Introduction
Attention Deficit Hyperactivity Disorder (ADHD) causes difficulties in day to day life due to issues with inattention, impulsivity, and hyperactivity. ADHD causes deficits in social interactions, peer relationships, executive functioning, and education. In order to address these impairments amongst children, several studies have been conducted to discover way to intervene and provide treatment.
Family and Academic Intervention Studies
Webster-Stratton, Reid, and Beauchaine (2011) conducted a study looking at the efficacy of a parent child training program called the Incredible Years. It was hypothesized that there would be positive changes in preschool aged children with ADHD with or without Oppositional Defiant Disorder (ODD) after participating in the Incredible Years parent and child training. Participants were recruited through teachers, counselors, local preschools, elementary schools, doctor offices, and community parent publications. There were 99 child participants (4-6 years old) and were randomly assigned to one of two groups. The groups were either the Incredible Years treatment condition or the control condition. Both the parent and the child training were 20 weekly, 2 hour sessions that occurred at the same time (Webster-Stratton et al., 2011). Parents were trained in areas like problem solving and strategies to reduce depression, manage anger, and build family support. The children were trained to follow group rules, identify feelings, anger management, problem solving and peer relationships. The results showed that as a whole the children in the intervention group were less aggressive, hyperactive, and oppositional than the children in the control group. However, they did not see positive change in oppositional and aggressive behavior in the classroom like they hoped (Webster-Stratton et al., 2011).
Continuing with the idea of family intervention for children with ADHD, Power et al. (2012) completed a study regarding family-school intervention. Although this article does have a similar idea to Webster-Stratton et al. (2011) study, Power and colleagues hypothesized that regarding the increase of family involvement; reducing ADHD and ODD symptoms; and improving teacher-parent relationship, homework performance, parent-child interactions, and academic behavior; Family-School Success (FSS) would be more effective than the control group. The study was conducted on students in grades 2—6 and the mean grade level was 3.5. The entire study was conducted through the ADHD center at a pediatric hospital. The participants were gathered through referrals either initiated by the parents within the hospital or from the school and community providers. The Family-School Success Intervention consisted of 12-sessions which were meant to improve parenting skills and involvement in education, family-school collaboration, and student productivity. The second intervention was Coping with ADHD Through Relationships and Education (CARE), which also consisted of 12-sessions that provided general information about ADHD to parents, taught them how to support their child, and discuss their child’s progress. CARE was used as a control for the non-specific effects of intervention that might occur (Power et al., 2012). Medication Trials were conducted prior to the assignment of groups. After medication trials, 81 children went into the intervention on medication.
Several measures were distributed to teachers and parents regarding treatment acceptability, perception of effective assistance with child’s education, perceptions of homework, parent-child relationship, and academic performance. The data were collected at baseline, midpoint, post-treatment, and then a 3-month follow up.
The data showed that the hypothesis was partially confirmed. There was a significant effect of time on every single measure. This effect was shown not only at post-test but also at the 3-month follow up. The children in the Family-School Success intervention also showed a significant decrease of negative/ineffective discipline on parent ratings at post intervention compared to the children in the CARE intervention. There was no effect on ADHD and ODD symptoms or academic performance.
Social Interaction Intervention Studies
After taking a look at two articles that discuss the parent intervention effects on academics, let’s see how parent intervention can also effect social play in children. Wilkes-Gillan et al., (2014) conducted a study that looked at how parent-delivered intervention could improve the social-play skills in children with ADHD. There were three hypotheses that were tested. Hypothesis 1 was that social play skills would improve in children with ADHD from pre- to post-test and would continue to improve from post- to the one-month follow-up. Hypothesis 2 was that the playmates social play skills would improve pre- to post-test and will continue to improve from the post- to one-month follow up. Hypothesis 3 stated that the children with ADHD’s empathy would improve pre- to post- test and from the post- to one-month follow up (Wilkes-Gillan et al., 2014). Eleven children with ADHD participated in the study and were between the ages of 6-11. Parents received extensive training regarding positive feedback, how to adapt feedback while their children are playing with others, helping children settle conflicts, and some strategies and games that will help their kids social interactions. The parents would also have play dates at home as well as the ones in the clinical setting that the therapists viewed. The authors concluded that hypothesis 1 was supported because the social play of children with ADHD significantly improved from pre- to post-test and then to the 1-month follow up. Hypothesis 2 was partially supported because the playmates social play skill did improve significantly from pre- to post-test but not at the one-month follow up. Hypothesis 3 was also partially supported because children with ADHD did significantly improve on 2 out of the 7 empathy items from pre- to post-test they and two more items improved from post-test to the one-month follow up. Therefore, by focusing on one aspect of ADHD (social skills) it potentially improved the data and they were able to conclude that there was a significant improvement in social play skills from pre- to post-test.
