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The efficacy, safety, and practicality of treatments for adolescents with attention-deficit/hyperactivity disorder (ADHD) |
Smith B H, Waschbusch D A, Willoughby M T, Evans S |
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Authors' objectives To review studies of interventions for adolescents diagnosed with attention-deficit/hyperactivity disorder (ADHD) in order to evaluate the efficacy of the interventions.
Searching MEDLINE, ERIC and PsycLIT were searched using the following keywords: 'treatment', 'adolescent', 'teen', 'ADHD', 'hyperactive', 'inattentive', and 'stimulant'. Further studies were identified from references in the review papers. No restrictions on publication language were reported.
Study selection Study designs of evaluations included in the reviewEmpirical studies were included.
Specific interventions included in the reviewAll interventions for the treatment of ADHD were eligible for inclusion. The specific interventions reported in the included studies were: methylphenidate; psychosocial treatments including note taking in the context of a summer treatment programme, behaviour modification, rational emotive therapy and family therapy; tricyclic antidepressants (nortriptyline and desipramine); other treatments (guanfacine, pemoline and bupropion). The mean duration of treatment was 7 weeks (range: 1 - 122).
Participants included in the reviewAdolescents aged between 12 and 18 with ADHD were included; 92% of the participants were male. Studies relating to college students were excluded.
Outcomes assessed in the reviewNo inclusion criteria relating to the outcomes were specified. The outcomes reported in the included studies were ADHD symptoms, aggressive behaviour, global functioning, academic performance, behaviour with peers, behaviour with adults, and treatment side-effects.
How were decisions on the relevance of primary studies made?The authors do not state how the papers were selected for the review, or how many of the reviewers performed the selection.
Assessment of study quality Studies were classified according to the study design, although no formal validity assessment was performed.
Data extraction The authors do not state how the data were extracted for the review, or how many of the reviewers performed the data extraction.
Data were extracted on: the author, the type and duration of treatment, the number of participants, the mean age of the participants, and key characteristics of the study design. Whenever possible, effect sizes were reported in the form of a modified Cohen's d. This was calculated by taking the differences in the mean values of the treated and untreated groups, and dividing by the standard deviation of the untreated group. The effect sizes were calculated across three domains: ADHD symptoms, social behaviour and academic performance.
Methods of synthesis How were the studies combined?A narrative synthesis was presented.
How were differences between studies investigated?Differences between the studies were discussed narratively.
Results of the review Twenty-nine studies with 551 participants were included: 9 used an historical design (the diagnostic status of the participants was uncertain), 10 used a crossover design, 3 were controlled studies, 5 were pre-test post-test single group studies, and 2 were case studies. The results of the studies with an historical design were not discussed in the review.
Methylphenidate (8 crossover studies).
All studies reported statistically-significant improvements from treatment. The effect sizes ranged from 0.13 to 3.00 for ADHD, from 0.03 to 1.09 for social behaviour, and from -0.50 to +3.36 for academic performance. Of the studies which looked at different dosage levels, less than 50% found significant differences between low and high doses. There were a few sporadic reports of difficulties in tolerating methylphenidate, but only one provided a detailed assessment of the side-effects. The side-effects reported by this study were dose dependent and virtually non-existent at the low dose.
Psychosocial interventions (n=6, 2 case studies and 4 controlled studies).
One controlled study looked at teaching adolescents to take structured notes while listening to lectures. Compared with simply listening to the lectures, this study found improvements in measures of comprehension, increased levels of on-task behaviour, and lower levels of disruptive behaviour. A second study looked at family-based interventions. This found significant improvements on a variety of rating scales completed by the parents and adolescents, but few participants exhibited clinically-significant improvements. The third controlled study looked at rational emotive therapy; no significant benefits of treatment were reported. A case study found that self-monitoring was an effective intervention. Another case study found functional assessment followed by classroom-based interventions to be effective. No adverse effects of treatment were reported.
Tricyclic antidepressants (n=3, one controlled and two pre-treatment post-treatment studies).
These studies reported that 65 and 90% of the adolescents treated with tricyclic antidepressants were judged to be improved in global measures of functioning. In the controlled trial, the effect size for ADHD was 0.50. One study reported that 24% of the participants exhibited electrocardiogram abnormalities, and one participant experienced heart palpitations.
Other pharmacological treatments (n=3 pre-treatment post-treatment studies).
The authors did not report the results of these studies as they stated that 'none of these treatments should be considered empirically validated for adolescents'.
Authors' conclusions The stimulant drug methylphenidate is safe and well-established empirically, but has some problems with inconvenience and non-compliance. Preliminary research supports the efficacy, safety, and practicality of some psychotherapeutic interventions; these included behavioural classroom interventions, note-taking training, and family therapy. Treatment with tricyclic antidepressants was judged to have minimal empirical support and debatable safety. Very little is known about the long-term effectiveness of treatments, long-term compliance, or multimodal treatment for adolescents, such as stimulants plus behaviour therapy.
CRD commentary This was a poor review of the area. The inclusion criteria, especially those relating to study design, were not reported clearly. It was unclear whether all the studies were included in the review or if sufficient controlled studies were identified, such as for methylphenidate, or whether studies of other designs were excluded.
Details of the literature search were lacking, although the search appears to have been adequate. Further details on the databases and years searched would be needed to confirm this. No attempts were made to locate unpublished studies, thus the results may be subject to publication bias.
No details of the review process, such as the number of authors involved in each stage of the review, were reported. It was, therefore, not possible to assess whether this was appropriate.
Study details were presented in tables and it was clear which studies were included in the review. The narrative synthesis presented, together with the calculation of effect sizes, was appropriate given the heterogeneity in the included studies. However, for methylphenidate, average effect sizes were reported that had not been appropriately pooled and heterogeneity was not investigated. These results should not have been presented.
The synthesis was confusing since it discussed both the results of the included studies and other studies, especially in relation to side-effects. One of the major limitations of this review was the failure to conduct a quality assessment, and to distinguish between the high- and poor-quality studies. The results of the review should be interpreted with caution due to these limitations. The authors' conclusions were not supported by the results presented.
Implications of the review for practice and research Practice: The authors did not state any implications for practice.
Research: The authors state that studies should use methylphenidate as the comparison treatment, and it is important to test multimodal treatments.
Bibliographic details Smith B H, Waschbusch D A, Willoughby M T, Evans S. The efficacy, safety, and practicality of treatments for adolescents with attention-deficit/hyperactivity disorder (ADHD) Clinical Child and Family Psychology Review 2000; 3(4): 243-267 Indexing Status Subject indexing assigned by NLM MeSH Adolescent; Antidepressive Agents, Tricyclic /adverse effects /therapeutic use; Attention Deficit Disorder with Hyperactivity /diagnosis /therapy; Central Nervous System Stimulants /adverse effects /therapeutic use; Humans; Psychotherapy; Treatment Outcome AccessionNumber 12001003548 Date bibliographic record published 30/04/2002 Date abstract record published 30/04/2002 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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