Efficacy of Multimodal Intervention for Children with Attention Deficit Hyperactivity Disorder (ADHD)—An Indian Study

Thudalikunnil Gopalan Rejani, Anna Oommen, Shoba Srinath, Malavika Kapur

Department of Clinical Psychology, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, India.
Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, India.
School of Psychology and Social Work, University Malaysia Sabah, Kota Kinabalu, Malaysia.

DOI: 10.4236/jbbs.2012.21014                

Abstract

Background: To find the efficacy of multimodal intervention on attention deficit and hyperactivity, behavioral problems in home and school situations and on academic achievement of children with ADHD and the impact of family stress and coping on the outcome of multi-modal intervention. Method: A sample (N = 40) of children aged 5 - 10 years registered in the Child and Adolescent Mental Health Unit (CAMHU) with a diagnosis of ADHD (on the ICD-10) with or without comorbidity were randomly allocated to one of two groups: Group I (medical management with parent counseling, N = 20) or Group II (multimodal intervention (routine medical management, parent training and attention enhancement training), N = 20). Assessments (pre-assessment, re-assessment at one month and post assessment after 10 weeks) were carried out by investigator, parent, teacher and blind rater. Results: Significant improvement was noticed for both groups but multimodal intervention was superior to routine medical management and parent counselling in reducing ADHD symptoms, behavioural problems at home and school, and in improving academic performance. Effect size estimates and the rates of clinically significant change also supported this finding. Parental stress did not predict the outcome of intervention. Conclusions: Multimodal intervention was found to be promising in the treatment of ADHD.

