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Research ArticlePeer Inclusion in Interventions for Children with ADHD:A Systematic Review and Meta-Analysis
1School of Occupational Therapy and Social Work, Curtin University, GPO Box U1987, Perth, WA 6845, Australia2College of Healthcare Sciences, James Cook University, 1 James Cook Drive, Townsville, QLD 4811, Australia3School of Allied Health, Australian Catholic University, P.O. Box 968, North Sydney, NSW 2059, Australia4Department of Special Needs Education, University of Oslo, Postboks 1140 Blindern, Olso 0318, Norway5Department of Otorhinolaryngology and Head and Neck Surgery, Leiden University Medical Centre, P.O. Box 9600,2300 RC Leiden, Netherlands
Correspondence should be addressed to Reinie Cordier; [email protected]
Received 30 October 2017; Accepted 9 January 2018; Published 18 March 2018
Objective. To assess the effectiveness of peer inclusion in interventions to improve the social functioning of children with ADHD.Methods. We searched four electronic databases for randomized controlled trials and controlled quasi-experimental studies thatinvestigated peer inclusion interventions alone or combinedwith pharmacological treatment.Datawere collected from the includedstudies andmethodologically assessed.Meta-analyses were conducted using a random-effectsmodel.Results. Seventeen studiesmeteligibility criteria. Studies investigated interventions consisting of peer involvement and peer proximity; no study included peermediation. Most included studies had an unclear or high risk of bias regarding inadequate reporting of randomization, blinding,and control for confounders. Meta-analyses indicated improvements in pre-post measures of social functioning for participants inpeer-inclusive treatment groups. Peer inclusion was advantageous compared to treatment as usual. The benefits of peer inclusionover other therapies or medication only could not be determined. Using parents as raters for outcome measurement significantlymediated the intervention effect. Conclusions. The evidence to support or contest the efficacy of peer inclusion interventions forchildren with ADHD is lacking. Future studies need to reduce risks of bias, use appropriate sample sizes, and provide detailedresults to investigate the efficacy of peer inclusion interventions for children with ADHD.
1. Introduction
Attention-Deficit Hyperactivity Disorder (ADHD) is themost prevalent neurobehavioural disorder affecting school-aged children [1]. Impaired social functioning is regardedas one of the core deficits for children with ADHD [2, 3].Individuals with ADHD frequently present with deficits inthe following executive function domains: problem solving,planning, flexibility, orienting, response inhibition, sustainedattention, and working memory [4]. They also experienceaffective difficulties, such as motivation delay and mooddysregulation [4]. These difficulties appear to form the basisof the social skills problems in children with ADHD [5, 6].
Quality friendships are important for children’s develop-ment and serve as a protective factor for those at risk for
current and future difficulties [7]. While having friends hasbeen found to be developmentally advantageous throughoutthe lifespan [8], more than 50% of children with ADHDexperience peer rejection from their classmates [3, 9]. Typ-ically developing peers often describe children with ADHDas being annoying, boisterous, irritating, and intrusive [6].Furthermore, the interpersonal relationships of children withADHD are frequently characterised as being negative andconflicting [3, 10]. Children with ADHD are likely to havedifficulties in establishing and maintaining satisfying inter-personal relationships as a result of difficultywith cooperativeplay with peers, perspective taking, responding to social cues,and self-regulation, placing them at higher risk of socialisolation [11].
HindawiBioMed Research InternationalVolume 2018, Article ID 7693479, 51 pageshttps://doi.org/10.1155/2018/7693479
There is a large body of empirical research that demon-strates that children with ADHD experience pervasive socialdifficulties that can cause social maladjustment in ado-lescence and adulthood [3, 7, 12]. Impairments in socialfunctioning can lead to school dropout, academic under-achievement, low self-esteem, and troublesome interpersonalrelationships with family members and peers [13]. As a result,children with ADHD are at greater risk of developing adverseproblems in adolescence and adulthood, including anxiety,depression, aggression, and early substance abuse [3].
There is much debate surrounding the causes of socialskills deficits in children with ADHD. Some researcherstheorise that the social difficulties of childrenwith ADHDarea result of having limited knowledge of age-appropriate socialskills, proposing that the social skill deficits are caused bydeficits in skill acquisition [3]. Other researchers have drawnfrom the well documented cognitive model of ADHD toexplain the mechanisms underlying social skill deficits inchildren with ADHD [52]. In this conceptual model, Barkley[52] concluded that children with ADHD possess adequatesocial skills but fail to apply them in specific social situations;thus their social skills deficit is a result of a performancedeficit.
Recent reviews conclude that performance deficits are thelikely cause of social problems in children with ADHD [99,100]. ChildrenwithADHDappear to possess age-appropriatesocial skills; however they fail to apply this knowledge tofunctionally interact with others [101].This lack of applicationof knowledge is likely due to a range of cognitive and affectivedifficulties, where children with ADHD may demonstratedisproportionate emotional reactions and decreased perspec-tive taking and forethought, impacting their ability to applythe necessary skills during spontaneous social interactionswith peers [52].
Several clinical practice guidelines, including those ofthe National Institute for Health and Clinical Excellence(NICE) in the United Kingdom, have concluded that non-pharmacological interventions are a necessary componentwhen treating children with ADHD [102]. The effective-ness of using nonpharmacological interventions, such asparent training (PT), cognitive-behavioural therapy (CBT),social skills training (SST), school-based interventions, aca-demic interventions, and multimodal treatment, has beenreviewed for children and adolescents with ADHD [102–104]. Although SST has been reviewed extensively, the corecomponents of psychosocial treatment, such as the use ofpeers in the interventions aimed at improving social skills,have not been systematically investigated for children withADHD.
Peers are commonly included in psychosocial interven-tions for children. Peer inclusion interventions are oftencoupled with psychoeducational interventions such as parenttraining and/or school-based interventions where teachersimplement daily report cards and behaviour response-tokenstrategies [104]. Peer inclusion interventions can also beimplemented within the context of a summer treatmentprogram where a range of different psychosocial interven-tions are conducted to improve ADHD symptoms, socialfunctioning, and overall impairment [105]. Peer inclusion
in interventions is postulated to have multiple benefits.Including peers in interventions may motivate children toparticipate and allow the intervention to be conducted ingroup settings, enhancing the feasibility of the approach[46, 55]. Moreover, including peers in interventions has thepossibility of improving intervention outcomes [106]. Froma social learning theory perspective, children are presentedwith frequent opportunities where social skills, behaviours,and consequences are modelled during group interactions[107]. Across the literature on psychosocial interventions forchildren with developmental disorders, the types of peerinclusion have been broadly described and categorised asfollows: (a) peer involvement, (b) peer mediation, and (c)peer proximity.
Peer involvement has been most commonly used in SSTand summer treatment programs (STP) interventions forchildren with ADHD. Peer involvement is most commonlycharacterised by interventions where participants facilitateeach other’s learning.Therefore, the number of opportunitiesto reinforce and practice target skills is increased, enhancingthe success of treatment outcomes. The children are taughtsocial interaction strategies such as sharing, helping, prompt-ing, instructing, or praising [108]. However, peers includedin these interventions often include children with similardiagnoses and skill difficulty in a group therapy context.Thus,intervention may incorporate facilitator-led role-plays andinteractions, where the focus is on increasing social skillsthrough instructions during peer-to-peer interactions [53, 61,66, 69].
Peer-mediated intervention involves an extension of peerinvolvement as the peer is a key component and an activeagent of change for the intervention. In peer-mediated inter-ventions, peers are trained to provide instruction and facili-tate social interactions with the target child/client [109]. Peer-mediated intervention involves a combination of peer initi-ation, modelling, prompting, and reinforcing of the desiredbehaviour [106]. Peer-mediated interventions can be read-ily incorporated into a child’s environment, particularly ininclusive settings, and can support the generalisation of skillsacross different environments [106]. Peer-mediated interven-tions are based on the notion that individuals’ behaviour isinfluenced by their peers, an influence that can be both overtand powerful [110]. For these reasons, typically developingpeers have been most commonly incorporated into peer-mediated intervention with stringent criteria regarding peerselection [106, 111].
Peer proximity involves carefully selected peers ofincreased skill, likely without a diagnosis, who are placed inclose proximity to the child, such as sitting at the same tablein a classroom [112]. Central to both peer-mediated and peer-proximity approaches is the careful and purposeful selectionof peers. Commonly used inclusion criteria for peers inboth peer-mediated and peer-proximity interventions wereas follows: typical social and language development, absenceof behaviour difficulties, an interest in interacting withthe target child, and regular availability [46, 106, 108, 111].The direct interaction between the client and their peers,which is the central characteristic of peer-mediated andpeer-proximity interventions, has many practical advantages
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and benefits including fostering inclusion in school settings[111]. An example of such an advantage is the abundanceof typically developing peers in schools and the use ofa practical approach to provide services to children withadditional needs that could lower cost and alleviate pressureson teachers, health professionals, and parents [113].
A peer-mediated approach is the most empirically sup-ported model of social skills interventions for children withAutism Spectrum Disorders (ASD) [108]. However, furtherresearch is required to strengthen the evidence base of theuse of peers in social interventions for children with ADHD.Similar to children with ADHD, children with ASD expe-rience significant social skills impairments. Training peersto support social skills development in target populationsis regarded as ecologically valid for children and has thepotential to address the problem of limited generalisabilityof treatment effects in adult mediated interventions [114]. Assuch there is a need to conduct a systematic review to examinethe effectiveness of peer inclusion in interventions aimed atimproving the social functioning for children with ADHD.
This systematic review aimed to examine the efficacy ofpeer inclusion in interventions targeting the social function-ing of children with ADHD. To capture the use of peers ininterventions in the existing literature and for the purposeof this systematic review, peer inclusion interventions weredefined as interventions that reported peer involvement, peermediation, or peer proximity. We also aimed to identify andsummarise the key characteristics of a range of peer inclusioninterventions, which will be used to analyse the feasibilityof using peers in treatment interventions for ADHD. Fur-thermore, we conducted a meta-analysis to examine the sig-nificance of improvements and effect sizes of peer inclusioninterventions designed to improve the social functioning ofchildren with ADHD. The manner in which improvementsand effect sizes varied between specific treatment approacheswas also examined.
2. Method
The methodology and reporting of this systematic reviewwere based on the PRISMA statement (see SupplementaryTable 1). The PRISMA statement checklist covers areas con-sidered necessary for the transparent reporting of systematicreviews in areas of health care [115].
2.1. Information Sources. To locate eligible studies, the fifthauthor conducted literature searches across four electronicdatabases between November 4 and 7, 2016. The searcheddatabases included the following: CINAHL, PsycINFO,Embase, and Medline with the following dates of coverage1937–2016, 1887–2016, 1902–2016, and 1946–2016, respec-tively. Supplementary search approaches such as checkingreference lists were also used to identify studies.
2.2. Search Strategy. Studies were identified through thefollowing procedure during the initial and updated searches.First, an electronic database search was conducted usingCINAHL, PsycINFO, Embase, and Medline. Two cate-gories of search terms (e.g., Mesh and Thesaurus terms)
were used in combination: (1) disorder (Attention-DeficitHyperactivity Disorder (ADHD), Attention-Deficit Disorder(ADD), and Attention-Deficit Disorder with hyperactivity)and (2) psychosocial interventions (peer, friend, friendship,buddy, playmate, group therapy, group intervention, grouprole-play, play group, play therapy, play treatment, playintervention, camp(s), school-based, play-based interven-tion, psychosocial, social skills, SST, social groups, socialbehaviour/behaviour, and group counselling). Limitationsapplied to the search included subject age (preschool child[2–5 years], child [6–12 years], and adolescent [13–18 years]),English language, and humans. The full electronic searchstrategy used for one of the major databases (Embase) isreported inTable 1.Using subheadings, free text searcheswerealso conducted for all four databases for studies publishedwithin the year prior to the search. The search terms andlimitations for the free text searches are also described inTable 1.
2.3. Inclusion/Exclusion Criteria. The following criteria forinclusion were applied: (1) children and/or adolescents hadto have a primary diagnosis of ADHD according to theDiagnostic and Statistical Manual of Mental Disorders 3rdEdition (Revised, DSM-III-R) or Diagnostic and StatisticalManual of Mental Disorders 4th Edition (DSM-IV) criteria;(2) studies included a control group; (3) the interventionsincluded peers; (4) the treatment content focused on socialfunctioning; and (5) the treatment outcome could be relatedto the peer inclusion intervention. Multimodal interventionprograms inwhich the peer inclusion interventionwas part ofa variety of empirically based behavioural components wereincluded if results can be extrapolated to provide insight intothe value of including peers as a core variable. These criteriawere selected to identify peer inclusion intervention studiesthat would be classed as either level II or III on the NationalHealth and Medical Research Council (NHMRC) Hierarchyof Evidence [116]. The NHMRC Hierarchy of Evidence wasdeveloped by the Australian NHMRC to rank and evaluatethe evidence of healthcare interventions [116]. Accordingto the NHMRC Hierarchy of Evidence, level I studies aresystematic reviews of randomized controlled trials (RCTs),level II studies are a well-designed RCTs, and level III studiesare, for example, quasi-experimental designswithout randomallocation. Studies with level III evidence were included asit was unlikely that a search limited only to level II studieswould identify all required studies to review the literature.
2.4. Systematic Review
2.4.1. Methodological Quality. The NHMRC Evidence Hier-archy “levels of evidence” [116] and the Kmet appraisal check-list [117] were used to assess the methodological quality ofthe included studies. Kmet has a three-point ordinal scoringsystem (yes = 2, partial = 1, and no= 0) that provides a system-atic, reproducible, and quantitative means of simultaneouslyassessing the quality of research encompassing a broadrange of study designs [117]. The total Kmet score can beconverted into a percentage score, with a Kmet score of >80%considered strong quality, a score of 60–79% considered good
4 BioMed Research International
Table1:Fu
llelectro
nics
earchstrategy.
Database
Search
term
sLimitatio
nsRe
sults
Subjecth
eading
s
CINAHL
(MH“A
ttentionDeficitH
yperactiv
ityDiso
rder”)AND((MH“PeerG
roup
”)OR
(MH“PeerC
ounseling”)O
R(M
H“Peer
Review
”)OR(M
H“Frie
ndship”)OR(M
H“Psychotherapy,G
roup
”)OR(M
H“G
roup
Processes”)O
R(M
H“Sup
portGroup
s”)O
R(M
H“R
oleP
laying
”)OR(M
H“PlayTh
erapy”)
OR(M
H“C
amps”)OR(M
H“SocialSkills
Training
”)OR(M
H“SocialSkills”)OR(M
H“C
ommun
icationSkillsT
raining”)O
R(M
H“Students,HighScho
ol”)OR(M
H“Schoo
ls,Middle”)O
R(M
H“Schoo
ls,Special”)
OR
(MH“Schoo
ls,Second
ary”)O
R(M
H“Schoo
ls,Elem
entary”)OR(M
H“SocialB
ehavior”))
Age:child,prescho
ol:2–5
years;child
:6–12years;
adolescent:13–18
years
280
Embase
(Atte
ntiondeficitdisorder/)AND(peer
rejection/OR“peerreview”/ORpeer
acceptance/orp
eerc
ounseling
/ORpeer
grou
p/ORfriend
ship/O
Rplay/O
Rplay
therapy/ORgrou
ptherapy/ORsocial
adaptatio
n/ORsocialbehavior/O
Rsocial
interaction/)
Age:prescho
olchild<1to6years>;schoo
lchild
<7to
12years>;ado
lescent<
13to
17years>
Lang
uage:E
nglish;
Hum
ans
1296
Medlin
e(atte
ntiondeficitdisorder
with
hyperactivity
/)AND(Frie
nds/ORPsycho
therapy,Group
/OR
play
therapy/ORsocialbehavior/)
Age:prescho
olchild
(2to
5years);child
(6to
12years);ado
lescent(13
to18
years)
Lang
uage:E
nglish
505
BioMed Research International 5
Table1:Con
tinued.
