Randomized Controlled Trial comparing the effectiveness of structured-play (ENGAGE) and behavior management (TRIPLE P) in reducing problem behaviors in preschoolers

Play With Me: Effects of a shared activities parenting intervention on parenting and relative reinforcing value of food

This pilot randomized controlled trial evaluated impacts of a novel shared activities intervention designed to promote positive parent-child interactions, which may function as an alternative reinforcer to food. The 4-week, at-home Play With Me intervention combines didactic parenting videos and play kits with materials for parent-child activities to practice skills. Aims of the present study were to examine the intervention's acceptability and its effects on parenting and the relative reinforcing value (RRV) of food versus parent-child activity at post-intervention. Thirty-two parents of 4-to-5-year-old children at risk for obesity were randomly assigned to the intervention or a waitlist control group. The intervention was well-liked by parents and feasible. Intervention parents reported more parenting structure and demonstrated higher observed sensitive parenting than controls at post; the latter finding was driven by greater parent positive mood, warmth, positive reinforcement, and relationship quality, with large effect sizes. There were no effects on the RRV of food. Inconsistent with hypotheses, there were trends toward control group parents reporting more parenting satisfaction and efficacy at post. Possible explanations are discussed. Results suggest Play With Me shows promise as an effective and acceptable intervention to promote positive parenting. Further research is needed to examine these effects and their implications for socioemotional development and health in a larger, more diverse sample over a longer time frame.

Interventions to improve executive functions in children aged 3 years and under: A systematic review

BACKGROUND

Early executive functioning (EF) skills are foundational capabilities that predict school readiness, academic development and psychiatric risk. Early interventions enhancing these capabilities could have critical import in improving outcomes. However, to develop interventions, it is necessary to identify specific EF skills that will vary with child age. Thus, we aimed to examine the characteristics and efficacy of interventions targeting EF in infancy and early childhood up to age 3.

METHODS

A comprehensive search of PubMed, Embase, CINAHL and APA PsycINFO databases was performed for studies published before December 2022. Randomized and non-randomized studies of interventions designed to improve at least one EF skill in children ≤3 years were included. EF skills included attentional control, inhibition/self-regulation, activity initiation, working memory, cognitive flexibility, planning ability, problem-solving and performance monitoring. We independently extracted data, used the revised Cochrane Risk-of-Bias tool to assess the quality of the evidence and conducted Synthesis Without Meta-analysis (SWiM). The overall quality of the evidence and the strength of recommendations was determined using elements of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Thirty-five studies met inclusion criteria (original n = 7467). Studies were highly variable in the EF skill targeted, target subject (i.e., child, parent and teacher), nature and dosage of the intervention, and timing of outcome assessment. Most interventions focused on improving impulse control and self-regulation. The overall quality of evidence was low to moderate with a high risk of bias, though six studies had low risk of bias but yielded mixed findings of efficacy.

CONCLUSIONS

The relatively small number of early EF intervention studies uses such variable methods that there is currently no converging evidence of efficacy to recommend a specific intervention. Thus, findings support the need for a more systematic, targeted approach to the design and implementation of early EF interventions for target populations.

Effectiveness of ENGAGE in reducing difficulties in everyday executive functions among Finnish preschoolers: a randomized controlled trial

Effective interventions applicable for young preschool-age children are needed to reduce the risk of widespread and sustained adversities that are linked to early executive function (EF) difficulties. This randomized controlled trial (RCT) examined the effectiveness of the play-based ENGAGE intervention in improving behavioral outcomes related to EFs among Finnish preschool-age children with hyperactivity and/or inattention problems. 95 children between 4 and 5 years of age and their parents were randomly assigned to the ENGAGE intervention or a waitlist control group. Parents and early childhood education (ECE) teachers rated the children's EF difficulties and problem behaviors at pre-intervention, post-intervention, and 5-month follow-up. Repeated measures linear mixed modeling was used to examine the effect of ENGAGE on child outcomes. Those receiving ENGAGE exhibited significantly greater decreases in parent-rated attentional problems, hyperactivity/impulsivity, and acting out behaviors than the control group did, with mostly moderate effect sizes. No consistent improvements in the teacher ratings of children's EF related difficulties were found in either group. Low dropout (8%) from the intervention and high acceptability ratings indicated that ENGAGE is a palatable intervention for parents. The present study showed that findings from an earlier RCT on ENGAGE conducted in New Zealand could be generalized to a different cultural setting, as the intervention effectively reduced young Finnish children's EF difficulties in the home context. Extending ENGAGE and other play-based interventions into different everyday contexts of children, such as ECE, could further enhance the beneficial effects on children's EFs and behavior.

