This series of NIHR-funded systematic reviews found that some things schools do (interventions) can help children with attention deficit hyperactivity disorder. These were grouped into 15 main approaches including reward and punishment, skills training and self-management, creative-based therapies, such as music therapy, and structured physical activity. These reviews covered different strategies to change behaviour other than giving children medication. Most showed positive effects. Due to substantial variation in the effect on symptoms, behaviour or educational achievement across the included studies, the reviews were not able to specify the best programme, or determine which elements were most closely linked with success. The reviews indicate that success was influenced by pupils’ relationships with their peers or teachers and the school context. Those designing programmes need to be sensitive to the school’s culture and organisation and should aim to minimise the stigma of this condition.
No UK-based studies were identified for the effectiveness review, making it harder to apply any findings to UK schools. The insights from this study are likely to help inform the design of future UK trials.
Why was this study needed?
A 2003 UK survey of over 10,000 children aged five to 15 years found that 3.62% of boys and 0.85% of girls had attention deficit hyperactivity disorder (ADHD). Many studies have shown increases in the prevalence of clinically diagnosed ADHD in the last couple of decades, especially in the US, but there are differences in how ADHD is diagnosed between countries. However, a small 2009 UK survey found there is still controversy about ADHD with half of GPs and 1 in 5 special education needs coordinators, believing that ADHD was not “a real neurological condition”.
The NIHR funded this series of systematic reviews to find out whether school-based interventions without drugs improve ADHD symptoms in children, and to investigate factors – like attitudes and beliefs – that enhance or limit delivery of such interventions.
What did this study do?
This study reported on four systematic reviews of non-drug programmes and interventions for ADHD delivered in schools. One measured effectiveness and cost effectiveness. Three looked into attitudes and experiences.
The effectiveness and cost-effectiveness review looked at studies of children with, or at risk of, ADHD. Fifty-four controlled trials were included, 39 of which were randomised controlled trials. The included trials evaluated interventions over a period of 32 years, which were grouped into 15 types of intervention packages including reward and punishment, skills training and self-management, creative-based therapies, such as music therapy, and structured physical activity. Few studies used similar combinations of packages. The results of the RCTs and the non-RCTs were analysed separately using meta-analysis.
Three reviews summarised qualitative research from 95 studies examining the attitudes and experiences of school practitioners, pupils, teachers and parents related to non-drug interventions for ADHD in schools.
No UK-based studies were included in the effectiveness review and there were only nine in the other reviews. Most of the RCTs were conducted in the US which limits the applicability of the findings to UK schools which have different educational systems. Other limitations included the breadth of the interventions and outcomes, and the poor quality of many of the included studies, for example, those assessing outcomes or rating children were often aware of the treatments received.
What did it find?
- Pooling the results of 36 randomised trials using any type of non-drug intervention showed improvements were possible in several outcomes, including core ADHD symptoms such as independently assessed inattention and hyperactivity/impulsivity (medium effect sizes: d+ = 0.44 and d+ = 0.33 respectively).
- The effects for teacher-rated inattention, externalising symptoms and educational outcomes ranged from medium to small (d+ = 0.60, d+ = 0.20 and d+ = 0.26).
- Substantial differences in effect sizes (from very small to large) were seen across studies. This was partly due to the lack of standardised interventions and outcome measures.
- Economic outcomes were not included in any studies so cost-effectiveness could not be assessed.
- The qualitative reviews highlighted the importance of context in terms of particular school and national education policies. They suggested that negative attitudes toward ADHD, and the relationships of pupils with their teachers and peers, could influence how well interventions worked.
What does current guidance say on this issue?
The 2008 NICE guideline on diagnosis and management of ADHD recommends non-drug interventions as the first-line treatment for children of school age with ADHD and moderate impairment. Outside of the school the recommended interventions include group parent training/education programmes, and/or group psychological treatment such as cognitive behavioural therapy, or social skills training for younger child. For older children, individual psychological treatment is an option. Drug treatment should be offered to children with persisting symptoms. The 2008 guideline recommends drugs as a first-line treatment for children with severe ADHD.
This guideline also recommends that teachers who have received training about ADHD and its management should provide behavioural interventions in the classroom to help children and young people with ADHD. However, the guideline says that teachers in England are not systematically trained to use classroom management and teaching strategies for children with ADHD.
What are the implications?
Fifteen types of non-drug intervention packages were identified during this research but few studies used similar combinations of packages. This research showed that non-drug interventions in schools could improve ADHD symptoms and educational outcomes, but given the lack of standardised interventions and common outcome measures it was not possible to recommend which strategies worked best. This limits the immediate implications for UK practice.
There are also implications for the training of teachers if these programmes are to be implemented at scale.
Childhood ADHD results in considerable cost for society. A 2013 study found that in the UK the mean cost per adolescent for NHS, social care and education resources was £5,493 per year in 2010 prices with education resources accounting for three times the costs of healthcare. The total annual cost for adolescents with ADHD in the UK was around £670 million.
Richardson M, Moore DA, Gwernan-Jones R, et al. Non-pharmacological interventions for attention-deficit/hyperactivity disorder (ADHD) delivered in school settings: systematic reviews of quantitative and qualitative research. Health Technol Assess. 2015 Jun;19(45):1-470.
This project was funded by the National Institute for Health Research Health Technology Assessment programme. The study is registered as PROSPERO CRD42011001716.
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Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre