A Randomized Controlled Trial Evaluating the Efficacy of a Psychoeducation Program for Families of Children and Adolescents With ADHD in the United Kingdom: Results After a 6-Month Follow-Up

Abstract

Objective: Psychoeducation forms part of the current practice for ADHD; however, its efficacy is yet to be established. Method: Sixty-nine children/adolescents with ADHD were randomly assigned for their families to receive either a well-structured psychoeducation program (n = 35), or belong to a control group (treatment-as-usual, n = 34). Results: One-way analyses of variance showed a statistically significant Treatment × Time interaction, for ADHD total symptoms, inattention/cognition, and hyperactivity/impulsivity subdomains according to the parents, the first two with medium-large effect sizes. The effects of the intervention on the ADHD total and the inattention/cognition domain persisted after 6 months follow-up. No significant differences in teacher ratings were found; however, an improvement in clinical functioning as measured by clinicians was observed. Conclusion: This psychoeducation program has shown effectiveness in reducing ADHD symptoms when compared with treatment as usual. Psychoeducation needs to be considered as a valid and additional approach in ADHD.

Keywords

treatment ADD/ADHD Families psychoeducation randomized controlled trial

Background

ADHD is the most frequent neuropsychiatric disorder in childhood, though it affects individuals throughout their life span. Although the main core symptoms are defined as hyperactivity, impulsivity, and inattention, ADHD is also associated with a number of co-morbid features such as emotional, social, or educational problems that affect not only the individual but also the family and social context (Ferrin & Taylor, 2011). Pharmacological treatments are efficacious in the short and medium term, but side effects are not uncommon (Graham et al., 2011), and long-term safety and efficacy remains controversial (Molina et al., 2009), making some young people, families, and clinicians reluctant about their use.

A wide variety of non-pharmacological treatments are available for ADHD. Recent trials and meta-analysis on non-pharmacological and psychosocial interventions are inconclusive or have demonstrated only a limited effect on reducing ADHD core symptoms (Fabiano et al., 2009; Sonuga-Barke et al., 2013b). However, some recent studies suggest that psychosocial and behavioral interventions might be more effective in reducing conduct problems, possibly by promoting positive parenting techniques and reducing negative parenting factors in the families, rather than for reducing ADHD core symptoms themselves (Daley et al., 2014; Sonuga-Barke et al., 2013a). To better understand what works for whom, there is a need for more methodologically appropriate controlled studies that specifically evaluate the effectiveness of these treatments in the ADHD population (Fabiano et al., 2012).

International guidelines on ADHD have suggested that psychoeducation programs can be a helpful part of the multimodal non-pharmacological management of this disorder (American Academy of Pediatrics, Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management, 2011; Canadian Attention Deficit Hyperactivity Disorder Resource Alliance, 2011; NICE, 2008). Psychoeducation may constitute part of the current practice for ADHD in itself, or be part of cognitive-behavioral packages (Sonuga-Barke, Daley, Thompson, Laver-Bradbury, & Weeks, 2001; Thompson et al., 2009). Still, the efficacy of psychoeducation programs for reducing ADHD symptoms is a matter of debate. A systematic review by Montoya, Colom, and Ferrin (2011) suggests psychoeducation could play an important role in a number of different variables, including patient’s behavior, parent and child satisfaction, treatment adherence, and child’s knowledge and opinion of ADHD.

A randomized controlled trial to evaluate the efficacy of a psychoeducation program was previously conducted in Spain (Ferrin et al., 2014). The study used an active control group consisting of parents receiving professional support but without psychoeducational intervention. Parents’ ratings were used to evaluate ADHD outcomes. However, given that an active control was used, participants were unaware of the treatment condition. The study in Spain revealed a reduction of ADHD symptoms according to parents’ rating both in the short term and after 1 year of follow-up. There was an additional improvement in clinical global functioning as perceived by the global impression by clinicians. The study was not able to determine any generalization of the effects outside the child and the family, possibly due to the lack of a “treatment as usual” group, or to the fact that these treatments can improve other outcomes beyond the ADHD core symptoms (Sonuga-Barke et al., 2001; Sonuga-Barke et al., 2013a, 2013b). In addition, because the study was restricted to a specific Spanish population, the external validity of this psychoeducation program has yet to be established. The findings, while consistent with the most recent meta-analysis pointing to the positive effect of behavioral interventions—decreasing conduct problems in children while promoting adequate parenting—were not associated with aspects such as quality of life or parental well-being (Daley et al., 2014; Pfiffner, 2014).

The aim of the present contribution is twofold: (a) To examine whether the same structured psychoeducation program that proved effective in a Spanish population might lead to a significant reduction of ADHD core symptoms, in comparison with a “treatment as usual” control group, in the U.K. population; and (b) to demonstrate that this psychoeducation program in families of ADHD children/adolescents might improve other clinical outcomes, such as child psychopathology, stress, global functioning, and impact on families, again in comparison with a “treatment as usual” control group.

This study involves a sample of families of children and adolescents with ADHD diagnosis living in the South East London area. To our knowledge, this is the first randomized clinical trial that specifically compares the efficacy of a structured psychoeducation program for ADHD with “treatment as usual” in the United Kingdom.

Method

Participants

Figure 1 illustrates the recruitment, allocation, and analysis pertaining to the study. A total of 69 families of children and adolescents (age range: 5-18) consecutively attending a Child and Adolescent Mental Health Service in the South London and Maudsley catchment area (London, UK) were enrolled over a 2-year period (2010-2012). These children were screened from a total sample of 192 children and adolescents, identified by their clinicians, and then referred to our clinic, where they were offered participation. Children underwent an extensive diagnostic procedure, that included the Conners’ Parent Rating Scale–Revised (CPRS-R) and the Conners’ Teacher Rating Scale–Revised (CTRS-R) Questionnaires, as well as a psychiatric interview with the child and adolescent psychiatrists who confirmed the diagnosis on the basis of the previous findings. Inclusion criteria were (a) diagnosis of ADHD, any subtype, according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association [APA], 1994), the diagnosis being confirmed by clinical interview with a child psychiatrist; (b) age of child between 3 and 19 years, either sex; (c) informed consent of the parents and the children; (d) parents’ age greater than or equal to 18 years; (e) responsibility and legal capacity of parents; and (f) stabilizing medication for 1 month prior to baseline assessment. Exclusion criteria included (a) severe learning disabilities (IQ < 70), (b) autistic spectrum disorder as primary diagnosis, (c) children with any clinically significant or unstable medical or psychiatric condition, and (d) children whose families had received any similar school-based individual and/or group treatments at any point in time. These children were excluded when the main diagnosis was not solely related to ADHD and thus an educational approach focused on this particular disorder was not considered appropriate. Families who have received a similar intervention were also excluded to avoid carryover effects of previous interventions. Children presenting with other co-morbidities, or children receiving medication for ADHD were not excluded from the study, but were not allowed to switch drugs or alter the dosage during the 6-week duration of the program. Participants were not permitted to attend any other educational parent training/psychoeducation groups until having completed the study. Parents and children/adolescents in both intervention and control groups were allowed to receive treatment as usual at their own clinics.

