Which Techniques Work in Behavioral Parent Training for Children with ADHD? A Randomized Controlled Microtrial

Innovations in Practice: Brief behavioral parent training for children with impairing ADHD characteristics - a pilot study

BACKGROUND

Behavioral parent training (BPT) is a well-established intervention for children with attention-deficit/hyperactivity disorder (ADHD), but most programs are long, which may limit their accessibility. This could be improved by making programs shorter. Here, we studied (1) the feasibility of a new brief BPT program and its procedures, and (2) pre-post changes in daily rated problem behaviors (primary outcome), children's disruptive behaviors, ADHD/ODD characteristics, impairment, and parents' sense of parenting competence (secondary outcomes).

METHODS

We conducted a nonrandomized pilot study including parents of 28 children (4-12 years) with impaired ADHD characteristics. We examined treatment dropout, parent and therapist satisfaction, recruitment rates, study drop-out, measurement response and completion rates, acceptability of measurements according to parents, and treatment fidelity. Pre-post changes in the treatment group were compared to those in a historical control group using mixed model analysis, except for those outcomes that were not assessed in the control group. Within-group differences were analyzed for all outcomes.

RESULTS

Feasibility of the program and study procedures were good. Treatment dropout was 14.2%, parents and therapists were satisfied with the new program. We recruited 1.5 participants per month, study dropout was 10.7%, response/completion rates ranged from 82% to 100%, measurements were acceptable for parents, and treatment fidelity was 96%. We found substantial within-group changes (d's = .68-.77) and medium-sized between-group changes (d's = .46-.48) on daily rated problem behaviors. We observed no changes on most of the secondary outcomes, except for disruptive behaviors and impairment.

CONCLUSION

Our newly developed brief BPT program was feasible and we observed improvements in children's daily-rated problem behaviors. These results suggest that brief BPT might be beneficial for clinical practice if the findings are confirmed in large-scale randomized controlled trials.

Parent Training for Disruptive Behaviors in Referred Children with Autism Spectrum Disorder: A Randomized Controlled Trial

The purpose of this study was to investigate whether face-to-face and therapist-assisted online (i.e., blended) behavioral parent training are effective on reducing disruptive behaviors in children with autism spectrum disorder (ASD) in routine mental health care. Ninety-seven children with ASD (4-13 years; 76 boys) were randomized to face-to-face parent training, blended parent training, or a waitlist control condition. We assessed treatment effects on parent-rated child noncompliance (primary outcome) and irritability (secondary outcome). This involved comparing both formats separately to the control condition using linear regression models. Child behaviors at 6 months follow-up were also examined. Children in the face-to-face parent training condition improved significantly more on noncompliance and irritability than children in the waitlist condition and improvements sustained to 6 months follow-up. Children in the blended condition did not improve more than children in the waitlist condition and attrition was high. Our results extend findings from efficacy studies to routine mental health care and advocate the use of face-to-face parent training for disruptive behaviors in children with ASD. More research into blended parent training programs for children with ASD and disruptive behaviors in routine mental health care should be conducted to draw more definite conclusions about the value of blended parent training for these children. Trial registration number NL4712; date of registration 22-10-2014.

The Relationship Between Symptom Change and Use of a Web-Based Self-Help Intervention for Parents of Children With Externalizing Behavior Disorders: Exploratory Study

BACKGROUND

Web-based self-help (WASH) has been found to be effective in the treatment of child externalizing behavior disorders. However, research on the associations of caregivers' use of WASH and symptom changes of child externalizing behaviors is lacking.

OBJECTIVE

This study examined the longitudinal and reciprocal associations between the use of WASH by caregivers of children with externalizing behavior disorders and their children's externalizing behavior symptoms.

METHODS

Longitudinal data of 276 families from 2 intervention conditions of a randomized controlled trial (either unguided or supported by a therapist over the phone) were analyzed. Caregiver- and clinician-rated child externalizing behavior symptoms were assessed before (T1), in the middle (T2), and after the 6-month WASH intervention (T3). Additionally, 2 indicators of the caregivers' use of the WASH intervention were considered: number of log-ins (frequency) and the percentage of completed material (intensity). Associations of caregivers' use during early (T1-T2) and late (T2-T3) treatment with child externalizing behavior symptoms were analyzed using path analyses (structural equation modeling).

RESULTS

Frequency and intensity of use were higher during the first 3 months than during the next 3 months of the intervention period. The number of log-ins at early treatment was significantly but weakly associated with caregiver-reported child externalizing behavior symptoms in the long term (T3). Moreover, caregiver-reported child externalizing severity at T2 predicted the number of log-ins in the late treatment. The results were not replicated when considering the percentage of completed material as a measure of use or when considering clinician ratings of child externalizing behavior symptoms.