Keywords

Multimodal Intervention; ADHD; Attention Enhancement Training; Parent Training

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	B. J. Coffey, “Attention Deficit Disorder,” In: J. D. Noshpitz, P. F. Kernberg and J. R. Bemporad, Eds., Handbook of Child and Adolescent Psychiatry, John Wiley and Sons, Inc., New York, 1997.
[2]	National Institute of Health Consensus Development Con- ference Statement, “Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder (ADHD),” Journal of Ame- rican Academy of Child and Adolescent Psychiatry, Vol. 39, No. 2, 2000, pp. 182-193.
[3]	W. E .Pelham, C. Carlson, S. E. Sams, V. G. Dixon and B. Hoza, “Separate and Combined Effects of Methylpheni- date and Behaviour Modification on Boys with Attention Deficit Hyperactivity Disorder in the Classroom,” Jour- nal of Consulting and Clinical Psychology, Vol. 61, No. 3, 1993, pp. 506-515. doi:10.1037/0022-006X.61.3.506
[4]	D. J. Kolko, O. G. Bukstein and J. Barron, “Methylphe- nidate and Behaviour Modifications in Children with ADHD and Comorbid ODD or CD; Main and Incre- mental Effects across Settings,” Journal of the American Academy of Child and Adolescent Psychiatry, Vol. 38, No. 5, 1999, pp. 578-586. doi:10.1097/00004583-199905000-00020
[5]	MTA Cooperative Group, “A 14-Month Randomized Clinical Trial of Treatment Strategies for Attention-Deficit/ Hyperactivity Disorder. The MTA Cooperative Group. Multimodal Treatment Study of Children with ADHD,” Archives of General Psychiatry, Vol. 56, No. 12, 1999, pp. 1073-1086.
[6]	R. G. Klein, H. Abikoff, L. Hechtman and G. Weiss, “De- sign and Rationale of Controlled Study of Long-Term Methylphenidate and Multi-Modal Psychosocial Treat- ment in Children with ADHD,” Journal of the American Academy of Child and Adolescent Psychiatry, Vol. 43, No. 7, 2004, pp. 792-801. doi:10.1097/01.chi.0000128798.91601.fe
[7]	M. D. Rapport, H. A. Murphy and J. S. Bailey, “Ritalin vs. Response Cost in the Control of Hyperactive Children: A Within-Subject Comparison,” In: P. E. Nathan and J. M. Gorman, Eds., A Guide to Treatments That Work, Oxford University Press, New York, 1982.
[8]	W. F. Horn, N. S. Ialongo, J. M. Pascoe, G. A. Greenberg, T. Packard, M. Lopez, A. Wagner and L. Puttler, “Addic- tive Effects of Psychostimulants, Parent Training and Self- Control Therapy with ADHD Children,” Journal of the American Academy of Child and Adolescent Psychiatry, Vol. 30, No. 2, 1991, pp. 233-240. doi:10.1097/00004583-199103000-00011
[9]	J. H. Satterfield, B. T. Satterfield and D. P. Cantwell, “Mul- timodality Treatment. A Two Year Evaluation of 61 Hy- peractive Boys,” Archives of General Psychiatry, Vol. 37, No. 8, 1980, pp. 915-919. doi:10.1001/archpsyc.1980.01780210073007
[10]	E. A. Schaughency and B. B. Lahey, “Mother’s and Fa- ther’s Perceptions of Child Deviance: Roles of Child Behavior, Parental Depression, and Marital Satisfaction,” Jour- nal of Consulting and Clinical Psychology, Vol. 53, No. 5, 1985, pp. 718-723. doi:10.1037/0022-006X.53.5.718
[11]	R. Calam, C. Bolton and J. Roberts, “Maternal Expressed Emotion, Attributions and Depression and Entry into The- rapy for Children with Behavioural Problems,” British Journal of Clinical Psychology, Vol. 41, No. 2, 2002, pp. 213-216. doi:10.1348/014466502163985
[12]	C. K. Conners, “Rating Scales for Use in Drug Studies with Children,” Psychopharmacology Bulletin (Special Issue on Children), Vol. 24, 1973, pp. 24-29.
[13]	V. V. Kamat, “Measuring Intelligence of Indian Children,” Oxford University Press, London, 1967.
[14]	W. Reich, P. M. Licht, H. Lehman, S. Sathyan and K. Unger, “Missouri Assessment of Genetics Interview for Children (MAGIC),” Washington University, Division of Child Psychiatry, St. Louis, 1997.
[15]	S. Srinath, M. Kovacs, S. C. Girimaji, S. P. Seshadri, “De- tailed Evaluation Schedule for Children and Adolescents,” 1991, Unpublished Manuscript.
[16]	M. Kapur, “Measurement of Organic Brain Dysfunction,” Ph.D. Thesis, Bangalore University, Bangalore, 1974.