Procedure

Families were approached either by contacting them over the phone or when they attended their Child and Adolescent Mental Health Service in the South London and Maudsley area. Randomization by minimization was applied, including gender, age, and medication use as factors (Han, Enas, & McEntegart, 2009). Randomization was performed using a computerized program (MACRO™) provided by the Clinical Trials Unit at King’s College, London, once families gave their consent. Minimization is a method of stratified sampling that is recommended for clinical trials. The aim is to minimize the imbalance between the number of patients in each treatment group stemming from a random selection. In our case, we selected age, gender, and medication use to minimize the possible imbalance of the groups in the study (Pocock, 1983).

Families randomized for psychoeducation started the group sessions within 3 weeks of assignment. Researchers collecting and entering the data were blind to the group allocation of the families. Sample size was calculated using the a priori Sample Size Calculator for one-way analysis of variance (ANOVA; http://www.danielsoper.com/statcalc3/calc.aspx?id=43), setting the size at Type I error (significance level) of .05 (α) and the power of the study at 80%, anticipating an effect size (Cohen’s d) of 0.7 (Sonuga-Barke et al., 2001; Swanson et al., 1993). An expected 10% drop out rate was initially calculated to derive the sample size. The study was registered as a clinical trial in the ISRCTN 26270684. The NHS Research Ethics Committee (NREC, reference 09/H0723/20) gave ethical approval, and permission was granted by the ethics committee of the Research and Development (R&D) department (reference 2009/053). Adequate procedure and data management was at all times guaranteed by direct supervision from the Clinical Trial Unit. An external committee of four expert clinicians supervised the delivery of the program and the progression of the study.

Psychoeducation

The psychoeducation program was developed for families of children and young people with ADHD in view of the basic structure of previous psychoeducation programs for disorders such as schizophrenia and bipolar disorders (Bäuml, Froböse, Kraemer, Rentrop, & Pitschel-Walz, 2006; Colom et al., 2003; Colom, Vieta, & Scott, 2006). The program in its Spanish version was used in a previous study, with a Spanish population (Ferrin et al., 2014); for this project it was translated from Spanish into English and back-translated by professional translators, supervised by the authors who were fluent in both languages. A brief summary of the content of the sessions and how they were organized is presented in Tables A1 and A2 of the appendix. The psychoeducation group comprised five successive groups of seven to 10 families, who received six sessions of 2 hr at weekly intervals. For the main purpose of the psychoeducation intervention, as defined by previous authors (Bäuml et al., 2006; Colom et al., 2003; Colom et al., 2006), families were primarily educated on the disorder; they were only very briefly introduced to a range of behavioral strategies for managing ADHD symptoms and reducing defiant behavior during the last three sessions. The integrity of the psychoeducation sessions was guaranteed by a manual that clearly outlined all the procedures to be used in the intervention. Two experienced child and adolescent psychiatrists and one psychologist conducted all the sessions. Sessions were audiotaped and an independent person using a checklist ensured that the different groups received an equivalent set of information. This psychoeducation program was not focused on behavioral strategies, which lie beyond the scope of this intervention; yet they were given the opportunity to express their own experiences and feelings about their child and the impact that the child’s condition had on them. At the end of each session, a handout was delivered and parents were assigned some short additional homework to prepare for the next session. Adherence to the program was measured by the number of the sessions that families attended (Kampman et al., 2000).

Treatment as Usual

Families allocated to the control group continued routine medical care as usual with their clinicians; they were offered the opportunity to join the psychoeducation group once their collaboration with the study had ended. Control participants received monthly follow-up appointments with their community team for controlling the symptoms and for monitoring the medication. The control group did not receive any specific psychosocial or educational intervention. However, they were given two-page information leaflets about ADHD and its treatment and encouraged to consult with the clinician or make use of internet resources. Control participants were contacted by study staff only to complete the follow-up assessments.

Measures

The ADHD Index using the 27-item CPRS-R: Short Form (CPRS-R:S) was established as the primary outcome measure of the study. This questionnaire has good internal consistency (.86-.94) and reliability (test–retest = .62-.85), and has been used in clinical research literature (Conners, 1989). The CPRS-R:S includes other clinical subscales, namely, oppositional, cognitive problems/inattention, and hyperactivity/impulsivity, which were considered as secondary outcomes. The ADHD Index and the different subscales were quantified at three points in time (T0, T1, and T2).

Other measures were evaluated as secondary outcomes of the study. ADHD symptoms were also evaluated using the CTRS-R: Short version (CTRS-R:S). This questionnaire has 28 items and has demonstrated good internal consistency (.88-.95) and reliability (test–retest = .72-.95; Conners, 1989).

Parents and teachers also completed the Strengths and Difficulties Questionnaire (SDQ)—a 25-item behavioral screening questionnaire including emotional symptoms, conduct problems, hyperactivity, problems with peers, and a pro-social dimension. The questionnaire has likewise shown good reliability, internal consistency (Cronbach’s α > .73), and validity (Goodman, 2001).

The Parental Stress Index: Short Form (PSI-SF; Abidin, 1995) is a 36-item self-report measure of parenting stress. The psychometric properties of the questionnaire have been found to be valid and reliable, with an acceptable internal consistency (α = .83), inter-rater reliability (.61-.75), and test–retest reliability (.31-.61; Haskett, Ahern, Ward, & Allaire, 2006). The different subdomains explored were parental distress, parent and child conflict, child difficulties, and defensive response.

