Which Type of Parent Training Works Best for Preschoolers with Comorbid ADHD and ODD? A Secondary Analysis of a Randomized Controlled Trial Comparing Generic and Specialized Programs

Non-pharmacological treatment of Attention Deficit Disorder with or without Hyperactivity (ADHD). Overview and report of the first international symposium on the non-pharmacological management of ADHD

Attention Deficit Disorder with or without Hyperactivity (ADHD is a neurodevelopmental disorder which affects the day-to-day functioning of children and adults with this condition. Pharmacological treatment can reduce the symptoms associated with ADHD, but it has some limitations. The objective of this symposium is to determine the effects of non-pharmacological approaches on ADHD symptoms. Results indicate that the following intervention are promising approaches: cognitive behavioral therapy (CBT), mindfulness-based interventions (MBI), yoga, cognitive and metacognitive intervention, neurofeedback and parental training programs. Current research advocates multimodal approaches in conjunction with school or work accommodations integrating innovative technologies.

The effect of psycho-education given to mothers of children with attention deficit hyperactivity disorder on mother-child interaction and family functionality

PROBLEM

One of the most prevalent psychiatric conditions in children is attention deficit hyperactivity disorder (ADHD). Regular psycho-education for people with chronic illnesses and their families is beneficial for prevention, treatment, and rehabilitation. This study aimed to determine the effect of psycho-education given to mothers of children with ADHD on mother-child interaction and family functionality.

METHODS

The sample of the study consisted of 98 mothers and children (50 participants for the intervention group and 48 participants for the control group). Mothers in the intervention group were given psycho-education. Pre and post-tests were completed by mothers.

FINDINGS

Post-test mean scores in terms of warmth/affection, hostility/aggression, indifference/neglect, and control subscales of the Parental Acceptance-Red/Control Scale were statistically significantly lower among the intervention group. Post-test mean scores in terms of communication, showing interest, and the behavior control subscales of the family assessment device were statistically significantly lower in the intervention group.

CONCLUSIONS

For families dealing with a child with ADHD, psychoeducation increased mother-child interaction and family functioning Therefore, psychoeducation should be widespread in the treatment of ADHD. When ADHD causes problems with mother-child contact, maternal psychoeducation may be helpful.

Treatments for child and adolescent attention deficit hyperactivity disorder in low and middle-income countries: A narrative review

BACKGROUND

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder that affects approximately 2-7 % of children globally and is associated with a myriad of difficulties that have long-term consequences. Most children and adolescents live in low- and middle-income countries (LMICs), but there are few reports and no consolidation of findings on ADHD treatment outcomes in this population. We conducted a review of ADHD treatment literature for children and adolescents living in LMICs.

METHODS

Studies were identified using databases (PsychoINFO, Pubmed, MEDLINER, EMBASE, Global Health, Academic Search Complete, Google Scholar). The initial search produced 139 articles. These were filtered for language, title, abstract, and full-text keyword identification to yield a final 20 articles to be included in this review.

RESULTS

Reports on outcomes of both psychological and pharmacological treatment were relatively sparse, particularly the former, which mostly referred to parent training and multimodal programs in pre-school children. Most evidence exists for the benefit of methylphenidate-IR with a few reports on other agents, including clonidine, atomoxetine, and lisdexamfetamine. Methylphenidate is the most common agent to treat ADHD in youth in LMICs. Younger age, combined subtype, and comorbid oppositional defiant disorder were associated with poorer treatment outcome.

CONCLUSION

Access to treatment for ADHD is overall limited in LMICs and varied among individual countries. Pharmacological treatments were generally more available than psychological interventions. Several barriers including stigma, cost, and lack of resources were reported to impact treatment acceptance. More research in LMICs is needed to improve and expand mental health services in these regions.

Behavioral Parent Training for Preschool ADHD: Family-Centered Profiles Predict Changes in Parenting and Child Outcomes

OBJECTIVE

Behavioral parent training (BPT) is the first line of treatment for preschool-aged children with attention-deficit hyperactivity disorder (ADHD); however, clinically significant improvements are not universal. In the current study, we employ a person-centered approach to create subgroups of families based on the intersection of multiple parent, child, and family pre-treatment factors. Further, we explore the utility of pre-treatment family profiles in predicting post-treatment differences in observed parenting behavior (i.e., behavioral control, parental warmth) and clinically significant change in child ADHD and oppositional symptoms.

METHOD

Longitudinal data were collected using observational and parent-, teacher- and clinician-reported assessments from 130 parent-child dyads (Mage= 3.57, range = 3.0- 4.11, 73.8% male, 69.2% White, 25.6% Hispanic) participating in BPT.

