Zwi Morris, Jones Hannah, Thorgaard Camilla, York Ann, Dennis Jane A
Richmond Royal Hospital, South West London & St George's NHS Mental Health Trust, Kew Foot Road, Richmond, Surrey, UK, TW9 2TE.
Cochrane Database Syst Rev. 2011 Dec 7;2011(12):CD003018. doi: 10.1002/14651858.CD003018.pub3.
Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterised by high levels of inattention, hyperactivity and impulsivity that are present before the age of seven years, seen in a range of situations, inconsistent with the child's developmental level and causing social or academic impairment. Parent training programmes are psychosocial interventions aimed at training parents in techniques to enable them to manage their children's challenging behaviour.
To determine whether parent training interventions are effective in reducing ADHD symptoms and associated problems in children aged between five and eigtheen years with a diagnosis of ADHD, compared to controls with no parent training intervention.
We searched the following electronic databases (for all available years until September 2010): CENTRAL (2010, Issue 3), MEDLINE (1950 to 10 September 2010), EMBASE (1980 to 2010 Week 36), CINAHL (1937 to 13 September 2010), PsycINFO (1806 to September Week 1 2010), Dissertation Abstracts International (14 September 2010) and the metaRegister of Controlled Trials (14 September 2010). We contacted experts in the field to ask for details of unpublished or ongoing research.
Randomised (including quasi-randomised) studies comparing parent training with no treatment, a waiting list or treatment as usual (adjunctive or otherwise). We included studies if ADHD was the main focus of the trial and participants were over five years old and had a clinical diagnosis of ADHD or hyperkinetic disorder that was made by a specialist using the operationalised diagnostic criteria of the DSM-III/DSM-IV or ICD-10. We only included trials that reported at least one child outcome.
Four authors were involved in screening abstracts and at least 2 authors looked independently at each one. We reviewed a total of 12,691 studies and assessed five as eligible for inclusion. We extracted data and assessed the risk of bias in the five included trials. Opportunities for meta-analysis were limited and most data that we have reported are based on single studies.
We found five studies including 284 participants that met the inclusion criteria, all of which compared parent training with de facto treatment as usual (TAU). One study included a nondirective parent support group as a second control arm. Four studies targeted children's behaviour problems and one assessed changes in parenting skills. Of the four studies targeting children's behaviour, two focused on behaviour at home and two focused on behaviour at school. The two studies focusing on behaviour at home had different findings: one found no difference between parent training and treatment as usual, whilst the other reported statistically significant results for parent training versus control. The two studies of behaviour at school also had different findings: one study found no difference between groups, whilst the other reported positive results for parent training when ADHD was not comorbid with oppositional defiant disorder. In this latter study, outcomes were better for girls and for children on medication.We assessed the risk of bias in most of the studies as unclear at best and often as high. Information on randomisation and allocation concealment did not appear in any study report. Inevitably, blinding of participants or personnel was impossible for this intervention; likewise, blinding of outcome assessors (who were most often the parents who had delivered the intervention) was impossible.We were only able to conduct meta-analysis for two outcomes: child 'externalising' behaviour (a measure of rulebreaking, oppositional behaviour or aggression) and child 'internalising' behaviour (for example, withdrawal and anxiety). Meta-analysis of three studies (n = 190) providing data on externalising behaviour produced results that fell short of statistical significance (SMD -0.32; 95% CI -0.83 to 0.18, I(2) = 60%). A meta-analysis of two studies (n = 142) for internalising behaviour gave significant results in the parent training groups (SMD -0.48; 95% CI -0.84 to -0.13, I(2) = 9%). Data from a third study likely to have contributed to this outcome were missing, and we have some concerns about selective outcome reporting bias.Individual study results for child behaviour outcomes were mixed. Positive results on an inventory of child behaviour problems were reported for one small study (n = 24) with the caveat that results were only positive when parent training was delivered to individuals and not groups. In another study (n = 62), positive effects (once results were adjusted for demographic and baseline data) were reported for the intervention group on a social skills measure.The study (n = 48) that assessed parenting skill changes compared parent training with a nondirective parent support group. Statistically significant improvements were reported for the parent training group. Two studies (n = 142) provided data on parent stress indices that were suitable for combining in a meta-analysis. The results were significant for the 'child' domain (MD -10.52; 95% CI -20.55 to -0.48) but not the 'parent' domain (MD -7.54; 95% CI -24.38 to 9.30). Results for this outcome from a small study (n = 24) suggested a long-term benefit for mothers who received the intervention at an individual level; in contrast, fathers benefited from short-term group treatment. A fourth study reported change data for within group measures of parental stress and found significant benefits in only one of the two active parent training group arms (P ≤ 0.01).No study reported data for academic achievement, adverse events or parental understanding of ADHD.
AUTHORS' CONCLUSIONS: Parent training may have a positive effect on the behaviour of children with ADHD. It may also reduce parental stress and enhance parental confidence. However, the poor methodological quality of the included studies increases the risk of bias in the results. Data concerning ADHD-specific behaviour are ambiguous. For many important outcomes, including school achievement and adverse effects, data are lacking.Evidence from this review is not strong enough to form a basis for clinical practice guidelines. Future research should ensure better reporting of the study procedures and results.
