Cognitive and Behavioral Treatment of Impulsivity in Children: A Meta-Analytic Review of the Outcome Literature

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NICHCY’s Structured Abstract 10 describes the following:

Title | Cognitive and Behavioral Treatment of Impulsivity in Children: A Meta-Analytic Review of the Outcome Literature

Author | Baer, R.A., & Nietzel, M.T.

Source Journal of Clinical Child Psychology, 20(4), 400-412.

Year Published | 1991

Abstract
Reviewed 36 outcomes studies that used cognitive and/pr behavioral treatment to reduce impulsivity in children. Treatments included self-statement modification, reinforcement contingencies, modeling, strategy training, problem-solving training, and numerous treatment combinations. Subjects were all described as impulsive, but varied in clinical diagnosis, including attention-deficit disorder hyperactivity disorder, conduct disorder, behavior disorder, and learning disability. Other subjects were labeled as non-self-controlled, or behavior problem. Meta-analytic techniques showed that intervention for impulsivity were associated with improvements of approximately one third to three quarters of a standard deviation relative to untreated control subjects. Treated subjects fell close to normative group means both before and after treatment.

Background
Impulsive children are often described as children who when facing a particular problem-solving situation, tend to respond quickly without thinking about consequences or possible solutions; and as a result make mistakes. The term impulsivity has been associated with different childhood behavioral problems such as aggression, disruptive behavior, peer relationship problems, antisocial behaviors, or as an essential characteristic of attention-deficit hyperactivity disorder. Different cognitive and behavioral strategies have been reported to treat impulsivity in children; however, the effectiveness of these strategies is still uncertain. Some of these strategies include scanning techniques for slowing responses, operant techniques such as reinforcement or response cost contingencies, modeling techniques, and self-instruction treatment; which is the most commonly used treatment.

Research Questions
The purpose of this meta-analysis was to examine the effectiveness of cognitive and/ or behavioral treatments approaches for impulsivity.

Research Design
Meta-Analysis*

  • Number of Studies Included | 36
  • Number of Subjects | N/A
  • Years Spanned | 1968-1991

Research Subjects
In some studies children were described as typical. In others, they were described as typical, but were screened on a test of impulsivity, usually the Matching Familiar Figures Test (MFF). In other studies, children had been independently diagnosed or la

Age/Grade of Subjects
Participants ranged from 4-17 years old, with an average age of 9.62 years old.

Specified Disability
In order to be included in the meta-analysis, children had to be described as impulsive regardless of other diagnoses they may have been given. The diagnosis included ADD, ADHD, conduct disorder, behavior disorder, learning disabled, aggressive, non self-

Intervention
Studies used one or more measures of impulsivity as an outcome measure, and compared at least one cognitive and/or behavioral treatment group with at least one placebo or no-treatment group. Most treatment was administered individually.  The types of treatment were:

  • Self statement modification (SSM), in which children were taught to self- instruct.
  • SSM plus in which self-statement modification was combined with one or more additional procedures such as problem solving training, reinforcement or response cost contingencies, and relaxation training.
  • Operant treatments which only include reinforcement and/or response cost contingencies.
  • Modeling treatment in which subjects watched a model who self-instructed, examined systematically, delayed responding, or did some combination of these.
  • Specific strategy in which children were taught to scan systematically, to respond slowly or to do both.
  • Strategy + operant in which children were taught a specific strategy and exposed to reinforcement.
  • Other treatments that encouraged children to use cognitive/or behavioral strategies, relaxation training and in which children were told to read instructions silently.

Duration of Intervention
Hours of treatment ranged from less than 1 hour to 32 hours, with a mean of 7 hours.

Findings

  1. The behavior described as impulsive continues to be poorly defined.
  2. Disruptive, aggressive, and antisocial responses all can be described as externalizing behavior; however, whether all externalizing behavior is impulsive is not clear.
  3. The studies reviewed did not make satisfactory distinctions between impulsive and externalizing behavior which makes it difficult to analyze the differences in outcomes between these types of behavior.
  4. Subjects who had been diagnosed or labeled as ADHD, conduct disorder, behavior disorder, non-self controlled, behavior problem, or aggressive; did not differ significantly from the norm.

Combined Effects Size
The overall mean effect size was 0.77

Conclusion/Recommendations

  1. There is a significant lack of relationship between length of treatment and effect size, which suggests that the amount of treatment needed, is unknown.
  2. The use of subjects in many studies, who were not clinically disturbed, may have hidden a relationship between length of treatment and effectiveness.
  3. Non-disturbed subjects may reach a maximum level of improvement in fewer sessions, while clinically disturbed subjects may require longer treatment.
  4. There is a need for further research that uses only clinically disturbed subjects and measures improvement frequently to clarify the relationship between length of treatment and efficacy.
  5. The variability in outcomes among types of treatments, suggests that there is a need of a more systematic comparative research.
  6. There is a need of further attention to the issue of generalizability of outcomes from specific measures to more general behavior of clinical significance.

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* Meta-Analysis | A widely-used research method in which (1) a systematic and reproducible search strategy is used to find as many studies as possible that address a given topic; (2) clear criterion are presented for inclusion/exclusion of individual studies into a larger analysis; and (3) results of included studies are statistically combined to determine an overall effect (effect size) of one variable on another.

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