Clinical improvement was evaluated by the clinicians, who were unaware of the intervention the family received, using the Clinical Global Impression Scale (CGI). The CGI allows the clinician to assess the Severity of Illness and the Global Improvement of global symptoms by rating both on a 7-point scale, using a range of responses from 1 (very much improved) to 7 (very much worse). It also evaluates the degree of therapeutic effects and side effects of the intervention using the Efficacy Index, ranging from 1 (no side effects, marked improvement of symptoms) to 16 (severe side effects outweighing therapeutic effects, unchanged or worse symptoms; Guy, 1976).

Clinicians also evaluated global functioning of the young person using the Children’s Global Assessment Scale (CGAS). The CGAS is a numeric scale (1 through 100) used by mental health clinicians to rate the general functioning of children under the age of 18. A score of 100 represents superior functioning in all areas including at home, at school, and with peers, and a score of 1 signals the need for constant supervision due to severe impairment (Shaffer et al., 1983).

All measures were obtained before intervention (T0) and once again after the program finished at Week 6 (T1). A final set of measures was taken at a 6-month follow-up (T2). All children/adolescents and their families continued receiving their usual treatment after the study was completed.

Statistical analysis

Data were analyzed using the Statistical Package for Social Sciences (SPSS™), version 20.0 (SPSS Inc., Chicago, IL, USA), after selecting a significance level of .05. Preliminary analyses (Kolmogorov–Smirnov test) confirmed whether the assumptions of normality held for the different variables. Group differences for categorical variables at the baseline, after intervention, and after follow-up were assessed using Yates’s correction for continuity of the chi-square test, and for the continuous variables using a Mann–Whitney U test.

The statistical significance of the effect of intervention was assessed by means of one-way repeated ANOVA measures; treatment (psychoeducation versus control) was the between-subject variable. Assumptions of sphericity were checked using Mauchly’s test of sphericity > .001. Scores at T0, T1, and T2 were the repeated measure (i.e., changes over the time). A statistically significant effect for time (i.e., change in confidence scores over the three different time periods T0, T1, and T2) was evaluated using Wilks’s Lambda multivariate test. Two-way comparisons were used to check for interactions. Effect sizes were calculated using partial eta squared values (η): 0.01, representing a small effect; 0.06, a medium effect; and 0.14, a large effect (Cohen, 1988). Finally, changes from baseline to the 6-month follow-up were also analyzed and presented as the difference in change between the two conditions (Sonuga-Barke et al., 2001).

Figure 1 illustrates the recruitment, random assignment, and data analysis process. Seven families (10.14%) dropped out of the trial: three families (8.58%) from psychoeducation and four families (11.76%) from the control group. Families in the psychoeducation group were no more likely to drop out than those in the control group. Dropouts were no more likely to be girls than boys or to be of a particular social class. Dropouts did not differ from other families in terms of either maternal characteristics or child symptoms or co-morbid conditions. Families withdrew from the psychoeducation group due to work or to problems attending the clinic, rather than dissatisfaction with the program itself. Intention to treat analysis was the basis for the inclusion of cases. Data were handled using the last intervention carried out in the most statistically conservative manner, by replacing their scores at T1 and T2 with values representing the poorest outcome for participants in their particular condition. This approach to dropouts prevents overestimation of the real effects (Jadad & Enkin, 2007).

Results

Table 1 shows the characteristics of the children and the families that participated in the study at baseline. Children/adolescents in the psychoeducation group did not differ from those in the control group on any of the demographic or clinical measures, including age, gender, ethnicity, ADHD subtype, IQ, or co-morbid conditions. Families in the psychoeducation group did not differ from those in the control group in age, years of study, or family composition. Altogether, 60.7% of the children were receiving pharmacological treatment for ADHD, and had received medication for 13.9 months before they enrolled in the study; no differences were found between the psychoeducation and the control groups. The same medication regime was maintained in participants throughout the course of the program.

Table 1.

Baseline Demographic Characteristics of the Groups.

	Psychoeducation (n = 35)	Control (n = 34)	p value
Age (years)	10.86 (3.04)	10.56 (3.20)	>.05^a
Gender (male)	29 (82.9%)	31 (91.2%)	>.05^b
ADHD subtype (combined)	21 (60.0%)	27 (79.41%)	>.05^b
Parental age
Mother	38.94 (9.71)	37.88 (10.96)	>.05^a
Father	29.20 (21.15)	26.41 (19.76)	>.05^a
Parental education level (some studies after O levels)
Mother	21 (60.00%)	27 (79.41%)	>.05^a
Father	29 (82.85%)	29 (85.29%)	>.05^a
Positive parental history of psychiatric disorder	5 (14.28%)	7 (20.5%)	>.05^b
Family composition
Biological parents	18 (51.4%)	25 (73.52%)	>.05^b
Adoptive	2 (5.71%)	0	>.05^b
Grandparents	0	1 (2.94%)	>.05^b
Biological mother	11 (31.43%)	7 (20.59%)	>.05^b
Other	4 (11.43%)	1 (2.94%)	>.05^b
IQ^c
Total	93.38 (8.42)	95.83 (11.33)	>.05^a
Medication
Patients on medication	25 (71.43%)	17 (50.0%)	>.05^b
Months on medication	11.60 (20.71)	16.29 (29.11)	>.05^a
Child’s ethnic background
White British/Other	15 (42.86%)	20 (58.82%)	>.05^b
Black British	1 (2.86%)	1 (2.94%)	>.05^b
White and Black Caribbean	7 (20%)	1 (2.94%)	>.05^b
White and Black African	1 (2.86%)	0 (0%)	>.05^b
Caribbean	1 (2.86%)	4 (11.76%)	>.05^b
African	3 (8.57%)	2 (5.88%)	>.05^b
Other mixed	6 (17.14%)	2 (5.88%)	>.05^b
Indian	0 (0%)	1 (2.94%)	>.05^b
Co-morbidities
ODD	34 (97.05%)	33 (97.14%)	>.05^b
CD	5 (14.29%)	2 (5.71%)	>.05^b
ASD	8 (22.86%)	5 (14.70%)	>.05^b
Anxiety/depression	5 (14.29%)	4 (11.76%)	>.05^b
Dyslexia/dyspraxia	12 (34.28%)	12 (35.29%)	>.05^b
Learning disabilities	17 (48.57%)	10 (29.41%)	>.05^b
OCD	6 (17.14%)	5 (14.71%)	>.05^b
Self-harm	4 (11.43%)	4 (11.76%)	>.05^b
Number of sessions attended	3.54 (2.39)	0 (0.00)	<.05^a

Note. Figures in parentheses are standard deviations or percentile. ODD = oppositional defiant disorder; CD = conduct disorder; ASD = autistic spectrum disorder; OCD = obsessive compulsive disorder.

