Parent training for preschool ADHD: a randomized controlled trial of specialized and generic programs

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.

Perception and behavior toward neuropsychiatric disorders in Saudi Arabia: A systematic review and quality assessment

LAY ABSTRACT

In 2010, Saudi Arabia became the first country from the Gulf Cooperation Council states to join the World Mental Health Survey Initiative, which collaborates with Harvard University and has undertaken over 33 countries. The Saudi National Mental Health Survey revealed that 80% of Saudis with severe mental health disorders do not seek treatment. Considering the strong evidence set out in Saudi national study and the recommendations for future research, this systematic literature review was initiated to examine the most studied neurodevelopmental disorders reported in the Kingdom of Saudi Arabia to explore public knowledge, attitudes, and behaviors. Findings have shown that attention deficit hyperactivity disorder and autism spectrum disorder have been the most studied neurodevelopmental disorders in Saudi Arabia since 2010. However, various groups in Saudi society, including healthcare professionals, medical students, and the general public, lacked knowledge about these health conditions, often leading to stigmatized attitudes and behaviors toward people with attention deficit hyperactivity disorder and autism spectrum disorder. However, demographic data showed that most of the studies were carried out in the Central and Western provinces. More research is needed in all regions of the Kingdom of Saudi Arabia to contribute to the knowledge about mental health conditions of attention deficit hyperactivity disorder and autism spectrum disorder children and their parents to increase knowledge about neurodevelopmental disorders and mental health disorders in the Kingdom of Saudi Arabia, thereby enabling people to rethink their attitudes and behavior.

Improving the efficacy and effectiveness of evidence-based psychosocial interventions for attention-deficit/hyperactivity disorder (ADHD) in children and adolescents

Attention-deficit/hyperactivity disorder (ADHD) is a prevalent, chronic, and impairing mental health disorder of childhood. Decades of empirical research has established a strong evidence-based intervention armamentarium for ADHD; however, limitations exist in regards to efficacy and effectiveness of these interventions. We provide an overview of select evidence-based interventions for children and adolescents, highlighting potential approaches to further improving the efficacy and effectiveness of these interventions. We conclude with broader recommendations for interventions, including considerations to moderators and under-explored intervention target areas as well as avenues to improve access and availability of evidence-based interventions through leveraging underutilized workforces and leveraging technology.

A pragmatic randomised controlled trial of the effectiveness and cost-effectiveness of Well Parent Japan in routine care in Japan: The training and nurturing support for mothers (TRANSFORM) study

BACKGROUND

Well Parent Japan (WPJ) is a new hybrid group parent training programme combining sessions to improve mothers' psychological well-being with a culturally adapted version of the New Forest Parenting Programme (NFPP). This study investigates the effectiveness and cost-effectiveness of WPJ against treatment as usual (TAU) within Japanese child mental health services.

METHODS

TRANSFORM was a pragmatic multi-site randomised controlled trial (RCT) with two parallel arms. Altogether 124 mothers of 6-12-year-old children with DSM-5 ADHD were randomised to WPJ (n = 65) or TAU (n = 59). Participants were assessed at baseline, post-treatment and three-month follow-up. The primary outcome was parent-domain stress following intervention. Secondary outcomes included maternal reports of child-domain stress, parenting practices, parenting efficacy, mood, family strain, child behaviour and impairment. Objective measures of the parent-child relationship were collected at baseline and post-treatment. Data analysis was intention to treat (ITT) with treatment effects quantified through analysis of covariance (ANCOVA) via multilevel modelling. An incremental cost-effectiveness ratio (ICER) assessed WPJ's cost-effectiveness.

RESULTS

WPJ was superior to TAU in reducing parent-domain stress post-treatment (adjusted mean difference = 5.05, 95% CI 0.33 to 9.81, p = .036) and at follow-up (adjusted mean difference 4.82, 95% CI 0.09 to 9.55, p = .046). Significant WPJ intervention effects were also observed for parenting practices, parenting efficacy and family strain. WPJ and TAU were not significantly different post-intervention or at follow-up for the other secondary outcomes. The incremental cost of WPJ was 34,202 JPY (315.81 USD). The probability that WPJ is cost-effective is 74% at 10,000 JPY (USD 108.30) per one-point improvement in parenting stress, 92% at 20,000 JPY (216.60 USD). The programme was delivered with high fidelity and excellent retention.

CONCLUSIONS

WPJ can be delivered in routine clinical care at modest cost with positive effects on self-reported well-being of the mothers, parenting practices and family coping. WPJ is a promising addition to psychosocial interventions for ADHD in Japan.

Mandated Parent Education: Applications, Impacts, and Future Directions

Mandated participation in parent education programs is a common practice across the United States for families who are undergoing divorce or who are involved in the child welfare or juvenile justice systems. Mandates to participate in parenting programs create substantial challenges for families, service providers, and service systems. Furthermore, the type and quality of the parenting services accessed vary widely, and their impacts need to be better understood. To address this need, an overview of the current state of the empirical literature on the impacts and outcomes of mandated parenting interventions for divorce and in child welfare and juvenile justice settings is provided, and suggestions to the field are offered to refine research related to mandated parenting programs. Given the challenges that mandated parenting programs pose, an alternative approach that views parenting through a public health lens is highlighted to build on the growing body of research on the impacts of population-wide applications of parenting support programs, and as a possible way to decrease the number of parents who are required to attend parenting programs. Opportunities to advance universal parenting support within a range of community settings, including primary care, early childhood education, and community mental health systems are offered. Gaps in knowledge regarding mechanisms of action of universal supports and impacts on the number of parents mandated to treatment are highlighted, and future directions for research in this area are suggested.

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.

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.

Sustained improvements by behavioural parent training for children with attention-deficit/hyperactivity disorder: A meta-analytic review of longer-term child and parental outcomes

Background

Behavioural parent training is an evidence-based intervention for children with attention-deficit/hyperactivity disorder (ADHD), but little is known about the extent to which initial benefits are maintained.

Aims

This meta-analytic review investigated longer-term (i.e., more than 2 months post-intervention) child and parental outcomes of behavioural parent training for children with ADHD.

Materials & Methods

We searched for randomized controlled trials and examined ADHD symptoms, behavioural problems, positive parenting, negative parenting, parenting sense of competence, parent-child relationship quality, and parental mental health as outcomes. We included 27 studies (31 interventions; 217 effect sizes), used multilevel random-effects meta-analyses for between- and within-group comparisons (pre-intervention to follow-up and post-intervention to follow-up), and explored twelve predictors of change.

Results

Between pre-intervention and follow-up (M = 5.3 months), we found significant small-to-moderate between-group effects of the intervention on ADHD symptoms, behavioural problems, positive parenting, parenting sense of competence and parent-child relationship quality. Within-group findings show sustained improvements in the intervention conditions for all outcome domains. There were few significant changes from post-intervention to follow-up. Additionally, the large majority of the individual effect sizes indicated sustained outcomes from post-intervention to follow-up. There were seven significant predictors of change in child outcomes, including stronger reductions in ADHD symptoms of girls and behaviour problems of younger children. In contrast with some meta-analyses on short-term effects, we found no differences between masked and unmasked outcomes on ADHD symptoms at follow-up.

