Interventions for Preschool Children at High Risk for ADHD: A Comparative Effectiveness Review

OBJECTIVES: The US Agency for Healthcare Research and Quality sponsored a comparative effectiveness review of interventions for preschoolers at risk for attention-deficit/hyperactivity disorder (ADHD). METHODS: Medline, Cochrane CENTRAL, Embase, PsycInfo, and Education Resources Information Center were searched from 1980 to November 24, 2011. Selected studies were comparative, and enrolled children <6 years with clinically significant disruptive behavior, including ADHD. The interventions evaluated were parent behavior training (PBT), combined home and school/day care interventions, and methylphenidate use. Data were extracted by using customized software. Two independent raters evaluated studies as good, fair, or poor by using the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies Risk of Bias. Overall strength of evidence (SOE) was rated for each intervention’s effectiveness, accounting for study design, systematic error, consistency of results, directness of evidence, and certainty regarding outcome. RESULTS: Fifty-five studies were examined. Only studies examining PBT interventions could be pooled statistically using meta-analysis. Eight “good” studies examined PBT, total n = 424; SOE was high for improved child behavior, standardized mean difference = –0.68 (95% confidence interval: –0.88 to –0.47), with minimal heterogeneity among studies. Only 1 good study evaluated methylphenidate, total n = 114; therefore, SOE for methylphenidate was low. Combined home and school/day care interventions showed inconsistent results. The literature reported adverse effects for methylphenidate but not for PBT. CONCLUSIONS: With more studies consistently documenting effectiveness, PBT interventions have greater evidence of effectiveness than methylphenidate for treatment of preschoolers at risk for ADHD. * Abbreviations: AAP — : American Academy of Pediatrics ADHD — : attention-deficit/hyperactivity disorder MAS — : mixed amphetamine salts PATS — : Preschool ADHD Treatment Study PBT — : parent behavior training RCT — : randomized controlled trial SMD — : standardized mean difference SOE — : strength of evidence