Psychoeducation Intervention Effectiveness to Improve Social Skills in Young People with ADHD: A Meta-Analysis

Objective: Attention Deficit Hyperactivity Disorder (ADHD) can be associated with limited understanding of the condition and poor social skills. Some evidence favors a psychoeducational approach, but little is known about the effectiveness of psychoeducation. Methods: Systematic review and meta-analysis of studies assessing psychoeducational interventions that aim to improve social skills of young people with ADHD. Results: Ten studies, including 943 participants, reported across 13 papers met the inclusion criteria. Although effect sizes were small, findings suggest the included interventions significantly improved social skills in young people with ADHD. Conclusions: Results show promise for psychoeducational behavioral interventions . However, the recommendations that can be developed from existing evidence are somewhat limited by the low quality of studies. Further rigorous trials are needed. In addition, future research should consider the long-term outcomes for these interventions, they should be iteratively co-designed and research should consider the context they intend to be delivered in.

impairment on a scale ranging from 0 (not a problem at all. Definitely does not need treatment of special services) to 6 (extreme problem. Definitely needs treatment and special services). The IRS also includes measures of the impact of child's peer relationships, relationships with their parents, family functioning and overall impairment (Fabiano et al., 2006).

Strengths and Difficulties Questionnaire (SDQ):
A five-step response scale from 1 (does not apply at all) to 5 (applies very well) and is a brief behavioral screening questionnaire for 3-16- year olds. There are five domains: emotional symptoms, conduct problems, hyperactivity/inattention, peer relationship problems, prosocial behavior. Ostberg et al (2012) used a version of the SDQ that is validated in Sweden (Malmberg et al., 2003;Smedje et al., 1999). The SDQ can be parent, child or teacher rated (Malmberg et al., 2003;Smedje et al., 1999). cooperation, assertion, responsibility, empathy and self-control (F. M. Gresham & Elliott, 1990).

Quality of Play
Questionnaire: Parents answer 18 questions on a 4 points scale from 0-3 (not at all, just a little, pretty much and very much) regarding how their child and friend interact during the most recent playdate and involves two subscales: conflict and disengagement (Frankel & Mintz, 2008).

University of California Irvine Social Skills Scale (UCI):
The UCI is a 10-item rating scale constructed specifically for  study and aims to measure social behaviors taught in the treatment groups. Parents rate to the extent their child follows game rules, maintains participation in an activity or game, says nice things to others, follows directions, uses assertive communication, ignores teasing, uses problem solving, recognises others' feelings, and deals with anger appropriately. Each skill is rated on a 5-point scale (1:never -5: most or all of the time) .

Test of Social Skills Knowledge: Designed to assess children's knowledge about social skills
taught during the class in  study. This measure is administered individually to each child and contains six questions including "What are some good examples of good sportsmanship?" "How would you show you are being assertive?" "What are some ways to deal with anger?" Children are asked to respond verbally, and an interviewer records the responses.
Responses are later allocated a score (1: no or inaccurate response, 2: partial response, 3 full accurate response).

Test of Life Skills Knowledge:
The Test of Life Skills Knowledge is designed to assess social and organizational skills taught in the child group (Pfiffner & Mikami, 2005). It is a 10-item child reported test including questions such as "What should you do if someone is teasing you?" "How would you show that you are being assertive?" "What are some ways to make a new friend?" Child responses are recorded and responses are later rated on a 3-point scale (1: no or inaccurate response, 2: partial response, 3: full accurate response) .

Social Competence Scale (SCS):
Consists of 12 items to assess parent perceptions of child's positive social behaviors (e.g. resolving peer problems, understanding others, sharing, being helpful, listening and emotional regulation) (McMahon et al., 1999).

Unclear
Of the included RCTs, eight did not report the random sequence generation  presented.
Low risk solutions to these barriers were developed.
The STEPP program also incorporated a subgroup, coping-modeling, problem-solving format within the traditional large-group format to improve social support between parents and to increase participation among parents. The STEPP program also incorporated a systematic, problem-solving treatment method to address parent-initiated problems (e.g., time management, conflicts with relatives) that may either interfere with their parenting or affect parents' psychosocial functioning. In addition, the STEPP program incorporates parent-child interactions within the children's social skills group to enhance parenting skill acquisition and a child motivation enhancement within the children's social skills group to provide children incentives for attaining within-session and home-based behavioral goals.

Ferrin, 2016
The psychoeducation group included five groups of seven to ten families, who received six sessions of 2 hour at weekly intervals. Families were primarily educated on the disorder; they were briefly introduced to a range of behavioral strategies for managing ADHD symptoms and reducing defiant behavior during the last three sessions. The integrity of the psychoeducation sessions was guaranteed by a manual that clearly outlined all the procedures to be used in the intervention. Two experienced child and adolescent psychiatrists and one psychologist conducted all the sessions. Sessions were audiotaped and an independent person using a checklist ensured that the different groups received an equivalent set of information. At the end of each session, a handout was delivered and parents were assigned some short additional homework to prepare for the next session.