RESULTS

Findings from the current study suggest three distinct family profiles, which consisted of one profile with high family stress (HFS) as evidenced by elevated symptomatology across parent, child, and family-level domains, a second profile with elevated parental anxiety (PA), and a final profile with elevated parental depression (PD). These family-centered profiles were differentially associated with changes in observed parenting practices. Specifically, the PD profile (39%) demonstrated minimal improvements in behavioral control and warmth following treatment. In contrast, the HFS profile (30%) only improved in behavioral control and the PA profile (31%) improved in both parenting domains following treatment. In addition, marginally significant differences in child oppositional and ADHD symptoms were observed across profiles.

CONCLUSIONS

Family-centered approaches may be useful for selecting and implementing interventions.

Individual differences in white matter of the uncinate fasciculus and inferior fronto-occipital fasciculus: possible early biomarkers for callous-unemotional behaviors in young children with disruptive behavior problems

BACKGROUND

Callous-unemotional (CU) behaviors are important for identifying severe patterns of conduct problems (CP). One major fiber tract implicated in the development of CP is the uncinate fasciculus (UF), which connects amygdala and orbitofrontal cortex (OFC). The goals of the current study were to (a) explore differences in the white matter microstructure in the UF and other major fiber tracks between young typically developing (TD) children and those with a disruptive behavior disorder (DBD) and (b) explore, within the DBD group, whether individual differences in these white matter tracts relate to co-occurring CP and CU behaviors.

METHODS

Participants included 198 young children (69% boys, M_age  = 5.66 years; 80% Latinx; 48.5% TD). CU behaviors and CP were measured via a combination of teacher/parent ratings. Non-invasive diffusion-weighted imaging (DWI) was used to measure fractional anisotropy (FA), an indirect indicator of white matter properties.

RESULTS

Relative to TD children, children in the DBD group had reduced FA on four out of the five fiber tracks we examined (except for cingulum and right ILF), even after accounting for whole brain FA, sex, movement, parental income, and IQ. Within the DBD group, no associations were found between CP and reduced white matter integrity across any of the fiber tracks examined. However, we found that even after accounting for CP, ADHD symptomology, and a host of covariates (whole brain FA, sex, movement, parental income, and IQ), CU behaviors were independently related to reduced FA in bilateral UF and left inferior fronto-occipital fasciculus (IFOF) in the DBD group, but this was not the case for TD children.

CONCLUSIONS

Alterations in the white matter microstructure within bilateral UF and left IFOF may be biomarkers of CU behaviors, even in very young children.

Parental Occupation Executive Training (POET): An Efficient Innovative Intervention for Young Children with Attention Deficit Hyperactive Disorder

Background: The American Academy of Pediatrics strongly recommends first-line treatment of preschool aged children with attention deficit hyperactivity disorder (ADHD) be parent- or teacher-administered behavior therapy.Aim: To assess the efficacy of Parental Occupation Executive Training (POET), a new intervention for young children with ADHD symptomatology.Materials and Methods: We implemented a controlled, counterbalanced design with a study and comparison group (72 children with mean age of 5.42 years identified as having ADHD symptomatology. using the DSM-IV and Conners Parents and Teachers Rating Scales). Intervention included parental-training sessions focused on children's occupational goals and capitalized on the assumed relationship between daily activities and executive functions. We evaluated achievement with the Canadian Occupational Performance Measure (COPM), Behavioral Rating Inventory of Executive Functions, and a questionnaire we developed related to parental knowledge and skills.Results: Executive functions and preselected daily functions significantly improved following the POET intervention. Parent perceptions related to their knowledge of their children's executive difficulties and appropriate management strategies changed significantly following the intervention, and significantly correlated with the COPM scores.Conclusions: A short-term parental training program, the POET improved daily functioning of young children with ADHD symptomatology by focusing on their parents' ability to cope with the children's executive delays.

Practitioner Review: Emotional dysregulation in attention-deficit/hyperactivity disorder - implications for clinical recognition and intervention

BACKGROUND

Because emotional symptoms are common in attention-deficit/hyperactivity disorder (ADHD) patients and associate with much morbidity, some consider it to be a core feature rather than an associated trait. Others argue that emotional symptoms are too nonspecific for use as diagnostic criteria. This debate has been difficult to resolve due, in part, to the many terms used to describe emotional symptoms in ADHD and to concerns about overlap with mood disorders.