Discussion & Conclusion

We conclude that behavioural parent training has longer-term benefits for children's ADHD symptoms and behavioural problems, and for positive parenting behaviours, parenting sense of competence and quality of the parent-child relationship.

Neural and behavioral effects of parent training on emotion recognition in mothers rearing children with attention-deficit/hyperactivity disorder

This randomized controlled study examined neurological changes in socioemotional processing skills through parent training in caregivers of children with attention-deficit/hyperactivity disorder. Thirty mothers of children with attention-deficit/hyperactivity disorder were stratified into parent training and non-parent training groups. Functional magnetic resonance imaging was performed during the "Reading the Mind in the Eyes" test, and parenting difficulties were evaluated using the Parenting Stress Index and the Parenting Scale, twice (before and after parent training). Only mothers in the parent training group showed a significant decrease in Parenting Stress Index and Parenting Scale scores. They also demonstrated increased activity in the left occipital fusiform gyrus during the task of estimating emotions from facial pictures. We presumed that these changes might reflect the potential impact of enrollment in parent training in reducing stress, which might have increased activation of the fusiform gyrus.

Children with ADHD Symptomatology: Does POET Improve Their Daily Routine Management?

Children with attention-deficit/hyperactivity disorder (ADHD) struggle with executive delays while managing their daily tasks. This is a secondary analysis of existing data from open-label research examining the efficacy of Parental Occupational Executive Training (POET). It further examines POET's efficacy in increasing young children's (3.83 to 7.08 years) executive control over daily routines, and in decreasing their ADHD symptoms. Additionally, the second analysis investigates which of the children's increased capabilities is better associated with the change in their daily routine management following the intervention. Parents of children with ADHD symptomatology (N = 72, 55 boys) received eight POET sessions. They completed standardised ADHD symptomatology, executive management of daily routines, and executive functions (EF) questionnaires at pretest, post-test, and 3-month follow-up. Children's ADHD symptoms and their management of daily routines significantly improved following the POET intervention. The children's score changes in EF accounted for 37% of the variance in their improved routine management. These findings suggest that interventions aiming to increase children's executive control over their daily routines should improve their broader array of EF besides decreasing core ADHD symptoms.

Conceptualizing the Role of Parent and Child Emotion Regulation in the Treatment of Early-Onset Behavior Disorders: Theory, Research, and Future Directions

Behavior disorders (BDs) are common and costly, making prevention and early-intervention a clinical and public health imperative. Behavioral Parent Training (BPT) is the standard of care for early-onset (3-8 years old) BDs, yet effect sizes vary and wane with time suggesting the role of underlying factors accounting for variability in outcomes. The literature on emotion regulation (ER), which has been proposed as one such underlying factor, is reviewed here, including a brief overview of ER, theory and research linking ER, externalizing symptoms, and/or BDs, and still largely preliminary work exploring the role of parent and child ER in BPT outcomes. Research to date provides clues regarding the interrelationship of ER, BDs, and BPT; yet, determining whether adaptations to BPT targeting ER are necessary or useful, for whom such adaptations would be most important, and how those adaptations would be implemented requires addressing mixed findings and methodological limitations. To guide such work, we propose a conceptual model elucidating how standard BPT may impact ER and processes linked to ER, which we believe will be useful in organizing and advancing both basic and applied research in future work.

Positive Parenting and Early Childhood Cognition: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

This review examines the effectiveness of positive parenting interventions aimed at improving sensitivity, responsiveness, and/or non-harsh discipline on children's early cognitive skills, in four meta-analyses addressing general mental abilities, language, executive functioning, and pre-academics. The objectives are to assess the magnitude of intervention effectiveness and identify moderators of effectiveness. We include randomized controlled trials of interventions targeting positive parenting to improve cognition in children < 6 years. Studies that include children with neurodevelopmental and/or hearing disorders were excluded. MEDLINE, PsycINFO, ERIC, and ProQuest Dissertations & Theses (October 2021) and citation chaining identified relevant records. Five reviewers completed screening/assessments, extraction, and risk of bias. Pooled analysis in Comprehensive Meta-Analysis (Version 3) used random effects modeling, with moderation via Q-statistics and meta-regression. Positive parenting interventions led to significant improvements in mental abilities (g = 0.46, N = 5746; k = 33) and language (g = 0.25, N = 6428; k = 30). Effect sizes were smaller and nonsignificant for executive functioning (g = 0.07, N = 3628; k = 14) and pre-academics (g = 0.16, N = 2365; k = 7). Robust moderators emerged for language and cognition. For cognition, studies with higher risk of bias scores yielded larger intervention effects. For language, studies with younger children had larger effect sizes. Studies mitigated selection and detection bias, though greater transparency of reporting is needed. Interventions that promote parental sensitivity, responsiveness, and non-harsh discipline improve early mental abilities and language. Studies examining executive functioning and pre-academics are needed to examine moderators of intervention effectiveness. Trial registration Systematic review PROSPERO registration. CRD42020222143.

Diagnosis and treatment of children and adolescents with autism and ADHD

Attention-deficit/hyperactivity disorder (ADHD) and autism are neurodevelopmental disorders that emerge in childhood. There is increasing recognition that ADHD and autism frequently co-occur. Yet, questions remain among clinicians regarding the best ways to evaluate and treat co-occurring autism and ADHD. This review outlines issues relevant to providing evidence-based practice to individuals and families who may be experiencing difficulties associated with co-occurring autism and ADHD. After describing the complexities of the co-occurrence of autism and ADHD, we present practical considerations for best practice assessment and treatment of co-occurring autism and ADHD. Regarding assessment, this includes considerations for interviewing parents/caregivers and youth, using validated parent and teacher rating scales, conducting cognitive assessments, and conducting behavior observations. Regarding treatment, consideration is given to behavioral management, school-based interventions, social skills development, and the use of medications. Throughout, we note the quality of evidence that supports a particular component of assessment or treatment, highlighting when evidence is most relevant to those with co-occurring autism and ADHD across stages of development. In light of the current evidence for assessment and treatment of co-occurring autism and ADHD, we conclude by outlining practical implications for clinical and educational practice.

Parent Training for ADHD: No Generalization of Effects From Clinical to Neuropsychological Outcomes in a Randomized Controlled Trial

OBJECTIVE

We examined whether neuropsychological function in ADHD can be improved by the New Forest Parenting Programme (NFPP), that combines standard parenting strategies with self-regulatory skills training, or predict ADHD and quality of life (QoL) treatment effects.

METHOD

Participants were 93 medication-naive preschool children with ADHD (3-7 years) randomized to either NFPP (n = 49) or treatment as usual (TAU; n = 44) in a recent randomized trial. Laboratory measures of executive function, reaction time variability, and delay of gratification were collected along with parent ratings of ADHD and QoL at baseline and post treatment. Ratings were collected again at 3-month follow-up.