In addition to looking at intervention on social play, Mikami et al. (2013) performed a study about a classroom intervention in order to increase peers’ social inclusion of children with ADHD. The study had two treatment conditions during the 4-week summer program: MOSIAC and COMET. This study hypothesized that children with ADHD would show better outcomes after the MOSIAC intervention in comparison to the COMET intervention. There were 24 participants with ADHD and 113 typically developing (TD) participants and were all between the ages of 6.8-9.8 years old (Mikami et al., 2013). All participants were recruited through advertisements, community center, pediatricians, and schools. All participants experienced both the COMET and the MOSIAC treatment. The COMET condition is based off the idea that in order to shape a child’s social behaviors they need consistent applications of contingencies (Mikami et al., 2013). The MOSIAC condition is similar because it uses behavioral management techniques like the COMET condition but then includes methods to improve peers’ inclusiveness. In order to measure the peer’s inclusiveness children selected the peers that they liked and thought they were friends with, rated each peer, wrote messages to peers, and were videotaped during recess in lunch. After collecting all the data, the results showed that participants with ADHD had less negative nominations in MOSIAC compared to in COMET. Children with ADHD also had better ratings and received a significant amount more of positive messages from peers when in MOSIAC than in COMET. However, there was no main effect for positive nominations (Mikami et al., 2013).
Executive Functioning and Language Intervention Studies
A study conducted by Dovis, Van der Oord, Wiers, & Prins in 2015 looked at improving executive functioning in children with ADHD. They recruited 89 children (ages 8-12) from 14 different outpatient mental-healthcare centers in the Netherlands. All participants were randomized into one of the three group: full-active condition, partially-active condition, and placebo condition. It was hypothesized that; the improvement on outcome measures would be related to the treatment the children received, the participants in the full-active condition would improve significantly more than the children in the partially-active or placebo condition, and participants in the partially active-condition would improve significantly compared to the placebo-condition. (Dovis et al., 2015) Children in the full-active condition had their working memory (WM), inhibition and cognitive-flexibility were all in training mode and the difficulty level of the tasks automatically adjusted according to how the child was performing. The partially-active condition had the inhibition and cognitive-flexibility in training mode but the WM task was in placebo-mode. The placebo condition has WM, inhibition and cognitive-flexibility all in placebo-mode. There was some post training drop out: 3 children in the full-active condition, 2 in the partially active condition, and 3 in the placebo condition. After collecting all the data, when comparing the full-active condition to the placebo condition it showed a main effect of Time, a main effect of Treatment condition, and a significant interaction of Treatment condition and Time. (Dovis et al., 2015) Partially-active versus placebo condition showed there was a main effect of time but no main effect of Treatment condition and no significant interaction of Treatment condition and Time. Lastly, when looking at the comparison between full-active condition versus partially-active condition there was a main effect of time but no main effect of Treatment condition and no significant interaction between Treatment condition and Time. Therefore, it shows that there was only a significant interaction between Treatment condition and Time between the full-active condition and the placebo condition. This research shows that there can be a significant effect on executive functioning in children with ADHD when training them using a computer game and this could contribute to future research to be done.
In addition to the research conducted to improve executive functioning; Docking, Munro, Cordier, & Ellis (2013) looked at the language skills of children with ADHD after a play-based intervention. Docking et al. (2013) were interested in addressing whether parent-reported pragmatic skills and problem solving skills improve after the play-based intervention and whether or not the children with ADHD who were in the play-based intervention have a language difficulty and if they do does it affect their play outcome. There were 14 participants in the study with ages between 5 and 7. To determine whether participants had language difficulties (LD) the CELF-4: Screener was used and they were then divided into two groups based on if they failed to meet the criteria for their chronological age or not (Docking et al., 2013). Participants were tested at pre- and post-test measuring playfulness, pragmatics and problem-solving skills. The play-based intervention consisted of seven 40-minute sessions which had both children with ADHD and typically developing (TD) children. The child with ADHD invited a TD child to participate in the intervention which included problem-solving discussion initiated by the therapist. The therapist would also model behaviors like sharing and supporting while the children were playing. When comparing the pre- and post-test scores about pragmatic skills, there was no improvement at post-test. There also was no significant difference between pre- and post-intervention when looking at problem-solving skills except in the Predicting subtest. Therefore, prediction was the only aspect of problem-solving skills that significantly improved. Lastly, both the LD subgroups significantly improved from pre- to post intervention. However, the children in the ADHD + LD subgroup were much worse at play prior to the play-based intervention when compared to the ADHD – LD. This means that the play-based intervention was effective in improving play skills in children with ADHD +LD that there wasn’t a significant difference when compared to children with ADHD – LD (Docking et al., 2013).