CONCLUSIONS

The findings provide the first, albeit weak, evidence for longitudinal associations between caregivers' use of WASH and improvements in caregiver-rated child externalizing behavior symptoms. However, as the associations were rather weak and could not be replicated across different rater perspectives and operationalizations of use, further research is needed to better understand these relations and their interplay with other putative influence factors (eg, quality of the implementation of the interventions, changes in parenting behaviors).

TRIAL REGISTRATION

German Clinical Trials Register DRKS00013456; https://www.drks.de/DRKS00013456.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12888-020-2481-0.

The short- and longer-term effects of brief behavioral parent training versus care as usual in children with behavioral difficulties: study protocol for a randomized controlled trial

BACKGROUND

The access to and uptake of evidence-based behavioral parent training for children with behavioral difficulties (i.e., oppositional, defiant, aggressive, hyperactive, impulsive, and inattentive behavior) are currently limited because of a scarcity of certified therapists and long waiting lists. These problems are in part due to the long and sometimes perceived as rigid nature of most evidence-based programs and result in few families starting behavioral parent training and high dropout rates. Brief and individually tailored parenting interventions may reduce these problems and make behavioral parent training more accessible. This protocol paper describes a two-arm, multi-center, randomized controlled trial on the short- and longer-term effectiveness and cost-effectiveness of a brief, individually tailored behavioral parent training program for children with behavioral difficulties.

METHODS

Parents of children aged 2-12 years referred to a child mental healthcare center are randomized to (i) three sessions of behavioral parent training with optional booster sessions or (ii) care as usual. To evaluate effectiveness, our primary outcome is the mean severity of five daily ratings by parents of four selected behavioral difficulties. Secondary outcomes include measures of parent and child behavior, well-being, and parent-child interaction. We explore whether child and parent characteristics moderate intervention effects. To evaluate cost-effectiveness, the use and costs of mental healthcare and utilities are measured. Finally, parents' and therapists' satisfaction with the brief program are explored. Measurements take place at baseline (T0), one week after the brief parent training, or eight weeks after baseline (in case of care as usual) (T1), and six months (T2) and twelve months (T3) after T1.

DISCUSSION

The results of this trial could have meaningful societal implications for children with behavioral difficulties and their parents. If we find the brief behavioral parent training to be more (cost-)effective than care as usual, it could be used in clinical practice to make parent training more accessible.

TRIAL REGISTRATION

The trial is prospectively registered at ClinicalTrials.gov (NCT05591820) on October 24th, 2022 and updated throughout the trial.

Parent training for disruptive behavior symptoms in attention deficit hyperactivity disorder: a randomized clinical trial

Background

Attention-Deficit/Hyperactivity Disorder (ADHD) affects 5% of children and 2.5% of adults worldwide. Comorbidities are frequent, and Oppositional Defiant Disorder (ODD) reaches 50%. Family environment is crucial for the severity of behaviors and for prognosis. In middle-income countries, access to treatment is challenging, with more untreated children than those under treatment. Face-to-face behavioral parent training (PT) is a well-established intervention to improve child behavior and parenting.

Method

A clinical trial was designed to compare PT-online and face-to-face effects to a waiting list group. Outcomes were the ADHD and ODD symptoms, parental stress and styles, and quality of life. Families were allocated into three groups: standard treatment (ST), ST + PT online, and ST + Face-to-Face PT. We used repeated measures ANOVA for pre × post treatment analysis corrected for multiple comparisons.

Results and discussion

Parent training was effective in reducing symptoms of ADHD (p = 0.030) and ODD (p = 0.026) irrespective of modality (p = 1.000). The combination of ST and PT was also associated with better quality of life in the physical domain for patients (p = 0.009) and their parents (p = 0.050). In addition to preliminary data, online intervention seems effective for parenting and improving social acceptance of children. The potential to reach many by an online strategy with a self-directed platform may imply effectiveness with a low cost for public health to support parents' symptoms management.