Mann–Whitney U test.

Chi-square test.

Wechsler Intelligence Scale for Children–IV/Wechsler Adult Intelligence Scale–III (Wechsler, 1991).

Table 2 reports data for the primary and secondary outcomes in both groups at the different points in time. The statistical significance of the effect of intervention was assessed with one-way repeated ANOVA measures; for each of the variables, the effect size of the intervention (η², partial eta square) was also included. For ADHD total symptoms shown there was no significant statistical effects over time for ADHD Index, F(2, 66) = 2.30; p = .108. However, a Treatment × Time interaction was found with a medium to large effect size (η² = .98) and a statistical power of 87%. For the cognitive/inattention domain, there were no significant statistical effects for time F(2, 66) = 1.64; p = .200; however, a statistically significant interaction Treatment × Time was initially found, with a medium to large effect size (η² = .95). For the hyperactivity/impulsivity domain, there were no significant statistical effects for time, F(2, 66) = 0.46; p = .630; again, a statistically significant interaction Treatment × Time was found with a small effect size (η² = .14). Finally, for the oppositional domain, there were no significant statistical effects for time, F(2, 64) = 1.90; p = .158, or Treatment × Time interaction; statistical power was 56%. Results for psychopathology using parents SDQ showed there were no significant statistical effects for interaction Treatment × Time; however, once again statistical power was low (20%).

Table 2.

Analyses of Variance, Comparisons Between The Two Groups.

	T0: baseline		T1: 6 weeks		T2: 6 months		Treatment × Time
	Psychoeducation (n = 35)	Control (n = 34)	Psychoeducation (n = 35)	Control (n = 34)	Psychoeducation (n = 35)	Control (n = 34)	F(2, 66)	p value	η²
	M (SD)	M (SD)	M (SD)	M (SD)	M (SD)	M (SD)	F(2, 66)	p value	η²
CPRS Index	28.46 (5.06)	28.09 (7.31)	28.40 (6.06)	25.35 (8.96)	24.54 (8.61)	28.15 (7.01)	3.57	.034	.098
CPRS opposition	12.57 (4.39)	12.79 (3.83)	12.09 (4.01)	11.76 (4.50)	12.21 (4.15)	11.43 (4.62)	0.38	.684	.012
CPRS Inat/Cog	13.94 (2.91)	13.56 (4.18)	13.83 (3.63)	12.38 (4.99)	11.69 (4.63)	13.76 (3.85)	3.45	.037	.095
CPRS Hyp/Imp	12.09 (4.80)	12.71 (4.47)	12.86 (3.54)	11.21 (5.21)	11.09 (4.36)	12.50 (4.46)	3.91;	.025	.014
CTRS Index	21.40 (7.43)	18.38 (9.64)	18.97 (10.49)	22.86 (8.50)	22.23 (10.13)	23.97 (10.2)	1.60	.210	.048
SDQ parents	24.11 (6.17)	25.00 (5.89)	22.50 (5.93)	21.46 (7.24)	21.21 (6.90)	22.43 (6.55)	0.99	.376	.036
SDQ teacher total	18.70 (4.40)	15.37 (5.58)	17.74 (4.79)	14.44 (4.54)	17.83 (8.20)	18.15 (6.03)	1.05	.356	.043
SDQ child total	15.15 (5.87)	16.50 (6.54)	16.67 (4.68)	15.67 (5.66)	16.25 (7.55)	20.08 (5.55)	0.63	.562	.085
PSI total	104.50 (21.36)	106.71 (24.41)	106.60 (23.92)	111.96 (25.81)	118.43 (30.65)	112.5 (27.5)	0.67	.521	.025
CGI severity of illness	4.22 (0.75)	4.03 (1.28)	3.60 (1.19)	3.76 (1.67)	3.25 (1.78)	3.34 (1.75)	0.40	.670	.013
CGI global improvement (from T0)	—	—	2.86 (1.06)	3.58 (1.48)	2.84 (0.99)	3.47 (1.62)	3.45	.038	.103
CGI Efficacy Index (from T0)	—	—	8.03 (3.81)	9.55 (4.40)	7.75 (4.51)	7.31 (4.74)	0.80	.450	.026
CGAS	62.72 (13.59)	59.32 (14.92)	66.16 (18.18)	51.39 (22.45)	59.69 (26.28)	55.48 (26.88)	2.89	.063	.088

Note. T = time point; η² = partial eta square; CPRS = Conners’ Parent Rating Scale; Inat/Cog = inattention and cognition; Hyp/Imp = hyperactivity and impulsivity; CTRS = Conners’ Teacher Rating Scale; SDQ = Strengths and Difficulties Questionnaire; PSI = Parental Stress Index: Short Form; CGI = Clinical Global Impression Scale; CGAS = Children’s Global Assessment Scale.

One-way repeated ANOVA for ADHD symptoms, according to the teachers’ report, showed there was not a statistically significant effect for time or an interaction between time and treatment. SDQ for teachers, SDQ for children, and PSI showed similar results, although statistical powers were below 30%. For Severity of illness measured by CGI, and for the Efficacy of Treatment using CGI, there were no statistically significant effects for time or an interaction between time and treatment either; again, statistical powers remained below 20%. However, for Global Improvement measured by the CGI, a statically significant Time × Group interaction effect was found with moderate to large effect sizes (η² = .103). Finally, one-way repeated ANOVA for CGAS showed a statistical trend for Time × Treatment interaction; the statistical power was nevertheless low (31%).