METHODS

We sought to clarify the nature of emotional symptoms in ADHD by reviewing conceptual and measurement issues and by examining the evidence base regarding specificity of such symptoms for ADHD. We reviewed the various terms used to define emotional symptoms in ADHD, clarify how these symptoms are demarcated from mood disorders, and assess the possibility that symptoms of emotional impulsivity and deficient emotional self-regulation should be considered as core symptoms. We addressed psychiatric comorbidities, the effects of ADHD treatments on associated emotional dysregulation, and the utility of current rating scales to assess emotional symptoms associated with ADHD.

RESULTS

Emotional symptoms are common and persistent in youth and adults with ADHD. Although emotional symptoms are common in other psychiatric disorders, emotional impulsivity (EI), and deficient emotional self-regulation (DESR) may be sufficiently specific for ADHD to function as diagnostic criteria.

CONCLUSIONS

Emotional symptoms in ADHD cause clinically significant impairments. Although there is a solid theoretical rationale for considering EI and DESR to be core symptoms of ADHD, there is no consensus about how to define these constructs sin a manner that would be specific to the disorder. An instrument to measure EI and DESR which demarcates them from irritability and other emotional symptoms could improve the accuracy of diagnostic criteria for ADHD.

Practitioner Review: Current best practice in the use of parent training and other behavioural interventions in the treatment of children and adolescents with attention deficit hyperactivity disorder

BACKGROUND

Behavioural interventions are recommended for use with children and young people with attention deficit hyperactivity disorder (ADHD); however, specific guidance for their implementation based on the best available evidence is currently lacking.

METHODS

This review used an explicit question and answer format to address issues of clinical concern, based on expert interpretation of the evidence with precedence given to meta-analyses of randomised controlled trials.

RESULTS

On the basis of current evidence that takes into account whether outcomes are blinded, behavioural intervention cannot be supported as a front-line treatment for core ADHD symptoms. There is, however, evidence from measures that are probably blinded that these interventions benefit parenting practices and improve conduct problems which commonly co-occur with ADHD, and are often the main reason for referral. Initial positive results have also been found in relation to parental knowledge, children's emotional, social and academic functioning - although most studies have not used blinded outcomes. Generic and specialised ADHD parent training approaches - delivered either individually or in groups - have reported beneficial effects. High-quality training, supervision of therapists and practice with the child, may improve outcomes but further evidence is required. Evidence for who benefits the most from behavioural interventions is scant. There is no evidence to limit behavioural treatments to parents with parenting difficulties or children with conduct problems. There are positive effects of additive school-based intervention for the inattentive subtype. Targeting parental depression may enhance the effects of behavioural interventions.

CONCLUSIONS

Parent training is an important part of the multimodal treatment of children with ADHD, which improves parenting, reduces levels of oppositional and noncompliant behaviours and may improve other aspects of functioning. However, blinded evidence does not support it as a specific treatment for core ADHD symptoms. More research is required to understand how to optimise treatment effectiveness either in general or for individual patients and explore potential barriers to treatment uptake and engagement. In terms of selecting which intervention formats to use, it seems important to acknowledge and respond to parental treatment preferences.

Parent Training for Preschool ADHD in Routine, Specialist Care: A Randomized Controlled Trial

OBJECTIVE

Parent training is recommended for attention-deficit/hyperactivity disorder (ADHD) in preschool children. Evidence-based interventions are important, but only if they produce better outcomes than usual care.

METHOD

The authors conducted a multicenter, 2-arm, parallel-group, randomized controlled trial in routine specialist ADHD clinics in the Danish Child and Adolescent Mental Health Services. Children (N = 164, 3-7 years old) with ADHD received a well-established parent training program (New Forest Parenting Programme; n = 88) or treatment as usual (n = 76). The primary outcome was parent ratings of child ADHD symptoms. Secondary outcomes included teacher ratings and direct observations of ADHD symptoms. Outcomes were measured at baseline, after treatment, and at follow-up (36 weeks later). Representativeness of participants was evaluated against the total national cohort of children (N = 1,378, 3-7 years old) diagnosed with ADHD during the same period using the Danish Civil Registration System. Statistical analysis used a repeated measure model.

RESULTS

After treatment, the parent training program was superior to treatment as usual on parent-rated ADHD symptoms (p = .009; effect size d = 0.30) and on parenting self-efficacy and family strain. Effects persisted to 36 weeks after treatment. There were no effects on teacher ratings or direct observations of ADHD or on ratings of conduct problems or parenting. The clinical sample was similar to the national cohort of young children with ADHD.

CONCLUSION

Evidence-based parent training has value as an intervention for preschool ADHD in routine clinical settings. As in previous trials, effects were restricted to parent-reported outcomes. Surprisingly, there were no effects on child conduct problems.

