|Year : 2017 | Volume
| Issue : 2 | Page : 61-67
Organizational skills training, neurofeedback, and/or pharmacotherapy in the treatment of school-aged children with attention-deficit hyperactivity disorder
Hanan G Azouz1, Faten I Abdel Latif2, Tarek E.S Omar1, Mona Khalil1, Marwa S Abdel Maksoud1
1 Department of Pediatrics, Faculty of Medicine, Alexandria University, Alexandria, Egypt
2 Department of Public Health, Faculty of Kindergarten, Alexandria University, Alexandria, Egypt
|Date of Submission||14-Aug-2017|
|Date of Acceptance||14-Sep-2017|
|Date of Web Publication||17-Jan-2018|
Marwa S Abdel Maksoud
Department of Pediatrics, Faculty of Medicine, Alexandria University, Alexandria
Source of Support: None, Conflict of Interest: None
Background Attention deficit hyperactivity disorder (ADHD) is the most common developmental and neurobehavioral disorder in childhood. It is characterized by hyperactivity, impulsivity, and/or inattention.
Objective To study the efficacy of implementation of different interventional modalities including medication (MED; atomoxetine) either alone or in combination with behavioral therapy (organization skills training; OST) or cognitive training (neurofeedback training; NFT) in alleviation of the core symptoms of ADHD and its comorbid conduct problem among school-aged children with ADHD.
Participants and methods This was a multigroup design study with preassessment and postassessment with the Arabic form of Conners’ Parent Rating Scale short form (CPRS-48). Participants were 45 school-aged children (age range from 6 to 10 years) with a diagnosis of ADHD according to the Diagnostic and Statistical Manual of Mental Disorders-5 diagnostic criteria. Children were recruited from the Pediatric Behavioral Outpatient Clinic of Alexandria University Children Hospital, Alexandria, Egypt, and they were allocated into the groups: group OST and MED (n=15); group NFT and MED (n=15); and group MED (n=15).
Results Combined OST and MED showed a significant decrease in hyperactivity/impulsivity (P=0.011) and comorbid conduct problem scores (P=0.030) on postinterventional assessment with CPRS-48. However, no statistically significant difference was found among the other studied groups, groups NFT and MED or group MED, either on ADHD core symptoms or its comorbid conduct problem.
Conclusion Combined OST and MED showed significant efficacy in the alleviation of ADHD core symptoms and comorbid conduct problem.
Keywords: attention-deficit hyperactivity disorder, atomoxetine, children, neurofeedback training, organizational skills training
|How to cite this article:|
Azouz HG, Abdel Latif FI, Omar TE, Khalil M, Abdel Maksoud MS. Organizational skills training, neurofeedback, and/or pharmacotherapy in the treatment of school-aged children with attention-deficit hyperactivity disorder. Alex J Pediatr 2017;30:61-7
|How to cite this URL:|
Azouz HG, Abdel Latif FI, Omar TE, Khalil M, Abdel Maksoud MS. Organizational skills training, neurofeedback, and/or pharmacotherapy in the treatment of school-aged children with attention-deficit hyperactivity disorder. Alex J Pediatr [serial online] 2017 [cited 2018 Oct 17];30:61-7. Available from: http://www.ajp.eg.net/text.asp?2017/30/2/61/223453
| Introduction|| |
Attention-deficit hyperactivity disorder (ADHD) is the most common neurodevelopmental and behavioral disorder affecting 4% of all children, ranging widely from 3 to 11%, with male predominance (male:female ratio 4:1) . It can profoundly affect the academic performance, social relationships, and general well-being of these children . According to The Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) , it is characterized by symptoms of inattention and/or impulsivity and hyperactivity. ADHD appears to be associated with a wide variety of other psychiatric or neurodevelopmental disorders (e.g. conduct problem) far more often than it appears alone . Many children diagnosed with ADHD continue to have problems as adolescents and adults; thus, the disorder is one of high individual and societal costs to the population .