RESULTS

NFPP did not improve neuropsychological function (compared to TAU), and baseline neuropsychological function did not predict treatment-related ADHD or QoL effects.

CONCLUSION

Although NFPP includes a neuropsychological training element and has been shown to improve several clinical outcomes, it did not improve the neuropsychological functions it targets.

Efficacy and safety of methylphenidate and behavioural parent training for children aged 3-5 years with attention-deficit hyperactivity disorder: a randomised, double-blind, placebo-controlled, and sham behavioural parent training-controlled trial

BACKGROUND

There is insufficient evidence to support treatment recommendations for preschool children aged 3-5 years with attention-deficit hyperactivity disorder (ADHD). We aimed to investigate the efficacy and safety of methylphenidate and behavioural parent training in reducing the frequency and severity of symptoms and improving global functioning in preschool children with ADHD.

METHODS

We did an 8-week, randomised, double-blind, placebo-controlled and sham behavioural parent training-controlled clinical trial (the MAPPA Study) in children aged 3-5 years with moderate-to-severe ADHD. The trial was conducted at the Institute of Psychiatry, Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Brazil. Participants were randomly assigned (1:1:1) to receive immediate-release methylphenidate plus educational intervention (sham behavioural parent training), placebo medication plus behavioural parent training, or placebo medication plus educational intervention. Randomisation was done by an independent research manager by use of a permuted block randomisation procedure. Parents, teachers, study staff, and evaluators remained masked to group allocation. Methylphenidate and placebo were titrated to a maximum dose of 1·25 mg/kg per day administered orally twice daily, and behavioural parent training and the educational intervention were delivered weekly through 90 min sessions with both the child and parent, conducted by two psychologists or learning therapists. The primary outcomes were parents' and teachers' composite scores of the Swanson, Nolan, and Pelham-IV scale (SNAP-IV-P/T), the Clinical Global Impressions Severity (CGI-S) scale, and the Children's Global Assessment Scale (CGAS). This trial is registered with ClinicalTrials.gov, NCT02807870, and is now complete. All participants were invited to participate in an open observational follow-up, which is ongoing.

FINDINGS

Between Aug 21, 2016, and Oct 21, 2019, 153 children were randomly assigned to receive methylphenidate plus the educational intervention (n=51), placebo plus behavioural parent training (n=51), or placebo plus the educational intervention (n=51). Nine (6%) children discontinued treatment. All participants were included in the intention-to-treat analysis. Children in the methylphenidate plus educational intervention group showed greater reductions in the SNAP-IV-P/T (endpoint mean difference -3·93 [95% CI -7·14 to -0·73], p=0·049; effect size -0·55 [95% CI -0·99 to -0·10]) and CGI-S scores (endpoint mean difference -0·49 [-0·82 to -0·17], p=0·0088; effect size -0·70 [-1·16 to -0·24]) and a greater increase in CGAS scores (endpoint mean difference 5·25 [95% CI 2·09 to 8·40], p=0·0036; effect size 0·80 [95% CI 0·32 to 1·28]) than children in the placebo plus educational intervention group. Children in the placebo plus behavioural parent training group did not have significantly different SNAP-IV-P/T scores (endpoint mean difference -3·18 [95% CI -6·38 to 0·02], p=0·077; effect size -0·44 [95% CI -0·89 to 0·003]) or CGI-S scores (endpoint mean difference -0·35 [-0·68 to -0·03], p=0·052; effect size -0·50 [-0·96 to -0·04]) compared to children in the placebo plus educational intervention group, but they had a greater increase in CGAS scores compared to the placebo plus educational intervention group (endpoint mean difference 3·69 [0·53 to 6·85], p=0·033; effect size 0·56 [0·08 to 1·04]). Children in the methylphenidate plus educational intervention versus placebo plus behavioural parent training group did not have statistically or clinically significant differences in primary outcomes. Children in the methylphenidate plus educational intervention group had more mild adverse events than the other two groups, and there were no between-group differences for moderate or severe adverse events.

INTERPRETATION

Methylphenidate was effective in reducing ADHD symptoms and improving functionality, and behavioural parent training was effective in improving functionality for preschool children with ADHD after 8 weeks of treatment.

FUNDING

São Paulo Research Foundation and Brazilian National Council for Scientific and Technological Development.

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.

Effectiveness of Clinic-Based Brief Behavioral Intervention (BBI) in Long-term Reduction of ADHD Symptoms Among Preschoolers

Preschoolers commonly experience symptoms of ADHD and disruptive behavior problems. Behavioral parent management training (PMT) is an evidence-based intervention for addressing both ADHD and disruptive behaviors in this population; however, many PMT programs are burdensome in length and have limited data regarding long-term effectiveness for ADHD specific outcomes. This study examined outcomes up to 1 year following completion of a brief behavioral intervention (M = 6.51 sessions) for preschoolers. Participants were children aged 2-6 years with clinically significant disruptive behaviors and their parents. Results demonstrated significant improvements in parent-reported child hyperactivity and inattention from pre-to-post intervention, with sustained improvement at 6 months and 1 year post intervention. Teacher-reported hyperactivity and inattention also showed significant improvements from pre-to-post intervention, which were maintained across time points. These results were also found among a subset of participants with clinically significant ADHD symptoms at baseline. This study highlights the long-term effectiveness of a brief PMT program to address symptoms of ADHD and disruptive behaviors in preschoolers. Findings support the recommendation to offer PMT as a first-line intervention for preschoolers with ADHD symptoms to reduce the need for early intervention with stimulant medication and address comorbid disruptive behaviors.

Psychosocial Interventions for Attention Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis by the CADDRA Guidelines Work GROUP

Multiple psychosocial interventions to treat ADHD symptoms have been developed and empirically tested. However, no clear recommendations exist regarding the utilization of these interventions for treating core ADHD symptoms across different populations. The objective of this systematic review and meta-analysis by the CADDRA Guidelines work Group was to generate such recommendations, using recent evidence. Randomized controlled trials (RCT) and meta-analyses (MA) from 2010 to 13 February 2020 were searched in PubMed, PsycINFO, EMBASE, EBM Reviews and CINAHL. Studies of populations with significant levels of comorbidities were excluded. Thirty-one studies were included in the qualitative synthesis (22 RCT, 9 MA) and 24 studies (19 RCT, 5 MA) were included in the quantitative synthesis. Using three-level meta-analyses to pool results of multiple observations from each RCT, as well as four-level meta-analyses to pool results from multiples outcomes and multiple studies of each MA, we generated recommendations using the GRADE approach for: Cognitive Behavioral Therapy; Physical Exercise and Mind–Body intervention; Caregiver intervention; School-based and Executive intervention; and other interventions for core ADHD symptoms across Preschooler, Child, Adolescent and Adult populations. The evidence supports a recommendation for Cognitive Behavioral Therapy for adults and Caregiver intervention for Children, but not for preschoolers. There were not enough data to provide recommendations for the other types of psychosocial interventions. Our results are in line with previous meta-analytic assessments; however, they provide a more in-depth assessment of the effect of psychosocial intervention on core ADHD symptoms.