Database
Search
term
sLimitatio
nsRe
sults
PsycIN
FO
(DE“A
ttentionDeficitD
isorder
with
Hyperactiv
ity”)AND(D
E(“peer
coun
selling
”)ORDE(“peer
tutorin
g”)o
rDE(“peers”)O
RDE(“peer
evaluatio
n”)O
RDE(“friend
ship”)
ORDE(“grou
pinterventio
n”)O
RDE(“grou
pparticipation”)O
RDE(“grou
ppsycho
therapy”)O
RDE(“grou
pdynamics”)
ORDE(“grou
pcohesio
n”)O
RDE(“grou
pparticipation”)O
RDE(“child
hood
play
behavior”)ORDE(“child
hood
play
developm
ent”)O
RDE(“play
therapy”)O
RDE
(“therapeutic
camps”)ORDE(“scho
olbased
interventio
n”)O
RDE(“psycho
social
developm
ent”)O
RDE(“psycho
socialfactors”)
ORDE(“psycho
socialreadjustm
ent”)O
RDE
(“psycho
socialrehabilitation”)O
RDE(“social
skills”)O
RDE(“socialskillstraining”)O
RDE
(“socialgrou
pwork”)O
RDE(“socialgrou
ps”)
ORDE(“socialintegration”)O
RDE(“social
interaction”)O
RDE(“So
cialbehaviou
r”)O
RDE(“grou
pcoun
selin
g”))
Age:prescho
olage<
age2
to5y
rs>;schoo
lage
<age6
to12yrs>;ado
lescence<age13to
17yrs>
737
Free
text
words
CINAHL
(ADHDORADDOR“A
ttentiondeficit
hyperactivity
disorder”)AND(peer∗
OR
friend∗ORbu
ddyORbu
ddiesO
Rplaymate∗
OR“group
interventio
n∗”O
R“group
therap∗”
OR“group
roleplay∗”O
R“playgrou
p∗”O
Rcamp∗
ORstp
OR“play-based”
OR
psycho
socialORscho
ol∗OR“Socialskills”O
R“Socialbehavio∗”)
Publish
eddate:20151101–20161131
Age:child,prescho
ol:2–5
years;child
:6–12years;
adolescent:13–18
years
280
Embase
AsperC
INAH
LFree
Text
Lastyear
Age:prescho
olchild<1to6years>;schoo
lchild
<7to
12years>;ado
lescent<
13to
17years>
Field:Title
andor
Abstract
177
Medlin
eAs
perC
INAH
LFree
Text
Publish
eddate:2016-C
urrent
Age:prescho
olchild
(2to
5years);child
(6to
12years);ado
lescent(13
to18
years)
97
6 BioMed Research International
Table1:Con
tinued.
Database
Search
term
sLimitatio
nsRe
sults
PSYC
INFO
AsperC
INAH
LFree
Text
Publish
eddate:20151101–20161131
Age:prescho
olage<
age2
to5y
rs>;schoo
lage
<age6
to12yrs>;ado
lescence<age13to
17yrs>
Field:Title
andor
Abstract
365
BioMed Research International 7
quality, a score of 50–59% considered adequate quality, and ascore < 50% considered to have poor methodological quality.
2.4.2. Data Collection Process. A data extraction form wascreated to extract the data within the included studies. Weextracted the data under the following categories: participantdiagnosis, control group, age range, mean and standard devi-ation, inclusion criteria, treatment condition, outcome mea-sures, treatment outcomes, peer/parent/teacher components,skills taught, medication use, method and level of evidence,use of blinding and randomization, and methodologicalquality (using Kmet).
2.4.3. Data Items, Risk of Bias, and Synthesis of Results. Dur-ing data collection, data points across all studies wereextracted using comprehensive data extraction forms.Duringthis process, risk of bias was assessed at an individualstudy level during the Kmet rating [117]. Data was thenextrapolated and synthesised into a number of categories:participant characteristics, inclusion criteria, treatment con-ditions and outcomes, components of studies, components ofthe interventions, and methodological quality. The principalsummary measures to assess treatment outcomes were effectsizes and significance of data. We only analysed the effectsizes of the social skills outcomes for the peer inclusioninterventions, as the focus of this review was on the use ofpeers to facilitate social skills development. Interrater relia-bility for abstract selection and Kmet ratings were establishedby two independent assessors based on Weighted Kappacalculations. There was no evident bias in scoring studyquality and extractor bias of the reviewers conducting thissystematic review, as neither reviewer has formal or informalaffiliations with any of the authors of the published studiesincluded.
2.5. Meta-Analysis
2.5.1. Data Analysis. Data was extracted from the relevantstudies in order to compare the effect sizes for the fol-lowing: (1) pre-post measures of social skills using peerinclusion interventions and (2) mean difference in socialskills measures from pre to post between peer inclusioninterventions versus comparison controls. Three studies [55–57] were excluded from both analyses as the reported datawas not separated from other typically developing peers orother diagnoses. One further study was excluded as truebaseline measures could not be provided [63]. To compareeffect sizes for both the peer inclusion and comparison groupconditions, group means, standard deviations, and samplesizes for pre- and postmeasurements were then entered intoComprehensive Meta-Analysis Version 3.3.070 [118].
Effect sizes were generated in Comprehensive Meta-Analysis using a random-effects model, as it was unlikelythat the included studies have the same true effect due tovariations in sampling, intervention approaches, outcomemeasurement, and participant characteristics. Heterogeneitywas estimated using the 𝑄 statistic to determine the spreadof effect sizes about the mean and 𝐼2 to estimate the ratioof true variance to total variance. Effect sizes were calculated
using the Hedges g formula for standardized mean difference(SMD) with a confidence interval of 95% and were inter-preted using Cohen’s 𝑑 convention as follows: 𝑑 ≤ 0.2 assmall; 𝑑 ≥ 0.5 as moderate; and 𝑑 ≤ 0.8 as large [119].
Forest plots of effect sizes for social skill measures’ scorewere generated for the following: (1) pre-post groups forpeer inclusion interventions and (2) peer inclusion inter-ventions versus comparison groups. Subgroup analyses werethen used to explore the effect sizes as a function of thefollowing: (1) specific type of peer inclusion intervention(peer involvement, peer mediation, or peer proximity) inpre-post group analysis and (2) comparison group type(medication only, treatment as usual, and another therapy)for the peer inclusion intervention versus comparison groupanalysis.
Publication bias was assessed using Comprehensive DataAnalysis software following the Begg and Muzumdar’s rankcorrelation test which reports the rank correlation betweenthe standardized effect size and the variances of theseeffects [120]. The statistical procedure produces tau whichis interpreted as a value of 0 indicating no relationship anddeviations away from 0 indicating a relationship, as well as atwo tailed𝑝 value. If asymmetry is caused by publication bias,high standard error would be associated with larger effectsizes. If larger effects are presented by low values, tauwould bepositive, while if large effects are represented by high values,tau would be negative. Publication bias was also assessedusing Duval and Tweedie’s trim-and-fill procedure [121]. Theprocedure investigates the publication bias funnel plot, whichis expected to be symmetric.That is, it is expected that studieswill be dispersed equally on either side of the overall effect.The trim-and-fill procedure initially trims the asymmetricstudies from the right-hand side to locate the unbiased effectand then fills the plot by reinserting the trimmed studies onthe right aswell as their imputed counterparts to the left of themean effect size. The program is looking for missing studiesbased on a fixed-effect model and is looking for missingstudies only to the left side of the mean effect.
3. Results
3.1. Study Selection. A total of 3,395 studies were found acrossthe following databases: CINAHL (280), PsycINFO (1073),Embase (1448), andMedline (594). Only one study was iden-tified through searching of additional sources.The 3,395 stud-ies identified through subject headings and free text searcheswere screened for duplicate titles and abstracts with 618 dupli-cates removed. Two researchers reviewed abstracts for inclu-sion in the review. To ensure rating accuracy, 20 randomlyselected abstracts were assessed by both raters to achieveconsensus before rating the remaining abstracts. A thirdresearcher (second author) was consulted if agreement couldnot be reached between the first two researchers to achieve100% consensus. The agreement (Weighted Kappa) betweenraters for all abstracts was 0.832 (95% CI 0.5648–1.000).A five-point ordinal scale was constructed to rate abstracteligibility using the five inclusion criteria (described earlier),and abstracts with a score of 4 or 5 were selected for full-textreview.
8 BioMed Research International
Inclu
ded
Scre
enin
g
Records identified through CINAHL:280
Number of records after duplicates removed: 2,777
Number of records screened:2,777
Number of full-text articles assessed for eligibility: 65
Total number of articles included:17
Number of full-text articles excluded:49
7 = not intervention studies19 = no description of peer inclusion8 = no social skills outcomes4 = no comparison group1 = protocol paper7 = dissertations1 = conference abstract2 = not in English
Number of records excluded:2,712
Records identifiedthrough Embase:1,448
Records identifiedthrough Medline:594
Records identified through PsychINFO:1,073
Number of studies included throughreference check: 1
Elig
ibili
tyId
entifi
catio
n
Figure 1: Flow diagram of the reviewing process according to PRISMA [115].
After assessing the abstracts based on criteria createdby the research team, a total of 65 studies were identified.Full-text records were accessed to determine if the studiesmet inclusion criteria. Of these 65 studies, 7 were notintervention studies, 19 did not provide a description ofpeer inclusion in the interventions with 8 of those studiesassessing ADHD symptoms and not social skills outcomes,8 were peer inclusion studies but did not report social skillsoutcomes, 4 were peer inclusion studies but did not includea comparison group, 1 was a protocol paper describing anincluded interventions, and 2 studies were not in English(Figure 1). A list of the studies published in peer reviewedjournals that were excluded and reasons for their exclusionare provided in Table 2. Based on the inclusion criteria,17 intervention studies were selected (see Table 3). Allincluded studies used a controlled design, provided a detaileddescription of the population, and included the use of peers tofacilitate treatment outcomes.The design and rationale of oneof the studies [53] were reported in another publication [122].Therefore both articles were assessed together to maximisedata collection.
3.2. Description of Studies. The included studies are describedin detail in Tables 3–5. The information was grouped andsynthesised as follows: peer inclusion intervention studiesfor children with ADHD (Table 3); intervention componentsof included studies (Table 4); and methodological quality ofincluded studies (Table 5).
3.3. Participants. The 17 studies included a total of 2,567participants aged between 6 and 16 years with 74% ofparticipants beingmale. A total of 2,284 participants receiveda diagnosis of ADHD. Diagnosis was confirmed with varioustools based on the international DSM-III-R or DSM-IV withparent and teacher interviews or reports on symptomology.The children with ADHD had the following comorbiditiesin the included studies: anxiety disorder, affective disorder,tic disorder, depressive disorder, learning disorder, conductdisorder (CD), developmental disorder, and oppositionaldefiant disorder (ODD), with the exception of Hantson,Wang [59], and Hannesdottir Hannesdottir, Ingvarsdottir[58] that did not report on comorbidities. There was alarge variation of sample sizes between the included studies,ranging from 24 to 579 participants (Table 3). Of the includedstudies, only two trials reported a power analysis to determinea sample size calculation before the start of the trial [64, 68].
3.4. Interventions. The 17 studies comprised multiple inter-ventions, including Social Skills Training (SST) [54–56, 59,60, 67, 68], behavioural treatment [57, 66, 69], behaviouraland SST [62, 63], and multimodal behavioural/psychosocialtreatment [53, 58, 61, 64, 65]. The interventions involvedvarious components of peer inclusion elements and parentsand/or teacher involvement (see Table 4).
3.5. Experimental Groups. Ten studies involved child focusedSST [54–56, 58–60, 62, 63, 67, 68], with four of these studies
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Table2:Re
ason
sfor
exclu
sionof
paperspu
blish
edin
peer
review
edjournals.
Stud
yRe
ason
fore
xclusio
nAntshel[14
]Nointerventio
nArnettetal.[15]
Nointerventio
nErhardtand
Hinshaw
[16]
Nointerventio
nHaasa
ndWaschbu
sch[17]
Nointerventio
nLand
auandMoo
re[5]
Nointerventio
nMikam
iand
Hinshaw
[18]
Nointerventio
nMikam
iand
Huang
-Pollock
[19]
Nointerventio
nAntshel[14
]Not
peer
inclu
sion—
descrip
tionof
interventio
ndidno
tinclude
peer
inclu
sioncompo
nent
Burrow
s[20]
Not
peer
inclu
sion—
descrip
tionof
interventio
ndidno
tinclude
peer
inclu
sioncompo
nent
Charleb
ois[21]
Not
peer
inclu
sion—
descrip
tionof
interventio
ndidno
tinclude
peer
inclu
sioncompo
nent
Evansa
ndSchu
ltz[22]
Not
peer
inclu
sion—
descrip
tionof
interventio
ndidno
tinclude
peer
inclu
sioncompo
nent
Fram
e[23]
Not
peer
inclu
sion—
descrip
tionof
interventio
ndidno
tinclude
peer
inclu
sioncompo
nent
Fram
eetal.[24]
Not
peer
inclu
sion—
descrip
tionof
interventio
ndidno
tinclude
peer
inclu
sioncompo
nent
Gardn
er[25]
Not
peer
inclu
sion—
descrip
tionof
interventio
ndidno
tinclude
peer
inclu
sioncompo
nent
Gerbere
tal.[26]
Not
peer
inclu
sion—
descrip
tionof
interventio
ndidno
tinclude
peer
inclu
sioncompo
nent
Gerber-vonMullere
tal.[27]
Not
peer
inclu
sion—
descrip
tionof
interventio
ndidno
tinclude
peer
inclu
sioncompo
nent
Lang
berg
[28]
Not
peer
inclu
sion—
descrip
tionof
interventio
ndidno
tinclude
peer
inclu
sioncompo
nent
Mikam
ietal.[29]
Not
peer
inclu
sion—
descrip
tionof
interventio
ndidno
tinclude
peer
inclu
sioncompo
nent
Abdo
llahian
etal.[30]
Not
peer
inclu
sion—
study
assessed
ADHDsymptom
swith
nosocialskillso
utcomes
Abikoff
etal.[31]
Not
peer
inclu
sion—
study
assessed
ADHDsymptom
swith
nosocialskillso
utcomes
AntshelandRe
mer
[32]
Not
peer
inclu
sion—
study
assessed
ADHDsymptom
swith
nosocialskillso
utcomes
10 BioMed Research International
Table2:Con
tinued.
