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Letters to the Editor   |    
Key Issues Relevant to the Efficacy of Behavioral Treatment for ADHD
Andrea Chronis-Tuscano, Ph.D.; Anil Chacko, Ph.D.; Russell Barkley, Ph.D.
Am J Psychiatry 2013;170:799-799. doi:10.1176/appi.ajp.2013.13030293
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Dr. Chacko has received advisory board fees from Shire Pharmaceutical. Dr. Barkley receives a pension from the State of Massachusetts; book and newsletter royalties from Guilford Press and Jones and Bartlett publishers; Internet course royalties from CMI Education Institute, J&K Seminars, PsychContinuingEd.com, and ContinuingEdCourses.com; and speaking or consulting fees from Eli Lilly and Theravance. Dr. Chronis-Tuscano reports no financial relationships with commercial interests.

From the Department of Psychology, University of Maryland, College Park; the Department of Psychology, Queens College, City University of New York, Flushing; and the Department of Psychiatry, Medical University of South Carolina, Charleston.

Copyright © 2013 by the American Psychiatric Association

Accepted April , 2013.

To the Editor: In their recent meta-analysis of nonpharmacological interventions for attention deficit hyperactivity disorder (ADHD), Sonuga-Barke et al. (1) concluded that limited evidence is available for behavioral interventions. We raise a number of key issues for consideration with respect to this conclusion.

Most importantly, ADHD symptoms were the primary outcome measure in this meta-analysis. Across disorders, however, functional impairment is what prompts treatment seeking, and reducing impairment is the desired outcome (2). ADHD symptom reduction does not necessarily equate to improvements in functioning (3); impairment is therefore a far more socially valid outcome than psychiatric symptoms per se. For behavioral interventions, the primary target of treatment has historically been impairment. For example, dysfunctional parent-child interactions as evaluated by blinded observational assessments determine larger effects on ADHD symptoms in parent training studies (4) and predict serious developmental outcomes for children with ADHD (5). ADHD symptoms are therefore by no means considered the only (and certainly not the most clinically important) target of treatment.

Additionally, the behavioral intervention studies included in this meta-analysis constitute only a small fraction of the larger treatment literature (4). Furthermore, combining diverse nonpharmacological interventions into a “behavioral intervention category” may grossly undermine the estimated effects of behavioral interventions. For instance, interventions such as direct child therapy and social skills training have little to no empirical evidence, whereas behavioral parent training and behavioral classroom interventions are well-established treatments (6). The approach taken by Sonuga-Barke et al. is analogous to a meta-analysis of pharmacological treatments for ADHD that combines stimulants, antidepressants, and atypical antipsychotics as a single category of “stimulant medications.”

A key issue highlighted in this article is the need to include active treatment comparison conditions to obtain objective evaluations of treatment outcomes, which we fully support. Unfortunately, the approach taken by the authors often involved evaluating teacher ratings after home interventions, parent ratings after school interventions, or brief laboratory or clinic observations of the child’s ADHD symptoms. Behavioral treatments demonstrate the largest effects in the setting in which they are implemented (6), and blinded assessments of behavior in these settings will likely yield a more valid evaluation of treatment effects.

We hope that this article encourages an investment in more rigorously designed outcome studies, but we have concerns about the potential implications of this meta-analysis despite more than 40 years of solid evidence for the efficacy of behavioral interventions.