Kia Tīmata Pai (Best Start): a study protocol for a cluster randomised trial with early childhood teachers to support children's oral language and self-regulation development

INTRODUCTION

Oral language skills are associated with children's later self-regulation and academic skills; in turn, self-regulation in early childhood predicts successful functioning later in life. The primary objective of this study is to evaluate the separate and combined effectiveness of an oral language intervention (Enhancing Rich Conversations, ENRICH) and a self-regulation intervention (Enhancing Neurocognitive Growth with the Aid of Games and Exercise, ENGAGE) with early childhood teachers and parents for children's oral language, self-regulation and academic functioning.

METHODS AND ANALYSIS

The Kia Tīmata Pai (Best Start) study is a cluster randomised controlled trial with teachers and children in approximately 140 early childhood centres in New Zealand. Centres are randomly assigned to receive either oral language intervention only (ENRICH), self-regulation intervention only (ENGAGE), both interventions (ENRICH+ENGAGE) or an active control condition. Teachers' and parents' practices and children's oral language and self-regulation development are assessed at baseline at age 1.5 years and approximately every 9 months to age 5, and academic performance at age 6. Teacher-child interactions will also be videotaped each year in a subset of the centres. Children's brain and behaviour development and parent-child interactions will be assessed every 6 months to age 6 years in a subgroup of volunteers.

ETHICS AND DISSEMINATION

The Kia Tīmata Pai trial and the two substudies (Video Project; Brain and Behaviour Development) have been approved by the University of Otago Human Ethics Committee (Health; H20/116), and reviewed for cultural responsiveness by: the Ngāi Tahu Research Committee (University of Otago), the Māori Advisory Group (University of Auckland, Liggins Institute) and an internal cultural advisory group. Results will be disseminated in international and national peer-reviewed academic journals and communicated to local, national and international organisations serving early childhood teachers, parents and young children. Data will be available via communication with the corresponding author.

TRIAL REGISTRATION NUMBER

ACTRN12621000845831.

Play is a play, is a play, is a play… or is it? Challenges in designing, implementing and evaluating play-based interventions

When a social-emotional learning (SEL) intervention is implemented in an early childhood classroom, it often involves play. Some interventions even list play as its main component. However, the advocates of play arguing for the return of play in early childhood education (ECE) classrooms still have difficulty convincing the proponents of more rigorous academic instruction. These proponents cite research pointing to the insufficient evidence of the positive effect of play on children’s short- and longer-term social, emotional, cognitive, and behavioral outcomes as well as their overall well-being. We believe that there are multiple issues with play-based interventions’ design, implementation, and evaluation that might account for this insufficient evidence. In our paper, we discuss the numerous ways play does (or does not) feature in SEL interventions and how it might affect the outcomes of these interventions. We also examine the methodological challenges of having child-controlled play as a component of an SEL intervention. While we are not proposing a specific protocol for re-evaluation of the results of existing interventions, we outline some ways such re-evaluation can be possible in the future, along with the development and evaluation of new play-based SEL interventions.

Adaption and implementation of the engage programme within the early childhood curriculum

Poor self-regulation has been associated with an array of adverse outcomes including difficulties with school transition, educational attainment, and social functioning in childhood, and employment, mental health, physical health, relationships, and criminal activity in adulthood. Enhancing Neurobehavioural Gains with the Aid of Games and Exercises (ENGAGE) is a play-based intervention fostering the development of self-regulation in pre-schoolers and has led to improvements within the home setting. The aim for this study was to ascertain whether ENGAGE can be implemented within an Early Childhood Education (ECE) group setting and whether this leads to improved self-regulation. This trial has been registered with the Australian New Zealand Clinical Trials Registry (ANZCTR); trial number ACTRN12622000364774; trial web address: https://www.anzctr.org.au/ACTRN12622000364774.aspx . 668 children aged 3-5 years and their teachers, across 28 ECEs participated. Children's self-regulation skills were assessed via scores on the Hyperactivity, Aggression, and Attention Problems subscales of BASC-2. Results indicted no significant changes in self-regulation skills across a 10-week waitlist period. Following 10 weeks of the ENGAGE programme, significant improvements in self-regulation were reported, and these were maintained at 2- and 6-month follow-up. These findings indicate that ENGAGE translates well into the ECE setting and has the potential to have population-based impacts which could lead to more positive societal outcomes.

