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. 2019 Jun 21;6(6):CD008223.
doi: 10.1002/14651858.CD008223.pub3.

Social skills training for attention deficit hyperactivity disorder (ADHD) in children aged 5 to 18 years

Ole Jakob Storebø  1 , Mette Elmose Andersen, Maria Skoog, Signe Joost Hansen, Erik Simonsen, Nadia Pedersen, Britta Tendal, Henriette E Callesen, Erlend Faltinsen, Christian Gluud
Affiliations

Social skills training for attention deficit hyperactivity disorder (ADHD) in children aged 5 to 18 years

Ole Jakob Storebø et al. Cochrane Database Syst Rev. .

Abstract

Background: Attention deficit hyperactivity disorder (ADHD) in children is associated with hyperactivity and impulsivity, attention problems, and difficulties with social interactions. Pharmacological treatment may alleviate the symptoms of ADHD but this rarely solves difficulties with social interactions. Children with ADHD may benefit from interventions designed to improve their social skills. We examined the benefits and harms of social skills training on social skills, emotional competencies, general behaviour, ADHD symptoms, performance in school of children with ADHD, and adverse events.

Objectives: To assess the beneficial and harmful effects of social skills training in children and adolescents with ADHD.

Search methods: In July 2018, we searched CENTRAL, MEDLINE, Embase, PsycINFO, 4 other databases and two trials registers.We also searched online conference abstracts, and contacted experts in the field for information about unpublished or ongoing randomised clinical trials. We did not limit our searches by language, year of publication, or type or status of publication, and we sought translation of the relevant sections of non-English language articles.

Selection criteria: Randomised clinical trials investigating social skills training versus either no intervention or waiting-list control, with or without pharmacological treatment of both comparison groups of children and adolescents with ADHD.

Data collection and analysis: We conducted the review in accordance with the Cochrane Handbook for Systematic Reviews of Intervention. We performed the analyses using Review Manager 5 software and Trial Sequential Analysis. We assessed bias according to domains for systematic errors. We assessed the certainty of the evidence with the GRADE approach.

Main results: We included 25 randomised clinical trials described in 45 reports. The trials included a total of 2690 participants aged between five and 17 years. In 17 trials, participants were also diagnosed with various comorbidities.The social skills interventions were described as: 1) social skills training, 2) cognitive behavioural therapy, 3) multimodal behavioural/psychosocial therapy, 4) child life and attention skills treatment, 5) life skills training, 6) the "challenging horizon programme", 7) verbal self-instruction, 8) meta-cognitive training, 9) behavioural therapy, 10) behavioural and social skills treatment, and 11) psychosocial treatment. The control interventions were no intervention or waiting list.The duration of the interventions ranged from five weeks to two years. We considered the content of the social skills interventions to be comparable and based on a cognitive-behavioural model. Most of the trials compared child social skills training or parent training combined with medication versus medication alone. Some of the experimental interventions also included teacher consultations.More than half of the trials were at high risk of bias for generation of the allocation sequence and allocation concealment. No trial reported on blinding of participants and personnel. Most of the trials did not report on differences between groups in medication for comorbid disorders. We used all eligible trials in the meta-analyses, but downgraded the certainty of the evidence to low or very low.We found no clinically relevant treatment effect of social skills interventions on the primary outcome measures: teacher-rated social skills at end of treatment (standardised mean difference (SMD) 0.11, 95% confidence interval (CI) 0.00 to 0.22; 11 trials, 1271 participants; I2 = 0%; P = 0.05); teacher-rated emotional competencies at end of treatment (SMD -0.02, 95% CI -0.72 to 0.68; two trials, 129 participants; I2 = 74%; P = 0.96); or on teacher-rated general behaviour (SMD -0.06 (negative value better), 95% CI -0.19 to 0.06; eight trials, 1002 participants; I2 = 0%; P = 0.33). The effect on the primary outcome, teacher-rated social skills at end of treatment, corresponds to a MD of 1.22 points on the social skills rating system (SSRS) scale (95% CI 0.09 to 2.36). The minimal clinical relevant difference (10%) on the SSRS is 10.0 points (range 0 to 102 points on SSRS).We found evidence in favour of social skills training on teacher-rated core ADHD symptoms at end of treatment for all eligible trials (SMD -0.26, 95% CI -0.47 to -0.05; 14 trials, 1379 participants; I2= 69%; P = 0.02), but the finding is questionable due to lack of support from sensitivity analyses, high risk of bias, lack of clinical significance, high heterogeneity, and low certainty.The studies did not report any serious or non-serious adverse events.

Authors' conclusions: The review suggests that there is little evidence to support or refute social skills training for children and adolescents with ADHD. We may need more trials that are at low risk of bias and a sufficient number of participants to determine the efficacy of social skills training versus no training for ADHD. The evidence base regarding adolescents is especially weak.

