CRITICALLY APPRAISED PAPER (CAP) FOCUSED QUESTION

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1 CRITICALLY APPRAISED PAPER (CAP) FOCUSED QUESTION Is a modified social skills program, parent psychoeducation, and parent training program in a 2-week therapeutic summer day camp an effective intervention for children diagnosed with attention deficit hyperactivity disorder? Hantson, J., Wang, P. P., Grizenko-Vida, M., Ter-Stepanian, M., Harvey, W., Joober, R., & Grizenko, N. (2011). Effectiveness of a therapeutic summer camp for children with ADHD: Phase I clinical intervention trial. Journal of Attention Disorders, 16(7), CLINICAL BOTTOM LINE: The results of the study support the hypothesis that a social skills training program that includes self/other perspective taking, parent psychoeducation, and parent training may provide improvement in attention deficit hyperactivity disorder (ADHD) symptoms, peer relationships, and overall functioning once students are reintegrated in regular community school. Occupational therapy practitioners can implement the results of this study in their practice if they work with the pediatric population. Practitioners can use the social skills training program in other settings to help clients improve their skills to engage in meaningful roles and activities. In contrast to Antshel and Remer s (2003) study, which showed only limited improvement with social skills training, this summer camp intervention showed significant improvement. An explanation is that the our social skills training in this study was more intensive (the children had a 5-hour period each day when they were continuously prompted to use the social skills they learned) and that parental involvement was critical in the camp. Parents attended 8 hours of psychoeducation and behavior therapy management training during the camp. It appears important to offer a combination of social skills training for the child with parent training sessions for the intervention to be effective. Researchers suggest further studies should include evaluating the long-term effects of this program as well as a larger sample size. Researchers also have proposed there should be teacher reports before and after the summer day camp to further evaluate the participants in the study. RESEARCH OBJECTIVE(S) List study objectives. The objective of this study was to evaluate the effectiveness of a 2-week therapeutic summer day camp, which included a social skills training program and a parent psychoeducation and training 1

2 program, for children with ADHD. This was an open-label, nonrandomized Phase I Clinical Intervention Trial. DESIGN TYPE AND LEVEL OF EVIDENCE: according to AOTA this study is level II of evidence Level II: Nonrandomized clinical intervention trial Limitations (appropriateness of study design): Was the study design type appropriate for the knowledge level about this topic? Circle yes or no, and if no, explain. Yes. The research question explored the difference between the improvement in symptoms, relationships, and functioning for children with ADHD in a controlled compared to a treatment. SAMPLE SELECTION How were subjects selected to participate? Please describe. 33 children with ADHD from the Douglas Mental Health University Institute were offered the chance to participate in a 2-week therapeutic summer day camp. Inclusion Criteria The children need to be diagnosed with ADHD based on the Diagnostic Interview Schedule for Children-Version IV, with the diagnosis made using the Diagnostic and Statistical Manual of Mental Disorders, IV Exclusion Criteria The children could not have an IQ of less than 70 on the Weschler Intelligence Scale for Children III or diagnosis of pervasive developmental disorder, Tourette s syndrome, or psychosis. SAMPLE CHARACTERISTICS N = 48 children Intervention n = 33 Control n = 15 % Dropouts 0% #/ (%) Male 34 (71%) #/ (%) Female 14 (29%) Ethnicity Does not specify Disease/disability diagnosis ADHD 2

3 Check appropriate : <20/study 20 50/study /study /study /study INTERVENTION(S) AND CONTROL GROUPS Add s if necessary Group 1 Experimental Brief Description Setting Who Delivered? Frequency? Duration? 33 children diagnosed with ADHD participated in a 2-week therapeutic summer camp. Through the camp, they participated in self-reflection, social skills training, music therapy, play therapy, exercise therapy, and art therapy. During all interventions, the focus remained on social skills training. Treatment goals included improving the child s ADHD symptoms, peer relationships and social skills, and self-esteem. During this same time, the parents received psychoeducation and parent training. The children attended the therapeutic summer day camp for a 2-week period. A total of 6 hours were spent on therapeutic interventions each day. Therapists with experience working in a day hospital for children with disruptive behaviors A total of 6 hours were spent on therapeutic interventions each day; an hour was dedicated to each of the following interventions: social skills training, music therapy, play therapy, exercise therapy, and art therapy. The camp lasted for 2 weeks Group 2 Control Group Brief Description Setting The control consisted of 15 children who were diagnosed with ADHD. They did not participate in the therapeutic summer camp and did not have any change in medication or treatment. The parents of these children did not attend education or training sessions. They answered the same questions on the assessment. Who Delivered? Therapists with experience working in a day hospital for children with disruptive behaviors Frequency? Duration? Intervention Biases: Circle yes or no and explain, if needed. Contamination 3