Stud
yRe
ason
fore
xclusio
nHariri
andFaisa
l[33]
Not
peer
inclu
sion—
study
assessed
ADHDsymptom
swith
nosocialskillso
utcomes
Jans
etal.[34]
Not
peer
inclu
sion—
study
assessed
ADHDsymptom
swith
nosocialskillso
utcomes
Jans
etal.[35]
Not
peer
inclu
sion—
study
assessed
ADHDsymptom
swith
nosocialskillso
utcomes
Looyeh
etal.[36]
Not
peer
inclu
sion—
study
assessed
ADHDsymptom
swith
nosocialskillso
utcomes
Tutty
etal.[37]
Not
peer
inclu
sion—
study
assessed
ADHDsymptom
swith
nosocialskillso
utcomes
Burrow
s[20]
Peer
inclu
sion—
nosocialskillso
utcomes
DuP
auletal.[38]
Peer
inclu
sion—
nosocialskillso
utcomes
GolandJarus[39]
Peer
inclu
sion—
nosocialskillso
utcomes
Hechtman
etal.[40
]Peer
inclu
sion—
nosocialskillso
utcomes
O’Con
nore
tal.[41]
Peer
inclu
sion—
nosocialskillso
utcomes
Power
etal.[42]
Peer
inclu
sion—
nosocialskillso
utcomes
RicksonandWatkins
[43]
Peer
inclu
sion—
nosocialskillso
utcomes
Storebøetal.[44
]Peer
inclu
sion—
nosocialskillso
utcomes
Cantrilletal.[45]
Nocomparis
ongrou
pWilk
esetal.[46
]Nocomparis
ongrou
pWilk
es-G
illan
etal.[47]
Nocomparis
ongrou
pWilk
es-G
illan
etal.[48]
Nocomparis
ongrou
pStorebøetal.[49]
Protocolpaper
Schm
itman
Gen
Pothmannetal.[50]
Non
-Eng
lish
Tabaeian
[51]
Non
-Eng
lish
Note.Tabledo
esno
tinclude
sevenexclu
deddissertatio
nsandon
eexcludedconference
abstr
act.
BioMed Research International 11
Table3:Peer
inclu
dedstu
dies
forc
hildrenwith
ADHD.
Design
Treatm
ent
cond
ition
ParticipantsN
Age
Years(mean±
SD)
Inclu
sioncriteria
Outcomem
easure
aTreatm
ento
utcome
Abikoff
etal.[53]
RCT:
rand
omassig
nment
ADHDpeer
interventio
n
1yearw
eekly,2n
dyear
mon
thly
(1)m
phon
ly(2)m
ph+MPT
+SST
(3)m
ph+AC
T
mph
:34(A
DHD)
mph
+MPT
:34
(ADHD)
mph
+AC
T:35
(ADHD)
8.2±0.8
ADHDdiagno
sisPo
sitiver
espo
nse
tomph
Socia
lskills
outco
mes:
SSRS
:parent+
child
form
Others:
TOPS
:teacher
form
Observatio
nsin
gym
SSRS
:significant
improvem
ent
TOPS
:significant
improvem
ent
Sign
ificantlyfewer
positive
andnegativ
ebehaviours
ChoiandLee[54]
RCT:
rand
omassig
nment
ADHDpeer
interventio
n
WeeklyEM
Tand
SSTtre
atmentfor
16weeks
(1)E
MTgrou
p(2)S
STgrou
p(3)W
aitlistcontrol
EMT:
25SST:
25Con
trol:24
EMT:
11.0±0.9
SST:
11.1±0.9
Con
trol:
10.8±0.8
ADHDdiagno
sisTo
tal
WISC-
Revised
Korean
VersionIQ
>90
Behaviou
rProblem
Scales
core
inclinicalrange
onCB
CL
Socia
lskills
outco
mes:
Peer
Relatio
nalSkills
Scale
Others
EmotionEx
pressio
nScale
forC
hildren
Child
DepressionInventory
State-TraitA
nxiety
InventoryforC
hildren
Nodifferences
betweenSST
andcontrolgroup
s.EM
Tgrou
pim
proved
significantly
morethan
control
EMTgrou
pim
proved
significantly
morethanSST
andcontrolgroup
sSSTgrou
pim
proved
significantly
morethan
controlgroup
,but
nodifferences
betweenEM
Tandcontrolgroup
s
12 BioMed Research International
Table3:Con
tinued.
Design
Treatm
ent
cond
ition
ParticipantsN
Age
Years(mean±
SD)
Inclu
sioncriteria
Outcomem
easure
aTreatm
ento
utcome
Frankeletal.[55]
QES
:child
and
parent
manually
assig
ned
Non
-ADHDpeer
interventio
n
SSTweeklyfor12
weeks
(1)T
reatment
(2)W
aitlistcontrol
Treatm
ent
35:A
DHD/14
:no
ADHD
Waitlistcontrol
12:A
DHD/12
noADHD
9.05±3.06
Peer
prob
lems
ADHD(usin
gmph
)ODDbasedon
DSM
-III-R
Socia
lskills
outco
mes:
SSRS
:parentform;
attentionandself-control
subscales
Others:
PEI:teacherform
SSRS
:significantly
greater
improvem
ent
PEI:no
nsignificant
improvem
ento
nthe
with
draw
alscale.
Sign
ificant
improvem
ento
nthea
ggressionscale
Gulietal.[56]
QES
:children
manually
assig
ned
ADHDandother
diagno
sispeer
interventio
ns
SSTweeklyfor12
weeks
ortwice
weeklyfor8
weeks
(1)S
CIPgrou
p(2)C
linicalcontrol
SCIP:18(5
ADHD/2
NLD
/11ASD
)Con
trol:16
(3ADHD/6
NLD
/7ASD
)
10.97±1.9
8ADHDdiagno
sisOverallintelligence
>80
onWISC-
III
Socia
lskills
outco
mes:
BASC
:parentform;
with
draw
alandsocialskills
subscales
DANVA
2Observedsocialinteraction
SSRS
:parentform
Others:
Parent
andchild
interviews
BASC
:nosig
nificanteffects
foun
dDANVA
2:no
significant
effectsfoun
dObservatio
ns:m
edium
effectsforincreases
inpo
sitiveinteractio
nsand
decreasesinsolitaryplay
fortreatmentg
roup
Baselin
emeasure
for
presence
ofclinically
significantsocialskills
deficits
75%repo
rted
oneo
rmore
specificp
ositive
changes
BioMed Research International 13
Table3:Con
tinued.
Design
Treatm
ent
cond
ition
ParticipantsN
Age
Years(mean±
SD)
Inclu
sioncriteria
Outcomem
easure
aTreatm
ento
utcome
Haase
tal.[57]
QES
:children
manually
assig
ned
Non
-ADHDpeer
interventio
n
Behaviou
ral
treatmentfor
8weeks
inthe
contexto
faST
P(1)T
reatment
(2)C
ontro
l
Treatm
ent
54:O
DDor
CP/A
DHD
Con
trol
16:noODDor
CP/A
DHD
9.48±1.5
8ADHDdiagno
sisNon
medicated
Socia
lskills
outco
mes:
SIRF
:staffob
servations
Peer
sociom
etric
interviews
Others:
Time-ou
tmeasures
SIRF
:significant
improvem
entinsocial
skillsa
ndprob
lem
solving
Peer
sociom
etric
s:sig
nificantimprovem
entin
LikertandDislike
nominations
Time-ou
t:sig
nificant
improvem
ents
Hannesdottir
etal.
[58]
RCT:
rand
omassig
nment
ADHDpeer
interventio
n
Behaviou
raland
SSTtre
atmentw
ithworking
mem
ory
training
(1)T
reatment
(2)W
aitlistcontrol
(3)P
arenttraining
Treatm
ent:16
Con
trol:14
Parent
training
:11
9.2±0.62
ADHDdiagno
sis
Socia
lskills
outco
mes:
SSRS
:parentform
Others:
ADHDRa
tingScale-IV
ERC
SDQ
IcelandicW
ISC-
IV
Sign
ificant
grou
p×tim
einteractions
favouring
treatmentg
roup
over
waitlistcontrol
Sign
ificant
grou
p×tim
einteractions
favouring
treatmentg
roup
over
waitlistcontrolfor
inattention,
butn
othyperactivity
/impu
lsivity
Nosig
nificantm
aineffect
oftim
eNosig
nificantm
aineffect
oftim
eSign
ificant
maineffectson
twosubscales(Cod
ingand
Lette
r-Num
ber
Sequ
encing
),bu
tno
significantg
roup×tim
einteractions
14 BioMed Research International
Table3:Con
tinued.
Design
Treatm
ent
cond
ition
ParticipantsN
Age
Years(mean±
SD)
Inclu
sioncriteria
Outcomem
easure
aTreatm
ento
utcome
Hantson
etal.[59]
QES
:child
and
parent
manually
assig
ned
ADHDpeer
interventio
n
SSTdaily
for2
weeks
inthe
contexto
fan
intensive
therapeutic
summer
daycamp
(1)T
reatment
(2)T
reatmentas
usualcon
trol
Treatm
ent
33:A
DHD
Treatm
entasu
sual
control
15:A
DHD
8.6±1.6
ADHDdiagno
sisIQ>70
onWISC-
III
Socia
lskills
outco
mes:
IPR:
child
form
WFIRS
-P:parentform
Others:
CGI-P:
parent
form
IPR:
significant
improvem
ent
WFIRS
-P:Significant
improvem
entsexcept
for
WFIRS
RiskyAc
tivities
subscale
CGI-P:
significant
improvem
ent
Huang
etal.[60]
QES
:child
and
parent
manually
assig
ned
ADHDpeer
interventio
n
WeeklySST
treatmentfor
8weeks
consistingof
80-m
inutes
essio
ns(1)S
STgrou
p(2)N
otre
atment
control
SST:
45Con
trol:52
SST:
8.2±0.9
Con
trol:
8.5±0.9
ADHDdiagno
sis
Socia
lskills
outco
mes:
SSRS
:child
+teacherform
Others
SNAP:
parent
+teacher
CBCL
:child
form
SSRS
-C:significant
improvem
entin
Self-Con
trolinfavour
ofSSTgrou
p;SSRS
-T:
significantimprovem
entin
activ
epartic
ipationin
favour
ofSSTgrou
pSN
AP-P:
maineffecto
fgrou
pon
Opp
osition
alsubscale;SNAP–T
:Main
effecto
fgroup
onAc
tive
Participationsubscale
CBCL
-C:m
aineffecto
fgrou
pon
Anx
ious/D
epressed
subscale
BioMed Research International 15
Table3:Con
tinued.
Design
Treatm
ent
cond
ition
ParticipantsN
Age
Years(mean±
SD)
Inclu
sioncriteria
Outcomem
easure
aTreatm
ento
utcome
Jensen
etal.[61]
RCT:
rand
omassig
nment
3-year
follo
w-up
ADHDpeer
interventio
n
Treatm
ento
ver14
mon
ths
(1)M
edicationon
ly(2)B
ehavioural
treatmentincl.
parent
training
+ST
P+
scho
ol-based
treatment
(3)C
ombinedincl.
medication+
behaviou
ral
treatment
(4)C
ommun
itycare
control
Medication
managem
ent
115:(A
DHD)
Behaviou
ral
treatment
127:(A
DHD)
Com
bined
treatment
127:(A
DHD)
Com
mun
itycare
control
116:(ADHD)
11.8±0.95
Child
renwho
participated
inthe
1999
MTA
study
Socia
lskills
outco
mes:
SSRS
:parent+
teacher
form
sOthers:
SNAP:
parent
+teacher
form
sWIAT:
readingscore
CIS
SSRS
:effectsiz
efor
improvem
entfrom
baselin
eto
36mon
thsa
crossa
lltre
atmentg
roup
swas
0.8–0.9
SNAP:
effectsizefor
improvem
entfrom
baselin
eto
36mon
thsa
crossa
lltre
atmentg
roup
swas
1.6–1.7forA
DHDand0.7
forO
DD
WIAT:
effectsizefor
improvem
entfrom
baselin
eto
36mon
thsa
crossa
lltre
atmentg
roup
swas
0.1–0.2
CIS:effectsizefor
improvem
entfrom
baselin
eto
36mon
thsa
crossa
lltre
atmentg
roup
swas
0.9–
1.0
16 BioMed Research International
Table3:Con
tinued.
Design
Treatm
ent
cond
ition
ParticipantsN
Age
Years(mean±
SD)
Inclu
sioncriteria
Outcomem
easure
aTreatm
ento
utcome
Kolkoetal.[62]
QES
:children
manually
assig
ned
ADHDandother
diagno
sispeer
interventio
ns
3weeklysessions
for5
weeks
(1)S
CSTgrou
p(2)S
Agrou
p
SCST
:36(10
ADHD/11
CD/15
OD)
SA:20(4
ADHD/12
CD/4
OD)
10.4±2.1
Scoreo
fatleast7
onafou
r-item
socialprob
lems
screen,w
ithatleast
onem
axim
umratin
g
Socia
lskills
outco
mes:
CAI-M:Self-report
LNS-M:Self-report
SPS:Staff
repo
rtSo
ciom
etric
Ratin
gs:Staff
Peer
Nom
ination
Behaviou
ralR
ole-Play
Invivo
behaviou
ral
observations
CAI-M:significant
improvem
entin
post-
training
scores
LNS-M:SCS
Tgrou
pshow
edsig
nificant
redu
ctionin
post-
training
scores
SPS:SC
STgrou
pshow
edsig
nificantreductio
nin
posttrainingscores
Both
grou
psim
proved
significant
SCST
grou
pshow
edgreater
pre-po
stredu
ction
nominations
SCST
grou
pshow
edsig
nificantimprovem
ent
SCST
grou
pexhibited
significantimprovem
ent
BioMed Research International 17
Table3:Con
tinued.
Design
Treatm
ent
cond
ition
ParticipantsN
Age
Years(mean±
SD)
Inclu
sioncriteria
Outcomem
easure
aTreatm
ento
utcome
Mikam
ietal.[63]
RCT:
rand
omassig
nment
Typically
developing
peer
interventio
n
Weekd
aysfor
four
weeks
total
Weekd
aysfor
2weeks
per
treatment
allocatio
n(1)M
OSA
ICthen
COMET
(2)C
OMET
then
MOSA
IC
MOSA
IC:12
ADHD/58TD
COMET
:12
ADHD/55TD
8.15±0.79
ADHDdiagno
sisaft
erscreening
IQ>80
onWASIl
Socia
lskills
outco
mes:
Peer
sociom
etric
nominations
Peer
interaction
observations
Messagesfrom
peers
Others:
Teacher-Ch
ildRa
tingScale
subscaleso
fprob
lem
behaviou
rs
Maineffecto
npo
sitive
nominations
fortreatment
was
notsignificant.
Received
fewer
negativ
eno
minations
andmore
reciprocated
friend
ship
nominations
whenin
MOSA
ICrelativeto
COMET
grou
pNomaineffectfor
treatmentcon
ditio
nRe
ceived
asignificantly
greaterp
ropo
rtionof
positivem
essagesw
henin
MOSA
ICrelativeto
COMET
grou
pNomaineffectsfor
treatmentcon
ditio
n
18 BioMed Research International
Table3:Con
tinued.
