Running head: AN INTEGRATIVE REVIEW: ADHD INTERVENTIONS 1

Attention Deficit Hyperactivity Disorder Interventions

Erika Swinson

April 11, 2017

Bon Secours Memorial College of Nursing

NUR 4122

Honor code: I pledge

AN INTEGRATIVE REVIEW: ADHD INTERVENTIONS 2

Abstract

The purpose of this integrative review is to evaluate the literature pertaining to the use of

Attention Deficit Hyperactivity Disorder (ADHD) interventions and the effect they have on

ADHD symptoms in children. ADHD affects various aspects of development in children

including social, emotional, and cognitive functions whether at home or school. ADHD usually

has behavioral symptoms such as inattentiveness, hyperactivity, and impulsiveness. Medication

and behavioral therapy interventions have been proven to be effective treatments of the disorder.

Combining these interventions is proving to be more effective on symptom treatment than just

medication or behavioral therapy alone. The research design is an integrative review. The search

for literature was conducted using the computer-based search engines PubMed and EBSCO

Discovery. The search through PubMed yielded 3,223 results. The search through EBSCO

Discovery yielded 13,958 results. The results and findings analysis of the five reviewed studies

indicate that medication and behavioral therapy interventions are both adequate treatments for

ADHD as indicated by the measured outcomes. Limitations to the review include the fact that the

researcher is a full-time student and that this is the researchers first time conducting an

integrative review. The implications of the findings suggest that combined interventions are the

best way to positively impact the treatment on a significant number of school aged children

suffering from ADHD. Future research should include studies on what medication has the best

effects on the symptoms when combined with behavioral interventions.

AN INTEGRATIVE REVIEW: ADHD INTERVENTIONS 3

Attention Deficit Hyperactivity Disorder Interventions

The purpose of this integrative review is to search the literature pertaining to the use of

ADHD interventions and the effect they have on ADHD symptoms in children. ADHD is the

most commonly diagnosed psychiatric disorder of childhood and is prevalent among

approximately 3-5% of school-aged children (van der Schans et al. 2017, p. 1). ADHD affects

various aspects of development including social, emotional, and cognitive functions of a child at

home and at school. ADHD usually has behavioral symptoms such as inattentiveness,

hyperactivity, and impulsiveness (Mohammadi, Soleimani, Ahmadi, & Davoodi, 2016).

Medication and behavioral therapy interventions are the most effective treatments of the disorder.

Combining these interventions is proving to be more effective on symptom treatment than just

medication or behavioral therapy alone. This area interests this researcher due to the researchers

personal battle with the disorder. Therefore, the proposed PICO question by this researcher is as

follows: In school-aged children, what is the effect of medication treatment compared with

behavioral therapy on ADHD symptoms?

Research Design, Search Methods, & Search Outcomes

The research design is an integrative review, which was a required assignment for a

nursing research course, that is part of a baccalaureate nursing degree. The search for research

was conducted using the computer-based search engines PubMed and EBSCO Discovery, which

were accessed by the Bon Secours electronic library. The search terms used on PubMed

included, children, ADHD, and treatment. The search through PubMed yielded 3,223

results. The search terms used on EBSCO Discovery included, ADHD, children, and

behavioral therapy. The search through EBSCO Discovery yielded 13,958 results. The search

was limited to peer-reviewed qualitative and quantitative research articles, published in English,
AN INTEGRATIVE REVIEW: ADHD INTERVENTIONS 4

and written between 2012-2017. The articles had to pertain to the researchers PICO question,

In school-aged children, what is the effect of medication treatment compared with behavioral

therapy on ADHD symptoms? The articles were chosen based on the following inclusion

criteria: school aged population, children with ADHD, medication interventions, and behavioral

interventions. The research articles were screened by making sure they pertained to the inclusion

criteria, and were significant to the PICO question. Articles that did not meet three out of the four

topics in the inclusion criteria were excluded from the review. The screening produced 5 ADHD

based intervention articles, including four quantitative and one qualitative.

Findings/Results

The findings and results of the five reviewed studies indicate that medication and

behavioral therapy interventions are both adequate treatments for ADHD, as indicated by the

measured outcomes (Coelho et al., 2015; McCarty, Stoep, Violette, & Myers, 2014; Mohammadi

et al., 2016; Pelham et al., 2014; & van der Schans et al., 2017). A synopsis of the compiled

research is presented in Appendix 1. The researcher outlined the review according to the

following categories: statistical significance of behavioral, pharmacological, or mixed

interventions, and parent/caregiver participation with interventions.