Figure 2 displays mean improvements and mean differences in the scores from baseline in the primary outcome (CPRS Index) as a function of intervention from baseline to the end of intervention (Week 6) and to the 6-month follow-up. Statistically significant differences were obtained in CPRS Index at T2. Changes from baseline were also analyzed and presented using the difference in change between the two conditions (Table 3). No differences were observed in any of the variables between T0 and T1. Once again, mean differences in scores between T2 and T1 showed there were statistically significant differences between the two groups for the ADHD total symptoms: the cognitive/inattention and the hyperactive/impulsive subdomains. In addition, mean differences in the change scores in the psychoeducation group confirmed that differences seen for the ADHD total symptoms and the cognitive/inattention subdomain were specific to the psychoeducation group (see Table 3).

Table 3.

Degree of Change in ADHD Symptoms (6-Month Follow-Up).

Outcome variable (T2-T1)	Degree of change (95% CI)		Difference in change between groups (95% CI)
Outcome variable (T2-T1)	Control	Psychoeducation	Difference in change between groups (95% CI)
CPRS Index	2.79 [−0.79, 6.37]	−3.85 [−7.29, −0.41]	6.65 [1.59, 11.70]	p = .011
CPRS opposition	0.44 [−1.66, 2.54]	−0.65 [−2.87,1.57]	1.09 [−2.02, 4.21]	p = .485
CPRS Inat/Cog	1.38 [−0.37,3.13]	−2.14 [−4.07,−0.21]	3.52 [0.86, 6.18]	p = .010
CPRS Hyp/Imp	1.29 [−0.97, 3.55]	−1.77 [−3.65, 0.11]	3.06 [0.78, 6.05]	p = .045

Note. T = time point; CI = confidence interval; CPRS = Conners’ Parent Rating Scale; Inat/Cog = inattention and cognition; Hyp/Imp = hyperactivity and impulsivity.

Discussion

The present study found evidence that psychoeducation has beneficial effects on ADHD total symptoms, the cognitive/inattention, and the hyperactivity/impulsivity subdomains. Our results also found a significant effect on the clinical global impression according to the clinician. In previous studies, differences between both groups were more evident just when the intervention had ended, while the effects tended to vanish over time (Banaschewski et al., 2009; Ialongo et al., 1993; Langberg et al., 2010; Molina et al., 2009). Our results showed differences between T1 and T2 in both the ADHD total and the inattention/cognition domain in the psychoeducation group, suggesting that the positive effect specific to this group is maintained after the 6 months of follow-up.

Our findings are also consistent with a previous study using a similar program with Spanish population (Ferrin et al., 2014). In this previous study, psychoeducation also improved ADHD total symptoms and cognition/inattention at the end of the study, and differences were maintained for the cognitive/inattention subdomain at 1 year of follow-up.

The positive effects of the program as implemented in the United Kingdom could be seen on ADHD symptoms. When the power of the study remained above 60%, medium and large effect sizes for reducing ADHD symptoms were observed, which contrasts with the small and moderate effect sizes found with the Spanish study (Ferrin et al., 2014). Possible explanations include the fact that our control group had treatment as usual, but no other active group intervention was used. In addition, differences in methodological aspects such as the number of sessions need to be considered. Furthermore, the different baseline characteristics between the Spanish and the U.K. study population demographics were striking (see Table A3 in the Appendix). Children in the U.K. sample had different ethnicities, did not often live with both parents, and presented more co-morbid oppositional and conduct problems, and more internalizing problems than the children in the Spanish sample. Particular characteristics of the sample and severity of the symptoms might have affected results. As discussed later, these special characteristics might have biased the representativeness of our sample in the case of the U.K. population (Ford, Goodman, & Meltzer, 2004).

The results obtained in the Spanish sample also showed improvement in pro-social aspects that remained over time. Interestingly, we could observe changes on the inattention and hyperactive/impulsive but not on the oppositional CPRS subscales. Once again, this may be due to methodological differences between the two separate studies, either the sample size or the fact that the length of the intervention in the Spanish study extended over 12 weeks. However, it might also reflect the fact that parents are more able to differentiate core ADHD symptoms from behavioral problems, and thus are more able to tolerate them. Importantly, the oppositional symptoms seem more likely to be modified by specific parenting programs (Daley et al., 2014), which were initially designed to improve oppositional and defiant behaviors in young people. Future research should clarify which specific treatments are more suitable for targeting the specific symptoms in these patients.

In line with other studies, teachers did not notice an improvement of ADHD symptoms, and the effects did not show any impact on parental well-being or family stress. However, we encountered a trend toward statistical significance in psychopathology using parents’ SDQ. This could be due to the small sample size, insufficient to detect changes in such settings, as for most of these variables statistical power varied between 7% and 27%. It is also important to highlight that the negative results in the family setting might have to do with external factors contributing to global family functioning. To conclude whether this kind of program is positively useful for reducing family stress, much larger samples or meta-analytical approaches might be needed. It could also be hypothesized that the effects of psychoeducation are only limited to the child and do not extend to the school or family setting (Chronis-Tuscano, Chacko, & Barkley, 2013; Daley et al., 2014; Sonuga-Barke et al., 2013a, 2013b). The lack of positive findings may also be due to the lower reliability of the informants (e.g., if pre- and post-treatment ratings were supplied by different teachers). Trials of behavioral interventions may be especially prone to inflating results as the individuals supplying these assessments are often directly involved in treatment delivery and assessment.

Nevertheless, the efficacy of our intervention in probably blind measures is suggested by using less proximal sources, such as the effect on the clinical global impression as reported by the clinician. Objective effects were reflected in improved clinical general impression by CGI which is important in the process of evaluating the impact of the ADHD symptoms in the different settings and consistent with previous studies (Ferrin et al., 2014). The focus on ADHD symptoms rather than on functional impairment has been extensively discussed (see Chronis-Tuscano et al., 2013; Pfiffner et al., 2014), because of the general impairment and non-core ADHD symptoms prompting the referral and access to clinical services, and typically leading to the seeking of treatment.

The mechanism of action of behavioral programs including psychoeducation is uncertain. Recent meta-analyses point to their improving positive parenting while reducing negative parenting techniques, which in turn might affect the children’s behavior (Daley et al., 2014; Neiderhiser, Reiss, Hetherington, & Plomin, 1999). Psychoeducation is a didactic and psychotherapeutic intervention for informing patients and their relatives about illness and its treatment, to facilitate a theoretical and practical approach toward understanding and coping with the consequences of a given disorder. For a psychoeducation intervention to be effective, a number of characteristics are necessary: the intervention must be carried out by sensitive and sympathetic therapist(s), and delivered once or twice a week, in group sittings, lasting approximately 60-90 min, and during four to 16 sessions (Bäuml et al., 2006; Colom et al., 2003; Colom et al., 2006).