Classifying Young Children with Attention-Deficit/Hyperactivity Disorder Based on Child, Parent, and Family Characteristics: A Cross-Validation Study

We aimed to identify subgroups of young children with differential risks for ADHD, and cross-validate these subgroups with an independent sample of children. All children in Study 1 (N = 120) underwent psychological assessments and were diagnosed with ADHD before age 7. Latent class analysis (LCA) classified children into risk subgroups. Study 2 (N = 168) included an independent sample of children under age 7. A predictive model from Study 1 was applied to Study 2. The latent class analyses in Study 1 indicated preference of a 3-class solution (BIC = 3807.70, p < 0.001). Maternal education, income-to-needs ratio, and family history of psychopathology, defined class membership more strongly than child factors. An almost identical LCA structure from Study 1 was replicated in Study 2 (BIC = 5108.01, p < 0.001). Indices of sensitivity (0.913, 95% C.I. 0.814−0.964) and specificity (0.788, 95% C.I. 0.692−0.861) were high across studies. It is concluded that the classifications represent valid combinations of child, parent, and family characteristics that are predictive of ADHD in young children.

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.

Meta-analysis: Which Components of Parent Training Work for Children With Attention-Deficit/Hyperactivity Disorder?

OBJECTIVE

Behavioral parent training is an evidence-based intervention for children with attention-deficit/hyperactivity disorder (ADHD), but it is unknown which of its components are most effective. This meta-regression analysis investigated which specific behavioral techniques that parents learn in parent training are associated with effects on parental outcomes.

METHOD

A search was performed for randomized controlled trials on parent training for children with ADHD, with positive parenting, negative parenting, parenting sense of competence, parent-child relationship quality, and parental mental health as outcome measures. After screening 23,026 publications, 29 studies contributing 138 effect sizes were included (N = 2,345). For each study, the dosage of 39 behavioral techniques was derived from intervention manuals, and meta-regression determined which techniques were related to outcomes.

RESULTS

Parent training had robust small- to medium-sized positive effects on all parental outcomes relative to control conditions, both for unblinded and probably blinded measures. A higher dosage of techniques focusing on the manipulation of antecedents of behavior was associated with better outcomes on parenting sense of competence and parental mental health, and a higher dosage of techniques focusing on reinforcement of desired behaviors was related to larger decreases in negative parenting. Higher dosages of psychoeducation were negatively related to parental outcomes.

CONCLUSION

Although techniques were not investigated in isolation, the results suggested that manipulation of antecedents of behavior and reinforcement techniques are key components of parent training for children with ADHD in relation to parental outcomes. These exploratory findings may help to strengthen and tailor parent training interventions for children with ADHD.

Do we over-diagnose ADHD in North America? A critical review and clinical recommendations

There has been a marked increase in the prevalence of attention-deficit/hyperactivity disorder (ADHD) in the last 25 years in North America. Some see this trend as positive and believe that it reflects a better identification of ADHD and even think that the disorder is still under-diagnosed. Others, however, contend that ADHD is over-diagnosed. To help mental health clinicians to maintain an informed and nuanced perspective on this debate, this critical review aims to (1) summarize empirical results on factors that might contribute to increase the number of ADHD diagnoses and (2) propose clinical recommendations coherent with these findings to improve clinical practices for ADHD assessment and treatment. We conclude that artifactual factors such as current formulation of diagnostic criteria, clinical practices, and inordinate focus on performance, which is rampant in North America, likely contribute to inflated prevalence rates.

Effects of Combing Group Executive Functioning and Online Parent Training on School-Aged Children With ADHD: A Randomized Controlled Trial

OBJECTIVE

The acceptance of drug treatment for younger children with attention-deficit/hyperactivity disorder (ADHD) in China remains low. Here, we explored the clinical benefits of a non-pharmaceutical intervention method combining a group and executive function training and an online parent training program, termed group executive functioning and online parent training (GEF-OPT), for school-aged students with ADHD through a randomized controlled trial.

METHOD

A total of 145 children (aged 6-8 years) were formally registered and randomized to the intervention group (n = 73) and waitlist group (n = 72). The enrolled children received eight sessions of GEF-OPT treatment, which consists of a hospital-based children executive function (EF) training program and an online parent training program. Treatment outcome was assessed by a parent/teacher report questionnaire and neurophysiological experiment.

RESULTS

After eight sessions of intervention, children in the intervention group showed a significant improvement in inattentive symptom compared to the waitlist group (14.70 ± 4.35 vs. 16.03 ± 2.93; p = 0.024), but an insignificant difference in hyperactive-impulsivity (9.85 ± 5.30 vs. 10.69 ± 5.10; p = 0.913). Comorbid oppositional defiant disorder was significantly reduced in the intervention group (7.03 ± 4.39 vs. 8.53 ± 4.41; p = 0.035). Children in the intervention group had greater reduction in the scores of behavioral regulation index (inhibition, emotional control) and metacognition index (working memory, planning/organization, monitoring) in executive function than those in the waitlist group (p < 0.05). Significant effects were also found in learning problem of Weiss Functional Impairment Scale-Parent form and parental distress between two groups at post-treatment (p < 0.05). In line with this, the result of go/no-go task showed significant improvements in accuracy change (4.45 ± 5.50% vs. 1.76 ± 3.35%; p = 0.001) and reaction time change (47.45 ± 62.25 s vs. 16.19 ± 72.22 s; p = 0.007) in the intervention group compared with the waitlist group.

CONCLUSION

We conclude that participants in the GEF-OPT program improved outcomes for inattentive symptom, executive function, learning problems, and parental distress. GEF-OPT is a promising non-pharmaceutical therapeutic option for younger children.

TRIAL REGISTRATION

ChiCTR2100052803.

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.

Research Review: The most effective parenting program content for disruptive child behavior - a network meta-analysis

BACKGROUND

Programs to support parents are the recommended strategy to reduce disruptive child behavior problems. Efforts have been made to demonstrate which program components (i.e., clusters of techniques taught) increase program effects, but these methods fail to account for the fact that components rarely operate in isolation. We examine how combinations of components cluster together to form program types and use network meta-analysis to estimate the relative effects of these program types.

METHODS

We updated an existing systematic review of parenting programs for disruptive child behavior and identified 197 randomized trials. We modeled clusters of components in each trial arm and chose the best-fitting model. We subsequently took 20 draws from the probability distribution of the latent class for each arm, entered each draw into a network meta-analysis model and combined findings using Rubin's rules. Combined estimates were bootstrapped to rank the clusters. We estimated main models and separate models for prevention and treatment settings.

RESULTS

A five-class solution fit the data best: (1) behavior management; (2) behavior management with parental self-management; (3) behavior management with psychoeducation and relationship enhancement; (4) maximal component loading and (5) no/minimal component loading (i.e. control). In the main model and in treatment settings, all four program types were effective compared to no/minimal components. In prevention settings, only behavior management and behavior management with parental self-management were effective compared to no/minimal components. Probabilistic ranking showed that overall and in treatment settings, behavior management had the largest chance, and in prevention settings, behavior management with self-management had the largest chance, of being most effective compared to no/minimal components.

