Peer Inclusion in Interventions for Children with ADHD: A ...downloads.hindawi.com/journals/bmri/2018/7693479.pdf · (peer involvement, peer mediation, or peer proximity) in pre-post

Research ArticlePeer Inclusion in Interventions for Children with ADHD:A Systematic Review and Meta-Analysis

Reinie Cordier ,1 Brandon Vilaysack,2 Kenji Doma,2

SarahWilkes-Gillan,3 and Renée Speyer1,4,5

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

Academic Editor: Nader Perroud

Copyright © 2018 Reinie Cordier et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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

http://orcid.org/0000-0002-9906-5300

https://doi.org/10.1155/2018/7693479

2 BioMed Research International

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

BioMed Research International 3

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


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


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


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


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.


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


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


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.


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


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


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


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


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


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


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


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


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


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


grou


grou

psHighlysig

nificantchanges

towards

fewer

symptom

sNostatisticallysig

nificant

differencew

hencomparin

ggrou

ps


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.


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


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


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%)


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


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%

)


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


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


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


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


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


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


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


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.


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.


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.


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.


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.


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.


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.


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.


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.


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

.


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


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)

Statistics for each studyStandard Lower Upper

g errorVariance

limit limitZ-value p value

0.699 0.247 0.061 0.215 1.183 2.828 0.0050.566 0.245 0.060 0.087 1.046 2.315 0.0210.390 0.242 0.059 −0.085 0.864 1.610 0.1070.615 0.246 0.060 0.134 1.096 2.506 0.0120.665 0.286 0.082 0.104 1.226 2.324 0.0200.400 0.359 0.129 −0.303 1.104 1.115 0.2651.345 0.270 0.073 0.816 1.874 4.983 0.0000.227 0.217 0.047 −0.198 0.653 1.047 0.2950.167 0.218 0.048 −0.261 0.594 0.763 0.4450.287 0.231 0.054 −0.166 0.741 1.241 0.2150.234 0.222 0.050 −0.202 0.670 1.052 0.2931.014 0.133 0.018 0.753 1.274 7.625 0.0000.827 0.243 0.059 0.350 1.304 3.401 0.0010.909 0.142 0.020 0.630 1.188 6.384 0.0000.563 0.125 0.016 0.319 0.807 4.516 0.0000.664 0.123 0.015 0.424 0.905 5.406 0.0000.827 0.243 0.059 0.351 1.304 3.403 0.0010.469 0.219 0.048 0.040 0.899 2.141 0.0320.563 0.274 0.075 0.027 1.100 2.058 0.0400.281 0.267 0.071 −0.243 0.805 1.052 0.2930.233 0.260 0.068 −0.277 0.742 0.896 0.3700.463 0.263 0.069 −0.051 0.978 1.764 0.0780.584 0.064 0.004 0.459 0.709 9.149 0.000

1.00 2.00Favours intervention

group

0.00−1.00−2.00Favours control

group

and 95% CIHedges’ gHedges’

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.).


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∗

Parent + teacher (𝑁 = 3) 0.832 6.786 <0.001∗

Parent (𝑁 = 6) 0.496 4.689 <0.001∗

Self (𝑁 = 6) 0.517 5.023 <0.001∗

Teacher (𝑁 = 7) 0.547 5.023 <0.001∗

Notes. ∗Significant.

Table 7: Metaregression results.

Set Covariate 95% lower 95% upper 𝑍-value 2-sided 𝑝 valueIntercept −0.0527 2.0452 1.86 0.0627

Blinding: no blinding −0.5548 0.158 −1.09 0.2752Parent Component: parent involvement −0.5257 0.4463 −0.16 0.8729Methodological quality: strong quality −0.5003 0.5989 0.18 0.8603

Study design: RCT −0.5616 0.6237 0.10 0.9182Rater Rater: parent-rated −0.9472 −0.0091 −2.00 0.0457∗

Rater Rater: self-rated −0.959 0.4601 −0.69 0.4908Rater Rater: teacher- rated −1.0655 0.1701 −1.42 0.1555Notes. ∗Significant.

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


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


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


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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