[17]	G. J. Dupaul, “Parent and Teacher Ratings of ADHD Sym- ptoms: Psychometric Properties in a Community Based Sample,” Journal of Clinical Child Psychology, Vol. 20, No. 3, 1991, pp. 245-253. doi:10.1207/s15374424jccp2003_3
[18]	G. J. Dupaul, M. D. Rapport and L. M. Perviello, “Tea- cher Ratings of Academic Skills: The Development of the Academic Performance Rating Scale,” School Psychology Review, Vol. 20, No .2, 1991, pp. 284-300.
[19]	R. A. Barkley, “Hyperactive Children: A Handbook for Diagnosis and Treatment,” Guilford Press, New York, 1981.
[20]	T. S. Altepeter and M. J. Breen, “Situational Variation in Problem Behaviour at Home and School in Attention Deficit Disorder with Hyperactivity: A Factor Analytic Study,” Journal of Child Psychology and Psychiatry and Allied Disciplines, Vol. 33, No. 4, 1992, pp. 741-752. doi:10.1111/j.1469-7610.1992.tb00909.x
[21]	S. C. Girimaji, “Counsellors Manual for Family Interven- tion in Mental Retardation,” Indian Council of Medical Research, New Delhi, 1996.
[22]	S. C. Girimaji, S. Srinath, S. Seshadri and S. Krishna, “Fa- mily Interview for Stress and Coping in Mental Retardation (FISC-MR): A Tool to Study Stress and Coping in Families of Children with Mental Retardation,” Indian Journal of Psychiatry, Vol. 41, No. 4, 1999, pp. 341-349.
[23]	N. Agarwal and S. L. Rao, “Neuropsychological Remedi- ation in Hyperactive Children,” Indian Journal of Psy- chiatry, Vol. 39, No.4, 1997, pp. 309-312.
[24]	H. V. Oberoi and M. Kapur, “Intervention with Hyperkinetic Boys in the School Setting,” NIMHANS Journal, Vol. 13, No. 1, 1995, pp. 123-131.
[25]	S. Basu and A. Deb, “Parent Training in Children with Attention Deficit Hyperactivity Disorder: An Integrated Approach for Greater Effectiveness,” Indian Journal of Clinical Psychology, Vol. 23, No. 1, 1996, pp. 184-191.
[26]	M. D. Lezak, “Neuro Psychological Assessment,” Oxford University Press, New York, 1995.
[27]	G. Plourde, Y. Joanette and P. Fontaine, “The Two Forms of Visual Spatial Neglect,” Journal of Clinical and Expe- rimental Neuropsychology, Vol. 10, No. 2, 1988, p. 317.
[28]	R. A. Barkley, “Defiant Children: A Clinician’s Manual for Assessment and Parent Training,” Guilford Press, New York, 1997.
[29]	J. Cohen, “Statistical Power Analysis for the Behavioural Sciences,” Erlbaum, New Jersey, 1988.
[30]	H. V. Hedges and I. Olkin, “Statistical Methods for Meta- Analysis,” Academic Press, Orlando, 1985.
[31]	N. S. Jacobson and P. Truax, “Clinical Significance: A Statistical Approach to Defining Meaningful Change in Psychotherapy Research,” Journal of Consulting and Cli- nical Psychology, Vol. 59, No. 1, 1991, pp. 12-19. doi:10.1037/0022-006X.59.1.12
[32]	N. S. Jacobson, W. C. Follette, D. Revenstorf, D. H. Bau- com, K. Hahlweg and G. Margolin, “Variability in Out- come and Clinical Significance of Behavioural Marital Therapy: A Reanalysis of Outcome Data,” Journal of Consulting and Clinical Psychology, Vol. 52, No. 4, 1984, pp. 497-504. doi:10.1037/0022-006X.52.4.497
[33]	L. Christensen and J. L. Mendoza, “A Method of Assess- ing Change in a Single Subject: An Alteration of the RC Index,” Behaviour Therapy, Vol. 17, No. 3, 1986, pp. 305-308. doi:10.1016/S0005-7894(86)80060-0
[34]	S. P. Hinshaw, B. Henker and C. K. Whalen, “Cognitive- Behavioural and Pharmacologic Interventions for Hyper- active Boys: Comparative and Combined Effects,” Jour- nal of Consulting and Clinical Psychology, Vol. 52, No. 5, 1984, 739-749. doi:10.1037/0022-006X.52.5.739
[35]	J. M. Langberg, L. E. Arnold, A. M. Flowers, J. N. Ep- stein, M. Altaye, S. P. Hinshaw, J. M. Swanson, R. Kot- kin, S. Simpson, B. S. Molina, P. S. Jensen, H. Abikoff, W. E. Pelham Jr., B. Vitiello, K. C. Wells and L. Hecht- man, “Parent-Reported Homework Problems in the MTA Study: Evidence for Sustained Improvement with Behav- ioral Treatment,” Journal of Clinical Child and Adoles- cent Psychology, Vol. 39, No. 2, 2010, pp. 220-233. doi:10.1080/15374410903532700
[36]	E. H. Nieweg, “Does ADHD Medication Stop Working after 2 - 3 Years? On the Surprising, but Little-Known Follow-Up of the MTA Study,” Tijdschrift Voor Psychi- atrie, Vo. 52, No. 4, 2010, pp. 245-254.
