CRITICALLY APPRAISED PAPER (CAP) Rosenberg, L., Maeir, A., Yochman, A., Dahan, I., & Hirsch, I. (2015). Effectiveness of a cognitivefunctional group intervention among preschoolers with attention deficit hyperactivity disorder: A pilot study. American Journal of Occupational Therapy, 69, 6903220040. http://dx.doi.org/10.5014/ajot.2015.014795 CLINICAL BOTTOM LINE: Occupational therapists often work with children with clinically diagnosed attentiondeficit/hyperactivity disorder (ADHD), because the symptoms of ADHD have an impact on a child s ability to function effectively in his or her daily life. One occupational therapy approach that may be effective with children with ADHD, the cognitive functional intervention, aims to improve executive deficits in occupational contexts. Cognitive Functional interventions have been shown to be effective for school- and preschool-age children when administered individually, but they have not been adapted for use in the group setting. In this study, Cognitive Functional group interventions seemed to significantly improve daily functioning, but they may be an effective intervention for children with ADHD who have deficits in executive function and social functioning. The evidence of this study may be limited because it is a pilot study with no control group and because the Sensory Processing Measure has not been validated for children with ADHD who do not have sensory processing deficits. RESEARCH OBJECTIVE(S) To examine the efficacy of a group treatment approach based on a Cognitive Functional intervention designed to engage both preschool-age children and their parents in functional goals relevant to daily life To examine whether this intervention can bring about improvements in executive functioning and social skills and a concomitant decrease in underlying ADHD symptoms DESIGN TYPE AND LEVEL OF EVIDENCE: Level III: Pilot pretest posttest intervention study 1
SAMPLE SELECTION Participants were diagnosed with ADHD by a physician and referred to occupational therapy services in a public health community center in Jerusalem, Israel, for intervention in ADHDrelated functional deficits. Participants were approached to participate in this study from this community health center. Inclusion Criteria Participants were included in the study if they either were mainstreamed before kindergarten or were kindergarten students with medically diagnosed ADHD who had not received occupational therapy services related to ADHD, if parents of participants gave written consent to participate in the study, and if they were willing to participate in 13 sessions. Exclusion Criteria Participants were excluded if they were receiving other nonpharmacological treatments or if they had central neurological deficits or peripheral impairments. SAMPLE CHARACTERISTICS N= (Number of participants taking part in the study) N = 17 participants, statistical analysis ranged from 14 to 17 participants. Of the 27 recruited for the study, 6 did not meet ADHD inclusion criteria, and 2 declined to participate for scheduling conflicts. #/ (%) Male: 12 (71%) #/ (%) Female: 5 (29%) Ethnicity: NR Disease/disability diagnosis: ADHD INTERVENTION(S) AND CONTROL GROUPS Add groups if necessary Group 1: Intervention group Brief description of the intervention The intervention was based on the Cognitive Functional intervention, which focuses on acquiring executive strategies in occupational performance for important occupations, such as play, self-care, and social participation. This intervention encouraged participation by teaching six specific executive strategies and used 2
How many participants in the group? Where did the intervention take place? Who Delivered? How often? For how long? games and activities to challenge the executive components necessary for success in areas of occupation. Additionally, children were encouraged to transfer strategies learned in games and activities to situations at home. Finally, parents attended a group session led by a social worker that encouraged transfer of skills learned in group activities to the home environment; parents were encouraged to use similar games and strategies at home. The parents also participated in the group with their children on alternate weeks. Seventeen parent child dyads completed the entire intervention. The intervention took place in a Jerusalem public community health center. The intervention was delivered by either one of two occupational therapists: Idit Dahan or Idit Hirsch. The intervention took place over the course of 11 weeks, with onceweekly group meetings. Each intervention session lasted 45 min. Intervention Biases: Check yes, no, or NR and explain, if needed. Contamination: Comment: There was no control group; therefore, contamination bias was not an issue. Co-intervention: Timing: Site: Comment: Children who had received occupational therapy in the past and those who were receiving other nonpharmacological treatments were excluded, which provided at least some control of cointervention bias, although pharmacological treatments might have been a factor. Comment: Timing bias might not have been directly addressed in the study, but a 3-month duration treatment for a 5-year old is not likely to result in major maturation effects. Comment: Because there was no control group and the intervention occurred at one site, site bias does not seem to be a problem in this study. 3
Use of different therapists to provide intervention: MEASURES AND OUTCOMES Measure 1: used: d? Is the Is the used? Comment: There was no control group in this study; however, the article suggests that the intervention was provided by either one of two therapists, and there is no mention of how consistency of delivery of the intervention was ensured. Canadian Occupational Performance Measure (COPM) Measures changes in performance and satisfaction (all graded on a scale ranging from 1 to 10) relevant to identified goals; used as an occupational performance Completed by parents before and after the 11-week intervention Measure 2: used: d? Is the Is the used? Measure 3: used: d? Goal Attainment Scaling Evaluates the efficiency of an intervention on the basis of a scale ranging from 2 (present level) to 2 (above the expected outcome), in which 0 represents achievement of the goal; used as an occupational performance Completed by parents before and after the 11-week intervention The Social Participation scale of the Sensory Processing Measure Measures a child s social participation on a scale ranging from 1 (always) to 4 (never); used as a of social functioning 4