Previous meta-analysis of the efficacy of parenting programs for reducing ADHD symptoms has found a moderate effect size when most proximal measures were used (Daley et al., 2014). However, the analysis also demonstrated efficacy for improving parenting techniques, with medium to large effect sizes even when blinded measures were used. Psychoeducation programs are likely to have a direct effect on improving parenting techniques. In our study, we have also included proxy measures (parents’ rating) as primary outcomes. If blinded measures were used, we would therefore expect a drop in the total effect size. However, it is important to note that a previous study carried out in Spain using parent ratings who were blind to the intervention demonstrated medium to large side effects for reducing ADHD symptoms. This study used the same education program but was conducted using a very homogeneous sample and for a longer time period (12 weeks).

Psychoeducation may work by influencing parental perceptions of their child’s difficulties. It may help them distinguish the behaviors from those of conduct problems. It may help them recognize the particular pattern of cognitive and attention deficits, giving them a specific explanation for the behaviors. Alternatively, it may improve their ability to convey the specifics of their child’s difficulties in their discussions with a clinician, enabling better treatment. As previous authors have suggested (Daley et al., 2014), improving parenting skills might have an important empowering effect in the process of breaking negative parent–child interactions as well as emphasizing the power that parents have in influencing developmental outcomes. Future studies that compare changes in parents’ perceptions as opposed to absolute behavioral changes might clarify this point. In any case, the potential impact on the child and family, presumably through a better understanding, and less critical or more positive parenting, may have a positive effect on self-esteem and other variables in the long run. Even if the measures that we used to evaluate change are not totally blind, this type of interventions might entail a positive clinical impact that needs to be carefully considered. Future studies should also determine what specific types of behavioral interventions are more useful and for whom, so that interventions can be tailored to specific patients and particular family needs (Ferrin & Taylor, 2011; Sonuga-Barke et al., 2013a, 2013b).

An important strength of this study is the robustness of its methodology, which used a randomized controlled design and reduces bias that may affect the interpretation of results. The program was adapted from previous programs that have demonstrated efficacy in other psychiatric disorders (Colom et al., 2003; Colom et al., 2009; Colom et al., 2006), taking into account different aspects and components of psychoeducation to result effective. The integrity of treatment was observed by an external observer to guarantee that sessions were all delivered in a similar way. Another main strength of the study is the length of the follow-up. The program finds improvement in certain areas that are traditionally impaired in ADHD, such as the global function according to the clinician. For a condition such as ADHD, where other aspects may play an important role in the long-term outcome, this is a finding deserving mention.

There are a number of limitations of this study that should be addressed here. First, a main limitation of the study was that assessment as a primary outcome was not blinded; results using raters who are blinded to treatment group are usually stricter and thus probably less biased (Chronis-Tuscano et al., 2013; Daley et al., 2014; Sonuga-Barke et al., 2013a, 2013b). Previous studies have found a significant reduction of the effects when blinded assessments were considered (Sonuga-Barke et al., 2013b). However, lack of blind measures is a common limitation of most studies evaluating psychological interventions. In addition, the study demonstrated an improvement in clinicians’ ratings on global functioning and treatment effectiveness. Although total blindness to the allocation of the participants could not be guaranteed, clinicians’ clinical global impression has been widely used in studies to objectively assess improvement of neuropsychological outcomes (Forkmann et al., 2011; Guy, 1976).

Second, in this randomized control study, families were allocated to receive either psychoeducation or treatment as usual, meaning the observed effects of the program are added to the effects of other interventions used for ADHD. Using an active control group might have limited the additional effects of the intervention. A direct comparison of parent-based and pharmacological treatments would have clarified the real basis of the benefits of this intervention. However, this scenario is the most common one, as families normally receive psychoeducation as part of a multimodal approach.

Third, the fact that the program consisted of only 6 weeks of intervention and had different therapists conducting the groups might have negatively affected the results. This aspect was discussed in designing our research; it was accepted as it made the study more naturalistic and adapted to the specific South London population. Once again, methodological differences of the current study need to be considered when comparing results with the previous Spanish study. In our study, two consultant child and adolescent psychiatrists and one expert psychologist delivered the intervention. Future studies will determine the efficacy of the results when the psychoeducation is implemented by less-experienced staff (e.g., nurses, health care assistants).

Fourth, the limited sample size did not allow us to co-vary for all the factors that might have affected results, such as the different co-morbidities, ethnicity, or the IQ. Age, gender, ADHD subtypes, and attendance to sessions were initially selected as co-variables on the basis of their possible influence on the effectiveness of the psychoeducation sessions (Daley et al., 2014; Ferrin et al., 2014); Bonferroni’s alpha correction was applied to adjust for multiple testing bias (Tabachnick & Fidell, 2001). However, as the groups at baseline were homogeneous and randomization by minimization was used, unadjusted results were finally used to avoid an excessive overadjustment due to these factors.

Finally, some of the co-morbidities seem to be slightly overrepresented in our sample (Molina et al., 2009). The overrepresentation of both internalizing and externalizing problems in the South London area has already been described in a number of previous studies including the British prevalence survey (Ford et al., 2004).

In conclusion, this is the first study to demonstrate the benefits of psychoeducation when compared with treatment as usual using a U.K. sample; these effects were perceived by parents in ADHD total symptoms and the cognitive/inattention and hyperactivity/impulsivity domains and persisted until the 6-month follow-up. Structured psychoeducation groups can help professionals to manage children/adolescents with ADHD as part of a multidimensional approach while reducing one-to-one interventions. To provide patients, families, and practitioners with an effective approach to ADHD that can be tailored to particular needs, expert- and evidence-based guidance would be necessary to implement psychoeducational programs for the management of ADHD.

Footnotes

Appendix

Table A3.

Comparison Between Baseline Demographic Characteristics Between the Spanish (Ferrin et al., 2014) and the U.K. Samples.