Systematic Review and Meta-analysis: The Science of Early-Life Precursors and Interventions for Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

To evaluate which early neurocognitive and behavioral precursors are associated with the development of attention-deficit/hyperactivity disorder (ADHD) and whether these are currently targeted in early interventions.

METHOD

We conducted 2 systematic reviews and meta-analyses of empirical studies to examine the following: (1) early-life (0-5 years) neurocognitive and behavioral precursors associated with familial likelihood for ADHD, an early ADHD diagnosis/elevated ADHD symptoms, and/or the presence of later-childhood ADHD; and (2) interventions delivered to children aged 0 to 5 years targeting the identified precursors or measuring these as outcomes. Standardized mean differences (Hedges' g) and pre-post-treatment change scores (SMD) were computed.

RESULTS

A total of 149 studies (165,095 participants) investigating 8 neurocognitive and behavioral domains met inclusion criteria for part 1. Multi-level random-effects meta-analyses on 136 studies revealed significant associations between ADHD and poorer cognitive (g = -0.46 [95% CIs: -0.59, -0.33]), motor (g = -0.35 [CIs: -0.48, -0.21]) and language (g = -0.43 [CIs: -0.66, -0.19]) development, social (g = 0.23 [CIs: 0.03, 0.43]) and emotional (g = 0.46 [CIs: 0.33, 0.58]) difficulties, early regulatory (g = 0.30 [CIs: 0.18, 0.43]) and sleep (g = 0.29 [CIs: 0.14, 0.44]) problems, sensory atypicalities (g = 0.52 [CIs: 0.16, 0.88]), elevated activity levels (g = 0.54 [CIs: 0.37, 0.72]), and executive function difficulties (g = 0.34 [CIs: 0.05, 0.64] to -0.87 [CIs: -1.35, -0.40]). A total of 32 trials (28 randomized, 4 nonrandomized, 3,848 participants) testing early interventions that targeted the identified precursors met inclusion criteria for part 2. Multi-level random-effects meta-analyses on 22 studies revealed significant intervention-related improvements in ADHD symptoms (SMD = 0.43 [CIs: 0.22, 0.64]) and working memory (SMD = 0.37 [CIs: 0.06, 0.69]).

CONCLUSION

Children aged 0 to 5 years with current or later-emerging ADHD are likely to experience difficulties in multiple neurocognitive/behavioral functions. Early interventions show some effectiveness in reducing ADHD symptoms, but their effects on neurocognitive/behavioral difficulties require further study.

Training Executive, Attention, and Motor Skills (TEAMS): a Preliminary Randomized Clinical Trial of Preschool Youth with ADHD

This preliminary randomized controlled trial compared Training Executive, Attention and Motor Skills (TEAMS), a played-based intervention for preschool children with attention-deficit/hyperactivity disorder (ADHD), to an active comparison intervention consisting of parent education and support (ClinicalTrials.gov Identifier: NCT01462032). The primary aims were to gauge preliminary efficacy and assist in further development of TEAMS. Four- and 5-year-old children with ADHD were randomly assigned to receive TEAMS (N = 26) or the comparison intervention (N = 26) with blinded assessments by parents, teachers and clinicians ascertained pretreatment, post-treatment, and 1- and 3-months post-treatment. Changes in ADHD severity, impairment, parenting factors, and neuropsychological functioning over time as a function of treatment condition were assessed using the PROC MIXED procedure in SAS. Across most measures, significant main effects for Time emerged; both treatments were associated with reduced ADHD symptoms that persisted for three months post-treatment. There were no significant Treatment effects or Time x Treatment interactions on symptom and impairment measures, suggesting that the magnitude of improvement did not differ between the two interventions. However, significant correlations emerged between the magnitude of behavioral change, as assessed by parents and clinicians, and the amount of time families engaged in TEAMS-related activities during treatment. Across a wide array of parenting and neuropsychological measures, there were few significant group differences over time. TEAMS and other psychosocial interventions appear to provide similar levels of benefit. Play-based interventions like TEAMS represent a potentially viable alternative/addition to current ADHD treatments, particularly for young children, but more research and further development of techniques are necessary.