RAIS: A tale of complexity Systematic review of ADHD interventions in school settings findings from the RAIS review

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1 RAIS: A tale of complexity Systematic review of ADHD interventions in school settings findings from the RAIS review RAIS: A tale of complexity RAIS = Review of ADHD Interventions in Schools Darren Moore & Ruth Gwernan-Jones Complex disorder Complex review methods Complex findings The Project We conducted a series of systematic reviews of qualitative and quantitative research to identify the effectiveness of school-based interventions for children with ADHD, including the experience of and attitudes towards ADHD interventions and ADHD more generally. This project was funded by the National Institute for Health Research Health Technology Assessment (NIHR HTA) programme (project number 10/140/02) and supported by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula (PenCLAHRC). Review findings will be published in full in Health Technology Assessment. Visit the HTA programme website for further project information. The views and opinions expressed are our own and do not necessarily reflect those of the HTA programme, NIHR, NHS or the Department of Health. Research Questions What are the effects of non-pharmacological interventions for ADHD delivered in the school setting for children with or at risk of ADHD? What are the experiences and attitudes toward ADHD interventions in school settings? What are the experiences and attitudes regarding ADHD in school settings? Organisation of systematic reviews ADHD a complex disorder Attention Deficit/Hyperactivity Disorder (ADHD) is a developmental disorder characterised by ageinappropriate levels of Inattention Hyperactivity Impulsivity (APA, 2013) Today we will mainly focus on findings drawn from Review 1 and the overarching synthesis Prevalence (worldwide) is estimated at 5 to 7% of children (Willcutt, 2012). Although prevalence figures range from 1.4% to 11%. 1

2 Comorbidities Anxiety Anger Autistic Spectrum Social Skills Tic Disorders ADHD Conduct Disorder Organisation ADHD Artistic Mood dysregulation Oppositional Defiant Emotional Disruptive Subtypes attentiondeficit/hyperactivity disorder hyperactiveimpulsive type attentiondeficit/hyperactivity disorder inattentive type attentiondeficit/hyperactivity disorder combined type ADHD cont. The cause of ADHD is complex and may be most clearly understood as involving the interplay of biological, psychological and social factors Various issues around ADHD as a developmental disorder, including its existence, diagnosis and attitudes, e.g. naughty boy syndrome'. in 2009 O Reganfound that 50% of General Practitioners and 20% of Special Educational Needs Coordinators in the UK did not believe that ADHD was a real neurological condition (p. 4). Myths Caused by: Too much sugar Too much TV or video games Bad parenting Behaviour management techniques should not be tried until the child with ADHD begins taking medication. There is a medical test that accurately diagnoses children with ADHD. Children with ADHD will outgrow this disorder. 2

3 Rationale While the effectiveness of medication is well established, its use remains controversial. It is only first line treatment for severe ADHD. Non-pharmacological interventions are an important part of any comprehensive plan for the treatment of ADHD. Teachers who have received training about ADHD and its management should provide behavioural interventions in the classroom to help children and young people with ADHD. Less research regarding the effectiveness of nonpharmacological interventions and less again focusing on school-based interventions specifically. Review Methods Protocol on HTA website Registered on Prospero Search strategy: ADHD terms School terms Intervention terms, qualitative terms and/or attitude terms Inclusion criteria (1) evaluation of a non pharmacological intervention primarily delivered in a school setting or experience of ADHD in schools (2) child participants aged between 4 and 18 years, with or at risk of ADHD or teachers, parents, peers etc (3) Treatment as usual or experimental comparator (4) data analysis included at least one child outcome or clear qualitative analysis of qualitative data Exclusion criteria: Samples with average IQs of < 70 and/or brain damage non-oecd countries, foreign language papers Searches 20 electronic databases 14,039 hits for first review effectiveness 4,114 hits for second review -attitudes 10,660 hits for qualitative reviews Additional finds: Update searches Citation searches of papers included Hand searching of key journals Personal/Expert contact Topic specific websites Screening Title/abstract screening in endnote, 2 reviewers Full text screening by 2 reviewers of 618 papers for effectiveness review 197 for attitude review 382 for qualitative reviews Extracted 87 for effectiveness review 28 for attitude review 56 for qualitative reviews Review Methods Data Extraction: Taking all the relevant data from included papers Quality Appraisal: Checklist assessing study quality Synthesis (Analysis) 3