The ultimate goal of ADHD treatment is to improve symptoms and optimize functional performance. Treatment consists of a variety of approaches including parenting practices, school interventions, behavioral therapy, cognitive training, and medication (MED). Psychostimulants (e.g. methylphenidate) are the first choice for ADHD treatment . Nonstimulants such as atomoxetine (ATX) (selective norepinephrine reuptake inhibitor) and α-2 receptor agonists are also FDA-approved MEDs for ADHD and considered second-line drugs . Organization skills training (OST) is a psychosocial/behavioral intervention that has been developed mainly for academic organizational aspects such as homework management and physical organization of school materials, which are not normalized by MEDs.
Neurofeedback training (NFT), also known as electroencephalogram (EEG) biofeedback, aims to enhance self-regulatory capacity over brain activity patterns and subsequently over brain mental functions . In clinical practice, electrodes are placed along the scalp and children are required to remain seated in front of a computer screen (a computer game) trying to find mental strategies to gain points. The computer reads the EEG signal and visual or auditory feedback is instantly generated. Changes in EEG activity, made in a desired direction, are rewarded.
| Aim|| |
In the current study, on the basis of the availability of many interventional modalities with different levels of evidence, the primary goal was to study the efficacy of implementation of different interventional modalities including MEDs alone or with either OST or NFT in alleviation of the core symptoms of ADHD (hyperactivity/impulsivity and inattention) and its comorbid conduct problems among school-aged children with ADHD. To our knowledge, no studies have been published to date comparing the efficacy of these three interventional modalities.
| Participants and methods|| |
The current study was carried out on 45 school-aged children with ADHD. The children were recruited from the Pediatric Behavioral Outpatient Clinic of Alexandria University Children Hospital, Egypt, and from some private clinics. Children were chosen according to the following inclusion criteria: (a) between 6 and 10 years of age; (b) fulfilled the ADHD DSM-5 diagnostic criteria by formal clinical interviews with both the child and the parents; (c) total intelligence quotient test score of 85 or more on Stanford Binet fourth ed. ‘Arabic version’; (d) children with no contraindications to nonstimulant MEDs; (e) parents are compliant and adherent to therapy; (f) lack of any abnormal neurological manifestation; and (g) children with no associated significant psychiatric disorders. This study was approved by the Human Research Ethics Committee of the Alexandria University, Alexandria, Egypt. Informed consent was obtained from the parents before any intervention.
The current study is a nonrandomized interventional clinical trial. The children included were allocated into three treatment groups: group OST and MED (n=15), group NFT and MED (n=15), and group MED alone (n=15).
All studied children had undergone preassessment and postassessment with the Arabic version of Conners’ Parent Rating Scale short form (CPRS-48) . This short rating form is based on subscales assessing (a) conduct problem (eight items), (b) learning problem (four items), (c) psychosomatic problem (four items), (d) impulsive–hyperactivity (four items), and (e) anxiety (four items). In addition, the CPRS-48 includes (f) the item hyperactivity index (10 items) that is considered to be the most sensitive to treatment effects, (i) inattention (eight items). The test was carried out by trained psychologists. Parent(s) rated their child’s behavior over the last 3 months on a four-point scale from 0 (not at all) to 3 (severely affected). Questionnaires usually took about 30–45 min to complete. The score of each question is converted into t scores with the average of 50 and SD of 10 (i.e. 50±10). If the t scores are two SDs higher than the average, the child has a problem .
Nonstimulant MED (ATX) was started at a dose of 0.5 mg/kg/day for a minimum of 3 days and then titrated up to a daily dose of ∼1.2 mg/kg, 4 weeks’ duration, in either one or two daily doses; the maximum daily dose did not exceed 1.4 mg/kg/day or 100 mg/day . In case of mild side effects, parents were given instructions to minimize or overcome them.
Organizational skills training
Clinic-based sessions were individually applied and addressing not only academic skills but also social and study skills (multicomponent intervention). The OST were taught using behavioral techniques including modeling, rehearsal, and contingency management, including point systems or token economies to monitor and reward adherence to a structured organizational skills system. Parents were also involved in the treatment and their role is to prompt, praise, and reward their child’s learning and performance of specific skills with the intent of reinforcing desirable behaviors and to promote generalization of skills to multiple contexts. The sessions were held by trained psychologists, once to twice per week for a 3-month duration or a total of 24 completed sessions, each session lasting from 30 to 45 min.