Parenting Styles
There are several everyday hassles that a child with ADHD can experience and they need their parents to help them through their struggles. However, there might be some instances where the parenting style might be harming the child rather than helping. A study conducted by Moghaddam et al. (2013), took a look at the parenting styles of children with ADHD in comparison to normal children. The intention of the study was to identify whether there was a difference between parenting styles of children with ADHD and normal children and if so, correct the wrong doing. Therefore, in order to conduct their study there was two groups: parents of children with ADHD and parents of healthy children. A questionnaire designed by Diana Baumriand in 1972 was used to identify the parenting style. Baumriand’s parenting styles were based on parental responsiveness and parental demandingness. There were three types of parenting styles: authoritarian, permissive, and authoritative (Moghaddam et al., 2013). Authoritarian parents were highly demanding, harsh, and had low responsiveness. Permissive parents were low demanding, never enforced rules, and were overly responsive to their children. Authoritative parents had moderate demandingness, firm, and responsiveness (Moghaddam et al., 2013). After collecting the data, the permissive parenting score in the ADHD group was a 27.4 and the normal children group was a 29.0. This shows that parents of children with ADHD are less permissive than parents of normal children. Also, the authoritarian parenting score in the ADHD group was 23.5 while the normal children group was 20.3 (Moghaddam et al., 2013). Therefore, parents of children with ADHD are more likely to be authoritarian than parents of normal children. There was no difference between authoritative parents. By knowing that authoritarian parents are highly demanding, harsh, and have low responsiveness, this could potentially be making the symptoms worse for a child with ADHD (Moghaddam et al., 2013).
Important Contributions
The studies discussed have provided a wide variety of interventions to help aid in the treatment of children with ADHD. Although no one study is the same, they all contribute several useful techniques that can help further future research on children with ADHD. Some studies do have similar components.
Webster-Stratton, Reid, and Beauchaine (2011) and Power et al. (2012) both focused on how family intervention can help children with ADHD. Both studies parents received extensive training: Webster-Stratton, Reid, and Beauchaine (2011) parents received Incredible Years Training and Power et al. (2012) parents received Family-School Success Training. Power et al.’s (2012) study was slightly different because of the focus on children’s academic performance rather than just overall positive changes in children with ADHD like Webster-Stratton, Reid, and Beauchaine (2011). Power et al. (2012) had better success with their study because the parents’ ratings of negative/ineffective discipline significantly decreased at post-test. This data gives the idea that the Family-School Success Training might be more effective than the Incredible Year Training. Further research would need to be conducted to conclude that. Wilkes-Gillan, Bundy, Cordier, & Lincoln (2014) also used parent training from therapists but looked at the effect on social play in children with ADHD. The results showed that there was a significant improvement in social skills from pre- to post-test. This study helps to contribute to the idea that it is more effective to use intervention that focuses on one problem that children with ADHD have in order to receive positive results. In addition, Moghaddam et al. (2013)did not use an intervention but observed parenting styles and how it might affect children with ADHD. They concluded that parents of children with ADHD are more likely to be authoritarian than parents of normal children. This could actually be worsening the children’s symptoms of ADHD because of the harsh parenting. Therefore, there might be a need for parent training that targets authoritarian parents of children with ADHD. Mikami et al. (2013) also provided useful data regarding the social inclusion of children with ADHD. This study compared two interventions, MOSIAC and COMET, to see which one had a better outcome. This study provides us with the information the MOSIAC intervention can help aid in peer inclusiveness of children with ADHD from typically developing children. There were also studies on executive functioning and language interventions but there were very few significant results to report.
Conclusion
Children with ADHD experience several struggles throughout their life regarding social relations, academic, relationships and more. These seven studies contribute valuable information to help aid in positive changes in struggles that children with ADHD might be facing. These studies do show that it might be more helpful to intervene on one symptom at a time to see the best results. These studies help pave the way for future research to be conducted on intervention and treatment for children with ADHD.