CLINICAL TRIAL REGISTRATION INFORMATION

A Controlled Study of Parent Training in the Treatment of ADHD in Young Children (D'SNAPP). http://clinicaltrial.gov/;NCT01684644.

Latent Class Analysis of ADHD Neurodevelopmental and Mental Health Comorbidities

OBJECTIVE

Many children diagnosed with attention-deficit/hyperactivity disorder (ADHD) experience co-occurring neurodevelopmental and psychiatric disorders, and those who do often exhibit higher levels of impairment than children with ADHD alone. This study provides a latent class analysis (LCA) approach to categorizing children with ADHD into comorbidity groups, evaluating condition expression and treatment patterns in each group.

METHODS

Parent-reported data from a large probability-based national sample of children diagnosed with ADHD (2014 National Survey of the Diagnosis and Treatment of ADHD and Tourette Syndrome) were used for an LCA to identify groups of children with similar groupings of neurodevelopmental and psychiatric comorbidities among children with current ADHD (n = 2495). Differences between classes were compared using multivariate logistic regressions.

RESULTS

LCA placed children who were indicated to have ADHD into 4 classes: (low comorbidity [LCM] [64.5%], predominantly developmental disorders [PDD] [13.7%], predominantly internalizing disorders [PID] [18.5%], and high comorbidity [HCM] [3.3%]). Children belonging to the HCM class were most likely to have a combined ADHD subtype and the highest number of impaired domains. Children belonging to the PDD class were most likely to be receiving school services, whereas children in the PID class were more likely to be taking medication than those belonging to the LCM class who were least likely to receive psychosocial treatments.

CONCLUSION

Latent classes based on co-occurring psychiatric conditions predicted use of varied treatments. These findings contribute to the characterization of the ADHD phenotype and may help clinicians identify how services could be best organized and coordinated in treating ADHD.

Do parental ADHD symptoms reduce the efficacy of parent training for preschool ADHD? A secondary analysis of a randomized controlled trial

Previous studies have suggested that children with Attention-Deficit/Hyperactivity Disorder (ADHD) may benefit less from behavioral parent training (BPT) if their parents have high levels of ADHD symptoms. We conducted a secondary analysis of data from a randomized controlled trial to test the hypothesis that parental ADHD symptoms reduce the efficacy of two BPT programs in a sample of preschoolers with ADHD. One intervention was specifically designed for children with ADHD (NFPP: New Forest Parenting Programme) and one was designed for children with Oppositional Defiant Disorder (ODD) (HNC: Helping the Noncompliant Child). Neither intervention was adapted to address parental ADHD symptoms. This secondary analysis included data from 164 parents and their 3-4 year-old children who were randomly assigned to one of the two programs or a waitlist group. Children were compared on ADHD and ODD outcomes at post-intervention and a 6-month follow-up. The presence of parent ADHD symptoms reduced the efficacy of BPT in only one of 16 analyses. Implications and limitations (e.g., low baseline rate of parental ADHD symptoms) of the findings are provided.

Attention Deficit Hyperactivity Disorder in Preschool-Age Children

Attention deficit hyperactivity disorder is a neurodevelopmental disorder marked by age-inappropriate deficits in attention or hyperactivity/impulsivity that interfere with functioning or development. It is highly correlated with other disorders, such as oppositional defiant disorder, conduct disorder, and mood symptoms. The etiology is multifactorial, and neuroimaging findings are nonspecific. Although assessment tools exist, there is variability among them, and historically, parent-teacher agreement has not been consistent. Treatment algorithm for attention deficit hyperactivity disorder in preschoolers includes behavioral interventions first followed by psychopharmacologic treatment when behavioral therapies fail. Other nonpharmacologic and nonbehavioral interventions are discussed including the role of exercise and nutrition.

Addressing Early Childhood Emotional and Behavioral Problems

More than 10% of young children experience clinically significant mental health problems, with rates of impairment and persistence comparable to those seen in older children. For many of these clinical disorders, effective treatments supported by rigorous data are available. On the other hand, rigorous support for psychopharmacologic interventions is limited to 2 large randomized controlled trials. Access to psychotherapeutic interventions is limited. The pediatrician has a critical role as the leader of the medical home to promote well-being that includes emotional, behavioral, and relationship health. To be effective in this role, pediatricians promote the use of safe and effective treatments and recognize the limitations of psychopharmacologic interventions. This technical report reviews the data supporting treatments for young children with emotional, behavioral, and relationship problems and supports the policy statement of the same name.