CONCLUSIONS

Programs with more focused content seem more likely to yield stronger effects, and different foci may be needed in treatment versus prevention settings. Next steps include identifying individual family differences in optimal program content.

Family-based treatments for attention-deficit/hyperactivity disorder: A review of family functioning outcomes in randomized controlled trials from 2010 to 2019

This review details advances in randomized controlled trials of family-based treatments for attention-deficit/hyperactivity disorder (ADHD) conducted in the United States from 2010 to 2019, and the impact of these treatments on the domain of family functioning. Twenty-two studies were included in the review and three types of family treatments, integrated parent-child treatments, parent-directed treatments, and youth treatments with adjunctive parent involvement, were identified for children and adolescents. Studies point to considerable advancements in consideration of understudied and diverse populations, and results of the review show all three types of family interventions for ADHD should be considered well-established interventions addressing family functioning. Practical guidelines are offered, and future directions for research are discussed.

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

OBJECTIVE

Behavioral parent training (BPT) is an evidence-based intervention for children with attention-deficit/hyperactivity disorder (ADHD), but little is known about the effects of separate techniques parents learn in BPT.

METHOD

In a three-armed randomized controlled microtrial including parents of 92 children (4-12 years) with ADHD, we examined the efficacy of two sessions parent training involving either stimulus control techniques (antecedent-based condition (AC)) or contingency management techniques (consequent-based condition (CC)), compared to a waitlist. Primary outcome was daily parent-rated problem behaviors, secondary outcomes were parent-rated symptoms of ADHD and oppositional defiant disorder (ODD), and mental health-care consumption. Measures were completed at baseline (T0), immediately after the training (T1), at two weeks (T2) and three months (T3) follow-up. We also explored whether child and parent characteristics moderated treatment effects.

RESULTS

Compared to the waitlist, in the AC, daily rated problem behaviors improved at T1 (d= .56) and T2 (d= .65); in the CC, these behaviors only improved at T2 (d= .53). Daily rated problem behaviors within both conditions remained stable between T2 and T3. In the AC compared to the other conditions, inattention symptoms decreased at T1 and T2. For both active conditions compared to waitlist, hyperactivity-impulsivity symptoms decreased only at T2 and ODD symptoms did not decrease. No moderators were identified. Mental health-care consumption after training was low and did not differ between the active conditions.

CONCLUSIONS

Brief training of parents in antecedent- or consequent-based techniques improves problem behaviors of children with ADHD. Antecedent-based techniques appear to be especially important to target inattention.

Research protocol for a pragmatic randomized controlled effectiveness and cost effectiveness study of Well Parent Japan (WPJ) for Japanese mothers of children with ADHD: The TRaining And Nurturing Support FOR Mothers TRANSFORM study (Preprint)

Background

Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder associated with numerous functional deficits and poor long-term outcomes. Internationally, behavioral interventions are recommended as part of a multimodal treatment approach for children with ADHD. Currently, in Japan, there are limited interventions available to target ADHD. Well Parent Japan (WPJ), a new hybrid parent-training program, provides a culturally acceptable and effective way to help support Japanese children with ADHD and their parents.

Objective

This pragmatic multicenter randomized controlled trial aims to provide preliminary evidence about the effectiveness and cost-effectiveness of WPJ evaluated against treatment as usual (TAU) within routine Japanese mental health services.

Methods

Mothers of children (aged 6-12 years) diagnosed with ADHD were recruited from child and adolescent mental health care services at three hospital sites across Japan (Fukui, Fukuoka, and Okinawa). The mothers were randomized to receive immediate treatment or TAU. The effectiveness and cost-effectiveness of WPJ over TAU at the end of the intervention and at 3-month follow-up will be evaluated. The primary outcome is maternal parent domain stress in the parenting role. The following secondary outcomes will be explored: child behavior, including severity of ADHD symptoms; parenting practices; emotional well-being; and the parent-child relationship and maternal child domain parenting stress. Data analysis will follow intention-to-treat principles with treatment effects quantified through analysis of covariance using multilevel modeling. An incremental cost-effectiveness ratio will be used to analyze the cost-effectiveness of the WPJ intervention.

Results

Study funding was secured through a proof-of-concept grant in July 2018. Approval by the institutional review board for the data collection sites was obtained between 2017 and 2019. Data collection began in August 2019 and was completed in April 2022. Participant recruitment (N=124) was completed in May 2021. Effectiveness and cost-effectiveness analyses are expected to be completed by July 2022 and December 2022, respectively. These timelines are subject to change owing to the COVID-19 pandemic.

Conclusions

This is the first multisite pragmatic trial of WPJ based on the recruitment of children referred directly to routine clinical services in Japan. This multisite randomized trial tests the effectiveness of WPJ in children and families by comparing WPJ directly with the usual clinical care offered for children diagnosed with ADHD in Japan. We also seek to assess and compare the cost-effectiveness of WPJ with TAU in Japan.

Trial Registration

International Standard Randomised Controlled Trial Number ISRCTN66978270; https://www.isrctn.com/ISRCTN66978270

International Registered Report Identifier (IRRID)

DERR1-10.2196/32693

Investigating Friendship Difficulties in the Pathway from ADHD to Depressive Symptoms. Can Parent-Child Relationships Compensate?

Attention deficit/hyperactivity disorder (ADHD) is associated with friendship difficulties. This may partly account for the increasingly recognised association between ADHD and subsequent depression. Little is known about the types of friendship difficulties that could contribute to the association between ADHD and depressive symptoms and whether other relationships, such as parent-child relationships, can mitigate against potential adverse effects of friendship difficulties. In a representative UK school sample (n = 1712), three main features of friendship (presence of friends, friendship quality and characteristics of the individual's classroom friendship group) were assessed in a longitudinal study with two assessment waves (W1, W2) during the first year of secondary school (children aged 11-12 years). These friendship features (W1) were investigated as potential mediators of the prospective association between teacher-rated ADHD symptoms (W1) and self-rated depressive symptoms (W2) seven months later. Parent-child relationship quality (W1) was tested as a moderator of any indirect effects of ADHD on depression via friendship. ADHD symptoms were inversely associated with friendship presence, friendship quality and positive characteristics of classroom friendship groups. Depressive symptoms were inversely associated with presence and quality of friendships. Friendship quality had indirect effects in the association between ADHD and subsequent depressive symptoms. There was some evidence of moderated mediation, whereby indirect effects via friendship quality attenuated slightly as children reported warmer parent-child relationships. This highlights the importance of considering the quality of friendships and parent-child relationships in children with ADHD symptoms. Fostering good quality relationships may help disrupt the link between ADHD symptomology and subsequent depression risk.