Components of Behavioral Parent Training for Children With Attention-Deficit/Hyperactivity Disorder: A Series of Replicated Single-Case Experiments

Behavioral parent training (BPT) is an evidence-based treatment for children with attention-deficit/hyperactivity disorder (ADHD). Stimulus control techniques (antecedent-based techniques, e.g., clear rules, instructions) and contingency management techniques (consequent-based techniques, e.g., praise, ignore) are the most common ones that are being taught to parents in BPT. However, research into the additive effects of these techniques is scarce. In this replicated single-case experimental ABC phase design, including six children on stable medication for ADHD (8-11 years) and their parents, the added efficacy of consequent-based techniques on top of antecedent-based techniques was evaluated. After a baseline period (phase A), we randomized the commencement time of two sessions parent training in antecedent-based techniques and two sessions parent training in consequent-based techniques for each child. Children's behaviors were assessed by daily parent ratings of selected problem behaviors and an overall behavior rating. Although visual inspection showed that behavior improved for most children in both phases, randomization tests did not demonstrate the added efficacy of the consequent-based techniques on top of the antecedent-based techniques. Limitations of the study and recommendations for future single-case experiments in this population are discussed.

Prospective associations between child screen time and parenting stress and later inattention symptoms in preschoolers during the COVID-19 pandemic

Introduction

Child attention skills are critical for supporting self-regulation abilities, especially during the first years of life. On the other hand, inattention symptoms in preschoolers have been associated with poor school readiness, literacy skills and academic achievement. Previous research has linked excessive screen time with increased inattention symptoms in early childhood. However, most research has only focused on TV exposure and did not investigate this association during the COVID-19 pandemic. This atypical context has increased screen time in children worldwide, including preschoolers. We hypothesize that higher levels of child screen media and parenting stress at age 3.5 will be associated with higher child inattention symptoms at age 4.5.

Method

This study draws on participants followed longitudinally over the span of 2-years for an investigation of Canadian preschoolers' screen media use during the pandemic (N = 315, 2020). A follow-up with this sample was completed in 2021 (N = 264).

Results

Analyses using multiple linear regression, revealed a positive association between child screen time at age 3.5 and inattention symptoms at 4.5 years. Parental stress was also positively associated with child inattention symptoms. Associations were observed above individual (child age, inhibitory control, and sex) and family (parent education and family income) characteristics.

Discussion

These results confirmed our hypothesis and highlight that preschooler screen use and parenting stress may undermine attentional skills. Since attention is a crucial component for children development, behavior and academic outcomes, our study reinforces the importance for parents of adopting healthy media habits.

[Pharmacotherapy and psychotherapy of children with attention deficit hyperactivity disorder]

The article presents a review of scientific publications devoted to the main psychotherapeutic approaches that have shown their effectiveness in correcting behavior in children with attention-deficit/hyperactive disorder (ADHD). The principles of psychotherapeutic methods are outlined to reduce the severity of the main symptoms of ADHD and improve the social adaptation of children with this disease. Approaches to the drug therapy of ADHD and the results of studies on the effectiveness of various drugs used to treat this pathology are considered.

Understanding Problematic Social Media Use in Adolescents with Attention-Deficit/Hyperactivity Disorder (ADHD): A Narrative Review and Clinical Recommendations

Attention-Deficit/Hyperactivity Disorder (ADHD) is consistently associated with a host of social problems, such as victimization and difficulties in maintaining close friendships. These problems are not limited to offline relations but also manifest in the online social world, as previous research shows that ADHD is associated with problematic use of social media. Given the ubiquitous nature of social media, the goal of the current review is to understand why adolescents with ADHD demonstrate more problematic social media use than their typically developing peers. To this end, we provide a narrative review on the evidence for the link between ADHD and social media use, and consequently present an integrative framework, which encompasses neurobiological mechanisms (i.e., imbalance theory of brain development and dual pathway model of ADHD) and social mechanisms, including influences from peers and parents. We conclude that empirical work shows most consistent evidence for the link between problematic social media use and ADHD (symptoms), while intensity of social media use is also associated with several other behaviors and outcomes. Finally, we hypothesize how existing interventions for ADHD may work on the identified mechanisms and provide at-hand clinical recommendations for therapists working with adolescents with ADHD who exhibit problematic social media use.

Multiple needs and multiple treatments. What's a clinician to do? Update on the psychosocial treatment of disruptive behaviours in childhood

PURPOSE OF REVIEW

There are a wide range of psychosocial treatment options, delivered in different modalities, for children with disruptive behaviour. However, clinicians face many challenges in ensuring the empirically supported treatments (ESTs) they select will be effective for their patient. This has prompted studies to generate knowledge on how to improve treatment outcomes for children with disruptive behaviour. This review identifies the major challenges in treatment selection as well as emerging research seeking to improve outcomes.