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Conflict of interest statement

Ole Jakob Storebø is an Associate Editor with the Cochrane Developmental, Psycosocial and Learning Problems Group. Mette Elmose Andersen ‐ none known Maria Skoog ‐ none known Signe Joost Hansen ‐ none known Erik Simonsen ‐ none known Nadia Pedersen ‐ none known Britta Tendal ‐ none known Henriette E Callesen ‐ none known Erlend G Faltinsen ‐ none known Christian Gluud ‐ none known

Ole Jakob Storebø, Maria Skoog, Erik Simonsen, and Christian Gluud were involved in the Storebø 2012 trial, which is included in this review. This trial was assessed by Nadia Pedersen, Mette Elmose, Signe Joost, and Mathilde Holmsov. These authors independently assessed the eligibility of this study, extracted data from it, assessed the risk of bias within it and assessed the quality of the evidence provided by it.

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
4
4
Trial Sequential Analysis of teacher‐rated social skills ‐ SSRS Footnotes DARIS: diversity‐adjusted required information size
 MD: mean difference
 SSRS: Social Skills Rating Scale
5
5
Trial Sequential Analysis of teacher‐rated social skills ‐ all studies transformed to SSRS Footnotes MIREDIF: minimum relevant difference
 SD: standard deviation
 SSRS: Social Skills Rating Scale
1.1
1.1. Analysis
Comparison 1 Social skills, Outcome 1 Primary meta‐analysis: Teacher‐rated social skills at end of treatment.
1.2
1.2. Analysis
Comparison 1 Social skills, Outcome 2 Secondary meta‐analyses: Social skills.
1.3
1.3. Analysis
Comparison 1 Social skills, Outcome 3 Teacher‐reported Walker‐McConnell Scale of Social Competence and School Adjustment.
1.4
1.4. Analysis
Comparison 1 Social skills, Outcome 4 Parent‐rated Social Skills Scale (UCI).
1.5
1.5. Analysis
Comparison 1 Social skills, Outcome 5 Child‐rated Test of Social Skill Knowledge.
1.6
1.6. Analysis
Comparison 1 Social skills, Outcome 6 Social Interaction Observation Code: Negative behaviour.
2.1
2.1. Analysis
Comparison 2 Emotional competencies, Outcome 1 Primary meta‐analysis: Teacher‐rated emotional competencies at end of treatment.
2.2
2.2. Analysis
Comparison 2 Emotional competencies, Outcome 2 Secondary meta‐analyses: Emotional competencies.
3.1
3.1. Analysis
Comparison 3 General behaviour, Outcome 1 Primary meta‐analysis: Teacher‐rated general behaviour at end of treatment.
3.2
3.2. Analysis
Comparison 3 General behaviour, Outcome 2 Secondary analyses: general behaviour.
4.1
4.1. Analysis
Comparison 4 Core ADHD symptoms, Outcome 1 Primary meta‐analysis: Teacher‐rated ADHD symptoms at end of treatment.
4.2
4.2. Analysis
Comparison 4 Core ADHD symptoms, Outcome 2 Secondary meta‐analyses: ADHD symptoms.
5.1
5.1. Analysis
Comparison 5 Teacher‐rated performance and grades in school, Outcome 1 At end of treatment.
5.2
5.2. Analysis
Comparison 5 Teacher‐rated performance and grades in school, Outcome 2 At longest follow‐up.
6.1
6.1. Analysis
Comparison 6 Observer‐rated performance and grades in school, Outcome 1 Wescheler Individual Achievement Test.
7.1
7.1. Analysis
Comparison 7 TSA, Outcome 1 Teacher‐rated social skills.
8.1
8.1. Analysis
Comparison 8 Subgroup analysis 1: Children aged five to 11 years versus children aged 12 to 18 years, Outcome 1 Teacher‐rated social skills.
9.1
9.1. Analysis
Comparison 9 Subgroup analysis 2: ADHD and comorbidity versus ADHD and no comorbidity, Outcome 1 Parent‐rated ADHD symptoms at end of treatment.
10.1
10.1. Analysis
Comparison 10 Subgroup analysis 3: Social skills training only versus social skills training supported by parent training, Outcome 1 Teacher‐rated social skills at end of treatment.
11.1
11.1. Analysis
Comparison 11 Subgroup analysis 4: Social skills training, parental training and medication versus social skills training and parental training without medication, Outcome 1 Parent‐rated social skills at end of treatment.
12.1
12.1. Analysis
Comparison 12 Subgroup analysis 5: No‐intervention control group versus waiting‐list control group with possible minor active intervention components, Outcome 1 Teacher‐rated social skills at end of treatment.
See this image and copyright information in PMC

Update of

Comment in

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References to studies awaiting assessment

NCT01019252 {published data only}
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References to ongoing studies

IRCT201609186834N11 {published data only}
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