Design
Treatm
ent
cond
ition
ParticipantsN
Age
Years(mean±
SD)
Inclu
sioncriteria
Outcomem
easure
aTreatm
ento
utcome
MTA
Coo
perativ
eGroup
[64]
RCT:
rand
omassig
nment
ADHDpeer
interventio
n
Treatm
ento
ver14
mon
ths
(1)M
edicationon
ly(2)B
ehavioural
treatmentincl.
parent
training
+ST
P+
scho
ol-based
treatment
(3)C
ombinedincl.
medication+
behaviou
ral
treatment
(4)C
ommun
itycare
control
Medication
managem
ent
144:(A
DHD)
Behaviou
ral
treatment
144:(A
DHD)
Com
bined
treatment
145:(A
DHD)
Com
mun
itycare
control
146:(A
DHD)
8.5±0.8
ADHDcombined
type
diagno
sisIn
resid
ence
with
thes
amep
rimary
caretaker(s)forlast
6mon
thso
rlon
ger
Socia
lskills
outco
mes:
SSRS
:parent+
teacher
Others:
SNAP:
parent
+teacher
MASC
:child
form
Parent-child
relatio
nship
questio
nnaire
WIAT:
(reading
,math+
spellin
g)
SSRS
:significant
improvem
entfor
parent-reported
internalizingprob
lemsfor
combinedtre
atmento
ver
behaviou
raltreatment
SNAP:
combined+
medicationmanagem
ent
werec
linicallyand
statisticallysuperio
rto
behaviou
raltreatment+
commun
itycare
MASC
:improvem
entsof
smallm
agnitude
Improvem
entsof
small
magnitude
Sign
ificant
improvem
ent
forreading
achievem
ent
scorefor
combined
treatmento
verb
ehavioural
treatment
BioMed Research International 19
Table3:Con
tinued.
Design
Treatm
ent
cond
ition
ParticipantsN
Age
Years(mean±
SD)
Inclu
sioncriteria
Outcomem
easure
aTreatm
ento
utcome
MTA
Coo
perativ
eGroup
[65]
RCT:
rand
omassig
nment
24-m
onth
follo
w-up
ADHDpeer
interventio
n
Treatm
ento
ver14
mon
ths
(1)M
edicationon
ly(2)B
ehavioural
treatmentincl.
parent
training
+ST
P+
scho
ol-based
treatment
(3)C
ombinedincl.
medication+
behaviou
ral
treatment
(4)C
ommun
itycare
control
Medication
managem
ent
128:(A
DHD)
Behaviou
ral
treatment
139:(A
DHD)
Com
bined
treatment
138:(A
DHD)
Com
mun
itycare
control
135:(A
DHD)
8.4±0.8
Child
renwho
participated
inthe
1999
MTA
study
Socia
lskills
outco
mes:
SSRS
:parent+
teacher
Others:
SNAP:
parent
+teacher
Negative/ineffectiv
edisciplin
efactor
WIAT:
(reading
,math+
spellin
g)
SSRS
:non
significant
overalltreatmenteffect
SNAP:
significanto
verall
treatmenteffect
Non
significanto
verall
treatmenteffect
WIAT:
nonsignificant
overalltreatmenteffect
Pfiffn
eretal.[66]
RCT:
rand
omassig
nment
ADHDandother
diagno
sispeer
interventio
ns
Treatm
ento
ver12
weeks
Firstcoh
ort:
(1)C
LASprogram
(2)W
aitlistcontrol
Second
-Fifth
coho
rt:
(1)C
LASprogram
(2)T
reatmentas
usualcon
trol
Five
coho
rtso
fchild
ren
rand
omized
toeither
CLAS
program
orcontrol
25:A
DHD,2:
Und
ifferentia
ted
AttentionDeficit
Diso
rder;19:
Opp
osition
alDefiantD
isorder,3:
Con
ductDiso
rder,
4:Separatio
nAnx
ietyDiso
rder,
5:Overanx
ious
Diso
rder,2:
Dysthym
icDiso
rder.
8.7±1.2
ADHDdiagno
sisIQ>80
onthe
WASI
Attend
ingscho
olfulltim
ewith
scho
olconsentin
gto
participatein
scho
ol-based
treatment
Socia
lskills
outco
mes:
SSRS
:parent+
teacher
Others:
Child
Symptom
Inventory
SCTScale
COSS:parent+
teacher
Testof
LifeSkill
Know
ledge
ClinicalGlobal
Impressio
ns:parent+
teacher
SSRS
:significant
improvem
ents
Sign
ificant
redu
ctions
innu
mbero
fDSM
-IV
inattentionsymptom
sSC
T:sig
nificanttreatment
effects
COSS:significant
improvem
entsof
organisatio
nalskills
Sign
ificantlyim
provem
ents
Sign
ificantlygreater
improvem
ent
20 BioMed Research International
Table3:Con
tinued.
Design
Treatm
ent
cond
ition
ParticipantsN
Age
Years(mean±
SD)
Inclu
sioncriteria
Outcomem
easure
aTreatm
ento
utcome
Shechtman
and
Katz[67]
RCT:
rand
omassig
nment
ADHDandother
diagno
sispeer
interventio
ns
Weeklyfor15
weeks
(1)G
roup
therapy
(2)W
aitlistcontrol
Group
Therapy:42
(20:ADDor
ADHD/22LD
)Waitlistcontrol:45
(14ADDor
ADHD/31L
D)
13.26±0.77
ADD/A
DHDor
LDdiagno
sis
Socia
lskills
outco
mes:
Adolescent
Interpersonal
Com
petenceQ
uestionn
aire
Intim
ateF
riend
ship
Scale
Working
Alliance
Inventory
Sign
ificant
treatment
cond
ition
bytim
eeffect
Non
significanttreatment
cond
ition
bytim
eeffect
Highassociationbetween
bond
ingwith
grou
pmem
bersandgainso
nsocialcompetence
Storebøetal.[68]
RCT:
rand
omassig
nment
ADHDpeer
interventio
n
Weeklyfor8
weeks
(1)E
xperim
ental
treatmentincl.SST
+parent
training
+sta
ndardtre
atment
(2)S
tand
ard
treatmentalone
Experim
ental
treatment
28:A
DHD
Standard
treatment
alon
e27:A
DHD
10.4±1.3
1
ADHDdiagno
sisIQ>80
Not
previously
medicated
Indexesfrom
Con
ners3
andCon
norsCB
RS:
Socia
lskills
outco
mes:
SocialProb
lemsscore
Peer
Relations
score
Others:
ExecutiveF
unctions
score
Academ
icscore
Aggressivenessscore
Emotionalscore
Hyperactiv
ityscore
Nostatisticallysig
nificant
differencew
hencomparin
ggrou
psNeutralresultbetween
grou
psNeutralresultbetween
grou
psNeutralresultbetween
grou
psHighlysig
nificantchanges
towards
fewer
symptom
sNostatisticallysig
nificant
differencew
hencomparin
ggrou
ps
BioMed Research International 21
Table3:Con
tinued.
Design
Treatm
ent
cond
ition
ParticipantsN
Age
Years(mean±
SD)
Inclu
sioncriteria
Outcomem
easure
aTreatm
ento
utcome
Waxmon
skyetal.
[69]
RCT:
rand
omassig
nment
ADHDpeer
interventio
n
Weeklyfor8
weeks
(1)A
tomoxetine+
BT (2)A
tomoxetine
alon
e
Atom
oxetine+
BT29:A
DHD
Atom
oxetinea
lone
27:A
DHD
8.59±1.5
8
ADHDdiagno
sisIQ>75
Positiver
espo
nse
toatom
oxetine
Socia
lskills
outco
mes:
SSRS
:parent+
teacher
Others:
Stud
entB
ehaviour
Teacher
Respon
seObservatio
nCod
eDBD
:parent+
teacher
APR
S:teacher
PSER
S:parent
+teacher
CDRS
-R:child
+parent
interview
DRC
/ITBE
ClinicalGlobalImpressio
nsScale:clinician
SSRS
:significantly
lower
parent-rated
prob
lem
behaviou
rsNodifferenceb
etween
grou
pspo
st-tre
atment
DBD
:marginally
significantimprovem
ento
fADHDandODD
symptom
sAPR
S:sig
nificantly
high
erteacher-ratedim
pulse
control
PSER
S:meanscores
well
with
inthem
ildrange.
Marginally
lower
depressio
nscores
post-
treatment.Suicidal
thou
ghtsdecreased
significantly
over
timeb
utwith
nodifferenceb
etween
grou
psDRC
/ITBE
:Significant
maineffecto
fmedication/tim
e51.9%of
subjectsin
Atom
oxetine-on
lyand
55.2%of
Atom
oxetine+
BTsubjectswerer
ated
asmuch
orvery
muchim
proved
Notes.RC
T=rand
omized
controlledtrial,QES
=qu
asi-e
xperim
entalstudy,m
ph=methylphenidate,M
PT=Multip
sychosocialT
reatment,SST=socialskillstraining,AC
T=attentioncontroltreatment,ADHD
=Attention-DeficitH
yperactiv
ityDiso
rder,SSR
S=S
ocialSkills
Ratin
gScale[70],T
OPS
=Taxon
omyo
fProblem
Situations
[71],E
MT=em
otionalm
anagem
enttraining,WISC-
RevisedKo
rean
Version=Wechsler
IntelligenceS
caleforC
hildren-Re
visedKo
rean
Version[72],C
BCL=Ch
ildBe
haviou
rChecklist[73,74],O
DD=op
positionald
efiantd
isorder,D
SM-III-R
=Diagn
ostic
andStatisticalManualofM
entalD
isorders
3rdEd
ition
,PEI
=Pu
pilE
valuationInventory[75],SCI
P=So
cialCom
petenceInterventionProgram,N
LD=no
nverballearningdisorder,A
SD=autism
spectrum
disorder,W
ISC-
III(WeschlerIntelligence
Scale
forC
hildren-III[76]),BASC
=Be
haviou
rAssessm
entSystem
forC
hildren[77],D
ANVA
2=Diagn
ostic
Analysis
ofNon
verbalAc
curacy
2Now
icki,200
4,CP
=cond
uctp
roblem
s,SIRF
=Staff
Improvem
entR
ating
Form
[78],E
RC=Em
otionRe
gulatio
nCh
ecklist
[79];SDQ
=Streng
thsa
ndDiffi
culties
Question
naire
[80],Iceland
icWISC-
IV=WechslerIntelligence
ScaleforC
hildren-Icela
ndicversion[81],IPR
=Indexof
Peer
Relations
[82],W
FIRS
-P=WeissFu
nctio
nalImpairm
entR
atingScale-Parent
Version[83],C
GI-P=Con
ners’G
lobalInd
ex-ParentV
ersio
n[84],SNAP=(Swanson,Nolan,and
Pelham
Ratin
gScale[85],ST
P=summer
treatmentp
rogram
,MTA
=Multim
odalTreatm
entStudy
ofCh
ildrenwith
ADHD,W
IAT=WechslerInd
ividualA
chievementT
est[86],CI
S=Colum
biaImpairm
entS
cale[87],SCS
T=social-cognitiv
eskillstraining,SA
=socialactiv
itygrou
p,CD
=cond
uctd
isorder,O
D=otherd
isorders,CA
I-M
=Ch
ildren’s
Assertiv
enessInventory-M
odified
[88],L
NS-M
=Lo
nelin
essS
caleforC
hildren-Mod
ified
[89],SPS
=So
cialProb
lemsS
creen,MOSA
IC=MakingSo
ciallyAc
ceptingInclu
siveC
lassroom
s,CO
MET
=contingencymanagem
enttraining,TD
=typically
developing
,WASI
=WechslerA
bbreviated
Scaleo
fIntelligence
[90],M
ASC
=Multid
imensio
nalA
nxietyScalefor
Child
ren[91],C
LAS=Ch
ildLifeandAttentionSkillsp
rogram
,SCT
Scale=
Slug
gish
Cognitiv
eTem
poScale[
92],CO
SS=Ch
ildren’s
OrganizationalScale[93],
DSM
-IV=Diagn
ostic
andStatisticalManualo
fMentalD
isorders4
thEd
ition
,LD=learning
disabilities,Con
ners3[94],C
onnersCB
RS=Con
nersBe
haviou
rRatingScales
[94],B
T=behaviou
rtherapy,D
BD=Disr
uptiv
eBe
haviou
rDiso
rdersR
atingScale[95],A
PRS=Ac
adem
icPerfo
rmance
Ratin
gScale[96],P
SERS
=Pittsbu
rghSide
EffectsRa
tingScale[97],C
DRS
-R=Ch
ildren’s
DepressionRa
tingScale-Re
vised
[98],and
DRC
/ITBE
=Daily
Repo
rtCa
rd/In
dividu
alTarget
Behaviou
rEvaluation.
a Whenhand
lingstu
dies
with
multip
lesocialskillso
utcomemeasures,on
esin
gularo
utcomemeasure
was
chosen
that
most
comprehensiv
elyreflected
thec
onstr
uctsocialskills.Th
issin
gularo
utcomem
easure
was
then
used
forthe
calculationof
aneffectsize.Nomeasuresw
erea
ggregatedwith
inthes
tudy
toob
tain
onee
ffectsiz
e.
22 BioMed Research International
Table4:Interventio
ncompo
nentso
fincludedstu
dies.
Stud
yPeer
compo
nent
Parent
compo
nent
Teacherc
ompo
nent
Skills
Medication
Frankeletal.
[55]
QES
Child
renwered
idactic
ally
presentedsocialskillsa
ndrequ
iredto
rehearse
behaviou
rsbetweeneach
other.Participantswe
realso
taug
htconversatio
nal
techniqu
esandrehearsed
them
inthec
ontext
ofintro
ductions
tootherc
lass
mem
bers
(i)Parent
sessions
(ii)P
arentratings
ofsocialskills
(iii)Ch
ildsocialisa
tion
homew
ork
(i)Teacherratings
ofantisocial,prosocial,
andaggressiv
ebehaviou
r
(i)Con
versation
(ii)T
echn
iques
(iii)Playing
together/gettin
galon
g(iv
)Giving
complim
ents&
criticism
AllADHD
participantswere
requ
iredto
take
medication(in
cl.methylphenidate,
dextroam
-ph
etam
ine,
pemoline,other
psycho
tropic
medication)
Gulietal.
[56]
QES
Thes
essio
nsinclu
ded
activ
ities
thatfocuso
nestablish
ingsocialskills
throug
hseveral
improvisa
tions
orprocess
dram
as,throu
ghwhich
they
practic
eperspectiv
etaking
andcogn
itive
flexibilitywith
theirp
eers.
(i)Parent
ratin
gsof
socialskills
(ii)P
arents
encouraged
home
challeng
es
(i)Non
e
(i)Group
cohesio
n(ii)E
motional
know
ledge
(iii)Fo
cusin
gattention
(iv)F
acialexpression
(v)B
odylang
uage
(vi)Vo
calcues
(vii)
Non
verbalcues
51.3%of
participantswere
repo
rted
totake
prescriptio
nmedication.
Treatm
ent:12
medication&6no
medication;
Con
trol:4
medication&12
nomedication
BioMed Research International 23
Table4:Con
tinued.
Stud
yPeer
compo
nent
Parent
compo
nent
Teacherc
ompo
nent
Skills
Medication
Haase
tal.
[57]
Cou
nsellor-ledqu
estio
nsprom
pted
adisc
ussio
nof
thes
ocialskills
byencouragingchild
rento
providea
descrip
tionof
the
socialskills(e.g
.,defin
ition
,exam
ples)a
ndto
mod
elandrole-playgood
andbad
exam
ples
ofho
wto
usethe
socialskill.