[37]	J. P. Zrull, J. C. Westman, B. Arthur and D. Rice, “A Com- parison of Diazepam, D-Amphetamine and Placebo in the Treatment of the Hyperkinetic Syndrome in Children,” American Journal of Psychiatry, Vol. 121, 1964, pp. 388- 389.
[38]	C. K. Conners and E. Taylor, “Pemoline, Methylpheni- date and Placebo in Children with Minimal Brain Dys- function,” Archives of General Psychiatry, Vol. 37, No. 8, 1980, pp. 922-930. doi:10.1001/archpsyc.1980.01780210080009
[39]	P. Choudhary, S. Girimaji, S. Srinath and S. P. Seshadri, “An Open Trial of Clonidine for Hyperkinesis in Children with Mental Retardation and Epilepsy,” Indian Journal of Psychological Medicine, Vol. 16, No. 1, 1993, pp. 41-44.
[40]	B. M. Atkeson and R. Forehand, “Parent Behavioural Train- ing for Problem Children: An Examination of Studies Us- ing Multiple Outcome Measures,” Abnormal Child Psy- chology, Vol. 6, No. 4, 1978, pp. 449-460.
[41]	T. M. Achenbach, S. H. McConaughy and C. T. Howell, “Child/Adolescent Behavioural and Emotional Problems: Implications of Cross-Informant Correlations for Situatio- nal Specificity,” Psychological Bulletin, Vol. 101, No. 2, 1987, pp. 213-232. doi:10.1037/0033-2909.101.2.213
[42]	G. R .Patterson, “Interventions for Boys with Conduct Problems: Multiple Settings, Treatments, and Criteria,” Journal of Consulting and Clinical Psychology, Vol. 42, No. 4, 1974, pp. 471-481. doi:10.1037/h0036731
[43]	A. B. Irvine, A. Biglan, K. Smlkowski, C. W. Metzler and D.V. Ary, “The Effectiveness of a Parenting Skills Pro- gramme for Parents of Middle School Students in Small Communities,” Journal of Consulting and Clinical Psy- chology, Vol. 67, No. 6, 1999, pp. 811-825. doi:10.1037/0022-006X.67.6.811
[44]	D. W. Murray, “Treatment of Preschoolers with Attention- Deficit/Hyperactivity Disorder,” Current Psychiatry Re- port, Vol. 12, No. 5, 2010, pp. 374-381. doi:10.1007/s11920-010-0142-6
[45]	L. L. Greenhill, J. Puig-Antich, H. Novacenko, M. Solo- mon, C. Anghern, J. Florea, R. Goetz, B. Fiscina and E. J. Suchar, “Prolactin, Growth Hormone and Growth Re- sponses in Boys with Attention Deficit Disorder and Hy- peractivity Treated with Methylphenidate,” Journal of American Academy of Child and Adolescent Psychiatry, Vol. 23, No. 1,1984, pp. 58-67. doi:10.1097/00004583-198401000-00008
[46]	S. Russell, R. Tannock, C. Charles and C. Penny, “Beha- vioural, Situational and Temporal Effects of Treatment of ADHD with Methylphenidate,” Journal of American Aca- demy of Child and Adolescent Psychiatry, Vol. 36, No. 6, 1997, pp. 754-763. doi:10.1097/00004583-199706000-00011
[47]	C. B. Carlson, W. E. Pelham, R. Milich and J. Dixon, “Single and Combined Effects of Methylphenidate and Behaviour Therapy on the Classroom performance of Children with Attention Deficit Hyperactivity Disorder,” Journal of Abnormal Child Psychology, Vol. 20, No. 2, 1992, pp. 213-232. doi:10.1007/BF00916549
[48]	H. Weingartner, M. H. Ebert, E. J. Mikkelsen, J. L. Ra- poport, M. S. Buchsbaum, E. E. Bunney and E. D. Caine, “Cognitive Processes in Normal And Hyperactive Chil- dren and Their Response to Amphetamine Treatment,” Journal of Abnormal Psychology, Vol. 89, No. 1, 1980, pp. 25-37. doi:10.1037/0021-843X.89.1.25
[49]	J. M. Halperin, K. Matier, G. Bedi, S. Sharma and J. H. Newcorn, “Specificity of Inattention, Impulsivity and Hy- peractivity to the Diagnosis of Attention Deficit Disor- der,” Journal of American Academy of Child and Adoles- cent Psychiatry, Vol. 31, No. 2, 1992, pp. 190-196. doi:10.1097/00004583-199203000-00002
[50]	A. D. Anastopoulos, T. L. Shelton, G. J. Dupaul and D. C. Guerremont, “Parent Training for Attention Deficit Hy- peractivity Disorder: Its Impact on Parent Functioning,” Journal of Abnormal Child Psychology, Vol. 21, No. 5, 1993, pp. 581-596.doi:10.1007/BF00916320
[51]	B. A. McBride, S. J. Shoppe and T. R. Rane, “Child Cha- racteristics, Parenting Stress and Parental Involvement: Fathers vs. Mothers,” Journal of Marriage and Family, Vol. 64, No. 4, 2002, pp. 998-1011. doi:10.1111/j.1741-3737.2002.00998.x