Sonuga-Barke  EJ;  Brandeis  D;  Cortese  S;  Daley  D;  Ferrin  M;  Holtmann  M;  Stevenson  J;  Danckaerts  M;  van der Oord  S;  Döpfner  M;  Dittmann  RW;  Simonoff  E;  Zuddas  A;  Banaschewski  T;  Buitelaar  J;  Coghill  D;  Hollis  C;  Konofal  E;  Lecendreux  M;  Wong  IC;  Sergeant  J; European ADHD Guidelines Group:  Nonpharmacological interventions for ADHD: systematic review and meta-analyses of randomized controlled trials of dietary and psychological treatments.  Am J Psychiatry 2013; 170:275–289
[CrossRef] | [PubMed]
 
Becker  K;  Chorpita  BF;  Daleiden  E:  Improvements in symptoms versus functioning: how do our best treatments measure up? Adm Policy Ment Health Ment Health Serv Res 2011; 38:440–458
[CrossRef]
 
Epstein  JN;  Langberg  JM;  Lichtenstein  PK;  Altaye  MB;  Brinkman  WN;  House  K;  Stark  LJ:  Attention-deficit/hyperactivity disorder outcomes for children treated in community-based pediatric settings.  Pediatrics 2010; 164:160–165
 
Fabiano  GA;  Pelham  WE  Jr;  Coles  EK;  Gnagy  EM;  Chronis-Tuscano  A;  O’Connor  BC:  A meta-analysis of behavioral treatments for attention-deficit/hyperactivity disorder.  Clin Psychol Rev 2009; 29:129–140
[CrossRef] | [PubMed]
 
Chronis  AM;  Lahey  BB;  Pelham  WE;  Williams  SH;  Baumann  BL;  Kipp  H;  Jones  HA;  Rathouz  PJ:  Maternal depression and early positive parenting predict future conduct problems in young children with attention-deficit/hyperactivity disorder.  Dev Psychol 2007; 43:70–82
[CrossRef] | [PubMed]
 
Pelham  WE  Jr;  Fabiano  GA:  Evidence-based psychosocial treatments for attention-deficit/hyperactivity disorder.  J Clin Child Adolesc Psychol 2008; 37:184–214
[CrossRef] | [PubMed]
 
References Container
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References

Sonuga-Barke  EJ;  Brandeis  D;  Cortese  S;  Daley  D;  Ferrin  M;  Holtmann  M;  Stevenson  J;  Danckaerts  M;  van der Oord  S;  Döpfner  M;  Dittmann  RW;  Simonoff  E;  Zuddas  A;  Banaschewski  T;  Buitelaar  J;  Coghill  D;  Hollis  C;  Konofal  E;  Lecendreux  M;  Wong  IC;  Sergeant  J; European ADHD Guidelines Group:  Nonpharmacological interventions for ADHD: systematic review and meta-analyses of randomized controlled trials of dietary and psychological treatments.  Am J Psychiatry 2013; 170:275–289
[CrossRef] | [PubMed]
 
Becker  K;  Chorpita  BF;  Daleiden  E:  Improvements in symptoms versus functioning: how do our best treatments measure up? Adm Policy Ment Health Ment Health Serv Res 2011; 38:440–458
[CrossRef]
 
Epstein  JN;  Langberg  JM;  Lichtenstein  PK;  Altaye  MB;  Brinkman  WN;  House  K;  Stark  LJ:  Attention-deficit/hyperactivity disorder outcomes for children treated in community-based pediatric settings.  Pediatrics 2010; 164:160–165
 
Fabiano  GA;  Pelham  WE  Jr;  Coles  EK;  Gnagy  EM;  Chronis-Tuscano  A;  O’Connor  BC:  A meta-analysis of behavioral treatments for attention-deficit/hyperactivity disorder.  Clin Psychol Rev 2009; 29:129–140
[CrossRef] | [PubMed]
 
Chronis  AM;  Lahey  BB;  Pelham  WE;  Williams  SH;  Baumann  BL;  Kipp  H;  Jones  HA;  Rathouz  PJ:  Maternal depression and early positive parenting predict future conduct problems in young children with attention-deficit/hyperactivity disorder.  Dev Psychol 2007; 43:70–82
[CrossRef] | [PubMed]
 
Pelham  WE  Jr;  Fabiano  GA:  Evidence-based psychosocial treatments for attention-deficit/hyperactivity disorder.  J Clin Child Adolesc Psychol 2008; 37:184–214
[CrossRef] | [PubMed]
 
References Container
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