(i)Parent
ratin
gsof
ADHD,O
DD,and
CDsymptom
s(ii)P
arentratings
ofcal-
lous/unemotional
traits
(i)Non
e
Socialskills:
(i)Va
lidation
(ii)C
ooperatio
n(iii)Com
mun
ication
(iv)P
artic
ipation
AllADHD
participantswere
either
nottaking
medicationor
prescribed
aplacebo
assig
nment.
How
ever,som
echild
renwereo
nmedicationfor
some(bu
tnot
all)
days
durin
gthe
summer
treatment
program
Hantson
etal.
[59]
QES
Thetherapistfirstdescrib
edho
wto
perfo
rmthes
kills
inan
approp
riatemanner.Th
echild
renwerethenpaire
dandaskedto
role-playthe
newskill
infro
ntof
the
grou
p.Fo
llowingthis,
child
renwerea
sked
torole-playthes
kills
from
the
other’s
perspectiveinan
efforttoun
derstand
situatio
nsfro
mother
person’spo
into
fview.
(i)Parent
psycho
education
andtraining
(ii)P
arentratings
offunctio
n,behaviou
r,and
ADHDsymptom
s
(i)Non
e
Socialskills:
(i)Intro
ducing
self
(ii)Joining
in(iii)Kn
owingyour
feeling
s(iv
)Dealin
gwith
anger
(v)S
elf-c
ontro
l(vi)Re
spon
ding
toteasing
(vii)
Stayingou
tof
fights
Participantswho
were
onmedicationsta
yed
onmedication;
thosew
howeren
oton
medication
remainedso.
Treatm
ent:20
medication&13
nomedication;
control:9
medication&6no
medication
24 BioMed Research International
Table4:Con
tinued.
Stud
yPeer
compo
nent
Parent
compo
nent
Teacherc
ompo
nent
Skills
Medication
Huang
etal.
[60]
QES
Child
renweretaught
vario
ussocialskill
mod
ules
viad
idactic
instr
uctio
ns,
mod
ellin
g,role-play
activ
ities
andbehaviou
ral
rehearsals
Positives
ocialbehaviour
was
reinforced
viaa
token
syste
m.
(i)Weeklyparent
sessions
toeducate
onADHD
(ii)P
arentratings
ofsocialskills
Teacherratings
ofattention,
hyperactivity,
impu
lsivity,
oppo
sitional,
coop
erative
behaviou
r,self-assertion,
self-controland
confl
ictcop
ing
(i)Con
versation
(ii)P
laying
together/gettin
galon
g(iii)Giving
complim
ents&
criticism
AllADHD
participants
received
methylphenidate
with
drug
compliance
controlled
Kolkoetal.
[62]
QES
Cotherapists
andchild
ren
engagedin
several
role-plays.Th
egroup
discussedeach
role-play
andprovided
constructiv
eperfo
rmance
feedback.
Inadequaterole-plays
were
rehearsedas
econ
dtim
eto
prom
otem
astery.
(i)Non
e
(i)One-year
follo
w-upteacher
ratin
gsof
socialskills
andou
tcom
emeasures
(i)So
cialinvolvem
ent
(ii)G
aze
(iii)Ph
ysicalspace
(iv)V
oice
volume/inflection
Open-
ers/complim
ents
(v)P
ositive
assertion
(vi)Negative
assertion
(vii)
Approp
riate
nonaggressivep
layor
sharing
Com
parable
percentageso
fchild
renin
SCST
andSA
grou
psreceived
methylphenidate
(22%
versus
20%),
imipramine(11%
versus
10%),
lithium
(8%versus
5%),or
other
medications
(7%
versus
5%)
BioMed Research International 25
Table4:Con
tinued.
Stud
yPeer
compo
nent
Parent
compo
nent
Teacherc
ompo
nent
Skills
Medication
Abikoff
etal.
[53]
RCT
Peersrole-played
and
mod
elledapprop
riateand
inapprop
riatesocial
behaviou
rsin
grou
psof
four.
(i)Parent
training
(ii)P
arentratings
ofsocialskills
(i)Teacherratings
ofsociallyrejected
and
accepted
child
ren
(ii)R
einforcement
strategies,daily
scho
olrepo
rtcard
(i)Ba
sicinteraction
skills
(ii)G
ettin
galon
gwith
others
(iii)Con
tactsw
ithadultsatho
mea
ndscho
ol(iv
)Con
versation
skills
(v)P
roblem
situatio
ns
Allparticipants
werep
rescrib
edmethylphenidate
after
a5-w
eek
clinical
methylphenidate
trialand
placebo
substitutionto
determ
inep
ositive
respon
seto
medicationpriorto
treatment
ChoiandLee
[54]
RCT
EMT:
child
renun
dertoo
kactiv
ities
thatcoveredfour
major
behaviou
ral
characteris
tics:(1)
identifi
catio
nandlabelling
ofem
otionalw
ords;(2)
emotionalrecognitio
nand
expressio
n;(3)emotional
understand
ing;and(4)
emotionalregulationin
socialsituatio
nsSST:
child
renweretaught
vario
ussocialskillsto
improvetheirinteractions
with
peersa
ndteachersby
usingprom
pts,role-play
andreinforcem
ent
(i)Parent
ratin
gson
emotionaland
behaviou
ral
prob
lemsin
child
ren
Interacted
with
child
renas
partof
the
SSTandEM
Tprograms
(i)Ba
sicinteraction
skills
(ii)R
egulating
emotions
with
ina
grou
p(iii)Prob
lem-solving
skills
(iv)C
onversation
skills
(v)L
isteningskills
(vi)Re
actio
nto
rejection,
negotia
tion,
beingteased
and
criticised
Allparticipants
werep
rescrib
edwith
medication
durin
gthec
ourse
ofthes
tudy
althou
ghno
tcontrolled
26 BioMed Research International
Table4:Con
tinued.
Stud
yPeer
compo
nent
Parent
compo
nent
Teacherc
ompo
nent
Skills
Medication
Hannesdottir
etal.[58]
RCT
Therapistsleaddiscussio
nsam
ongstg
roup
softhree
child
rento
aidsolving
prob
lemsp
resented
ata
numbero
f“sta
tions.”
Stations
inclu
dedthe
EmotionStation,
Friend
ship
Station,
Stop
ping
Station,
and
Prob
lem-Solving
Station.In
additio
n,therew
asaB
rain
Training
Station,
atwhich
child
renpractic
edcompu
ter-basedexecutive
functio
ntasks.
(i)Parent
ratin
gsof
socialskills
(ii)P
arenttraining
(one
meetin
g)
Non
e
(i)Identifying
facial
expressio
ns(ii)H
idingfeelings
(iii)Re
laxatio
nand
angerm
anagem
ent
techniqu
es(iv
)Interpreting
ambiguou
ssitu
ations
(v)M
eetin
gnewpeers
(vi)Re
ading
nonverbalm
essages
(vii)
Com
prom
ising
(viii)W
orking
mem
ory
(ix)Th
inking
before
actin
g/speaking
(x)P
roblem
solving
everyday
prob
lems
100%
ofparticipantsin
treatmentg
roup
were
onmedicationforthe
duratio
nof
the
study.Th
erew
ere
12participantson
medicationin
the
controlgroup
(85.7%
)atstudy
commencement,
drop
ping
to11
participantsatthe
endof
thes
tudy
(78.6%
)
BioMed Research International 27
Table4:Con
tinued.
Stud
yPeer
compo
nent
Parent
compo
nent
Teacherc
ompo
nent
Skills
Medication
Jensen
etal.
[61]
RCT
Sessions
inclu
deinstruction,
mod
ellin
g,role-play
ingandpractic
ein
keysocialconceptssuch
ascommun
ication,
aswell
asmores
pecific
skills.In
additio
nto
theses
essio
ns,
thec
hildrenengagedin
adaily
coop
erativeg
roup
task
thatisdesig
nedto
prom
otec
ooperatio
nand
contrib
utetocohesiv
epeer
relationships.A
budd
ysyste
mwas
employed
tohelpchild
rendevelop
individu
alfriend
shipsthat
may
“buff
er”them
from
the
possiblenegativ
eeffectso
fbeingun
popu
lar.Th
iswas
accomplish
edby
assig
ning
each
child
abud
dywith
who
mtheirg
oalistoform
aclose
friend
ship.Th
echild
renengage
inav
ariety
ofactiv
ities
with
their
budd
iesa
ndmeetregularly
with
adult“bu
ddycoaches”
who
assistthem
inworking
outrelationshipprob
lems.
(i)Parent
training
(ii)P
arentratings
ofADHD,
internalizing,
oppo
sitional,and
aggressiv
esymptom
s,and
socialskills
Scho
ol-based
treatment:
(i)Teacher
consultatio
nfocused
onbehaviou
rmanagem
ent
strategies
(ii)P
araprofessional
aid
(iii)Teacherratings
ofADHD,internalizing,
oppo
sitional,and
aggressiv
esym
ptom
sandsocialskills
(i)So
cialskills
effectiv
efor
peer
grou
pfunctio
ning
71%of
combined
treatmentand
medication
managem
ent
participantswere
usingmedication
athigh
levels
comparedto
62%
and45%of
commun
itycare
andbehaviou
ral
treatment
participants,
respectiv
ely.
Average
medicationdo
ses
differedacrossall
grou
ps
28 BioMed Research InternationalTa
ble4:Con
tinued.
Stud
yPeer
compo
nent
Parent
compo
nent
Teacherc
ompo
nent
Skills
Medication
Mikam
i,Grig
gs[63]
RCT
Peersw
eretrained
tobe
mores
ocially
inclu
sivein
theM
OSA
ICtre
atment
cond
ition
.Teachers
assig
nedchild
rento
work
inteam
sfor
collabo
rativ
eactiv
ities
where
child
ren
hadto
worktogether
inordertosucceed.
(i)Non
e(i)
Summer
program
teacherratings
ofprob
lem
behaviou
rs
(i)So
cialskills
(ii)S
ocialinclusio
n(iii)Peer
grou
pfunctio
ning
10ou
tof24
child
renwith
ADHDwere
medicated
with
psycho
tropic
medication,
and
somew
eretaking
additio
nal
medications
for
comorbid
cond
ition
s.All
medicated
child
ren
stayedon
aconsistentregim
endu
ringthes
ummer
program
TheM
TACoo
perativ
eGroup
[64]
RCT
Sessions
inclu
ded
instruction,
mod
ellin
g,role-play
ing,andpractic
ein
keysocialconceptssuch
ascommun
ication,
aswell
asmores
pecific
skills.In
additio
nto
theses
essio
ns,
thec
hildrenengagedin
adaily
coop
erativeg
roup
task
thatwas
desig
nedto
prom
otec
ooperatio
nand
contrib
utetocohesiv
epeer
relationships.A
Budd
ySyste
mwas
employed
tohelpchild
rendevelop
individu
alfriend
shipsthat
may
“buff
er”them
from
the
possiblenegativ
eeffectso
fbeingun
popu
lar.Th
iswas
accomplish
edby
assig
ning
each
child
abud
dywith
who
mtheirg
oalistoform
aclose
friend
ship.Th
echild
renengagedin
avarie
tyof
activ
ities
with
theirb
uddies
andmet
regu
larly
with
adult“bu
ddy
coaches”who
assistedthem
inworking
outrela
tionship
prob
lems.
(i)Parent
training
(ii)P
arentratings
ofADHD,
internalizing,
oppo
sitional,and
aggressiv
esymptom
s,and
socialskills
Scho
ol-based
treatment:
(i)Teacher
consultatio
nfocused
onbehaviou
rmanagem
ent
strategies
(ii)P
araprofessional
aid
(iii)Teacherratings
ofADHD,internalizing,
oppo
sitional,and
aggressiv
esym
ptom
s,andsocialskills
(i)So
cialskills
effectiv
efor
peer
grou
pfunctio
ning
Allparticipantsin
thetreatment
grou
pswere
prescribed
medication,
however
3.1%
ofthec
ombined
treatmentand
medication
managem
ent
subjectswereo
nno
medication
BioMed Research International 29
Table4:Con
tinued.
Stud
yPeer
compo
nent
Parent
compo
nent
Teacherc
ompo
nent
Skills
Medication
MTA
Coo
perativ
eGroup
[65]
RCT
Sessions
inclu
ded
instruction,
mod
ellin
g,role-play
ing,andpractic
ein
keysocialconceptssuch
ascommun
ication,
aswell
asmores
pecific
skills.In
additio
nto
theses
essio
ns,
thec
hildrenengagedin
adaily
coop
erativeg
roup
task
thatwas
desig
nedto
prom
otec
ooperatio
nand
contrib
utetocohesiv
epeer
relationships.A
Budd
ySyste
mwas
employed
tohelpchild
rendevelop
individu
alfriend
shipsthat
may
“buff
er”them
from
the
possiblenegativ
eeffectso
fbeingun
popu
lar.Th
iswas
accomplish
edby
assig
ning
each
child
abud
dywith
who
mtheirg
oalistoform
aclose
friend
ship.Th
echild
renengagedin
avarie
tyof
activ
ities
with
theirb
uddies
andmet
regu
larly
with
adult“bu
ddy
coaches”who
assistedthem
inworking
outrela
tionship
prob
lems.
(i)Parent
training
(ii)P
arentratings
ofADHD,
internalizing,
oppo
sitional,and
aggressiv
esymptom
s,and
socialskills
Scho
ol-based
treatment:
(i)Teacher
consultatio
nfocused
onbehaviou
rmanagem
ent
strategies
(ii)P
araprofessional
aid
(iii)Teacherratings
ofADHD,internalizing,
oppo
sitional,and
aggressiv
esym
ptom
s,andsocialskills
(i)So
cialskills
effectiv
efor
peer
grou
pfunctio
ning
70%of
combined
treatmentand
72%
ofmedication
managem
ent
participantswere
usingmedication
athigh
levels
comparedto
62%
and38%of
commun
itycare
andbehaviou
ral
treatment,
respectiv
ely
30 BioMed Research International
Table4:Con
tinued.
Stud
yPeer
compo
nent
Parent
compo
nent
Teacherc
ompo
nent
Skills
Medication
Pfiffn
eretal.
[66]
RCT
Child
renrole-playedthe
positiveu
seof
askill,using
briefscriptsof
common
prob
lem
situatio
nswith
peerso
rsiblin
gs(e.g.,
enterin
gag
ame,getting
out
durin
gag
ame,andbeing
teased).Ch
ildrenevaluated
each
other’s
perfo
rmance
ofthes
ocialskills
immediatelyaft
ereach
role-playandwe
recalled
onto
give
specificr
easons
fortheirratin
gs.