RECENT FINDINGS

This review emphasizes the salience of the research-practice gap associated with establishing ESTs using narrow definitions of clinical problems. Recent research is reviewed considering the complex determinants of disruptive behaviours, including parent and family factors that influence outcomes. The review subsequently outlines recent advances in research and clinical practice guidelines aiming to surmount these challenges. Key advances discussed include examining the most impactful components of ESTs, personalizing interventions by targeting core dysfunction underlying behaviour, and addressing parent factors including mental health and cultural relevance to improve outcomes.

SUMMARY

Thorough assessment of patients' needs, combined with knowledge of treatment response predictors, are recommended to determine the most suitable treatment plan. Recent advances have focused on developing and designing interventions that meet needs in a way that is flexible and tailored.

Pandemic Perils and Promise: Implementation of a Virtual Parenting Intervention during COVID-19 among Children with Early Neurological Conditions

OBJECTIVE

In this study, we examined feasibility, acceptability, and preliminary efficacy of a telepsychological positive parenting intervention (I-InTERACT-North, Internet-basedInteracting Together Everyday: Recovery After Childhood Traumatic Brain Injury) during the COVID-19 pandemic among Canadian families of children at-risk for neurodevelopmental challenges given congenital or neonatal conditions. I-InTERACT-North was developed to improve behavioral and emotional outcomes in children with neurological conditions by utilizing and adapting parenting strategies from several established family-focused programmes.

METHODS

A pragmatic prospective pre-post single-site pilot study design was used to assess feasibility, acceptabilty, and preliminary efficacy of I-InTERACT North during the COVID-19 pandemic.

RESULTS

Thirty-five families of children ages three to nine years were referred between March 2020 and January 2021. Eighteen families enrolled, and 12 (67% adherence) completed the programme. Parents reported strong therapeutic alliance and programme acceptability with barriers due to competing time demands. Therapists reported high acceptability but perceived parental burnout. Parenting confidence (d = 0.70), and child behavior (d = 1.30) improved following the intervention.

CONCLUSIONS

Results demonstrate the programme's value to families during the pandemic, while underscoring unique participation barriers. Future research and clinicial implications are discussed.

ADHD-Gaming Disorder Comorbidity in Children and Adolescents: A Narrative Review

Attention Deficit/Hyperactivity Disorder (ADHD) is a neurobiological condition characterized by developmentally inadequate levels of inattention, hyperactivity, and impulsivity, and a neurobiological disruption in brain neurotransmitters and circuitry causing abnormal responses to rewards. Playing electronic games generates a biological response that activates the neuronal circuits linked to pleasure and reward, and there is a growing attention to this type of activity, which can also turn into a mental health condition. The existence and the boundaries between the functional and the dysfunctional are still a source of debate, with the recognition of 'Internet Gaming Disorder' (IGD) as a condition belonging to the broader area of addiction requiring more in-depth study with respect to the DSM-5, while 'Gaming Disorder' (GD) was officially recognized as a new diagnosis by the World Health Organization (WHO) in the updated revision of the International Classification of Diseases (ICD-11). Notwithstanding, the suggested criteria for the diagnosis of Gaming Disorder are still debated. Since ADHD has been reported as a risk factor for developing addictions, this narrative review aims to provide the current state-of-the art of the knowledge about the comorbidity between ADHD and Gaming Disorder. For this aim, a literature search was conducted using a combination of specific keywords and the results are discussed within the R-Do-C framework and dimensions, and implications for treatment are considered.

Review: Which components of behavioral parent and teacher training work for children with ADHD? - a metaregression analysis on child behavioral outcomes

BACKGROUND

This metaregression analysis examined which behavioral techniques that are commonly used in behavioral parent and teacher training programs for children with attention-deficit/hyperactivity disorder (ADHD) were related to program effectiveness on children's behavioral outcomes.

METHODS

We included 32 randomized controlled trials (N = 2594 children) investigating behavioral parent training, teacher training, or a combination, in children with ADHD under 18 years. Outcomes were symptom counts of total ADHD, inattention, and hyperactivity-impulsivity and behavioral problems. The dosage of techniques was extracted from the intervention manuals. Metaregression was used to assess which techniques and intervention characteristics (setting, delivery method, duration, and home-school collaboration) were associated with intervention effectiveness.

RESULTS

Higher dosage of psycho-education for parents was associated with smaller effects on behavioral problems and, only in case of parent training, also with smaller effects on ADHD symptoms. Higher dosage of teaching parents/teachers to use negative consequences was associated with larger effects on behavioral problems. Individual training compared with group training was associated with larger effects on ADHD and hyperactivity-impulsivity symptoms.

CONCLUSIONS

This study provides first insights into the specific techniques that are essential in behavioral parent and teacher training programs for children with ADHD. This knowledge can eventually be used to improve and tailor interventions.