Pfiffner, 2007; CLAS Study, (Pfiffner, 2014; Haak, 2017)
Child Life and Attention Skills (CLAS) treatment involved parent and child skills training that included: Teacher consultation: This involved an overview of behavioural interventions and ADHD classroom-based accommodations. Target behaviours were identified and the skills that were taught in the child group were also shared with teachers so they could reinforce the behaviours in the classroom.
Parent training: This involved providing the parents with an overview of ADHD, ADHD management strategies and a "home challenge" that involved specific target behaivors.
Child skills training: This was divided into modules that focussed on skills for independence (e.g., academic study, organisaiton, self-care, daily living skills) and skills for social competence.

Mikami, 2010
Parental Friendship Coaching (PFC) consisted of eight 90-minute group sessions, delivered once-weekly, involving five to six parents and led by two clinicians. Sessions were manualized, although minor changes to content occurred based on parent feedback. Each PFC session began with a review of homework from the previous week. Then, the target parental coaching strategies of the week (e.g. building a positive parent-child relationship, using active listening, debriefing with child after a playdate, review and future directions) were explained using handouts, activities, and role plays. Parents were encouraged to bring up ways in which strategies could be tailored to their child's specific needs. Group viewing of videotapes of each parent's interaction with his/her child during the playgroups was used as a teaching tool.

Ostberg, 2012
A slightly modified version of Barkley's parent training programme adapted to Swedish circumstances and conditions. A parallel and similar programme for teachers was constructed with the goal to address the child's two major contexts, home and school at the same time. The intervention is manual based, as is training for group leaders. Parents met for 10 weekly 2-hour sessions, and teachers met for eight sessions, with parents and teachers of about eight children per group. The sessions focussed upon information about neuropsychiatric problems and on participants learning to use reinforcements, to solve problems and to communicate with the child. Home assignments and discussions of these were part of the programme, and a structure for the co-operation between home and school was formed.

Pfiffner, 1997
Children received eight 90-minute sessions during consecutive weeks. Sessions were taught by the same two therapists. During each session, leaders taught skill modules using brief didactic instruction, symbolic (puppets, stuffed animals) and in vivo modelling, role playing and behavioral rehearsal. Six modules were covered: good sportsmanship, accepting consequences, assertiveness, ignoring provocation, problem solving, recognising and deadline with feelings.
Sessions were structured in the following way: Review of social skill used in the previous week, discussion of "good sports bucks" earned at home for targeted social skills. Second, leaders introduced the "skill of the week" and then reviewed how, when and why to use the skill with child participation in a group challenge game. Handouts were distributed to parents at the end of each week.

CLS Study (Pfiffner, 2016; 2018)
The Collaborative Life Skills Training (CLS) involved three components: Classroom Component: Teachers attended one 1-hour orientation session, one 30-minute troubleshooting meeting and two to three individual 30-minute meetings attended by the parent, the student, and the student's individual teacher. The classroom intervention consisted of a school-home daily report card (classroom challenge), homework plan, and classroom accommodations as needed (e.g., preferential seating, targeted use of praise, providing prompts to improve student compliance). Each student's CC included two to three target behaviors (e.g., academic work, classroom deportment, social interactions) rated up to three times per day. Points earned for meeting target goals were exchanged for daily home rewards and brought to the child group each week for group-based reinforcement. Target behaviors were refined throughout the intervention period during the individual meetings.
Parent Component: Parents attended ten 1-hour group sessions. Modules taught skills covered by traditional parent training programs, including effective use of commands, rewards, and discipline, plus strategies covered in the child group (e.g., homework time, organization, independence in completing daily routines, peer interactions, and social skills) and stress management for parents. Families developed a homework plan and home challenges targeting child skills. They also learned skills for supporting the CC at home.
Child Skills Component: Children attended nine 40-minute group sessions during the school day and two celebratory parties with parents, teachers, and students. Modules targeted social functioning and independence. Social skills modules included good sportsmanship, accepting consequences, assertion, dealing with teasing, problem solving, self-control, and friendship making. Independence modules included homework skills, completing chores and tasks independently, and establishing and following routines. Activities accommodated developmental needs (e.g., having older children take more of a leader/helper role in groups, The IY Dinosaur training program (for the children) was held at the same time as the parent program. Program topics included following group rules, identifying and articulating feelings, problem solving, anger management, friendship skills, and teamwork. Each two-hour session consisted of three short circle times and three to four planned activities to reinforce concepts presented in circle time. Therapists used coaching methods during unstructured play times to encourage appropriate peer interactions and targeted social and emotional skills.

Wilkes Gillen, 2016
Children watched videos of themselves playing and received feedback from therapists.
Therapists helped children remember 3 key things for when they next enter the playroom.
During play, the therapist modelled desired pro-social skills; sharing, perspective taking, problem solving, negotiating and responding to playmates verbal and non verba cues. Childre later played without therapist support.