Is the Is the used? Measure 4: used: d? Is the Is the used? Measure 5: used: d? Is the Is the used? Measure 6: used: What outcome was d? Completed by parents before and after the 11-week intervention Behavior Rating Inventory of Executive Function Pediatric Used to rate preschoolers executive function in their natural surroundings. Divides executive function into scales (Inhibit, Shift, Emotional Control, Working Memory, and Plan/Organize) and indexes (Inhibitory Self- Control, Flexibility, Emergent Metacognition), providing a global executive composite (GEC) score. Used as an executive function. Completed by parents and the kindergarten preschool teacher before and after the 11-week intervention Conners Parent Rating Scales Revised Assesses ADHD and related problematic behavior. Scales include Oppositional, Cognitive, Hyperactivity, Anxious Shy, Perfectionism, and Social and Psychosomatic Problems scales and seven indexes. Used as an ADHD symptomatology. Completed by parents before and after the 11-week intervention Conners Teacher Rating Scales Revised (CTRS R) Assesses ADHD and related problematic behavior. Scales include Oppositional, Cognitive, Hyperactivity, Anxious Shy, Perfectionism, and Social and Psychosomatic Problems scales and seven indexes. Used as an 5
ADHD symptomatology. Is the Is the used? Completed by the kindergarten preschool teacher before and after the 11- week intervention Measurement Biases Were the evaluators blind to treatment status? Check yes, no, or NR, and if no, explain. Comment: Recall or memory bias. Check yes, no, or NR, and if yes, explain. Others (list and explain): Comment: Several of the outcome s were self-report tools requiring report by memory on the part of the parents and teachers. The parents were not masked to treatment status; whether the teachers were masked to treatment status is not reported. This seems to place them at risk for recall bias. Hawthorne effect: Most of the s relied on parental questionnaires; parents might have seen improvement because of their involvement in the process. RESULTS List key findings based on study objectives Include statistical significance where appropriate (p<0.05) Include effect size if reported Significant changes in occupational performance, as seen in COPM s, were found in both performance outcome and parental satisfaction with the outcome (p <.001). A frequency analysis of COPM goals revealed that 66% of the goals improved with clinical significance. Scores on 16% of the Goal Attainment Scaling goals remained at baseline level, scores on 18% of the goals improved slightly but did not reach the set goal, and 66% of the goals were reached. No significant change was found in median T scores on the parents GEC scores or any of the Behavior Rating Inventory of Executive Function Pediatric indexes (p >.05), which indicates that the intervention did not improve executive function. Teachers GEC scores 6
showed significant improvement after the interventions (p <.05). When the authors analyzed only children who had deficits before the intervention, they found significant improvement in median GEC scores (p <.05). The authors found no significant improvement when analyzing Conners Parent Rating Scales Revised and Conners Teacher Rating Scales Revised scores after the intervention, which indicates that the intervention did not improve ADHD symptomatology. No significant change was found on the Sensory Processing Measure s Social Participation scale for the entire group, which indicates that the intervention did not improve social function overall. When the authors analyzed only children who had deficits before the intervention, they found significant improvement (p <.05). Was this study adequately powered (large enough to show a difference)? Check yes, no, or NR, and if no, explain. Comment: Yes, for this type of pretest posttest study Were appropriate analytic methods used? Check yes, no, or NR, and if no, explain. Comment: Were statistics appropriately reported (in written or table format)? Check yes or no, and if no, explain. Comment: Was the percent/number of subjects/participants who dropped out of the study reported? Limitations: What are the overall study limitations? This study had several limitations. First, the sample was small and recruited from one small clinical center. This limits the applicability of the findings of this study to the larger pediatric population. Additionally, most of the outcome s in this study relied on parental questionnaires. Thus, the Hawthorne effect might have been at play in this study, whereby parents see improvements in their children because of their own involvement in the 7
intervention process. Finally, children with executive functioning scores that were within the normal range were included in this study, which might have decreased group changes in executive functioning, given that the purpose of the intervention was to improve those particular skills. CONCLUSIONS Overall, this study demonstrates improvements in occupational performance and mixed results in executive functioning and social participation in groups of preschool children. This study provides initial evidence that the Cognitive Functional intervention method may be effective as a group intervention for improving daily activities for children with ADHD, especially children with ADHD who show impaired executive functioning. In terms of occupational therapy practice, this study indicates that a group intervention that involves guided parent involvement and training that focuses on executive strategies, games, and activities (as well as occupational goals developed by each parent) is effective in meeting those occupational goals and improving parents satisfaction with their child s performance. Additionally, this study indicates that children with executive functioning difficulties may improve those skills when participating with their parents in a group occupational therapy program that is geared specifically to improve executive functioning skills. This work is based on the evidence-based literature review completed by Katie Pruitt, OTS; Kaylin Staley, OT; and Martina Allen, OTD, OTR, Indiana University. CAP Worksheet adapted from Critical Review Form Quantitative Studies. Copyright 1998, by M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch, & M. Westmorland, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA. Contact: www.copyright.com 8