Using a single-channel neurofeedback machine (flex comb infinity/DA 2101) and (BioGraph infinity software version 5.0; Thought Technology Ltd., Montreal, Quebec, Canada) at the early intervention center of childhood, children were subjected to a standard protocol of inhibiting θ amplitude (4–8 Hz), muscle movement (43–59 Hz), and rewarding β 1 enhancement (15–21 Hz) plus θ/β ratio training either on CZ or C3. All children received 24 sessions either once or twice per week. Sessions were 30 min each. The first four sessions were introductory to permit children to understand the aim of training and cope with the neurofeedback device. During training, each child could choose between three different screens (games, puzzles, etc.) including immediate auditory/visual feedback, counter points accompanying, and an animation that progressed as they increased the points earned. Training of all children was conducted by the same therapist.
Data were collected and entered into the computer using the statistical package for the social sciences (SPSS; IBM Corp., Armonk, NY) program for statistical analysis (version 20) . Data were entered as numerical or categorical, as appropriate. The Kolmogorov–Smirnov test of normality showed significance in the distribution of some variables; thus, the nonparametric statistics was adopted. An α level was set to 5%.
| Results|| |
The three intervention groups were similar at baseline in terms of their demographic characteristics, namely, their age and sex. Although being homogenously distributed, male predominance was noticed among the three studied groups. There was no statistically significant difference between groups in their mean intelligence quotient as P=0.074. In terms of the predominant presentation of ADHD, combined presentation was the most common type among the three studied groups ([Table 1]).
|Table 1 Comparison between the three studied attention deficit hyperactivity disorder groups according to demographic data, predominant presentation, and total intelligence quotient scores|
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Results of treatment groups showed a statistically significant difference before and after the intervention among the OST and MED groups according to CPRS-48 scores on conduct problem (P=0.030) ([Table 2]) impulsive–hyperactive scores (P=0.011) ([Table 3]); and item hyperactivity index (P=0.041) ([Table 4]). However, no similar significant difference was found in inattention scores ([Table 5]). In contrast, the other two studied groups NFT and MED or MED only did not show any statistically significant difference on CPRS-48 either on ADHD core symptoms (hyperactivity/impulsivity and inattention) or on conduct problem scores (P<0.05).
|Table 2 Conduct problem scores on Conners’ Parent Rating Scale short form-48 before and after the interventions among attention deficit hyperactivity disorder children in the three studied groups|
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|Table 3 Impulsive–hyperactive scores on Conners’ Parent Rating Scale short form-48 before and after the interventions among attention deficit hyperactivity disorder children in the three studied groups|
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|Table 4 Item hyperactivity index scores on Conners’ Parent Rating Scale short form-48 before and after the interventions among attention deficit hyperactivity disorder children in the three studied groups|
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|Table 5 Inattention scores on Conners’ Parent Rating Scale short form-48 before and after the interventions among attention deficit hyperactivity disorder children in the three studied groups|
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| Discussion|| |
OST has been included as part of a number of multicomponent interventions, as in the current study, for children with ADHD. These interventions target behavior problems, social skills, and other educational skills (e.g. study skills). These multicomponent interventions have been shown to lead to significant improvements in interpersonal functioning and organizational skills as well as decreases in parent and teacher ratings of overall academic impairment ,,.
The significant efficacy of combined OST and MED on the core ADHD symptoms, mainly hyperactivity and impulsivity, in the current study is consistent with a recent meta-analysis  that concluded that ‘OST leads to significant improvements in organizational skills of children with ADHD as rated by parents’. Also in support of the results of the current study, Evans et al.  conducted atrial to examine the treatment benefits of the OST program on the functional impairment associated with ADHD in young children and adolescents. Parent ratings of hyperactivity–impulsivity resulted in statistically significant treatment effects; however, the rating of inattention was insignificant, which is also consistent with the results of the current study .