Statistical Significance of Behavioral, Pharmacological, or Mixed Interventions

There was an agreement among four studies that behavioral, pharmacological and mixed

interventions all have a significant effect on treating the symptoms of ADHD (Coelho et al.,

2015, Mohammadi et al., 2016, Pelham et al., 2014, van der Schans et al., 2017). In the

quantitative study conducted by Coelho et al. (2015), it was determined that the use of cognitive

behavioral therapy with token economy (TE) decreased problematic behaviors and may be used

as a secondary strategy combined with medication. Token economy uses a strategy that awards
AN INTEGRATIVE REVIEW: ADHD INTERVENTIONS 5

points or tokens for desirable behaviors. The studies design was quasi-experimental with a

sample size of 25 children and adolescents with ADHD. The sample was recruited after

completing a diagnostic assessment using a randomized sampling method. Data was collected

before the interventions were applied by pre-analysis forms filled out by the children and

parents, which included behaviors of the child that are inappropriate and cause functional

impairment due to negative consequences for the child themselves or their family (Coelho et al.,

2015). Data was collected throughout the study by parents recording throughout the week when

their child had an inappropriate behavior, the parent reported to the therapist at each weekly

behavioral therapy session the number of times each week the child had that inappropriate

behavior and the therapist took note of the numbers. To analyze the data token economy system

forms were used to examine improvement of less frequent problem behaviors. Variations in time

frequencies of behavioral categories over the weeks were examined using generalized estimating

equations (GHGs) with Poisson distribution for counting data and first-order auto regressive

correlation structure. Problematic behaviors decreased significantly in 7 out of 11 categories

examined. In this study, functional improvement was observed when applying TE for 10 weeks,

this type of intervention may be used as a support strategy when combined with medication.

(Coelho et al., 2015). This study contributes to the body of literature by showing that mixed

interventions improve the symptoms of ADHD.

The purpose of the quantitative study, by Mohammadi et al. (2016), was to determine

how effective combined parent behavioral management training (PBMT) and medication

treatment were at reducing symptoms of ADHD in children. This experimental study recruited 47

children, ages 6-12, through a stratified random relative manner using the Cochran formula.

Clinical Interviews were performed by the child psychiatrist for diagnosis, which is based on
AN INTEGRATIVE REVIEW: ADHD INTERVENTIONS 6

DSM-IV-TR criteria. Pre-and-post tests were given to the parents participating in the research.

Comparison of the experimental group and the control group was analyzed using t-tests to

determine which group had the most symptom reduction. Levenes test was used to analyze

equality of variance (Mohammadi et al., 2016). It was determined that combination

interventions through medication treatment with PBMT of children with ADHD had an almost

significant effect on reducing ADHD symptoms (Mohammadi et al., 2016, p. 507). The

statistical significance of combined interventions with medication therapy being an effective

treatment of ADHD symptoms contributes to this integrative review.

Pelham et al. (2014), studied the manipulation of the intensity of both behavioral

interventions and pharmacological therapy on the symptoms of ADHD in a social setting. This

was an experimental, quantitative study that had a sample that consisted of 48 children with

ADHD, ages 5-12 years old, that met DSM-IV diagnostic criteria, had an IQ of at least 80, and

had no documented adverse effects to or medical conditions that would prevent them from taking

methylphenidate (Pelham et al., 2014). A comprehensive points system with rewards and cost

components were used to collect data from the interventions each day. The children lost and

gained points depending on their behaviors and would receive feedback based on their behavior.

Counselors complete the Pittsburgh Side Effects Rating Scale daily, and study staff monitored

the ratings for clinically significant adverse events (Pelham et al., 2016, p. 1023). The points

system, which was analyzed for differences, using the General Linear Model. Linear and

quadratic effects were tested to determine the dose-response effect of increasing levels of

treatments. Pairwise follow-up contrasts were used to detect differences among increasing

dosages of both behavioral modifications and medication (Pelham et al., 2016, p. 1023). To

analyze frequency categories, fourth-root transformations were used. The studys results
AN INTEGRATIVE REVIEW: ADHD INTERVENTIONS 7

determine that both behavioral treatment and methylphenidate have large effects on the social

behavior of children with ADHD, the combination of the low doses of the two modalities has

substantial beneficial effects, and the presence and dose of either treatment influences the

efficacy of the other treatment in several important ways (Pelham et al., 2016, p. 1026). The

results of the study and the fact that no other studies of this type have ever been conducted helps

contribute to the body of literature.

The quantitative, descriptive study, conducted by van der Schans et al. (2017), assessed

the differences in school performance of children using methylphenidate at the end of primary

school based on various parameters of methylphenidate use. The study sample was retrieved

from dispensed prescription records and consisted of 7,736 children born between 1996-2001in

the Netherlands. All children in the Netherlands take a test at the end of primary school called the

Central Institute of Test Development test (Cito-test). Cito-test scores were collected and

compared from year to year. The authors performed an analysis of covariance (ANCOVA) to test

for significant differences in school performance between the treatment groups and Cohens d

was calculated to determine the standardized differences between the two means for significant

findings (van der Schans et al. 2017, p. 4). The study showed that methylphenidate users have a

lower school performance compared to children who have no history of ADHD medication (van

der Schans et at., 2017). While the study by van der Schans et at. (2017) revealed an association

between various parameters of methylphenidate use and school performance, it must be noted

that without a clear comparator group and using only correlational data no conclusions can be

drawn about cause and effect of methylphenidate use and school performance (p. 8) which

contributes to the body of literature.

AN INTEGRATIVE REVIEW: ADHD INTERVENTIONS 8

Parent/Caregiver Participation with Interventions

Three of the five studies had parent/caregiver participation in the interventions and would

not have produced the same without their participation in the studies (Coelho et al., 2015;

McCarty et al., 2014; & Mohammadi et al., 2016). In the study conducted by Coelho et al.