(i)Parent
training
(ii)P
arentratings
ofinattentionand
sluggish
cogn
itive
tempo
symptom
s,socialskills,
organizatio
nal
skills,andoverall
improvem
ent
(i)Teacher
consultatio
n(ii)S
choo
l-hom
edaily
repo
rtcard
(iii)Teacherratings
ofinattentionand
sluggish
cogn
itive
tempo
symptom
s,socialskills,
organizatio
nalskills,
andoverall
improvem
ent
(i)So
cialcompetence
(ii)A
cademic
(iii)Stud
y(iv
)Organization
(v)S
elf-c
are
(vi)Dailylivingskills
Child
renwere
exclu
dedifthey
changed
medicationsta
tus
durin
gthec
ourse
ofthes
tudy.O
nly
twosubjects(both
inCL
ASprogram
grou
p)beganthe
study
taking
medication
(atomoxetine);
they
continued
medicationat
posttreatmentand
follo
w-up.Tw
ochild
renin
the
controlgroup
beganmedication
atpo
sttreatment,
andon
edid
soat
follo
w-up
Shechtman
andKa
tz[67]
RCT
Thee
xpressive-supp
ortiv
emod
ality
uses
anintegrativetheoretical
approach
intherapy,with
astr
ongem
phasison
self-expressiv
enessa
ndgrou
psupp
ort.Ac
tivities
andtherapeutic
games
are
consistently
used
tohelp
participantsfunctio
nin
the
grou
pprocess.
(i)Non
e(i)
Non
e
(i)Initiation
(ii)E
motional
supp
ort
(iii)Negative
assertion
(iv)D
isclosure
(v)C
opingwith
confl
icts
(vi)Intim
acyin
friend
ship
Nomentio
nof
whether
participantswere
medicated
orno
nmedicated
BioMed Research International 31
Table4:Con
tinued.
Stud
yPeer
compo
nent
Parent
compo
nent
Teacherc
ompo
nent
Skills
Medication
Storebøetal.
[68]
RCT
Differentm
etho
dsof
teaching
thec
hildrenwere
used.Th
eseinclude
didacticinstr
uctio
ns,w
ork
with
symbo
ls(e.g.,do
lls),
role-play,creativ
etechniqu
es,physic
alexercises,music,story
reading,games,and
movies.Ea
chsessionhada
them
eofa
particular
aspect
ofsocialskillstraining.
(i)Parent
training
(ii)P
arent
educationalgroup
(iii)Parentalscreen
fora
dultADHD
symptom
s
(i)Teacherratings
ofacadem
icand
behaviou
ral
perfo
rmance,social
prob
lems,peer
relatio
nsand
emotionalregulation
(i)Self-worth
(ii)N
onverbal
commun
ication
(iii)Feelings
(iv)Impu
lsecontrol
(v)A
ggression
managem
ent
(vi)Con
flict
resolutio
n(vii)
Prob
lem
solving
(viii)S
ocialcues
Allparticipants
werep
rescrib
edmedication.
Treatm
entstarted
with
thefi
rst
choice:
methylphenidate;
thes
econ
dchoice:
dexamph
etam
ine;
andatom
oxetineif
significantanx
iety
compo
nent
change
orsuspicionof
dexamph
etam
ine
abuse
Waxmon
sky
etal.[69]
RCT
Each
sessionbeganwith
abriefd
escriptio
nof
the
socialskillso
fthe
day,
which
was
presentedto
the
child
didacticallyand
throug
hmod
ellin
gand
role-playing
.
(i)Parent
training
(ii)P
arentratings
ofADHD,O
DD,
CD,and
depressio
nsymptom
s,social
skills,prob
lem
levels,
adverse
emotionalevents
(i)Teacher
implem
enteddaily
repo
rtcard
(ii)T
eacher
ratin
gsof
academ
icand
behaviou
ral
perfo
rmance,and
adversee
motional
events
(i)Coo
peratio
n(ii)P
artic
ipation
(iii)Va
lidation
(iv)C
ommun
ication
(v)F
ollowingrules
(vi)Com
pleting
assig
nments
(vii)
Com
plying
with
adults
(viii)T
easin
g
Allparticipants
werep
rescrib
edatom
oxetine
Ifas
ubjectwas
alreadytaking
ADHDmedication
otherthan
atom
oxetine,the
otherm
edication
was
stopp
edfora
tleast4
8ho
ursp
rior
toscreening
Notes.QES
=qu
asi-e
xperim
entalstudy
;RCT
=rand
omized
controlledtrial;A
DHD=attention-deficit/hyperactivity
disorder;O
DD=op
positionaldefiantd
isorder;C
D=cond
uctd
isorder;SCS
T=social-cognitiv
eskillstraining;SA
=socialactiv
ity;E
MT=em
otionalm
anagem
enttraining;SST=socialskillstraining;MOSA
IC=MakingSo
ciallyAc
ceptingInclu
siveC
lassroom
s;andCL
AS=Ch
ildLifeandAttentionSkills
program.
32 BioMed Research International
Table5:Metho
dologicalqualityof
inclu
dedstu
dies.
Stud
yTreatm
ent
Con
trol
NHMRC
evidence
level
Rand
omization
Blinding
Metho
dologicalquality
Abikoff
etal.
[53]
Child
and
parent
training
with
medication
Attention
controlw
ithmedication
II
Block
rand
omization
schemew
ithblocks
of4child
ren.
The
grou
pswere
balanced
fora
ge,
sex,op
positional
defiant
disorder,
andethn
icity
Trainedob
servers,blindto
treatmentand
diagno
sis,
observed
thes
tudy
child
ren
andcla
ssmates
asap
rimary
outcom
e
Strong
quality
(score
23/28).R
eliableuseo
fpeers.Samplingstr
ategy
approp
riatewith
subject
characteris
ticssuffi
ciently
describ
edin
companion
metho
dologicalarticle
presentedby
Klein
etal.
(200
4).Insuffi
cientd
atato
assesssamples
ize.Blinding
foro
neof
thep
rimary
outcom
eswas
repo
rted.
Rand
omizationno
trepo
rted
indetail.No
estim
ates
ofvaria
nce
repo
rted.
ChoiandLee
[54]
Child
training
Waitlist
control
II
Block
rand
omization
schemew
ithblocks
of5child
ren.
No
evidence
ofstratifi
catio
n
Noblinding
ofparticipants
orperson
nelreported.All
instr
umentsweree
ither
parent-o
rchild-report
measures
Goo
dqu
ality
score(18/28).
Reliableu
seof
peers.
Samplingstrategy
approp
riatewith
buto
nly
subjectage,gendera
ndscho
olgraded
escribed.
Blinding
notreportedfor
outcom
emeasurement.
Insufficientd
atatoassess
samples
ize.Estim
ates
ofvaria
ncep
rovidedfortim
epo
intsof
interest,
butn
otarou
ndthed
ifference.
BioMed Research International 33Ta
ble5:Con
tinued.
Stud
yTreatm
ent
Con
trol
NHMRC
evidence
level
Rand
omization
Blinding
Metho
dologicalquality
Frankeletal.
[55]
Child
and
parent
training
with
medication
Waitlist
controlw
ithmedication
III
Norand
omization
evident
Noblinding
ofparticipants
orperson
nelreported
Goo
dqu
ality
(score
18/28).
Reliableu
seof
peers.
Samplingstrategy
approp
riatewith
subject
characteris
ticssuffi
ciently
describ
ed.Insuffi
cientd
ata
toassesssamples
ize.
Blinding
and
rand
omizationno
trepo
rted.A
utho
rsrepo
rted
thetreatmentand
waitlist
grou
psdifferedsig
nificantly
inmeansocioecono
mic
statush
owever
didno
tcorrelatew
ithanyou
tcom
evaria
ble.Au
thorsreported
ADHDchild
renwere
prescribed
medicationby
theiro
wnprivate
physicians
anddo
sage
was
notverified
bythep
resent
authorsthu
spossib
lyaffectin
gther
esults.
Gulietal.[56]
Child
training
Clinical
control
III
Norand
omization
evident
Noblinding
ofparticipants
orperson
nelreported
Goo
dqu
ality
(score
20/28).
Reliableu
seof
peers.
Samplingstrategy
approp
riatewith
subject
characteris
ticssuffi
ciently
describ
ed.Insuffi
cientd
ata
toassesssamples
ize.
Blinding
and
rand
omizationno
trepo
rted.E
stimates
ofvaria
ncep
rovided.Re
sults
repo
rted
insufficientd
etail
with
supp
ortin
gconclusio
ns.A
utho
rsrepo
rted
somec
hildrenin
thetreatmentand
control
grou
pweretaking
prescriptio
nmedication
thus
possiblyaffectin
gthe
results.
34 BioMed Research International
Table5:Con
tinued.
Stud
yTreatm
ent
Con
trol
NHMRC
evidence
level
Rand
omization
Blinding
Metho
dologicalquality
Haase
tal.[57]
Child
training
Child
training
for
nodiagno
siscontrol
III
Norand
omization
evident
Cou
nsellorsw
horated
child
ren’s
behaviou
rwere
naıvetothec
ondu
ctprob
lemsa
ndcallo
us/unemotionaltraits
statuso
feachchild
Goo
dqu
ality
(score
20/28).
Reliableu
seof
peers.
Samplingstrategy
not
describ
ed.Sub
ject
characteris
ticssuffi
ciently
describ
ed.B
linding
repo
rted
foro
neof
the
prim
aryou
tcom
es.
Rand
omizationno
trepo
rted.A
utho
rsrepo
rted
arelatively
smallsam
ple
with
limitedpo
wer
todetecttre
nds.Asthe
sampleo
nlyinclu
ded
child
renwith
high
levelsof
CPandADHDthed
atac
anon
lybe
safelygeneralised
tochild
renwith
high
levelsof
CPandADHD.Treatment
outcom
esmay
have
been
affectedby
medicated
and
unmedicated
behaviou
ras
somec
hildrenwereo
nmedicationforsom
e(bu
tno
tall)
days
thereforethis
may
have
affectedresults.
BioMed Research International 35
Table5:Con
tinued.
Stud
yTreatm
ent
Con
trol
NHMRC
evidence
level
Rand
omization
Blinding
Metho
dologicalquality
Hannesdottir
etal.[58]
Child
training
Waitlist
control
III
Rand
omization
proceduren
otdescrib
ed
Noblinding
ofparticipants
orperson
nelreported
Goo
dqu
ality
score(18/28).
Reliableu
seof
peers.
Samplingstrategy
approp
riatewith
subject
characteris
ticssuffi
ciently
describ
ed.R
ando
mization
was
repo
rted,but
proceduren
otdescrib
ed.
Blinding
notreported.
Insufficientinformationto
calculates
amples
ize.No
estim
ates
ofvaria
nce
arou
nddifferences
repo
rted.
Hantson
etal.
[59]
Child
and
parent
training
Treatm
entas
usualcon
trol
III
Norand
omization
evident
Noblinding
ofparticipants
orperson
nelreported
Goo
dqu
ality
(score
19/28).
Reliableu
seof
peers.
Samplingstrategy
approp
riatewith
subject
characteris
ticssuffi
ciently
describ
ed,how
ever
comorbiditie
sweren
otrepo
rted.B
linding
and
rand
omizationno
trepo
rted.R
elatively
small
samples
ize.Noestim
ates
ofvaria
ncer
eported.
36 BioMed Research International
Table5:Con
tinued.
Stud
yTreatm
ent
Con
trol
NHMRC
evidence
level
Rand
omization
Blinding
Metho
dologicalquality
Huang
etal.[60]
Child
and
parent
training
Com
mun
itycare
control
IINorand
omization
evident
Noblinding
ofparticipants
orperson
nelreported
Goo
dqu
ality
score(17/28).
Reliableu
seof
peers.
Samplingstrategy
approp
riatewith
subject
characteris
ticssuffi
ciently
describ
ed.C
ontro
lgroup
consisted
offamilies
intereste
din
thep
rogram
butu
nabletoattend
atspecifica
ppointmenttim
es,
thus
nottrulyrand
omized.
Noblinding
repo
rted.
Insufficientinformationto
calculates
amples
ize.No
estim
ates
ofvaria
nce
arou
nddifferences
repo
rted.A
utho
rsrecogn
isethatparticipants
with
good
medication
complianceh
adbette
rou
tcom
eson
some
measures,bu
tdid
not
controlfor
medication
complianceinallanalyses.
BioMed Research International 37
Table5:Con
tinued.
Stud
yTreatm
ent
Con
trol
NHMRC
evidence
level
Rand
omization
Blinding
Metho
dologicalquality
Jensen
etal.[61]
Child
,parent,
and
scho
ol-based
training
with
medication
Com
mun
itycare
control
II
Rand
omization
was
done
centrally
andstr
atified
bysiteinblocks
of16
(4to
each
grou
p).
Sealed,ordered
envelopesw
ere
sent
tosites
for
successiv
eentrie
s.Treatm
ent
assig
nmentw
asconcealedun
tilthe
family
confi
rmed
agreem
entto
accept
rand
omization
Noblinding
ofperson
nel
repo
rted
Goo
dqu
ality
(score
21/28).
Reliableu
seof
peers.
Samplingstrategy
approp
riatewith
subject
characteris
ticssuffi
ciently
describ
ed.B
linding
was
repo
rted
however
itisno
tcle
arwho
was
blinded.
Rand
omizationno
tdescrib
edin
detail.
Approp
riatesamples
ize.
Varia
ncee
stim
ates
repo
rted
inapprop
riatelyas
study
provided
varia
ncea
roun
dthep
aram
eterso
finterest
however
notaroun
dthe
difference.
Kolkoetal.[62]
Child
training
Child
socialisa
tion
grou
pIII
Norand
omization
evident
Second
trainedresearch
assistant
unaw
areo
fchild’s
grou
passig
nmentrecorded
invivo
behaviou
ral
observations.Interrater
agreem
ento
fbehavioural
role-play
testwerea
ssessed
bycomparin
gratin
gsassig
nedby
atrained
research
assistant
unaw
are
ofgrou
passig
nment
Goo
dqu
ality
(score
18/28).
Reliableu
seof
peers.
Samplingstrategy
may
have
intro
ducedbias.Sub
ject
characteris
ticssuffi
ciently
describ
ed.B
linding
was
adequatelyrepo
rted
for
someo
fthe
ratersho
wever
notall.Ra
ndom
izationwas
notreported.Noestim
ates
ofvaria
ncer
eported.
Approp
riatesamples
ize.
38 BioMed Research International
Table5:Con
tinued.
Stud
yTreatm
ent
Con
trol
NHMRC
evidence
level
Rand
omization
Blinding
Metho
dologicalquality
Mikam
ietal.
[63]
Child
training
for
ADHD
child
ren
Child
training
for
TDchild
ren
II
Rand
omlyassig
ned
viaa
compu
ter-
generatedsequ
ence
either
toa
classroom
inthe
MOSA
ICtre
atment
cond
ition
inSession1and
adifferent
classroom
intheC
OMET
treatment
cond
ition
inSession2or
vice
versa.As
signm
ent
was
stratified
bychild
agea
ndsex
Trainedresearch
assistants
unaw
areo
ftreatmentgroup
administered
allprim
ary
outcom
emeasures
Strong
quality
(score
25/28).R
eliableuseo
fpeers.Samplingstr
ategy
approp
riatewith
subject
characteris
ticssuffi
ciently
describ
ed.B
linding
was
adequatelyrepo
rted
fora
llou
tcom
emeasures.
Rand
omizationwas
adequatelyrepo
rted.
Estim
ates
ofvaria
nce
provided.A
utho
rsrepo
rted
asmallsam
ples
izew
hich
limits
thec
onfid
ence
for
mod
erationresults.
TheM
TACoo
perativ
eGroup
[64]
Child
,parent,
and
scho
ol-based
training
with
medication
Com
mun
itycare
control
II
Rand
omization
was
done
centrally
andstr
atified
bysiteinblocks
of16
(4to
each
grou
p).