The effect of OST on ADHD symptoms can be explained by the following mechanisms: (a) it is likely that organizational skills such as task planning and materials management also rely on the same executive functions that are impaired in ADHD ; (b) multicomponent OST interventions that include elements such as study skills training, daily living, and social skills (as in the current study) can also contribute toward the improvement of ADHD symptoms; , and (c) parent participation may lead to contingent rewards for staying on task during homework and activities of daily living, which might improve other ADHD symptoms . However, the lack of a significant impact on inattention on the studied group, of the current study, is explained with the lack of the use of assisting materials such as school daily report cards, and also poor cooperation of the schools administrators and teachers in implementation of any interventional skills or material for most of the studied children.
This impact of OST on conduct problem could be related to the multicomponent nature of the interventions provided such as social skills, peer problem solving, and parental practices, which is used to reinforce the favored behavior in organizational skills, and is also used for undesired disruptive behavior.
In contrast with these findings, the Challenging Horizons Program has recently shown that the efficacy of OST for improving aggressive and disruptive behaviors has not been reported . However, the Challenging Horizons Program study was carried out on adolescents with many comorbid psychiatric conditions compared with the current study (median age=8 years), with no major psychiatric disorders.
Moreover, the combined use of MED with behavioral therapy, as in the current study, was also suggested as an explanation for the significant impact shown on conduct problems. In support with this notion, a recent Canadian systematic review  was carried out to develop evidence-based guidelines on pharmacotherapy for severe disruptive and aggressive behavior in children and adolescents with ADHD. The review recommended that MEDs for ADHD should be used in combination with psychosocial interventions in case of severe disruptive or aggressive behavior. Furthermore, ATX received a conditional recommendation in favor of use.
Studies on the efficacy of NFT on the core ADHD symptoms are mixed. Recent meta-analysis  and recent randomized clinical trials , in agreement with the current study, showed no clinical response of the NFT training on improvement of ADHD core symptoms. Moreover, Orgim et al.  did not show any additional impact of NFT to MED in comparison with MED alone in his randomized pilot study in 2013. However, other literature studies showed a significant improvement in ADHD symptoms as rated by parents ,,. These mixed results between the studies might be related to the different protocols used in the training; number of sessions; frequency of session per week and its duration; age of the participant; different rating scales used for assessment of ADHD symptoms; and sample size of the participants.
Pharmacological treatment is considered by the American Academy of Pediatrics as the recommended treatment for school-aged children with ADHD older than 6 years of age, especially those with moderate to severe functional impairment either on their social or academic performance. In the current study, ATX was used, although it is considered the second line of treatment after stimulants because of different considerations including (a) stimulants are not easy to get as they require special prescription and are available only in limited places; (b) on the basis of wrong cultural beliefs, parents are convinced that stimulants are dependent drugs and may lead to substance abuse later on; and (c) although ATX is relatively more expensive than stimulants, it was provided to the children through the Pediatric Neurology Association of Alexandria University Children Hospital.
In agreement with the results of the current study on the efficacy of MED only in the studied children, studies by Kratochvil et al.  and Bedarde et al.  showed that children in the ATX group remained, on average, significantly impaired at the end of the study and no effect of ATX on attention could be detected. In contrast, a recent review article  showed that ATX is effective in the treatment of ADHD symptoms and comorbid disorders, including conduct problems.
These differences in the findings among the studies on the effectiveness of ATX may be because of variations in patient characteristics, mainly symptom severity; associated neuropsychiatric impairment; and the age of the participants. Moreover, dose of the ATX has been studied as an important determinant for the clinical outcome. Some studies ,, which utilized a dose above the recommended maximum dosage specified by the manufacturer of 1.4 mg/kg/day (unlike the current study), suggested greater efficacy in the treatment of ADHD symptoms with increased dose even above the recommended.
| Conclusion|| |
The current study concluded that the combination of OST and MED is an effective intervention in improving not only the ADHD core symptoms, mainly impulsivity and hyperactivity, but also the associated comorbid conduct problems among school-aged children with ADHD. However, ATX, either alone or in combination with NFT, was not significantly effective in alleviation of the core ADHD symptoms or its comorbid conduct problem.
The authors thank Lamia Gamal for sharing her expertise in NFT with us during the course of this research. They are also grateful to Amal Hamdy and Shymaa Fathy for their participation in the psychometric testing and behavioral training sessions during this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]