注意力缺陷多动障碍（ADHD）是一种神经发育障碍，其特征是在七岁之前出现高度的注意力不集中、多动和冲动，在多种情况下均有表现，与儿童的发育水平不符，并导致社交或学业障碍。家长培训计划是一种心理社会干预措施，旨在培训家长掌握相关技巧，使他们能够管理孩子具有挑战性的行为。
与未接受家长培训干预的对照组相比，确定家长培训干预措施对于诊断为ADHD的5至18岁儿童减少ADHD症状及相关问题是否有效。
我们检索了以下电子数据库（截至2010年9月的所有可用年份）：Cochrane系统评价数据库（2010年第3期）、医学期刊数据库（1950年至2010年9月10日）、荷兰医学文摘数据库（1980年至2010年第36周）、护理学与健康领域数据库（1937年至2010年9月13日）、心理学文摘数据库（1806年至2010年第1周9月）、国际学位论文摘要数据库（2010年9月14日）以及对照试验元注册库（2010年9月14日）。我们联系了该领域的专家，询问未发表或正在进行的研究的详细信息。
比较家长培训与无治疗、等待名单或常规治疗（辅助性或其他方式）的随机（包括半随机）研究。如果ADHD是试验的主要重点，参与者年龄超过五岁且具有由专科医生使用DSM-III/DSM-IV或ICD-10的操作性诊断标准做出的ADHD或多动障碍临床诊断，我们纳入这些研究。我们仅纳入报告了至少一项儿童结局的试验。
四位作者参与筛选摘要，至少两位作者独立查看每一篇摘要。我们共审查了12,691项研究，评估其中五项符合纳入标准。我们提取数据并评估了五项纳入试验中的偏倚风险。荟萃分析的机会有限，我们报告的大多数数据基于单项研究。
我们发现五项研究包括284名符合纳入标准的参与者，所有这些研究均将家长培训与事实上的常规治疗（TAU）进行了比较。一项研究将非指导性家长支持小组作为第二个对照组。四项研究针对儿童的行为问题，一项评估了育儿技能的变化。在针对儿童行为的四项研究中，两项关注家庭行为，两项关注学校行为。两项关注家庭行为的研究结果不同：一项发现家长培训与常规治疗之间没有差异，而另一项报告了家长培训与对照组相比具有统计学意义的结果。两项关于学校行为的研究结果也不同：一项研究发现组间没有差异，而另一项报告当ADHD与对立违抗性障碍不共病时家长培训有积极结果。在后者的研究中，女孩和正在服药的儿童的结局更好。我们评估了大多数研究中的偏倚风险，充其量不明确，而且往往很高。任何研究报告中均未出现关于随机化和分配隐藏的信息。不可避免地，对于这种干预措施，参与者或人员的盲法是不可能的；同样，结局评估者（大多数情况下是实施干预的家长）的盲法也是不可能的。我们仅能够对两个结局进行荟萃分析：儿童“外化”行为（一种衡量违规、对立行为或攻击行为的指标）和儿童“内化”行为（例如，退缩和焦虑）。对三项提供外化行为数据的研究（n = 190）进行的荟萃分析结果未达到统计学显著性（标准化均数差 -0.32；95%可信区间 -0.83至0.18，I² = 60%）。对两项关于内化行为的研究（n = 142）进行的荟萃分析在家长培训组中得出了显著结果（标准化均数差 -0.48；95%可信区间 -0.84至 -0.13，I² = 9%）。可能对这一结局有贡献的第三项研究的数据缺失，我们对选择性结局报告偏倚有些担忧。关于儿童行为结局的单项研究结果不一。一项小型研究（n = 24）报告了儿童行为问题清单上的积极结果，但有一项附加说明，即仅当对个体而非团体进行家长培训时结果才是积极的。在另一项研究（n = 62）中，干预组在一项社交技能测量上报告了积极效果（在对人口统计学和基线数据进行调整后）。评估育儿技能变化的研究（n = 48）将家长培训与非指导性家长支持小组进行了比较。报告家长培训组有统计学显著性改善。两项研究（n = 142）提供了适合进行荟萃分析的家长压力指数数据。结果在“儿童”领域显著（均数差 -10.52；95%可信区间 -20.55至 -0.48），但在“家长”领域不显著（均数差 -7.54；95%可信区间 -24.38至9.30）。一项小型研究（n = 24）关于这一结局的结果表明，接受个体水平干预的母亲有长期益处；相比之下，父亲从短期团体治疗中受益。第四项研究报告了家长压力组内测量的变化数据，发现仅在两个积极的家长培训组中的一组中有显著益处（P≤0.01）。没有研究报告学业成绩、不良事件或家长对ADHD的理解的数据。
家长培训可能对ADHD儿童的行为有积极影响。它也可能减轻家长压力并增强家长信心。然而，纳入研究的方法学质量较差增加了结果偏倚的风险。关于ADHD特定行为的数据不明确。对于许多重要结局，包括学业成绩和不良反应，数据缺乏。本综述的证据不足以作为临床实践指南的基础。未来的研究应确保更好地报告研究程序和结果。