(2015), the researchers evaluated the dysfunctional behavior reported by parents and children,

and used these evaluations to try to show how you can reduce inappropriate behavior by

applying TE. The researchers from this study taught all parents and children how to identify the

target behaviors and how to register them on the form they filled out, which was discussed

above. It was found that behavioral interventions based on consequential strategies, such as the

TE technique, helped develop self-control and improve disruptive behaviors; therefore, this

technique is quite efficacious specifically for these behavioral categories (Coelho et al., 2015, p.

7). In the study led by Mohammadi et al. (2015) The rate of ADHD whose parents received

PBMT was further reduced, compared to those children whose parents did not receive training

(p. 505).

The qualitative study conducted by McCarty et al. (2014) looked at Telemental Health as

an approach to help with treating ADHD in children living in rural areas. The study was a

randomized controlled trial that consisted of a sample size of 111 children with moderate to

severe levels of ADHD symptoms and their caregivers. The sample was randomized to receive

the Childrens ADHD Telemental Health treatment study (CATTS) intervention. Symptoms of

ADHD were screened using the Child Behavior Checklist and their diagnosis was confirmed

using the Computerized Diagnostic interview Schedule for Children completed in person with

the community therapist. All telepsychiatrist sessions were recorded (McCarty et al., 2014).

Parents completed the IOWA Conners Rating Scale and the Global Assessment of improvement
AN INTEGRATIVE REVIEW: ADHD INTERVENTIONS 9

scale at each session. The researchers assessed caregiver engagement by using attendance data

from the six medication sessions and quiz scores from brief quizzes that were administered at

each medication session. Caregivers used the Client Satisfaction Questionnaire that was modified

to reflect caregiver satisfaction with their childs ADHD management. Therapist and

telepsychiatrist coordinated and shared their activities through WebCATTS. The therapist logged

all relevant information such as vital signs, materials covered during training sessions, any

assigned homework, and scores on rating scales for the telepsychiatrist to look at and help with

treatment decisions (McCarty et al., 2016, p. 1739). According to McCarty et al. (2016) both

parts of the intervention were well received by families who engaged with the treatment (p.

1741). Families indicated high levels of satisfaction with the intervention, which contributes to

the body of literature.

Discussion/Implications

The findings of this integrative review address the reduction of symptoms of ADHD by

using behavioral, pharmacological and mixed interventions, as well as parent participation with

the interventions in three of the studies discussed. The findings convey and support the

researchers PICO question. The PICO question specifically asked about the effects of

medication treatment compared with behavioral treatment on ADHD symptoms in school aged

children. Three of the four quantitative studies showed that combined behavioral and

pharmacological interventions have a significant effect on the reduction of symptoms of ADHD

(Coelho et al., 2015, Mohammadi et al., 2016, & Pelham et al. 2014). The qualitative study by

van der Schans et al. (2017) showed a connection between various parameters of

methylphenidate use and school performance. In three of the studies discussed in this review,
AN INTEGRATIVE REVIEW: ADHD INTERVENTIONS 10

parent participation in the intervention played a major role in the outcomes of the studies

(Coelho et al., 2015; McCarty et al., 2014; & Mohammadi et al., 2016).

The implications of the findings suggest that combined interventions are the best way to

positively impact the treatment on a significant number of school aged children suffering from

ADHD. From this, the researcher recommends further research on the effects of combination

therapy with different types of medications and behavioral therapies be studied to find the

optimal treatment for the symptoms of ADHD.

Limitations

There are several limitations to this integrative review that are acknowledged by the

researcher. The review was based on five research articles that have been published within the

past five years. The review was a major class assignment that is worth almost a third of the final

grade for the course. The researcher is a full-time student that is taking 13 credits worth of other

classes that also require the researchers attention. The assignment instructions were confusing

and changed throughout the semester. This is the researchers first time conducting and writing an

integrative review, so there is a lack of comprehension in terms of how to properly write up the

review.

Conclusion

The findings of this integrative review support the importance of using combined,

behavioral, and pharmacological interventions to reduce the dysfunctional symptoms of ADHD.

Parent/caregiver participation in the interventions was shown to be effective in the studies in

which they participated in. Behavioral treatment and methylphenidate both show large effects on

the social behavior of children with ADHD and the combination of the low doses of the two

interventions has a positive effect. Nurses have the opportunity to share their knowledge and
AN INTEGRATIVE REVIEW: ADHD INTERVENTIONS 11

dedicate their time to further research on what specifically interests them about the treatment of

ADHD.
AN INTEGRATIVE REVIEW: ADHD INTERVENTIONS 12

Reference:

Coelho, L. F., Barbosa, D. L. F., Rizzutti, S., Muszkat, M., Bueno, O. F. A., & Miranda, M. C.

(2015). Use of cognitive behavioral therapy and token economy to alleviate dysfunctional

behavior in children with attention-deficit hyperactivity disorder. Frontiers in

psychiatry, 6.