	United Kingdom (n = 69)	Spain (n = 81)	p
Age years, M (SD)	10.71 (3.10)	10.59 (3.06)	>.05^a
Gender: Male	87.0%	80.3%	>.05^b
ADHD subtype combined	69.7%	76.6%	>.05^b
IQ total, M (SD)	94.49 (10.04)	91.9 (15.08)	>.05^a
Parental age years, M (SD)
Mother	38.42 (10.28)	40.05 (5.01)	>.05^a
Father	27.83 (20.37)	42.92 (7.17)	<.05^a
Parental history of psychiatric disorder	17.3%	12.4 %	>.05^b
Family composition (child living with both parents)	62.4%	90.9%	<.05^b
Ethnicity: White	50.8%	99.9%	<.05^b
Patients receiving medication:	60.7%	84.1%	<.05^b
Adherence
% of sessions attended	60.0	79.1	<.05^b
Co-morbidities
ODD	97.0%	29.6%	<.05^b
CD	10.0%	4.9%	<.05^b
Anxiety/depression disorder	13%	2.5%	<.05^b

Note. ODD = oppositional defiant disorder; CD = conduct disorder.

Mann–Whitney U test.

Chi-square test.

Acknowledgements

We are grateful to the children and parents for their participation in the study. Special thanks to Jean Louise Sanders for translating and copy editing the manual, and to C. Murphy and J. Kenner at the Control Trial Unit (CTU) at the Institute of Psychiatry.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study has been funded by the South London and Maudsley NHS Charitable Funds. Maite Ferrin also received economic support from the Instituto de Salud Carlos III (ETS 07/90902, BAE 09/90088), Consejeria de Salud, Junta de Andalucia (EF-0029), Gobierno de Navarra (Beca Ayanz), and Fundacion Alicia Koplowitz.

Author Biographies

Maite Ferrin works as consultant in a Child and Adolescent psychiatric intensive care unit. She has worked with children/adolescents with ADHD and their families in Spain and the UK since 2005. She has sat on the European ADHD Guidelines Group since 2010, and is part of the steering comitee of the European Project Continuum. Dr. M. Ferrin is also Honorary Clinical Lecturer for the University of Southampton.

Viviana Perez-Ayala has worked as research assistant and assistant psychologist at the Southwark Neuropsychiatric Team.

Samaa El-Abd work as consultants child and adolescent psychiatrist in the Southwark Neuropsychiatric Team and the Belgrave Clinic at King College Hospital respectively.

Teresa Lax-Pericall work as consultants child and adolescent psychiatrist in the Southwark Neuropsychiatric Team and the Belgrave Clinic at King College Hospital respectively.

Brian Jacobs has worked as consultant in Child and Adolescent Psychiatry at South London and Mausdley.

Andrea Bilbow is chief executive of ADDISS.

Eric Taylor is emeritus professor of Child and Adolescent Psychiatry at the Institute of Psychiatry, King’s College London. He is part of the European ADHD Guidelines Group and has contributed with a number of peer-reviewed publications in the field.

References

Abidin

R. R.

(1995). Parenting Stress Index (PSI) manual (3rd ed.). Charlottesville, VA: Pediatric Psychology Press.

American Academy of Pediatrics, Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management. (2011). Evaluation and treatment of attention-deficit/hyperactivity disorder. Pediatrics, 128, 1007-1022.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

Banaschewski

Buitelaar

Coghill

D. R.

Sergeant

J. A.

Sonuga-Barke

Zuddas

. . . ADHD European Guidelines Group. (2009). The MTA at 8. Journal of the American Academy of Child and Adolescent Psychiatry, 48, 1120-1121.

Bäuml

Froböse

Kraemer

Rentrop

Pitschel-Walz

(2006). Psychoeducation: A basic psychotherapeutic intervention for patients with schizophrenia and their families. Schizophrenia Bulletin, 32(Suppl. 1), S1-S9.

Canadian Attention Deficit Hyperactivity Disorder Resource Alliance. (2011). Canadian ADHD practice guidelines (3rd ed.). Toronto, Ontario, Canada: Author.

Chronis-Tuscano

Chacko

Barkley

(2013). Key issues relevant to the efficacy of behavioral treatment for ADHD. American Journal of Psychiatry, 170, 799

Cohen

(1988). Statistical power analysis for the behavioral sciences. Hillsdale, NJ: Lawrence Erlbaum.

Colom

Vieta

Reinares

Martínez-Arán

Torrent

Goikolea

J. M.

Gastó

(2003). Psychoeducation efficacy in bipolar disorders: Beyond compliance enhancement. Journal of Clinical Psychiatry, 64, 1101-1105.

10.

Colom

Vieta

Sánchez-Moreno

Palomino-Otiniano

Reinares

Goikolea

J. M.

. . .Martínez-Arán

(2009). Group psychoeducation for stabilised bipolar disorders: 5-year outcome of a randomised clinical trial. British Journal of Psychiatry, 194, 260-265.

11.

Colom

Vieta

Scott

(2006). Psychoeducation manual for bipolar disorder. Cambridge, UK: Cambridge University Press.

12.

Conners

C. K.

(1989). Conners’ Rating Scales Manual. New York, NY: Multi Health Systems.

13.

Daley

van der Oord

Ferrin

Danckaerts

Doepfner

Cortese

. . . ADHD Guidelines Group. (2014). Behavioral interventions in attention-deficit/hyperactivity disorder: A meta-analysis of randomized controlled trials across multiple outcome domains. Journal of the American Academy of Child & Adolescent Psychiatry, 53, 835-847, 847.e1-847.e5.

14.

Fabiano

G. A.

Pelham

W. E.

Jr. Coles

E. K.

Gnany

E. M.

Chronis-Tuscano

O’Connor

B. C.

(2009). A meta-analysis of behavioural treatments for attention-deficit hyperactivity disorder. Clinical Psychology Review, 29, 129-140.

15.

Fabiano

G. A.

Pelham

W. E.

Cunningham

C. E.

Gangloff

Buck

. . .Gera

(2012). A waitlist-controlled trial of behavioral parent training for fathers of children with ADHD. Journal of Clinical Child & Adolescent Psychology, 41, 337-345.

16.

Ferrin

Moreno-Granados

J. M.

Salcedo-Marin

M. D.

Ruiz-Veguilla

Perez-Ayala

Taylor

(2014). Evaluation of a psychoeducation programme for parents of children and adolescents with ADHD: Immediate and long-term effects using a blind randomized controlled trial. European Child and Adolescent Psychiatry, 23, 637-647.