Recommendations for Measurement of Attention Outcomes in Preschoolers With Neurofibromatosis

Children with neurofibromatosis type 1 (NF1) are at increased risk for attention problems. While most research has been conducted with school-aged cohorts, preschool-aged children offer a novel developmental window for clinical studies, with the promise that treatments implemented earlier in the developmental trajectory may most effectively modify risk for later difficulties. Designing research studies around the youngest children with NF1 can result in intervention earlier in the developmental cascade associated with NF1 gene abnormalities. Furthermore, clinical trials for medications targeting physical and psychological aspects of NF1 often include individuals spanning a wide age range, including preschool-aged children. In a prior report, the REiNS Neurocognitive Subcommittee made recommendations regarding performance-based and observer-rated measures of attention for use in clinical trials and highlighted the need for separate consideration of assessment methods for young children. The observer-rated Attention-Deficit/Hyperactivity Disorder Rating Scale-Preschool version is recommended as a primary outcome measure. The NIH Toolbox Flanker, Dimensional Change Card Sort, and List Sort Working Memory tasks and Digits Forward from the Differential Ability Scales-2nd Edition (performance-based measures) are recommended as secondary outcome measures. Specific methodologic recommendations for inclusion of preschoolers in clinical trials research are also offered.

Mediators of Change in a Parent Training Program for Early ADHD Difficulties: The Role of Parental Strategies, Parental Self-Efficacy, and Therapeutic Alliance

Objective: The aim was to explore mediators of change in parent training (PT) for 3- to 8-year-old children with ADHD difficulties. Method: Parents of 64 children received PT with Incredible Years® and assessed child ADHD symptoms and conduct problems and their parenting strategies, parental self-efficacy, and therapeutic alliance before, during, and after PT. Product-of-coefficients mediation analyses in multilevel models were applied, and causal relations between mediators and outcome were investigated in time-lagged analyses. Results: Increased parental self-efficacy and reduced negative parenting statistically mediated reductions in ADHD and conduct problems in the product-of-coefficient analyses. However, time-lagged analyses were unable to detect a causal relation between prior change in mediators and subsequent child symptom reduction. There was limited evidence of therapeutic alliance as mediator of child symptom reduction or change in parenting variables. Conclusion: Parental self-efficacy and reductions in negative parenting may mediate change in PT, but more fine-grained time-lagged analyses are needed to establish causality.

An RCT of an Online Parenting Program for Parents of Preschool-Aged Children With ADHD Symptoms

Objective: This randomized control trial evaluated the efficacy of an online self-help program in a sample of parents of preschoolers with ADHD symptoms. Method: Parents were randomly assigned to the intervention group (n = 27) or the delayed intervention group (n = 26). Child behavior measures were completed by mothers, fathers, and teachers, and parenting measures were completed by mothers. Results: Intent-to-treat analyses indicated significant post-intervention improvements in mother-rated child hyperactivity/inattention, restlessness/impulsivity, defiance/aggression, social functioning, and teacher-rated prosocial behavior, as well as significant improvements in maternal over-reactivity, verbosity, laxness, positive parenting, parenting satisfaction, self-efficacy, stress, and depression. At 6-month follow-up, effects were maintained for maternal over-reactivity and verbosity, parenting satisfaction and self-efficacy, and parental stress and depression. Conclusion: This study provides evidence for the effectiveness of an online self-help parenting program in reducing preschool inattentive behavior difficulties, and in increasing parenting competence, satisfaction in the parenting role, and maternal well-being.

Practitioner Review: Assessment and treatment of preschool children with attention-deficit/hyperactivity disorder

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) often emerges during the preschool years and remains impairing throughout the life span. Early identification and intervention may yield lasting benefits that alter the often-adverse trajectory of the disorder.

METHODS

This Practitioner Review provides up-to-date information regarding the evaluation and treatment of ADHD in preschool children. The clinical presentation of ADHD in preschool children, its persistence into later childhood, the applicability of DSM-5 criteria for preschoolers with ADHD, and early predictors of long-term trajectories are addressed, as well as current findings from randomized controlled trials of both nonpharmacological and pharmacological interventions.

RESULTS

Symptoms of hyperactivity/impulsivity extend down to age 3, but several inattention symptoms, as defined by DSM-V, less accurately differentiate preschoolers with and without ADHD. Most preschool youth with ADHD symptoms continue to manifest symptoms and impairment into school-age and adolescence. However, few predictors of persistence beyond early severity have been identified. Behavioral interventions constitute a first-line treatment for preschool ADHD symptoms, with telepsychiatry increasing in prominence to help to mitigate financial, geographic, and/or logistical barriers to care. Pharmacological interventions, particularly psychostimulants, also confer demonstrable benefits, yet efficacy and safety profiles are less desirable relative to findings in school-age youth.

CONCLUSIONS

Acute treatments have demonstrable efficacy, but do not appear to fundamentally alter underlying mechanisms or long-term trajectories.

A scoping review of mental health prevention and intervention initiatives for infants and preschoolers at risk for socio-emotional difficulties

BACKGROUND

Infant mental health has emerged as a unique area of practice and research distinguished from child and youth sub-specialties by its advocacy for a relational practice framework with an emphasis on parents/caregivers being integral to assessment, treatment, and prevention initiatives. A diverse array of initiatives offered across a broad spectrum of delivery methods is available to clinicians. However, to date, a large-scale mapping of the research evidence regarding these interventions has yet to be completed to help inform clinician's decisions regarding the best approaches for their clients. To address this knowledge gap, this study aimed to report on the landscape of research pertaining to mental health interventions for infants and preschoolers (0-5 years), and their families at risk for socio-emotional difficulties and negative developmental outcomes.

METHOD

A scoping review methodology was used to conduct a large-scale mapping of the intervention research pertaining to infants and preschoolers (0-5) at risk for socio-emotional difficulties. We searched MEDLINE, PsycINFO, EMBASE, Web of Science, The Cochrane Library, CINAHL, LILACS, ProQuest Nursing & Allied Health Source, World Cat, and ClinicalTrials.gov , from inception to December 31, 2012. We extracted information regarding publication date, geographical location, study design, level of risk, population, key intervention mechanism, and outcome measures.

RESULTS

We identified 533 potential studies from 1233 title and abstracts after the first round of screening. Full text article review in the second round of screening resulted in a total of 162 included articles for the final analysis. Results indicated that over 50% of interventions evaluated were randomized controlled trials conducted in Westernized countries. Most studies could be subdivided by level of risk within a preventative public health framework including universal, selected, indicated, and direct treatment for children formally diagnosed with a mental disorder. Risk factors experienced by children and their families were heterogeneously defined and numerous outcome measures across included studies. The results of this study are limited to the last search date of 2012.

CONCLUSIONS

Key intervention mechanisms spanned a range of approaches including parenting groups, dyadic, in-home, cognitive-behavioral therapy, and day care-based interventions. The findings are discussed in terms of implications for broad trends and gaps in research and policy for this population.

Short- and Long-Term Effects of Parent Training for Preschool Children With or at Risk of ADHD: A Systematic Review and Meta-Analysis

OBJECTIVE

The aim of the study was to synthesize the evidence of parent training (PT) as an early intervention for preschool children aged 2.5 to 6 years with ADHD or ADHD symptoms.

METHOD

A systematic review and meta-analysis was conducted.