DOI: 10.3389/fpsyt.2015.00167

McCarty, C. A., Vander Stoep, A., Violette, H., & Myers, K. (2015). Interventions developed for

psychiatric and behavioral treatment in the childrens ADHD telemental health treatment

study. Journal of Child and Family Studies, 24(6), 1735-1743.

DOI: 10.1007/s10826-014-9977-5

Mohammadi, M. R., Soleimani, A. A., Ahmadi, N., & Davoodi, E. (2016). A comparison of

effectiveness of parent behavioral management training and methylphenidate on

reduction of symptoms of Attention Deficit Hyperactivity Disorder. Acta Medica

Iranica, 54(8), 503-509.

Pelham, W. E., Burrows-MacLean, L., Gnagy, E. M., Fabiano, G. A., Coles, E. K., Wymbs, B.

T., & Hoffman, M. T. (2014). A dose-ranging study of behavioral and pharmacological

treatment in social settings for children with ADHD. Journal of abnormal child

psychology, 42(6), 1019-1031.

DOI: 10.1007/s10802-013-9843-8

van der Schans, J., iek, R., Vardar, S., Bos, J. H., de Vries, T. W., Hoekstra, P. J., & Hak, E.

(2017). Methylphenidate use and school performance among primary school children: a

descriptive study. BMC psychiatry, 17(1), 116.

DOI: 10.1186/s12888-017-1279-1
Running head: AN INTEGRATIVE REVIEW: ADHD INTERVENTIONS
First Author
(Year)/Qualifications
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied (and
their definition), if appropriate
Appendix 1; Qualitative and Quantitative table of evidence
Luzia Flavia Coelho, (2015), Psychobiology Department, Universidade Federal de So Paulo, So Paulo,
Brazil
Medication has proved highly efficacious as a means of alleviating general symptoms of attention-
deficit hyperactivity disorder (ADHD.
In many cases, even with pharmacological intervention, patients may continue to display significant
functionally impairment in behavioral terms, thus compromising quality of life for individuals with ADHD
and their families.
In order to diminish these impairments and improve overall functioning, multimodal treatment
approaches have been increasingly proposed.
The token economy (TE) system is one of the most widespread for managing and measuring
dysfunctional behavior.
This type of tool has been showing efficacy in improving ADHD related symptoms.
The researchers did not identify a theoretical framework.
Children with ADHD were recruited from an outpatient clinic, associated with the Universidade Federal
de So Paulo (UNIFESP).
Children were selected after parent reported symptoms of agitation, being unable to remain quiet, and
having difficulty paying attention.
A screening interview conducted with a questionnaire covering developmental aspects and DSM-IV
criteria.
The questionnaires were then submitted to neuropsychological and medical examinations (by a
psychiatrist and a neurologist).
The sample was recruited immediately after the diagnostic assessment, before subdividing into groups
for intervention.
The sample consisted of 25 children with ADHD, 19 boys, 6 girls, mean age was 10.11, average IQ
was 108.20, 13 inattentive subtype, and 12 combined subtype.
The setting is in the participants homes in Brazil.
Procedures were approved by the research ethics committee at Universidade Federal de So Paulo.
Parents provided written consent as well as the informed assent for all children.
The major variables studied were: Attention deficit hyperactivity disorder (ADHD), cognitive behavioral
therapy (CBT), token economy (TE), and dysfunctional behaviors in children with ADHD (inattention,
impulsivity, hyperactivity, disorganization, disobeying rules and routines, poor self-care, verbal/physical
aggression, low frustration tolerance, compulsive behavior, antisocial behavior, lacking initiative and
AN INTEGRATIVE REVIEW: ADHD INTERVENTIONS
Measurement Tool/Data
Collection Method
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
distraction)
Pre-analysis forms with descriptions of target behaviors list by children and their parents.
For exploring material, behavioral categories were created based on similarities and data from
recording units were coded.
Two specialist in cognitive behavioral therapy (CBT) and neuropsychology classified behaviors
separately.
A third specialist (judge) re-categorized any discrepancies between the first two for the final version.
They used generalized estimating equations (GHGs) with Poisson distribution for counting data and
first-order autoregressive correlation structure.
Interactions were analyzed for time, gender, age, IQ, and ADHD subtype.
Problematic behaviors decreased significantly in seven categories: impulsiveness, hyperactivity,
disorganization, disobeying rules and routine, poor self-care, low frustration tolerance, compulsive
behaviors, and antisocial behaviors.
Caregiver attitudes to childrens inappropriate behavior were discussed and reshaped.
As functional improvement was observed on applying TE for 10 weeks, this type of intervention may be
used as an auxiliary strategy combined with medication.
This study will help medical professionals by giving them another treatment option to give to parents of
children with ADHD so they can identify which behaviors their child specifically has and may help those
patients to better understand what types of behavior is acceptable and unacceptable by rewarding
them when they do good and taking it away when they misbehave.
AN INTEGRATIVE REVIEW: ADHD INTERVENTIONS