Sealed,ordered
envelopesw
ere
sent
tosites
for
successiv
eentrie
s.Treatm
ent
assig
nmentw
asconcealedun
tilthe
family
confi
rmed
agreem
entto
accept
rand
omization
Theo
penparent,teacher,
andchild
ratin
gsfor5
out
of6ou
tcom
eswere
augm
entedby
blinded
ratin
gsof
scho
ol-based
ADHDand
oppo
sitional/a
ggressive
symptom
s.Ra
tersblindto
treatmentcon
ditio
nperfo
rmed
stand
ardized
labo
ratory
taskstoassess
parent-child
interactions
Strong
quality
(score
24/28).R
eliableuseo
fpeers.Samplingstr
ategy
approp
riatewith
subject
characteris
ticssuffi
ciently
describ
ed.B
linding
was
adequatelyrepo
rted.
Rand
omizationno
trepo
rted
indetail.
Approp
riatesamples
ize
basedon
power
analyses.
Explicituseo
fmanualised,
evidence-based
treatments
andcomprehensiv
erange
ofou
tcom
eassessm
ents.
Varia
ncee
stim
ates
repo
rted
inapprop
riatelyas
study
provided
varia
ncea
roun
dthep
aram
eterso
finterest
however
notaroun
dthe
difference.
BioMed Research International 39
Table5:Con
tinued.
Stud
yTreatm
ent
Con
trol
NHMRC
evidence
level
Rand
omization
Blinding
Metho
dologicalquality
MTA
Coo
perativ
eGroup
[65]
Child
,parent,
and
scho
ol-based
training
with
medication
Com
mun
itycare
control
II
Rand
omization
was
done
centrally
andstr
atified
bysiteinblocks
of16
(4to
each
grou
p).
Sealed,ordered
envelopesw
ere
sent
tosites
for
successiv
eentrie
s.Treatm
ent
assig
nmentw
asconcealedun
tilthe
family
confi
rmed
agreem
entto
accept
rand
omization
Noblinding
ofperson
nel
repo
rted
Goo
dqu
ality
(score
21/28).
Reliableu
seof
peers.
Samplingstrategy
approp
riatewith
subject
characteris
ticssuffi
ciently
describ
ed.B
linding
not
repo
rted.R
ando
mization
notd
escribed
indetail.
Approp
riatesamples
ize.
Varia
ncee
stim
ates
repo
rted
inapprop
riatelyas
study
provided
varia
ncea
roun
dthep
aram
eterso
finterest
however
notaroun
dthe
difference.
Pfiffn
eretal.
[66]
Child
and
parent
training
with
teacher
consultatio
n
Waitlist
controlor
treatmentas
usual
II
Rand
omization
was
stratified
bysex(w
hentwo
child
renof
the
sames
exwere
identifi
ed,one
was
rand
omlyassig
ned
toCL
ASprogram
andon
etothe
controlgroup
).Investigators
requ
iredatleast
twoparticipantsof
thes
ames
exin
the
treatmentg
roup
Interviewersa
ndraterswho
wereb
lindto
child
’sgrou
passig
nmentadm
inistered
theT
esto
fLife
Skill
Know
ledgeo
utcome
measure
Goo
dqu
ality
(score
22/28).
Reliableu
seof
peers.
Samplingstrategy
approp
riatewith
subject
characteris
ticssuffi
ciently
describ
ed.B
linding
was
adequatelyrepo
rted.
Rand
omizationwas
not
repo
rted
indetail.No
estim
ates
ofvaria
nce
repo
rted.A
ppropriate
samples
ize.Participantu
seof
medicationwas
aconfou
ndingvaria
ble
however
unlik
elyto
have
serio
uslydisto
rted
results.
40 BioMed Research International
Table5:Con
tinued.
Stud
yTreatm
ent
Con
trol
NHMRC
evidence
level
Rand
omization
Blinding
Metho
dologicalquality
Shechtman
and
Katz[67]
Child
training
for
ADHD
child
ren
Waitlist
control
II
Theg
roup
was
rand
omlydivided
(byalph
abetical
order)into
anexperim
entaland
awaitlistcontrol
grou
p(to
betre
ated
then
ext
year)
Noblinding
ofparticipants
orperson
nelreported
Strong
quality
(score
24/28).R
eliableuseo
fpeers.Samplingstr
ategy
approp
riatewith
subject
characteris
ticssuffi
ciently
describ
ed.B
linding
not
repo
rted.R
ando
mization
was
adequatelyrepo
rted.
Estim
ates
ofvaria
nce
provided.A
ppropriate
samples
ize.Participantu
seof
medicationwas
not
repo
rted
thereforem
aybe
confou
nding.
Storebøetal.
[68]
Child
and
parent
training
with
stand
ard
treatment
Standard
treatment
alon
eII
TheC
openhagen
TrialU
nit
cond
uctedcentral
rand
omization
with
compu
ter-
generated,
perm
uted
rand
omization
sequ
encesin
blocks
offour
with
anallocatio
nratio
of1:1stratified
for
sexand
comorbidity
Theinterventions
given
weren
ot“blin
d”to
participants,
parents,
treatingph
ysicians,or
person
nel.How
ever,the
outcom
eassessors
(teachers)w
erek
ept
blindedof
thea
llocated
interventio
n.Blindeddata
werethenhand
edover
for
dataentryandsta
tistic
alanalyses
Strong
quality
(score
26/28).R
eliableu
seof
peers.Samplingstr
ategy
approp
riatewith
subject
characteris
ticssuffi
ciently
describ
ed.B
linding
was
adequatelyrepo
rted
fora
llou
tcom
emeasures.
Blinding
was
notapp
arent
forp
artic
ipants.
Rand
omizationwas
repo
rted
indetail.
Estim
ates
ofvaria
nce
provided.Sam
ples
ize
calculationcompleted
with
anapprop
riatesamples
ize
collected.
BioMed Research International 41
Table5:Con
tinued.
Stud
yTreatm
ent
Con
trol
NHMRC
evidence
level
Rand
omization
Blinding
Metho
dologicalquality
Waxmon
skyet
al.[69]
Child
and
parent
training
with
scho
ol-based
daily
repo
rtcard
and
medication
Medication
alon
eII
One-halfo
fthe
subjectswere
rand
omlyassig
ned
toreceive
atom
oxetine+
BTandther
emaining
subjectsrand
omly
assig
nedto
receive
atom
oxetinea
lone
Thes
econ
d(reliability)
observer
forthe
behaviou
rtherapyarm
was
blindedto
grou
passig
nment
Goo
dqu
ality
(score
22/28).
Reliableu
seof
peers.
Samplingstrategy
approp
riatewith
subject
characteris
ticssuffi
ciently
describ
ed.P
rimary
investigatorsw
eren
otblinded.Ra
ndom
ization
was
notreportedin
detail.
Varia
ncee
stim
ates
repo
rted
inapprop
riatelyas
study
provided
varia
ncea
roun
dthep
aram
eterso
finterest
however
notaroun
dthe
difference.Samples
izew
ascalculated
forthe
prim
ary
outcom
emeasure
howe
ver
notthe
second
arymeasures
therefores
amplem
ayno
thave
hadsufficientsub
jects
todetectgrou
pdifferences
forsecon
dary
measures.
Notes.NHMRC
levelII=
RCTs;le
velIII=qu
asi-e
xperim
entaldesigns
with
outrando
mallocatio
n;ADHD=Attention-DeficitH
yperactiv
ityDiso
rder;C
P=cond
uctproblem
s;MOSA
IC=MakingS
ocially
Accepting
Inclu
siveC
lassroom
s;CO
MET
=contingencymanagem
enttraining;andCL
AS=Ch
ildLifeandAttentionSkillsp
rogram
.
42 BioMed Research International
incorporating additional parent training [55, 59, 60, 68].Pfiffner et al. [66] used child focused SST and parent trainingwith the addition of teacher consultation in the experimentalgroup. The MTA trials consisted of child focused SST, parenttraining, teacher consultation, and classroom behaviouralintervention [64, 65]. Haas et al. [57] and Jensen et al. [61]used a behavioural treatment in the context of a summertreatment program; Jensen et al. [61] also included parenttraining and school-based treatment. Three trials assessedchild focused SST and parent trainingwithmedical treatmentin the experimental group against medical treatment alone[53, 68, 69]. Abikoff et al. [53] also included academicplanning skills training and individual psychotherapy. Han-nesdottir et al. [58] included additional executive functiontraining via computer-based activities.
3.6. Control Groups. Six studies used medications in bothexperimental and control groups and added one (or more)therapy to medication—thus using “medication only” asthe control group [53, 61, 64, 65, 68, 69]. Ten studiesutilised either typically developing children or no treatmentor assigned participants to waitlist control groups [54–60,63, 66, 67]. Kolko et al. [62] compared a social-cognitiveskills training program against a social activities groupwhere children were merely provided with semistructuredopportunities for socialisation rather than a peer-mediatedintervention.
3.7. Use of Peers. There was great variation between studiesas to the degree of detail used in describing and reporting onthe characteristics of the included peers. Of the 17 studies,only 3 used non-ADHD diagnosed or typically developingpeers to facilitate intervention [55, 57, 63]. Additionally, theinvolvement of the peers in the intervention varied, withno identified studies reporting detailed involvement of peersto be considered peer-mediated interventions accordingto our adopted definition. Sixteen studies reported peerinvolvement [53–62, 64–69] and one study reported a peer-proximity intervention [63].
3.8. Risk of Bias in Included Studies. Of the nine RCTs, onlytwo reported generation of random allocation in detail [63,68]. The other seven RCTs did not report the generation ofallocation sequence; therefore the risk of bias was unclear[53, 54, 58, 64, 66, 67, 69]. The MTA trial did report the con-cealment of allocation, unlike the other trials; thus risk of biaswas unclear for those studies. The blinding of participants orclinicians involved in the delivery of interventions is a well-known difficulty [123, 124]. All studies in this review wereat risk of bias due to limited blinding of participants. Of theincluded studies, only two reported blinding for all outcomes[63, 68] and six studies reported blinding for at least one ofthe outcomes [53, 57, 62, 64, 66, 69]. The studies at high riskof bias due to lack of blinding were as follows: Choi and Lee[54], Frankel et al. [55], Guli et al. [56], Hantson et al. [59],Huang et al. [60], Hannesdottir et al. [58], Jensen et al. [61],MTACooperative Group [64], and Shechtman andKatz [67].
Eight studies included data of medicated and nonmedi-cated children and therefore were at high risk of confounding
Funnel plot of standard error by Hedges’ g
0.4
0.3
0.2
0.1
0.0
Stan
dard
erro
r
1.00.50.0 1.5 2.0−1.0−1.5 −0.5−2.0Hedges’ g
Figure 2: Publication bias funnel plot.
bias [56–60, 62, 63, 66]. Huang et al. [60] recognised thispotential for bias and analysed the impact of drug complianceon results through linear mixed modelling. Waxmonsky etal. [69] conducted a sample size calculation for the primaryoutcome measure, however not the secondary outcomemeasures which included the social skills outcome. This mayhave increased the risk of Type 2 errors as the analysismay not have had the required power to detect trendsfor all outcome measures. Many of the authors may havehad potential invested interest bias, as they have conductedprevious research on the topic [53, 55–57, 61, 63–68].
The Begg and Mazumdar rank correlation procedureproduced a tau of −0.032 (two-tailed 𝑝 = 0.833), indicatingthere is no evidence of publication bias. This finding wassupported by Duval and Tweedie’s trim-and-fill procedureusing the fixed-effect model; the point estimate for thecombined studies is 0.607 (95% CI: 0.522, 0.692). Using trimand fill these values are unchanged.Under the random-effectsmodel the point estimate for the combined studies is 0.562(95% CI: 0.431, 0.693). Using trim and fill these values areunchanged. Both of these procedures indicate the absence ofpublication bias (see Figure 2 for funnel plot).
3.9. Methodological Quality. We identified 17 studies pub-lished between 1990 and 2016 for children with ADHD. Ofthese selected studies, nine were randomized controlled trials(RCTs), six were quasi-experimental studies, and two werelongitudinal follow-up studies. Of these studies, eleven wereclassified as level II evidence and six as level III evidencebased on the NHMRC Evidence Hierarchy NHMRC [116].The overallmethodological quality of the studies ranged fromgood to strong with ten studies ranked as good and four asstrong according to the Kmet ratings (Table 5).The interrateragreement (Weighted Kappa) for the Kmet ratings was 0.74(95% CI 0.61–0.86).
3.10. Effects of Interventions: Meta-Analysis Results
3.10.1. Effect of Peer Inclusion Interventions on Pre-Post SocialSkills Outcomes. The pre-post intervention effect sizes forthe included studies ranged from 0.167 [60] to 1.345 (large;[59]) (Figure 3). In five of the peer inclusion groups, effectsizes were large, indicating that peer inclusion accounted fora significant proportion of standardized mean difference for
BioMed Research International 43
Study name
Abikoff et al. 2004 (P) 06moAbikoff et al. 2004 (P) 12moAbikoff et al. 2004 (P) 18moAbikoff et al. 2004 (P) 24moChoi and Lee 2015 (S)Hannesdottir et al. 2017 (P)Hantson et al. 2012 (S)Huang et al. 2015 (S)Huang et al. 2015 (S) 4moHuang et al. 2015 (T)Huang et al. 2015 (T) 4moJensen et al. 2007 (B)Kolko et al. 1990 (S)The MTA Cooperative Group 1999 (B)The MTA Cooperative Group 1999 (P)MTA Cooperative Group 2004 (B)Pfiffner et al. 2007 (P + T)Shechtman and Katz 2007 (T)Storebø 2012 (3mo)Storebø 2012 (6mo)Waxmonsky et al. 2010 (P)Waxmonsky et al. 2010 (T)
Figure 3: Within intervention group pre-post meta-analysis. Notes. Hedges’ 𝑔 interpreted as per Cohen’s d conventions: ≤0.2 = negligibledifference, 0.2–0.49 = small, 0.5–0.79 = moderate, and ≥ 0.8 = large.
these five studies. A significant postintervention between-group effect size total in favour of peer inclusion interventionswas found using a random-effects model (𝑧(21) = 9.149,𝑝 < .001, Hedges 𝑔 = 0.584, and 95% CI = 0.459–0.709),indicating moderate improvement in social skills outcomesfollowing peer inclusion interventions. Between-study het-erogeneity was significant (𝑄(21) = 40.711, and 𝑝 = .006),with 𝐼2 showing heterogeneity accounted for 48.417% ofvariation in effect sizes across studies, as opposed to chance.
3.10.2. Effect of Confounds on Pre-Post Social Skills Outcomes.Given the significant heterogeneity, subsequent subgroupanalyses were conducted comparing effect sizes betweenintervention groups to examine variables that could poten-tially confound social skills outcomes. Comparisons weremade based on the following: (a) the presence or absenceof parent training and psychoeducation within the interven-tions; (b) study design (i.e., quasi-experimental design, RCT);(c) methodological quality rating (i.e., good, strong); (d) thepresence or absence of blinding for outcome measurement;and (e) the outcome rating respondent (i.e., self-rated, parentrated, teacher rated, and combined parent and teacher rated).