4 Co-intervention Children who were previously receiving medication for their ADHD continued on the same medication; however, this was not changed throughout the study. Timing There was not enough time to measure the long-term effect of the summer camp on the child s behavior. Site This took place in an artificial environment; it is important to observe whether these children can generalize their behaviors to a more natural environment. Use of different therapists to provide intervention Different therapists were used to conduct intervention; however, all of them had the same training experience and were provided with the same knowledge. MEASURES AND OUTCOMES Complete for each relevant measure when answering the evidence-based question: Name of measure, what outcome was measured, whether the measure is reliable and valid (as reported in article yes/no/nr [not reported]), and how frequently the measure was used. The initial severity of the children s problems was assessed using the Child Behavior Checklist (CBCL), which has good known validity and internal consistency. The CBCL is a 113-item questionnaire that measures participants behaviors. Three questionnaires were used to assess changes in behavior of the children: the Weiss Functional Impairment Rating Scale (WFIRS), Conners Global Index-Parent Version (CGI-P), and Index of Peer Relations (IPR). The WFRIS has internal consistency greater than 0.9. The WFIRS measures a child s ability to function and how the child s behavior affects ability to complete tasks. This assessment is made up of 50 questions that relate to the child s family, learning, life skills, self-concept, and social and risky activities. The IPR has excellent known-s validity. While the article did not report validity or reliability of the CGI-P, it was used to measure the severity of the ADHD symptoms in the participants. The WFIRS and CGI-P were administered as a follow-up after finishing camp. Each assessment was used prior to the camp and 3 weeks after the starting period to provide a pretest and posttest comparison. Measurement Biases Were the evaluators blind to treatment status? Circle yes or no, and if no, explain. The study was not blind; parents were aware of the assigned for their children. 4

5 Recall or memory bias. Circle yes or no, and if yes, explain. NO Others (list and explain): NR RESULTS List results of outcomes relevant to answering the focused question The results were measured based on the child s performance in various aspects of the WFIRS, family, learning and school, life skills, self-concept, social activities, and risky activity. Of these categories, p < except for the category of risky activity (p < 0.020), which meant that these s were statistically significant. The effect size was reported as a large treatment according to Cohen s criteria, with a number greater than 0.8; WFIRS family and risky behavior subscales were only reported as moderate. Results demonstrate a social skills program, parent psychoeducation, and parent training program may be an effective intervention for children diagnosed with ADHD. Due to the large effect size of the IPR, WFIRS learning and school, WFIRS child concept, WFIRS social activity, and CGI-P indicate the intervention was successful and can be used in a clinical setting. Was this study adequately powered (large enough to show a difference)? Circle yes or no, and if no, explain. Were appropriate analytic methods used? Circle yes or no, and if no, explain. Were statistics appropriately reported (in written or table format)? Circle yes or no, and if no, explain. CONCLUSIONS State the authors conclusions that are applicable to answering the evidence-based question. The results of this study show that the intensive 2-week summer therapeutic day camp for children with ADHD, which includes self-/other perspective taking and a parent psychoeducation and training program, appears to be a highly effective method for improving behavior, peer relationships, and overall functioning in children with ADHD. The statistical analysis demonstrated significant improvement in scores for the treatment on all three test measures. These conclusions answer the objective of the study, which was to evaluate the effectiveness of a 2-week intensive summer day camp for children with ADHD. 5

6 This work is based on the evidence-based literature review completed by Jennifer Abraham, OTS; Julie Mathew, OTS; Julianne Soby, OTS; and Colleen Maher, OTD, OTR, CHT, Faculty Advisor, University of the Sciences, Philadelphia. CAP Worksheet adapted from: Critical Review Form Quantitative Studies Law, M., Stewart, D., Pollack, N., Letts, L., Bosch, J., & Westmorland, M., 1998, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA.Contact: 6