First Author Carolyn A. McCarty (2014) Center for Child Health, Behavior and Development, Seattle Childrens
(Year)/Qualifications Research Institute
Background/Problem Attention-deficit hyperactivity disorder (ADHD) is highly prevalent across geographic areas, but children
Statement living in non-metropolitan communities lack access to evidence-based treatments for ADHD, as child
mental health specialist are concentrated in urban and suburban areas.
In the 14 years since publication of the finding from the Multimodal Treatment of ADHD study, PCPs
have become more skilled in treating ADHD, but the guidelines for the treatment of ADHD in primary
care have been variably implemented, and PCPs still need assistance in treating children who
demonstrate more severe or complex disorders.
Telemental health (TMH) is one approach to rectifying geographic disparity in access to evidence-
based mental health treatment for ADHD.
Conceptual/theoretical The Childrens ADHD Telemental Health Treatment Study (CATTS) is a 5 year randomized control trial
Framework (RCT) designed to test the effectiveness of TMH as a service delivery model to assist PCPs in their
efforts to provide evidence-based mental health care for children with ADHD living in underserved
areas.
Design/ Children randomized to treatment through TMH received medication treatment and psychoeducation
Method/Philosophical through videoteleconferencing (VTC) and Caregiver Behavior Training in their home community
Underpinnings supervised remotely by a clinical psychologist.
Children randomized to the control group received a single telepsychiatry consultation with treatment
recommendations made to the referring PCPs for implementation at their discretion.
CATTS adapted the Multimodal Treatment intervention was approach (MTA) to a brief stabilization
model that was appropriate to collaboration with PCPs.
The stabilization model aimed to reduce ADHD symptoms and provide caregivers with behavioral
training and then return children to the care of their referring PCPs with recommendations for ongoing
treatments.
This stabilization model provided six sessions spaced 3-4 weeks apart with Telepsychiatry and
Caregiver Behavior Training provided at each session.
Each of the six sessions consisted of two components: ongoing diagnostic clarification and medication
management; and psychoeducation on the neurobiological model of ADHD.
As a roadmap guide the sequence of medication choices during ADHD treatment, telepsychiatrists
followed the Texas Childrens Medication Algorithm Project (TCMAP) for ADHD with and without
comorbidity.
There are 5 TCMAP algorithms: ADHD alone; ADHD with anxiety; ADHD with depression; ADHD with
tics; and ADHD with aggression.
These algorithms were included on an electronic decision-making and treatment documentation tool,
termed WebCATTS.
The telepsychiatrists decided which algorithm best matched the childs current treatment needs and at
which stage in the algorithm to initiate treatment based on prior medication trails, symptom severity,
AN INTEGRATIVE REVIEW: ADHD INTERVENTIONS
Sample/ Setting/Ethical
Considerations
Major Variables Studied (and
their definition), if appropriate
Measurement Tool/Data
Collection Method
course, and side effects.
Each of the six ADHD telepsychiatry sessions was accompanied by a module addressing current
understanding of the neurobiological roots of ADHD.
Each family received a notebook of the modules to review with the telepsychiatrist during each session.
Materials were adapted to suit individual delivery to parents, to condense material to fit into the
framework of six sessions and to ensure concepts and examples were relevant to the full age spectrum
intended for CATTS (5 - 12 years old).
Worksheets were developed for therapists use to gather key information from the caregiver in a
systematic way, and parents were provided with handouts covering educational and psychological
information to take home.
Therapist assigned home practice to caregivers at each session to implement the skills being taught
that week, and to report back on their progress, results, and difficulties encountered.
A clinical psychologist at the research hub provided training in the Caregiver Behavioral Training
protocol using multimedia techniques.
The clinical psychologist also provided bi-weekly supervision to the community-based therapist, during
which time all clinical cases were briefly reviewed.
The therapist and telepsychiatrists they coordinated and shared their activities through WebCATTS, a
decision-making, treatment documentation, and tracking tool.
The therapist logged relevant session information such as vital signs and scores on rating scales, into
WebCATTS for the telepsychiatrist to review remotely and aid in treatment decisions.
They also documented materials covered during the caregiver training sessions, quiz scores, and any
assigned homework.
The therapists and telepsychiatrists information was then electronically integrated into an ADHD
management Plan that was sent to families and their referring PCPs.
A total of 111 children and their caregivers were randomized to receive the Childrens ADHD Telemental
Health treatment study (CATTS) intervention, from a total of 223 enrolled in the trial.
CATTS recruited the sample with moderate to moderately severe levels of ADHD symptomatology,
impairment and comorbidity, predominantly oppositional defiant disorder and/or anxiety disorders.
Seven communities in Washington and Oregon participated. All sites had capability for high definition,
real time videoteleconferencing (VTC).
The trail was open to all PCPs in and surrounding theses seven communities.
Eighty-eight PCPs made successful referrals to the study and agreed to resume care at the end of their
patients participation.
The major variables studied were: Telemental health (TMH), Attention deficit hyperactivity disorder
(ADHD), TMH delivery of medication, Satisfaction of Caregivers and Therapist, psychoeducation,
Caregiver Behavioral Training, and under-served communities
Symptoms of ADHD and comorbid disorders were screened using the Child Behavior Checklist and
diagnosis confirmed with the Computerized Diagnostic Interview Schedule for Children completed in
person with the community therapist.
AN INTEGRATIVE REVIEW: ADHD INTERVENTIONS