17.

Ferrin

Taylor

(2011). Child and caregiver issues in treatment of attention deficit-hyperactivity disorder: Education, adherence and treatment choice. Future Neurology, 6, 399-413.

18.

Ford

Goodman

Meltzer

(2004). The relative importance of child, family, school and neighbourhood correlates of childhood psychiatric disorder. Social Psychiatry and Psychiatric Epidemiology, 39, 487-496.

19.

Forkmann

Scherer

Boecker

Pawelzik

Jostes

Gauggel

(2011). The clinical global impression scale and the influence of patient or staff perspective on outcome. BMC Psychiatry, 11, 83.

20.

Goodman

(2001). Psychometric properties of the Strengths and Difficulties Questionnaire. Journal of the American Academy of Child & Adolescent Psychiatry, 40, 1337-1345.

21.

Graham

Banaschewski

Buitelaar

Coghill

Danckaerts

Dittmann

R. W.

. . . ADHD Guidelines Group. (2011). European guidelines on managing adverse effects of medication for ADHD. European Child and Adolescent Psychiatry, 20, 17-37.

22.

Guy

(1976). ECDEU assessment manual for psychopharmacology, revised 1976. Rockville, MD: U.S. Department of Health, Education, and Welfare.

23.

Han

Enas

N. H.

McEntegart

(2009). Randomization by minimization for unbalanced treatment allocation. Statistics in Medicine, 28, 3329-3346.

24.

Haskett

M. E.

Ahern

L. S.

Ward

C. S.

Allaire

J. C.

(2006). Factor structure and validity of the Parenting Stress Index-short form. Journal of Clinical Child & Adolescent Psychology, 35, 302-312.

25.

Ialongo

N. S.

Horn

W. F.

Pascoe

J. M.

Greenberg

Packard

Lopez

. . .Puttler

(1993). The effects of a multimodal intervention with attention-deficit hyperactivity disorder children: A 9-month follow-up. Journal of the American Academy of Child & Adolescent Psychiatry, 32, 182-189.

26.

Jadad

Enkin

(2007). Randomised controlled trials: A user’s guide (2nd ed.). Oxford, UK: Blackwell.

27.

Kampman

Laippala

Väänänen

Koivisto

Kiviniemi

Kilkku

Lehtinen

(2000). Indicators of medication compliance in first-episode psychosis. Psychiatry Research, 110, 39-48.

28.

Langberg

J. M.

Arnold

L. E.

Flowers

A. M.

Epstein

J. N.

Altaye

Hinshaw

S. P.

. . .Hechtman

(2010). Parent-reported homework problems in the MTA study: Evidence for sustained improvement with behavioral treatment. Journal of Clinical Child & Adolescent Psychology, 39, 220-233.

29.

Molina

B. S.

Hinshaw

S. P.

Swanson

J. M.

Arnold

L. E.

Vitiello

Jensen

P. S.

. . . MTA Cooperative Group. (2009). The MTA at 8 years: Prospective follow-up of children treated for combined-type ADHD in a multisite study. Journal of the American Academy of Child & Adolescent Psychiatry, 48, 484-500.

30.

Montoya

Colom

Ferrin

(2011). Is psychoeducation for parents and teachers of children and adolescents with ADHD efficacious? A systematic literature review. European Psychiatry, 26, 166-175.

31.

NICE. (2008, September). Attention deficit hyperactivity disorder: Diagnosis and management of ADHD in children, young people and adults. NICE clinical guideline 72. Retrieved from www.nice.org.uk/CG72 [NICE guideline].

32.

Neiderhiser

J. M.

Reiss

Hetherington

E. M.

Plomin

(1999). Relationships between parenting and adolescent adjustment over time: Genetic and environmental contributions. Developmental Psychology, 35, 680-692.

33.

Pfiffner

L. J.

(2014). Meta-analysis supports efficacy of behavioral interventions for attention-deficit/hyperactivity disorder-related problems. Journal of the American Academy of Child & Adolescent Psychiatry, 53, 830-832.

34.

Pocock

(1983). Clinical trials: A practical approach. Chichester, UK: Wiley-Blackwell.

35.

Shaffer

Gould

M. S.

Brasic

Ambrosini

Fisher

Bird

Aluwahlia

(1983). A children’s global assessment scale (CGAS). Archives of General Psychiatry, 40, 1228-1231.

36.

Sonuga-Barke

E. J. S.

Brandeis

Cortese

Daley

Danckaerts

Döpfner

. . . European ADHD Guidelines Group. (2013a). Response to Chronis-Tuscano et al. and Arns and Strehl (letter). American Journal of Psychiatry, 170, 800-802.

37.

Sonuga-Barke

E. J. S.

Brandeis

Cortese

Daley

Ferrin

Holtmann

. . . European ADHD Guidelines Group. (2013b). Non-pharmacological interventions for attention-deficit/hyperactivity disorder: Systematic review and meta-analyses of randomised controlled trials of dietary and psychological treatments. American Journal of Psychiatry, 170, 275-289.

38.

Sonuga-Barke

E. J. S.

Daley

Thompson

Laver-Bradbury

Weeks

(2001). Parent based therapies for pre-school attention deficit/hyperactivity disorder: A randomised, controlled trial with a community sample. Journal of the American Academy of Child & Adolescent Psychiatry, 40, 402-408.

39.

Swanson

J. M.

McBurnett

Wigal

Pfiffner

L. J.

Lerner

M. A.

Williams

. . .Fisher

T. D.

(1993). Effect of stimulant medication on children with attention-deficit disorder: A review of reviews. Exceptional Children, 60, 154-162.

40.

Tabachnick

B. G.

Fidell

L. S.

(2001). Using multivariable statistics (3rd ed.). New York, NY: HarperCollins.

41.

Thompson

M. J.

Laver-Bradbury

Ayres

Le Poidevin

Mead

Dodds

. . .Sonuga-Barke

E. J.

(2009). A small-scale randomized controlled trial of the revised new forest parenting programme for preschoolers with attention deficit hyperactivity disorder. European Child and Adolescent Psychiatry, 18, 605-616.

42.

Wechsler

(1991). Wechsler Intelligence Scale for Children (3rd ed.). San Antonio, TX: The Psychological Corporation.