RESULTS

Sixteen studies including 1,003 children were analyzed. Parent-rated outcomes revealed moderate effect sizes (ESs; Hedges' g) of 0.51 for ADHD symptoms, 0.4 for conduct problems, and 0.63 for negative parenting. Based on independent assessment, results were only significant for negative parenting. Parent-rated outcomes were sustained at follow-ups of 3 to 12 months. Program type, intervention modality, and child diagnostic status did not moderate the effect.

CONCLUSION

PT was partially supported as an efficacious intervention for preschool children with ADHD or ADHD symptoms with moderate ESs on parent-rated outcomes, but no significant results on independently assessed ADHD symptoms.

Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder in Preschool-Aged Children

OBJECTIVES

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder defined as a persistent pattern of inactivity and/or hyperactivity that interferes with behavioral function or development. Diagnosis and treatment of ADHD in the preschool-aged population (children 3-5 years old) is more complicated compared with older children because of developmental and physiological differences. This article reviews the available literature regarding the challenges associated with ADHD diagnosis and treatment in preschool-aged children, as well as the unmet needs of preschool-aged children with ADHD.

METHODS

Key considerations for ADHD diagnosis and treatment patterns in preschool-aged children are summarized in this review, including the need for early intervention, the association with comorbidities, and the differences in pharmacokinetic profiles between preschool-aged children and older children.

RESULTS

Efficacy and safety data are lacking, as clinical trial design and execution pose unique challenges in this population. Preschool-aged children often have difficulty with pill swallowing and tolerating phlebotomy necessary for the collection of pharmacokinetic and safety data. However, early diagnosis and treatment are essential to mitigate ADHD symptoms and comorbidities that may develop during childhood and adolescence in patients with persistent ADHD.

CONCLUSION

This review describes the established diagnostic and treatment modalities, along with the unmet needs of preschool-aged children with ADHD.

Response to Time-Out Among Preschoolers with Externalizing Behavior Problems: The Role of Callous-Unemotional Traits

This study examined the role of callous-unemotional (CU) traits in preschoolers with externalizing behavior problems (EBP) and their response to time-out (TO). One hundred ninety preschoolers (76% boys, M^age = 4.92) with at-risk/clinically elevated levels of EBP participated in an 8-week summer treatment program (STP-PreK). Total number of minutes spent daily in TO for intentional aggression (IA) and repeated non-compliance (RNC) were recorded during the initial (T1) and final (T2) phases of the STP-PreK. After accounting for severity of EBP and levels of TO at T1, higher levels of CU traits predicted greater total levels of TO at T2. An interaction also emerged between symptoms of oppositional defiant disorder (ODD) and CU traits in predicting IA. Specifically, greater ODD symptoms predicted fewer number of IA related TO at T2, but only for children with low CU traits. Implications for treatment are discussed.

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.

A Review of the Clinical Utility of Systematic Behavioral Observations in Attention Deficit Hyperactivity Disorder (ADHD)

This review evaluates the clinical utility of tools for systematic behavioral observation in different settings for children and adolescents with ADHD. A comprehensive search yielded 135 relevant results since 1990. Observations from naturalistic settings were grouped into observations of classroom behavior (n = 58) and of social interactions (n = 25). Laboratory observations were subdivided into four contexts: independent play (n = 9), test session (n = 27), parent interaction (n = 11), and peer interaction (n = 5). Clinically relevant aspects of reliability and validity of employed instruments are reviewed. The results confirm the usefulness of systematic observations. However, no procedure can be recommended as a stand-alone diagnostic method. Psychometric properties are often unsatisfactory, which reduces the validity of observational methods, particularly for measuring treatment outcome. Further efforts are needed to improve the specificity of observational methods with regard to the discrimination of comorbidities and other disorders.

Informant-related effects of neurofeedback and cognitive training in children with ADHD including a waiting control phase: a randomized-controlled trial

There is controversy regarding the clinical efficacy of neurofeedback (NF) and computerized cognitive training (CogT) as treatments for ADHD. Meta-analyses claim that probably blinded teachers observe smaller effects than parents, because they are less biased. We investigated informant-specific effects by manipulating the involvement of informants, by controlling for waiting time effects, and by adding a blinded outcome measure. Seventy-seven children with ADHD were randomly allocated to slow cortical potential NF or to individualized CogT (of attention, working memory or inhibition). The training was conducted in schools (NF: n = 19, CogT: n = 19) or in outpatient clinics (NF: n = 19, CogT: n = 20). Three assessments were scheduled: baseline, followed by a waiting period, pre-training, and post-training. Multivariate Analyses of Variance were conducted to assess parent- and teacher-rated changes in ADHD symptoms and executive functions (EF), and changes according to standardized classroom observations. Both treatments resulted in significant improvements according to informants, with larger effects for parents (ADHD symptoms: parent η _p²  = .32; teacher η _p²  = .10), and according to observations (η _p²  = .19). The setting had no effect on outcome. Considerable waiting time effects were revealed for ADHD symptom ratings by both informants, for EF ratings only by teachers. Changed classroom behavior was uncorrelated with teacher-rated changes. Overall, the results do not support the notion that teachers are more objective while being as sensitive to change as parents. The three sources seem to contribute differential and mostly unrelated pieces of information to the evaluation of treatments.

A comparison of the clinical effectiveness and cost of specialised individually delivered parent training for preschool attention-deficit/hyperactivity disorder and a generic, group-based programme: a multi-centre, randomised controlled trial of the New Forest Parenting Programme versus Incredible Years

The objective of this study is to compare the efficacy and cost of specialised individually delivered parent training (PT) for preschool children with attention-deficit/hyperactivity disorder (ADHD) against generic group-based PT and treatment as usual (TAU). This is a multi-centre three-arm, parallel group randomised controlled trial conducted in National Health Service Trusts. The participants included in this study were preschool children (33-54 months) fulfilling ADHD research diagnostic criteria. New Forest Parenting Programme (NFPP)-12-week individual, home-delivered ADHD PT programme; Incredible Years (IY)-12-week group-based, PT programme initially designed for children with behaviour problems were the interventions. Primary outcome-Parent ratings of child's ADHD symptoms (Swanson, Nolan & Pelham Questionnaire-SNAP-IV). Secondary outcomes-teacher ratings (SNAP-IV) and direct observations of ADHD symptoms and parent/teacher ratings of conduct problems. NFPP, IY and TAU outcomes were measured at baseline (T1) and post treatment (T2). NFPP and IY outcomes only were measured 6 months post treatment (T3). Researchers, but not therapists or parents, were blind to treatment allocation. Analysis employed mixed effect regression models (multiple imputations). Intervention and other costs were estimated using standardized approaches. NFPP and IY did not differ on parent-rated SNAP-IV, ADHD combined symptoms [mean difference - 0.009 95% CI (- 0.191, 0.173), p = 0.921] or any other measure. Small, non-significant, benefits of NFPP over TAU were seen for parent-rated SNAP-IV, ADHD combined symptoms [- 0.189 95% CI (- 0.380, 0.003), p = 0.053]. NFPP significantly reduced parent-rated conduct problems compared to TAU across scales (p values < 0.05). No significant benefits of IY over TAU were seen for parent-rated SNAP, ADHD symptoms [- 0.16 95% CI (- 0.37, 0.04), p = 0.121] or parent-rated conduct problems (p > 0.05). The cost per family of providing NFPP in the trial was significantly lower than IY (£1591 versus £2103). Although, there were no differences between NFPP and IY with regards clinical effectiveness, individually delivered NFPP cost less. However, this difference may be reduced when implemented in routine clinical practice. Clinical decisions should take into account parental preferences between delivery approaches.