To monitor symptom change and guide decisions about whether to continue or modify treatment, at
each session parents completed two rating scales: the IOWA Conners Rating Scale and the Global
Assessment of Improvement scale.
The researchers modified the original 10-item IOWA Conners Rating Scale by adding five more
symptoms of inattention and hyperactivity that are included in common ADHD rating scaled and they
adapted the Global Assessment of Improvement to parent report.
Data Analysis Caregiver engagement in the intervention was assessed using attendance data from the six medication
sessions as well as quiz scores at each session.
The brief quizzes (3-5 items) were administered to caregivers at each medication appointment, and at
all but the first behavioral training sessions.
A checklist reflecting 8-11 elements of the core components for the telepsychiatry intervention session
was developed for the telepsychiatrists to follow.
All sessions were recorded, and two recordings per family were randomly selected for independent
rating of the telepsychiatrists completion of the items on the checklists.
A random set of 18 session recordings were double coded by the independent raters and the
telepsychiatry trainer (KM), who acted as the gold standard rater.
For each module of Caregiver Behavior Training, a list of 8-10 elements was created and scored
dichotomously as present or absent by one pf our seven trained fidelity raters.
Approximately one intervention session per family was randomly selected for fidelity rating to ensure
representation of all therapist across all modules.
A random set of 10 session videos were double coded by the fidelity rating trainers (CMc), who was
selected as the gold standard rater.
Caregivers reported their satisfaction with the treatment received using the Client Satisfaction
Questionnaire, which was adapted to reflect caregiver satisfaction with their childs ADHD treatment.
Five of the eight therapists responded to a confidential electronic survey
Findings/Discussion To carry out the CATTS study the researchers developed an intervention for the TMH delivery of
medication treatment with psychoeducation and Caregiver Behavioral Training to families of children
with ADHD from underserved communities.
Overall, both parts of the intervention were well received by families who engaged with the treatment
as evidenced by high rates of attendance, and who learned information and skills, as evidenced by
high scores on quizzes.
Families indicated very high levels of satisfaction with the active intervention, even though it was
relatedly brief in nature (six sessions).
This brief stabilization model of intervention is particularly relevant to working with a remote population
where treatment resources are scarce.
Paired with the data on treatment effectiveness, the CATTS study demonstrates that it is possible to
provide direct medical services through telepsychiatry and to train supervise therapist remotely.
Both telepsychiatrist and therapist were highly faithful to the intervention protocols, as demonstrated by
their independently-rates fidelity.
AN INTEGRATIVE REVIEW: ADHD INTERVENTIONS
Appraisal/Worth to practice
First Author
Study outcomes, including caregiver engagement, family satisfaction, therapist fidelity and therapists
ratings of increases in knowledge and skills were robustly high across differing levels of therapist
expertise and experience in delivering family-based treatment.
The CATTS trail was not designed to parse the differential effects of telepsychiatry versus Caregiver
Behavioral Training on outcomes, but rather to test a service model that responds to the call to use
telecommunications technologies to improve the mental health care and outcome for children living in
under-served communities.
Provides a service model that uses telecommunications to improve the mental health care and
outcomes for children living in under-served communities.
Mohammad Reza Mohammadi (2015)/From the Psychiatry and Psychology Research center and Tehran
AN INTEGRATIVE REVIEW: ADHD INTERVENTIONS
(Year)/Qualifications
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied (and
their definition), if appropriate
Measurement Tool/Data
Collection Method
University of Medical Sciences in Tehran, Iran.
ADHD is one of the most common psychological disorders of childhood.
It affects various aspects of development including social, emotional, and cognitive functions of a child
either at home or school.
ADHD disorder is identified with such behavioral symptoms such as inattention, hyperactivity, and
impulsivity.
Children with ADHD may also suffer from cognitive disorders that may affect their daily living activities
at school or home.
Difficulty in attention and concentration is one of the fundamental problems in children with ADHD.
Methylphenidate is a highly effective treatment of ADHD.
Experience has shown that combination therapies are more effective in improving and maintaining
patients health level in the long term in the majority of mental disorders.
Most researchers believe that the combination therapy may be a selective treatment for ADHD.
The study is aimed to determine how effective combined parent behavioral management training and
medication treatment is in reducing ADHD symptoms in 6-12 year old children.
The theoretical framework was not stated in the article but I believe it is Experimental because there is
an experimental group and a control group and randomized sampling was used.
They started out with 50 children ages 6-12 with ADHD who had been referred to Roozbeh hospital and
child psychiatry clinic were put on a list.
They selected 47 children through a stratified random relative manner.
Using the Cochran formula the children were divided into two groups: the experimental group which
had 22 children in it received PBMT and methylphenidate treatment and the control group which had
25 children in it received only methylphenidate treatment.
Children in both groups were matched for age and sex.
Children with all types of ADHD participated In this study and frequency dispersion as follows: 39 with
the combined type, 17 with inattentive type, and 14 with hyperactive-impulsive type.
They started out with 50 children ages 6-12 with ADHD who had been referred to Roozbeh hospital and
child psychiatry clinic in 2011.
They selected 47 children through a stratified random relative manner.
The Setting is in Iran.
Parental consent was obtained prior to the study.
The mjor variable studied were: Attention deficit hyperactivity disorder (ADHD), parent behavioral
management training (PMBT), methylphenidate medication, symptoms of ADHD, combined PBMT and
methylphenidate treatment, parents education level, and parents age
Clinical interviews performed by the child psychiatrist for diagnosis based on DSM-IV-TR and Conners
parent rating scale answered by the parent that is participating in the research were used to collect
AN INTEGRATIVE REVIEW: ADHD INTERVENTIONS
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
First Author
(Year)/Qualifications
Background/Problem
date.
T-test was used for the comparison of the two groups.
Levenes test was used for equality of variance.
The rate of ADHD in children whose parent received PBMT was further reduced compared to those
children whose parents did not receive training.
Combination treatment had a almost significant effect on reducing ADHD symptoms.
PBMT was found to be more effective in younger parents than older ones.
The efficiency of PBMT in children with ADHD was independent of parents education.
I believe this article is valuable to the medical profession because it shows that combined PBMT and
methylphenidate treatment is more effective when it comes to treating ADHD than methylphenidate
treatment alone.
William E. Pelham (2014) Psychology and Psychiatry, Center for Children and Families MMC, Florida
International University
Behavioral treatments, psychostimulants medication, and their combination are the most widely studied
AN INTEGRATIVE REVIEW: ADHD INTERVENTIONS