Attachment Representation Moderates the Effectiveness of Behavioral Parent Training Techniques for Children with ADHD: Evidence from a Randomized Controlled Microtrial

Behavioral parent training is an evidence-based intervention for children with attention-deficit/hyperactivity disorder (ADHD), but knowledge on the differential effects of behavioral techniques for specific subgroups of children is very limited. Attachment representations of children with ADHD may affect how receptive children are to changes in parenting. In this study, we investigated whether specific behavioral techniques were more or less effective for children with ADHD in relation to their attachment representations. We included parents of 74 children with ADHD (4-11 years, M = 8.15) who took part in a larger randomized controlled microtrial in which they were randomized to a two session training in antecedent-based techniques (i.e., stimulus control techniques: rules, instructions; n = 26), a two session training in consequent-based techniques (i.e., contingency management techniques: praise, rewards, ignoring; n = 25) or a waitlist control condition (n = 23). We examined whether attachment representation moderated the effectiveness of a) training versus waitlist, and b) antecedent- versus consequent-based techniques. Attachment representations were measured with a story stem task, the intervention outcome was daily parent-rated problem behaviors of the children. Attachment representation did not moderate the effects of the training compared to the waitlist. However, compared to antecedent-based techniques, consequent-based techniques were less effective for more securely and less disorganized attached children, and particularly effective for more disorganized attached children. This was the first study examining attachment as a moderator of behavioral techniques for ADHD. If replicated, the findings of this study can be used for treatment development and tailoring.

Effectiveness of Specific Techniques in Behavioral Teacher Training for Childhood ADHD Behaviors: Secondary Analyses of a Randomized Controlled Microtrial

Behavioral teacher training is an effective intervention for children with attention-deficit/hyperactivity disorder (ADHD). Intervention effectiveness may be enhanced by including intervention components that carry the strongest evidence for their effectiveness. A previous article of this group showed that both antecedent- (i.e., stimulus-control) and consequent-based (i.e., contingency management) techniques were highly effective in reducing daily teacher-rated, individually selected problem behaviors in a specific situation of the child. Effects were observed up to three months post intervention. Here, we tested whether effects were also present in teacher-rated and masked DSM-based assessments that comprise the full range of ADHD and oppositional defiant disorder (ODD) symptoms, as well as on teacher-rated impairment. Teachers of 90 children with (subthreshold) ADHD (6–12 years) were randomly assigned to one of three conditions: a short (two sessions), individualized intervention consisting of either a) antecedent-based techniques or b) consequent-based techniques; or c) waitlist. Multilevel analyses showed that both sets of techniques were effective in reducing teacher-rated ADHD symptoms and impairment immediately after the intervention and up to three months later, as compared to waitlist. Masked observations of ADHD behavior were in line with teacher ratings, with effects being most pronounced for inattention. No effects on teacher-rated or masked ODD behavior were found. This study showed that antecedent- and consequent-based techniques were effective in improving classroom ADHD symptoms and impairment. Long-term changes in teacher-rated ADHD are promising. These results extend previous findings and show the potential of short individually tailored interventions in classroom settings as treatment of ADHD symptoms.

Attachment Representations in Children with and without Attention-Deficit/Hyperactivity Disorder (ADHD)

Attention-Deficit/Hyperactivity Disorder (ADHD) in children is associated with several adverse family characteristics, such as higher parenting stress, more conflicted parent–child relationships, lower parental competence, and higher levels of parental psychopathology. Hence, children with ADHD more often grow up under suboptimal circumstances, which may impact the development of their attachment representations. Here, we investigated whether children with ADHD have more insecure and disorganized attachment representations than their typically developing peers, and which factors could explain this association. We included 104 children between 4 and 11 years old, 74 with ADHD (without Conduct Disorder) and 30 typically developing control children. Children completed a state-of-the-art story stem task to assess their attachment representation, and we measured parents’ expressed emotion (as an index of parent–child relationship quality), parents’ perceived sense of competence, parental education levels, and parent-rated ODD symptoms of the child. We found that, after controlling for multiple comparisons, children with ADHD had less secure and more ambivalent and disorganized attachment representations relative to their typically developing peers. These group differences were independent of comorbid ODD and parental education levels. There were no group differences on avoidant attachment representations. Explorative analyses within the ADHD group showed that attachment representations were not related to parent–child relationship quality, perceived parenting competence, parental education levels, and comorbid ODD symptoms. We conclude that children with ADHD disproportionately often have attachment problems. Although this conclusion is important, treatment implications of this co-occurrence are yet unclear as research on ADHD and attachment is still in its infancy.