All subgroup comparisons produced a significant result(see Table 6). While analyses based on level of parentinvolvement, methodological quality rating, and blinding ofoutcomes measures produced significant results, the differ-ences in effect sizes for subgroups in these comparisons werenegligible. Effect sizes for comparisons based on respondenttype for outcome measurement ranged from a large positive
effect for ratings completed by parents and teachers, tomoderate positive effects for ratings completed by teachers orparents or the child with ADHD. Intervention effect favouredRCT studies to a small degree.
3.10.3. Factors Mediating the Intervention Effect. Given thesignificant results found in all subgroup analyses and sim-ilarities in effect sizes for a majority of the comparisons,metaregression was performed to determine if any of thevariables contributed as a significantmediator of interventioneffect. All variables of the subgroup analysis were enteredas covariates in the regression model. Results showed thatvariable of parents as raters for outcome measurement wasthe only variable contributing as a significant mediator ofintervention effect (𝑧(3) = −2.00; 𝑝 = 0.0457). See Table 7for full results of the metaregression.
3.10.4. Effect of Peer Inclusion Interventions on Social SkillsCompared with Comparison Groups. When comparing peerinclusion interventions and comparison groups, the differ-ence between the pre-post scores for peer inclusion groupsand each comparison group type was not significant (𝑧(2) =0.926; 𝑝 = 0.355). Heterogeneity in the included studies wassignificant (𝑄(21) = 41.032; p = 0.006), with 𝐼2 = 48.820%indicating the percentage of variability due to heterogeneityrather than chance. The subgroup analysis indicated whenpeer inclusion interventions were compared to medicationonly interventions or treatment as usual, no significantdifference was measured (𝑝 = 0.599 and 𝑝 = 0.644, resp.).
44 BioMed Research International
Table 6: Subgroup analysis comparing intervention groups of included studies.
Subgroups Hedges’ 𝑔 𝑍-value p valueParent component 0.595 9.085 <0.001∗
No parent involvement (𝑁 = 4) 0.606 4.606 <0.001∗
Parent involvement (𝑁 = 18) 0.577 7.833 <0.001∗
Study design 0.629 11.344 <0.001∗
RCT (𝑁 = 16) 0.643 11.025 <0.001∗
Quasi-experimental (𝑁 = 6) 0.496 2.784 0.001∗
Methodological quality 0.609 5.696 <0.001∗
Good (𝑁 = 17) 0.576 7.206 <0.001∗
Strong (𝑁 = 5) 0.588 3.712 <0.001∗
Blinding of outcome measures 0.608 11.176 <0.001∗
Blinded (𝑁 = 12) 0.622 10.187 <0.001∗
No blinding (𝑁 = 10) 0.556 4.623 <0.001∗
Outcome measure respondent type 0.594 9.999 <0.001∗
A significant but small effect in favour of peer inclusioninterventions was measured when compared to other inter-ventions (𝑧(6) = 2.440, 𝑝 = 0.015, Hedges 𝑔 = 0.242, 95% CI= 0.048–0.436).
4. Discussion
This study aimed to systematically evaluate and analysethe efficacy of peer inclusion interventions in improvingsocial functioning in children diagnosed with ADHD, usingsystematic review and meta-analysis procedures. The meta-analysis included both RCTs and quasi-experimental studiesof peer inclusion interventions, in order to broaden thescope and include all studies which involved peer includedelements.
4.1. Systematic Review Findings. All but one study byMikamiet al. [63], which employed peer proximity, utilised peerinvolvement interventions in the form of peer modellingand role-plays. Children were didactically presented withsocial skills scenarios and were required to teach the other
children the correct and incorrect use within a range ofcontexts. The inclusion of parents and teachers to facilitategeneralisability of treatment effects was common for most ofthe studies included. Eight studies included parent trainingand psychoeducation of ADHD as an add-on to the peerinvolvement intervention [53, 55, 59, 60, 64, 66, 68, 69]. Ofthese eight studies, four also included teacher consultationand daily report cards to increase the behavioural outcomesachieved at school [53, 64, 66, 69].
An important finding is that only 3 of the 17 studies usedtypically developing peers or peers without a diagnosis forthe intervention. This is in stark contrast to findings of asystematic review investigating peer-mediated interventionsfor children with ASD where 34 of the 42 studies reportedusing peers with no disability used for the intervention[111]. Moreover, empirical studies have shown the potentialnegative effect that the involvement of peers with behaviouralproblemsmay have on the behaviour of children with ADHD[125–127]. In fact, one study reported that the behaviour ofchildren with the inattentive subtype of ADHD deterioratedfollowing the peer intervention, postulating these children
BioMed Research International 45
may imitate some of the negative behaviours displayed byother children [126]. The lack of typically developing peersincluded in the interventions may have reduced potentialbenefits. There is emerging evidence in literature suggestingthat peer inclusion interventions should take the followinginclusion criteria for peers into account: typical social andlanguage development, absence of behaviour difficulties, aninterest in interacting with the target child, and regularavailability [46, 106, 108, 128]. Moreover, it is widely acceptedthat skill generalisation of social skills is difficult for childrenwith ADHD [129, 130]. As such interventionsmay have betteroutcomes when conducted with typically developing peers(including siblings) in the child’s natural social environment[113].
Another important finding is that none of the studies usedpeer-mediated interventions, only peer involvement and peerproximity. Given that a peer-mediated approach is the mostempirically supported model of social skills intervention forchildren with ASD [108], it is a surprising finding that noneof the studies employed peer mediation which, at least inASD literature, has the best support for improving socialfunctioning. Both children with ASD and ADHD experiencesignificant impairments in social functioning and, giventhe concomitant presentation of social skills difficulties inthese comorbid conditions, a greater overlap in the approachto address the social skills difficulties was expected. Thefindings of this systematic review point to an urgent need forresearchers to give serious consideration to both the inclusioncriteria of peers involved in the intervention (i.e., includingpeers without behavioural problems) and their approachto peer inclusion interventions (i.e., consider incorporatingpeer-mediated interventions).
A noteworthy limitation of these studies is the paucityof blinding. Without blinding, results may be exposed toa high risk of bias as teachers, parents, and investigatorsmay have vested interests or rate children better due toknowledge of treatment efficacy [124]. Parents are oftenknown as the experts of their children’s behaviour; however,they may be inclined to rate their child differently due to aclose attachment or a false sense of achievement based onknowledge of treatment. Teachers and investigators may alsoreport incorrect improvements of the treatments if they areaware of diagnosis and/or the treatment itself [123, 124]. Theseven randomized controlled trials included in this revieware also at high risk of bias due to a paucity of informationregarding randomization methods, allocation concealment,and power to detect trends.This is problematic as it limits theability to blind key stakeholders and determine the necessarynumber of participants required to detect significance ofresults [123, 124].
Social skills interventions often have difficulty general-ising skills outside of the treatment setting [61, 65]. Peerinclusion interventions aim to address this issue by providingcontextual peer relationships to facilitate learning wherebysocial skills can be further applied to other settings [105].The included studies did not provide a clear justificationas to the efficacy of peer inclusion interventions or theeffect of generalisability; however, they do present clear pre-post and follow-up findings of significant improvements in
social skills competences and peer interactions through theuse of multiple components including peers, parents, andteachers versus waitlist controls or equivalent no treatmentcontrols. Further research should aim to determine theefficacy of treatments where these components are combinedand separated to allow for a more clear analysis of the effectsof the peer included component of social skills interventions.
4.2. Meta-Analysis Findings
4.2.1. Pre-Post Effects and as a Function of Level of PeerInclusion. We attempted to include as many studies in themeta-analysis as were deemed appropriate, with only fourstudies being excluded due to inadequate reporting of resultsor lack of true baseline measurement [55–57, 63]. The meta-analysis revealed a significant improvement in social skillsmeasures and peer relationships for children and adolescentswith ADHD when the pre-post scores of participants inthe intervention groups were analysed as a whole. However,significant heterogeneity indicated that effect sizes variedacross the studies more than would be expected by chanceand that these studies cannot be assumed to have beenrecruited from the same sample. This is unsurprising, giventhe variation in the treatments including peers and the profileof the participants included in each of the studies.
It is important to note that only peer involvement inter-ventions were included in this meta-analysis.We were unableto make comparisons based on types of peer inclusion, asthe single study looking at a peer-proximity intervention didnot report true baseline data and hence was not included inthe meta-analysis. As such, the literature remains unclear asto the level of peer inclusion required in an intervention inorder to maximise the effect of interventions on social skillsand peer relationships. Peer proximity should be consideredin the future development and evaluation of interventions sothat stronger conclusions can be drawn as to the ideal level ofpeer inclusion for maximising benefits.
The subgroup analysis revealed significant differencesbetween studies based on level of parent involvement, studydesign, methodological quality, blinding of outcome mea-sures, and the rater completing outcomemeasurement. How-ever, when effect sizes are compared, negligible differenceswere identified in three of the comparisons. Interventionsinvolving parents did not differ greatly from interventionswithout a parent training component, studies with strongmethodological quality found similar effects to studies with“good” methodological quality, and blinded outcome mea-sures produced similar results to measures that were notblinded. This lack of conclusive results calls for furtherresearch into peer inclusion interventions
The most significant finding of the meta-analysis is theinfluence that the person chosen to rate outcome mea-surements can have upon study findings. The person whorated the children’s social skills outcomes following peerinclusion interventions showed significance between sub-group differences. Studies that reported on combined parent-teacher ratings showed overall large effect sizes, whereasindividual parent, teacher, or child self-ratings demonstratedoverall moderate effect sizes. Furthermore, using parents as
46 BioMed Research International
raters was found to significantly mediate the interventioneffect. Careful consideration should be given tomeasurementselection clinically, and in future studies of peer inclusion,such that observations from a variety of raters are consideredand interpreted in the light of these results.
4.2.2. Effects as a Function of Treatment Group Type. Overall,the peer inclusion interventions did not significantly dif-fer from the three comparison group types. The subgroupanalysis showed that peer inclusion interventions were moreeffective in improving social skills and peer relations thancomparison interventions for children and adolescents diag-nosed with ADHD, but the effect size was small. However,the heterogeneity indicates that participants in these studiescannot be assumed to be drawn from the same sample,suggesting that peer inclusion interventionsmay not result inbetter social skills outcomeswhen comparedwith other socialskill interventions in children and adolescents with ADHD.Further studies are needed to establish the generalisability ofthe results of this subgroup analysis.
In contrast, the question of whether peer inclusion inter-ventions were more efficacious when compared with otherpsychosocial and behavioural therapies and pharmacologicaltreatment could not be determined. Results from the meta-analysis revealed that the subgroup overall effect size formedication only as comparison group slightly favouredmed-ication over peer inclusion interventions. Conversely, whenlooking at the subgroup of peer involvement interventionsthat were compared to treatment as usual comparison groupsresults slightly favoured peer inclusion interventions. How-ever, for both subgroup analyses the differences were notsignificant. It is possible that, as previous research suggests,usual course of medication for children and adolescents peershould be used in combination with psychosocial therapies,such as peer-inclusive treatments in order for clear therapeu-tic gains to be made.
4.2.3. Other Possible Confounds. The large variation in effectsizes of within-groups pre- to posttest comparisons of peerinclusion interventions could be due to the differing lengthof treatments in the reviewed studies. Interestingly, in thestudieswith large effect sizes (e.g., [59, 64]) the treatment pro-grams which included peer involvement interventions wereintensive and/or involved long periods of treatment, whereasthe study with the smallest effect sizes [69] was designed tobe less intensive, replicating an outpatient model in order tocurtail the need for extensive involvement of mental healthprofessionals. This indicates that length and intensity ofpeer involvement intervention could be a confounding factoron posttreatment outcomes. Future research with matchedparticipants receiving varying lengths and intensity of peerinvolvement interventions are needed to investigate whetherlength and intensity are significant factors in increasingtreatment outcomes. Furthermore, inconsistency in effectsizes may be attributed to a number of confounding variablessuch as the following: (a) the use of different treatment com-ponents; (b) large variation of sample sizes across and withinstudies; and (c) the influence ofmedicated and nonmedicateddata. Including parents and teachers in the interventions
was common amongst the interventions reviewed, with eightstudies providing parents with training in addition to peerinvolvement [53, 55, 59, 60, 64, 66, 68, 69]. Four of those stud-ies also included behavioural therapeutic techniques [53, 64,66, 69]. As such, the addition of these treatment componentsparallel with peer involvement makes it difficult to isolate thespecific effect of peer inclusion in these interventions. Totalsample sizes ranged between 24 and 579 participants withonly two studies conducting power analyses to determinetheir appropriate sample size. Medication was a potentialconfounder for studies where participants’ improvementsmay have been influenced by the use of medication [57, 59,62, 63]. Some studies assessed medicated and nonmedicatedparticipants within treatment groups but did not control fortheir potential confounding influence within their analysis[57, 59, 62, 63]. Therefore the use of this confounding datamay have significantly impacted the reliability of results fortreatment groups attempting to report on the effectivenessof peer inclusion interventions. Comparing several outcomesacross a multitude of different treatments may also cause thecomparisons to differ significantly with unclear inferences, aswas evident in the Kolko et al. [62] and Mikami et al. [63]studies.
5. Limitations
The current study underwent a rigorous review processby searching relevant databases, comprehensively screeningabstracts between two independent researchers, and ensuringacceptable interrater reliability agreements for study selectionand Kmet methodological quality ratings. Despite the carethat was taken to reduce bias, this review is subject to anumber of limitations. Every study was at a risk of bias dueto inadequate blinding, randomization, or incomplete controlof confounding variables. In addition, a scarce amount of evi-dence was available to draw conclusions from regarding theefficacy of peer inclusion interventions on social functioning,which limited the translatability of the findings to practicalsettings. These methodological limitations were contributorsto comparatively poorer Kmet ratings of the studies.
6. Conclusion
The limitations of pharmacological treatment make it neces-sary to investigate the use of psychosocial interventions suchas peer inclusion interventions as an addition or alternativeto medication. It is clear that interventions which includepeer inclusion components may be an appropriate SSTmethod for children with ADHD. However, RCTs and quasi-experimental studies of children with ADHD which meet allthe criteria for peer mediation are needed.Thismeta-analysisfound evidence of a substantial difference between peer inclu-sion interventions plus medication treatment versus medi-cation alone. Peer inclusion interventions were significantlybetter at improving social competence and peer relationsthan no treatment or waitlist control groups, indicating thatpsychosocial interventions are valuable in treatment. Thereis a need for more studies to test the use of peer-mediatedinterventions; use typically developing peers; appropriately
BioMed Research International 47
calculate sample size; and control for medication as a poten-tial confound. In addition, the reporting on the specificcharacteristics and involvement of peers in the intervention,as demonstrated in the peer inclusion interventions forASD research, will assist with clarity regarding methods,effectiveness, and outcomes. Furthermore, the current reviewsystematically highlighted the necessity for more high qualitystudies to evaluate the use of peer inclusion interventionswhere the design allows for effect sizes to be calculatedseparately for peer, teacher, and parent components.
Additional Points
References [53–69] are the studies included in the reviewwhile all the other references are additional references.
Conflicts of Interest
The authors declare that there are no conflicts of interestregarding the publication of this article.
Acknowledgments
The authors would like to thank Lauren Parsons, RebeccaTotino, and Cally Kent for research assistant support.
Supplementary Materials
Supplementary Table 1: the methodology and reporting ofthis systematic review and meta-analysis in accordance withThe PRISMA 2009 Checklist. (Supplementary Materials)
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