Statement and accepted treatments for attention deficit hyperactivity disorder (ADHD).
Several studies, reviewed in the article suggest that the most effective short-term treatment for ADHD
appears to be a combination of pharmacologic and behavioral treatment.
With the exception of a few case studies, previous investigations have not manipulated the intensity of
both behavioral interventions and medication in the same study.
The limited range of treatments studied can lead researchers to make conclusions that may not hold
true if a wider range of treatment intensities were studied.
Conceptual/theoretical The researchers did not list a theoretical framework but I believe it is Quasi-Experimental because they
Framework are trying to determine the effects of interventions/treatments on patient outcomes.

Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied (and
their definition), if appropriate
Consisted of 2 factors: medication (placebo, 0.15mg/kg/dose MPH t.i.d., 0.3mg/kg/dose MPH t.i.d., and
0.6 mg/kg/dose MPH t.i.d.) and behavior modification (no behavior modification, NBM; low-intensity
behavior modification, LBM; and high-intensity behavior modification HBM).
Medication was randomly assigned within each child and varied daily. Behavioral treatment was varied
in 3-week blocks with order of the 3 conditions counterbalanced.
Over the course of the study each participant had 3-4 days in each medication X behavioral treatment
condition.
Children were placed in groups of 12 according to age, and supervised by 5 students who were trained
and supervised by permanent staff members.
Children spent 2 hours in academic settings and the remainder of the day in group recreational
activities.
The behavioral conditions outlined were implemented for 3 weeks each.
In all behavioral conditions, children were suspended or sent home for severely aggressive or
disruptive behavior that would endanger any child or adult.
The sample consisted of 48 children with ADHD ages 5-12, 44 boys, and 4 girls.
They were required to meet DSM-IV diagnostic criteria for ADHD, to have a full-scale IQ of at least 80,
and to have no documented adverse response to or medical conditions that would contraindicate use
of MPH.
The study took place in the context of a summer treatment program that lasted for 9 hours per day on
weekdays and ran for 9 weeks.
Parents and children provided informed consent and the University of Buffalo Health Sciences IRB
approved the protocol.
The children, their parents, and clinical staff members were uninformed of medication condition and
only the research coordinator, pharmacist and medical director had access to the medication order.
The medical director could reveal medication condition in cases of severe side-effect reports.
The major variables study were: Methylphenidate (MPH), Attention deficit hyperactivity disorder
(ADHD) treatment, High-intensity behavior modification (HBM), Low-intensity behavior modification
(LBM), No behavior modification (NBM), Combined treatment, and Social behavior
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Measurement Tool/Data
Collection Method
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
For those children that are under the high intensity behavior modification category, a comprehensive
points system with both rewards and cost components was in place throughout the day during the
summer treatment program.
For those under the Low-Intensity behavior modification the point system worked differently because
the counselors just provided feedback based on their behavior and did not earn or lose points for the
behavior.
For those under the no behavior modification intervention the staff members recorded all point system
behaviors and rule violations that children exhibited, but provided feedback to children without
awarding or taking away points.
For the point system measures and ratings, 2 separate 4 (medication: placebo, 0.15 mg/kg, 0.3 mg/kg,
0.6 mg/kg) x 3 (BMOD: NBM, LBM, HBM) repeated-measures multivariate analyses of variance were
performed in SPSS GLM.
Linear and quadratic effects were tested to determine the dose-response effect of increasing levels of
treatment.
Pairwise follow-up contrasts were used to detect differences among increasing dosages of both BMOD
and medication.
Where significant interactions were found, simple effects test were performed within each level of
treatment.
Fourth-root transformations were used on the frequency categories.
T-test comparisons were performed among pairs of effect sizes to test differences among conditions.
Pairwise test were used for each treatment combination relative to a baseline of one of the unimodal
treatments.
To examine individual differences in response to the treatments, the proportion of the sample that had
negative, small medium, and large effect sizes was computed for each treatment combination.
Simple effects tests showed that all BMOD had significant effects at all levels of drug and that drug had
significant effects at all levels of BMOD.
The only side effect reported at a moderate to severe level on the average was appetite loss as
measured by the amount of lunch eaten.
This study was conducted in an effort to explore more fully the efficacy of different doses of behavioral
and pharmacological treatments for ADHD.
This is the first controlled, large study that has manipulated the dosages of both medication and
behavioral treatment in social-recreational settings.
Results replicate previous studies conducted in the STP setting with the addition of a lower-intensity
behavioral treatment.
The results show that (1) both behavioral treatment and MPH have large effects on the social behavior
of children with ADHD, (2) the combination of the low doses of the two modalities has substantial
beneficial effects, and (3) the presence and dose of either treatment influences the efficacy of the other
treatment in several important ways.
This study was conceptualized as a well-controlled, laboratory, analogue-based efficacy study, because
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no previous studies of the type have been conducted.

