Collateral Benefits of the Homework Success Program for ADHD

Introduction

Nearly 11 percent of all children between the ages of 4 and 17 have been diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD) in the United States, according to the Centers for Disease Control and Prevention (CDC, 2013). Of these, an estimated 18 percent remain untreated. These estimates reveal the obstacles teachers face when trying to help all of their students succeed academically, because the main symptoms — attention impairments, hyperactivity, and impulsivity — are severe enough to interfere with daily functioning and development (CDC, 2014). The symptoms most relevant to the classroom include poor listening skills, frequent mistakes, disorganization, avoidance of mentally challenging tasks, distractibility, memory deficits, fidgeting, excessive talking, and interrupting others. Accordingly, researchers, educators, and physicians have been searching for strategies and treatments that could help these children perform better academically.

Children between the ages of 4 and 18 who display academic, attention, and/or hyperactivity/impulsivity problems across settings should be formally evaluated for ADHD (Hauk, 2013; Dang, Warrington, Tung, Baker, & Pan, 2007). Behavioral therapy is the preferred treatment choice for all children and the only treatment recommended for preschool children (Hauk, 2013). Should behavioral therapy fail to control symptoms, medications — primarily stimulants — may be prescribed. The medical community therefore emphasizes a behavioral therapy approach as the primary treatment for children with ADHD, with medications prescribed only when behavioral therapy has failed to adequately control symptoms.

Successful interventions designed to improve academic performance, however, depend less on behavioral therapy and medications and more on addressing psychosocial factors. Researchers have revealed that ADHD has a genetic component (Thapar, Cooper, Eyre, & Langley, 2013), which is consistent with findings showing that families with ADHD children tend to suffer from psychosocial problems (Kaplan, Crawford, Fisher, & Dewey, 1998). These problems include difficulty making decisions, lack of intimacy, and ill will toward each other. Psychosocial interventions with a record of success include the Homework Success Program (HSP) (Habboushe et al., 2001), which strives to help parents engage with teachers and manage ADHD behavioral problems in their children effectively. HSP has been shown to reduce homework and behavioral problems, in addition to lowering parental stress.

Statement of the Problem

The purpose of this study was to objectively evaluate the efficacy of the HSP intervention using a more objective measure of cognitive performance: the WISC-IV. Prior research has relied primarily on parent and teacher reports of improvements following the intervention, but the subjective nature of these findings cannot reveal whether academic performance is actually improved or is merely perceived to have improved.

Literature Review

A number of studies have revealed that family-of-origin characteristics predict the prevalence of childhood ADHD, including genetic studies (Thapar et al., 2013) and correlational studies revealing a relationship between family dysfunction and childhood ADHD (Kaplan et al., 1998). The genetic factors appear to affect the dopaminergic and serotonergic neurotransmitter systems (Thapar et al., 2013); however, the magnitude of the genetic contribution is too slight to render it diagnostically useful.

Although little can be done at present to address the genetic contribution to ADHD prevalence, psychosocial interventions addressing family dysfunction have shown promising results. The HSP is a seven-session, 10-week group intervention that trains parents to engage teachers effectively and manage ADHD behavioral problems in their children (Habboushe et al., 2001). The primary goal is to collaborate on efforts to encourage completion of homework assignments, while children are invited to join a child-only group focused on learning the behavioral strategies being taught to the parents. A number of problems can arise, including variable parent adherence and teacher buy-in (DuPaul & Power, 2008). Solutions to these drawbacks are being sought; Raggi and colleagues (2009) suggest that one solution to low rates of teacher buy-in is to organize parent-only HSP groups at the beginning of the intervention. This strategy lowers the amount of time teachers must devote to the HSP intervention by addressing parent-specific concerns and training first. The initial two group sessions can present behavioral strategies to address homework issues, homework management skills, goal-setting, contingency contracting, and parent-teacher consultation skills. Although the studies by Habboushe et al. (2001) and Raggi et al. (2009) suffered from small sample sizes and a lack of scientific rigor, the results revealed reductions in homework problems, parent-child conflict, and parental stress.

Power and colleagues (2012) addressed the methodological shortcomings of earlier studies investigating the efficacy of psychosocial interventions, using a randomized controlled trial design comparing the Family-School Success (FSS) and Coping with ADHD through Relationships and Education (CARE) programs. The main difference between the two programs was the parent-teacher collaboration component of the FSS program, which had the effect of improving parent-as-educator outcomes, homework productivity and compliance, and discipline outcomes. In contrast to earlier studies, however, ADHD and oppositional-defiant disorder symptomology remained equivalent between the FSS and CARE groups throughout the trial period. By the end of the intervention, parent-teacher interactions, parent-as-teacher outcomes, homework productivity and adherence, and inattention/avoidance were better for families in the FSS group; however, by the end of the three-month follow-up period, only parent-teacher interactions and lower inattention/avoidance remained significantly improved in the FSS group. Improvements in parent-as-teacher outcomes and homework productivity/adherence were lost after the intervention ended. A similar trend was observed for academic performance (p = .0625 post-intervention; p = .0981 follow-up period), although statistical significance was not achieved for a sample size of 164 families randomly assigned to the experimental (N = 77) and control (N = 87) groups. These findings, together with those of earlier studies, reveal that psychosocial interventions addressing parent-teacher relationships and ADHD behavioral problems produce positive improvements in academic performance.

All of the above studies rely on parent and teacher ratings, which are subjective in nature. This should not be surprising, since an ADHD diagnosis depends to a significant extent on subjective data (Gualtieri & Johnson, 2005); however, objective tests revealing neurocognitive deficits common to ADHD sufferers are available. The Wechsler Intelligence Scale for Children (WISC-III) is one such test, capable of revealing deficits in auditory memory, working memory, and processing speed. Children with ADHD perform more poorly on several composite scores on the WISC-III (Williams, Weiss, & Rolfhus, 2003a). A medium effect size was observed for the processing speed index (PSI), and small effect sizes were found for the verbal comprehension index (VCI) and working memory index (WMI). As noted by Williams and colleagues (2003a), these results are consistent with prior research showing that children with ADHD tend to score in the normal range on general intellectual function tests but not on tests measuring processing speed and working memory. The clinical validity of the WISC-III when evaluating children with ADHD has been well established (Williams, Weiss, & Rolfhus, 2003a).