4 Synthesis Meta-analysis: Statistical procedure that integrates the results of several independent studies considered to be combinable. Narrative synthesis: Descriptive analysis where other methods of syntheses are not appropriate. Meta-ethnography: Method for combining data from qualitative evaluation and research, especially ethnographic data, by translating concepts and metaphors across studies. Review 1 What are the effects of non-pharmacological interventions for ADHD delivered in the school setting for children with or at risk of ADHD? Complex review methods: Conceptual syntheses Interventions Outcomes We referred to previous reviews as well as the included papers: Intervention categories Behavioural Management Self-regulation Academic modifications Skills Training Combined Behaviour modification techniques Daily Report Card Self-Monitoring Neurofeedback Task Modifications Classroom modifications Peer Tutoring Study and Organisational Skills Training Cognitive Training Social Skills Training Combined Functional Based Assessment Outcome categories Outcome Example/s Academic Academic Performance Rating Scale; School Grades Classroom Behaviour Behavioral Observa on of Students in Schools Symptoms: Hyperactivity/Impulsivity Self-Control Rating Scale Symptoms: Inattention Conners Continuous Performance Test Symptoms: Combined Swanson, Kotkin, Agler, M-Flynn and Pelham scale Social, Personal, Emotional Coopersmith Self-esteem Inventory Conduct Conners Teacher Rating Scale: Conduct Findings Summary of Review 1 Findings Small to medium effect sizes for school-based interventions on several teacher and child outcomes. Complex meta-analysis: 61 intervention/outcome/rater combinations. Combining similar interventions and outcomes within studies. Currently updating meta-analysis of RCTs to include comparison of interventions. Higher quality trials are needed to clarify the size of the effects and the presence of potential moderators. 4

5 Overarching synthesis The aim of the overarching synthesis was to draw together the findings from Reviews 1, 2, 3 and 4 Methods Synthesis of quantitative and qualitative review findings is relatively uncommon. We: Synthesised qualitative findings to describe complexities of the school context that might impact the effectiveness of school-based interventions, and Juxtaposed findings about attitudes and experiences to findings from Review 1 in order to create hypotheses about: potential moderators of effectiveness, potential content for intervention development, and Useful approaches to evaluate interventions. Complexity of the school context Elements that the two reviews of qualitative research suggested might impact the effectiveness of interventions in schools. Implications: targeting classrooms and schools for change in addition to pupils may increase effectiveness Potential moderators and implications for intervention development and future research Knowledge and beliefs about ADHD Stigma Quality of relationships Pupil self-perceptions Knowledge and beliefs about ADHD Many studies suggested teachers and pupils lacked knowledge about ADHD. Pupils almost exclusively understood ADHD in biological terms. Teachers and parents understood ADHD in either biological or sociological terms. By contrast, accounts of experience of ADHD by pupils, teachers and parents suggested an interaction of factors Polarised attributions could have the effect of exacerbating difficulties by narrowing treatment options, creating conflict over treatment and reducing pupil agency 5

6 Knowledge and beliefs about ADHD Stigma Goffman (1990) defines stigma as an undesired differentness that sets a person apart as not quite human, which justifies acts of discrimination, where the person is disadvantaged in relation to peers. The attributes that provoke stigma are not innately discrediting, but are discrediting in relation to the value systems of the context from which they are allocated. Thornicroft(2006) emphasises the protective function of stigma in perpetuating institutional structures, rather than it necessarily being an intentional infliction of personal harm. Those stigmatised can internalise stigma, believing that others negative judgments are personally accurate. Stigma Quality of relationships Pupil self-perceptions 6

7 Final comments following from the qualitative findings doi/ / /abstract Hyperactive/impulsive and defiant behaviour seemed to be of greatest concern in schools because it prevented learning for all pupils. By contrast, pupils were most concerned by their relationships with teachers and peers The main findings, for example The importance of relationships, particularly the teacher pupil relationship; The damaging effects of stigma for the pupil; The need for interactional rather than unitary understanding of difficulties; are common across special educational needs, and relate to systemic issues rather than individual pupil needs. With thanks to: Tamsin Ford, Michelle Richardson, Jo Thompson-Coon, Obi Ukoumunne, Morwenna Rogers, Rebecca Whear, Tamsin Newlove-Delgado, Stuart Logan, Chris Morris, Eric Taylor, Paul Cooper, Ken Stein, Ruth Garside, Catherine Shotton, Tracy Elliott, Will Pritchard, Rebecca Abbott, Jeni Reeve, Daniel Racey, Rosina Kyeremateng, Angelica Chan, Brahm Norwich, Carolyn Webster-Stratton, Kapil Sayal, Ginny Russell, Bogdan Grigore, Astrid Jannsens, AnniVanhatalo, Sara Ingarfield, Hilary Kaube, Kate Allen, Kate Grimes, Pamela Bowman, Abigail Russell, Chris Cooper, Felix May, Sarah Whittaker, Emily Rhodes, Rachel Dbeis. References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Publishing. O ReganF. (2009). A review of SENCoand GP attitudes towards ADHD. ADHD in Practice, 1, 4-7. Willcutt, E. G. (2012). The prevalence of DSM-IV attentiondeficit/hyperactivity disorder: a meta-analytic review. Neurotherapeutics, 9(3),