I feel that this study has a good worth to practice because there are no other studies that show the
effects on childrens behavior by changing the doses of medication administered and by changing the
level of behavioral modification.

First Author Jurjen van der Schans (2017) Groningen Research Institute of Pharmacy, Pharmacotherapy, Epidemiology
(Year)/Qualifications & Economics, University of Groningen, the Netherlands.
Background/Problem There is no conclusive evidence that stimulants have beneficial effects on major associated outcome
Statement parameters, particularly school performance.
The researchers assessed the differences in school performance among children using
methylphenidate at the end of primary school in relation to various parameters of methylphenidate use.
AN INTEGRATIVE REVIEW: ADHD INTERVENTIONS

Conceptual/theoretical The framework was not addressed throughout the article. It is however listed in the title as a descriptive
Framework study.

Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied (and
their definition), if appropriate
The researchers linked children from a pharmacy prescription database with standardized achievement
test results at the end of primary school.
The researchers explored differences in test scores between current methylphenidate users versus
never users and methylphenidate users who stopped treatment at least 6 months before the test, early
versus late starters, different dosage of methylphenidate, and concurrent antipsychotic or asthma
treatment.
The study population consisted of 22,063 children born between 1996 and 2001.
By using a personal identification number unique to every citizen, a linkage with data from Statistics
Netherlands (CBS) was performed.
Statistic Netherlands was responsible for performing the linkage between the two datasets and
removed all identification information from the dataset, hence researchers were unable to identify
patients.
The final study population comprised all children whose full data were available which was 7,736
children.
An analysis for the University of Groningen IADB pharmacy prescription database was performed.
The IADB database is a longitudinal pharmacy-dispensing database with detailed patient-based drug
prescription data from 1994 till 2012 from approximately 600,000 patients in the Netherlands.
Patient anonymity is guaranteed by the use of an unique anonymous identifier, hence the ethical
approval from observational studies with data from the IADB has been waived.
The major variables studied were: Methylphenidate, Attention-deficit hyperactivity disorder, School
performance, and Children.

Measurement Tool/Data In the Netherlands, all children at the end of primary school education around the age of 12 choose
Collection Method which type of secondary education is the most appropriate for them.
They do so by taking the Central Institute for Test Development test (Cito-test) which covers language,
arithmetic/mathematic, and general study skills.
Because of this transformation, the researchers were able to compare the scores from year to year
despite difference in difficultly of the tests.
The score is an indicator for the learning achievement of a child; indirectly it also is an indicator for
intelligence, motivation, concentration and drives to learn.
Data Analysis Frequencies of the baseline characteristics were compared using Pearson chi-squared test.
The researchers described crude mean Cito-test scores and tested for significance difference with
analysis of variance (ANOVA).
They tested the interaction terms between covariates and methylphenidate exposure by using
backward elimination to exclude non-contributable confounding from the prediction model to measure
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Findings/Discussion
Appraisal/Worth to practice
whether the association between methylphenidate use and Cito-test score differed.
An analysis of covariance (ANCOVA) was subsequently conducted to test whether there was a
statistically significant difference in school performance measured by Cito-test scores between the
methylphenidate treatment groups after controlling simultaneously for the effects of confounding.
They performed ANCOVA analyses to test for significant differences in school performance between
different treatment groups.
Cohens d was calculated to determine the standardized differences between two means for the
significant findings.
All analyses were conducted using Statistical Package of Social Sciences (SPSS) version 22 and a
two-sided p value <0.05 was considered to be statistically significant.
This study shows that methylphenidate users have a lower school performance compared to children
who have no history of ADHD medication.
The results indicate that early starters of methylphenidate treatment have significantly lower school
performance than children starting later with the treatments.
Finally, past treatment compared to current treatment of methylphenidate, different dosage of
methylphenidate and concurrent treatment with antipsychotic or asthma medication all appear to not be
related to school performance.
The study shows an association between various parameters of methylphenidate use and school
performance, it must be noted that without a clear comparator group and using only correlational data
no conclusion can be drawn about cause and effect of methylphenidate use and school performance.