four studies examining each of these particular measures
- Third, due to a lack of overlap between intervention elements and the use of different outcome measures, the authors were unable to identify any reliable moderators of intervention effectiveness.
Review 2: Attitudes towards school interventions
Nineteen studies using quantitative measures of acceptability and perceived effectiveness towards school interventions were included in the synthesis. Participants were typically given brief descriptions of potential school interventions. Attitude ratings were categorised as positive >60%, neutral 60-40% or negative <40%.
The analysis revealed positive attitudes towards all five daily report card interventions where teachers provide daily feedback for parents about their child. There was no consistency in attitudes towards the other intervention types: contingency management, self-monitoring, special education, social skills training, and classroom accommodations. Although, attitudes were generally positive or neutral.
Sixty-one relevant studies were excluded because they examined attitudes of participants who experienced specific interventions. This is a relatively large dataset, which, might have added value to the review. Analysis of these data could have contributed to the evaluation of intervention types and enabled comparison with the data from Review 1. Furthermore, the majority of included studies were limited by their use of unstandardised measures and previously untested interventions.
Review 3: Attitudes and experiences of school interventions
Thirty-three studies were included. These studies qualitatively measured pupils’, peers’, parents’, and teachers’ attitudes and experiences of school interventions. Most studies employed semi-structured interviews and thematic analysis. The data were collectively analysed using meta-ethnography, which is a process of finding analogy between themes and explaining contradictory findings.
The main issues identified from the meta-ethnography were:
- Structural constraints within school: staff’s time, class size and funding
- Individualising interventions to meet the child’s need
- The balance of routine and structure versus flexibility and agency
- Whether the skills and knowledge learned would be applied given the self-regulation difficulties common in ADHD, and whether this would lead to improvements on important outcomes (e.g. academic achievement)
- The importance of good relationships, particularly pupil-teacher and school-home
- The relationship between attitudes and intervention effectiveness
The discussion was limited by the lack of theoretical integration within studies’ analyses. The contribution of this review to the research question was also potentially limited by the lack of studies focusing on specific interventions.
Review 4: Experiences and perceptions of children with ADHD in school
Thirty-four studies were included. These studies qualitatively measured pupils’, teachers’ and parents’ experiences and perceptions of children with ADHD in school. Most studies employed semi-structured interviews and thematic analysis. The studies were synthesised by participant type and analysed using a similar approach to Review 3.
The central theme developed from the synthesis emphasised the role of school structure and expectations on ADHD-related behaviours. The underlying issues identified were:
- Aggravation of ADHD symptoms due to school structure and relationship difficulties
- Polarised attributions about ADHD, i.e. either biological or sociological causes
- Marginalisation and stigma
- Impact of ADHD on relationships
The synthesis was limited by divergent theoretical approaches and data collection methods across studies. Furthermore, no studies specifically addressed gender, pupil maturity, or school level, which may be important issues.
- The authors highlight the importance of context, which operates at several levels: the pupil, classroom, school, and socio-political level. It is suggested that interventions need to be tailored to these contexts and supported by the school and government to be effective.
- Psychoeducation was identified as a potentially useful adjunct to any intervention to overcome stigma.
- Building relationships was perceived as an important target for an intervention, yet there was no empirical evidence for social skills training in Review 1.
- Several potentially important moderators of intervention effectiveness are suggested: age, gender, medication, intervention length, school context, home-school collaboration and stigma.
Strengths and limitations
- The authors present the first published reviews of the qualitative experiences of school interventions for ADHD and the experience of ADHD in school.
- The quantitative reviews also include a greater number of studies than previous reviews. The reviews benefited from broad search strategies and appropriate techniques to analyse the data.
- Quality assessments helped to guide the analyses in reviews 3 and 4, however, the low quality of studies in reviews 1 and 2 reduces the reliability of the findings.
- There was significant variability in the type of interventions studied and this severely limits the interpretability of the findings.
- There was also substantial variation in the age of pupils studied across the reviews, which limited the integration of the findings.
- There was a lack of UK studies available for review, which potentially limits the applicability of the findings to the UK education system.
There is mixed evidence for whether school interventions improve ADHD symptoms or academic outcomes. The lack of good quality studies, the variation in intervention types, and the use of different outcome measures makes it difficult to identify what works well and for whom. This requires further empirical investigation with well-controlled studies and outcome measures that are comparable across studies.
General considerations for the design of interventions were raised in the qualitative reviews: individualised interventions for the child and school, and holistic interventions that target relationships, attitudes, understanding, and self-concept.
The authors also encourage more support at the socio-political level in the form of guidelines for ADHD, teaching strategies, and school-home collaboration.
Richardson M, Moore DA, Gwernan-Jones R, Thompson-Coon J, Ukoumunne O, Rogers M, et al. (2015) Non-pharmacological interventions for attention-deficit/hyperactivity disorder (ADHD) delivered in school settings: Systematic reviews of quantitative and qualitative research. Health Technology Assessment 2015; 19 (45).
Sonuga-Barke EJS, Brandeis D, Cortese S, Daley D, Ferrin M, Holtmann M, … Sergeant J. (2013) Nonpharmacological interventions for ADHD: Systematic review and meta-analyses of randomized controlled trials of dietary and psychological treatments. The American Journal of Psychiatry, 170(3), 275-289. [PubMed abstract]