Nonpharmacologic Treatments for Attention-Deficit/Hyperactivity Disorder: A Systematic Review

CONTEXT

Nonpharmacologic treatments for attention-deficit/hyperactivity disorder (ADHD) encompass a range of care approaches from structured behavioral interventions to complementary medicines.

OBJECTIVES

To assess the comparative effectiveness of nonpharmacologic treatments for ADHD among individuals 17 years of age and younger.

DATA SOURCES

PubMed, Embase, PsycINFO, and Cochrane Database of Systematic Reviews for relevant English-language studies published from January 1, 2009 through November 7, 2016.

STUDY SELECTION

We included studies that compared any ADHD nonpharmacologic treatment strategy with placebo, pharmacologic, or another nonpharmacologic treatment.

DATA EXTRACTION

Study design, patient characteristics, intervention approaches, follow-up times, and outcomes were abstracted. For comparisons with at least 3 similar studies, random-effects meta-analysis was used to generate pooled estimates.

RESULTS

We identified 54 studies of nonpharmacologic treatments, including neurofeedback, cognitive training, cognitive behavioral therapy, child or parent training, dietary omega fatty acid supplementation, and herbal and/or dietary approaches. No new guidance was identified regarding the comparative effectiveness of nonpharmacologic treatments. Pooled results for omega fatty acids found no significant effects for parent rating of ADHD total symptoms (n = 411; standardized mean difference -0.32; 95% confidence interval -0.80 to 0.15; I² = 52.4%; P = .10) or teacher-rated total ADHD symptoms (n = 287; standardized mean difference -0.08; 95% confidence interval -0.47 to 0.32; I² = 0.0%; P = .56).

LIMITATIONS

Studies often did not reflect the primary care setting and had short follow-up periods, small sample sizes, variations in outcomes, and inconsistent reporting of comparative statistical analyses.

CONCLUSIONS

Despite wide use, there are significant gaps in knowledge regarding the effectiveness of ADHD nonpharmacologic treatments.

How evolutionary thinking can help us to understand ADHD

We argue that current debates about attention-deficit hyperactivity disorder (ADHD) can be considered afresh using an evolutionary lens. We show how the symptoms of ADHD can often be considered adaptive to their specific environment. We suggest that, from an evolutionary point of view, ADHD symptoms might be understood to result from an ‘evolutionary mismatch’, in which current environmental demands do not fit with what evolution has prepared us to cope with. For example, in our ancestral environment of evolutionary adaptedness (EEA), children were not expected to sit still and concentrate on academic tasks for many hours a day. Understanding ADHD in terms of such a ‘mismatch’ raises significant issues regarding the management of childhood ADHD, including ethical ones. An approach based on the concept of mismatch could provide an alternative to current debates on whether ADHD results from nature or nurture and whether it is under- or over-diagnosed. It would allow clinicians and policy makers to take both the child and the environment into account and consider what might be desirable and feasible, both in society and for specific children, to lessen the mismatch.

LEARNING OBJECTIVES

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Young Children with Behavior Disorders in Low-Income Families: The Role of Clinic Observations in the Assessment of Parenting

Children from low-income families are at elevated risk of meeting diagnostic criteria for behavior disorders. Although mastery-based Behavioral Parent Training (BPT) programs have a robust evidence-base for reducing disruptive behaviors of young children, socioeconomically disadvantaged families are more likely to drop out of treatment and, in turn, are less likely to benefit. Therefore, efficient assessment and treatment may be needed. Less research, however, has addressed the value of time-consuming behavioral observations relative to caregiver-report of problem behaviors in the assessment of this at-risk and underserved group. In the current study, 43 low-income parents and their clinic-referred child were observed during a standard mastery-based BPT interaction task (Child's Game) at baseline. Findings revealed that parents were observed to displayed an extremely high proportion of maladaptive behaviors targeted for reduction by subsequent treatment (Instructions plus Questions) relative to behaviors that the treatment was designed to increase (Attends plus Rewards). In contrast, parents reported they utilized relatively high and low rates of positive and negative parenting, respectively. Behaviorally-observed parenting was not correlated with caregiver-reported parenting. The findings suggest that baseline observations of behaviors targeted in mastery-based BPT interventions are an important part of assessment in parenting programs for low-income families with young disruptive children.

Preschool Predictors of ADHD Symptoms and Impairment During Childhood and Adolescence

PURPOSE OF REVIEW

This paper summarizes key, recently published research examining longitudinal outcomes for preschoolers with high levels of inattention and/or hyperactivity/impulsivity.

RECENT FINDINGS

Symptom trajectories show that hyperactivity/impulsivity declines across childhood. At the group level, the course of inattention appears more variable. However, identification of subgroups of children showing stable, rising, and falling inattention over time is promising. Early ADHD-like symptoms portend risk for academic and social difficulties, as well as comorbid emotional and behavioral problems in childhood and adolescence. Several early risk factors appear to moderate these relations, including comorbid symptoms, parental psychopathology, socioeconomic disadvantage, and perhaps neuropsychological dysfunction. Furthermore, high levels of inattention and/or hyperactivity/impulsivity during the preschool period appear to compromise development of regulatory and neuropsychological functions, which in turn increases risk for negative outcomes later in childhood. Identified risk factors are targets for novel interventions, which ideally would be delivered early to at-risk children.

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.

Adapting an attention-deficit hyperactivity disorder parent training intervention to different cultural contexts: The experience of implementing the New Forest Parenting Programme in China, Denmark, Hong Kong, Japan, and the United Kingdom

The New Forest Parenting Programme (NFPP) is a parenting program developed for parents who have a child with attention-deficit hyperactivity disorder (ADHD). It is a manualized program that is delivered in a parent's home over 8 weeks, or in a group format, or through a self-help manual. Three randomized controlled trials have been carried out in the United Kingdom. The NFPP group has adapted the program according to feedback from parents and therapists, and for use with different populations, both within the United Kingdom and internationally. The first international trial took place in New York, United States. Trials in Denmark, Hong Kong, and Japan followed. More recently, a trial of the self-help manual has been carried out in mainland China. This paper will outline the adaptions that were needed in order to be able to deliver the program in different countries with their own expectations of parenting, culture, and language. Training had to be differently focused; manuals and handouts had to be revised, translated and back-translated; and supervision had to be delivered at a distance to maintain the fidelity of the program. The international group will outline their experience of running trials in their own countries with the NFPP in a face-to-face format (Denmark), a group format (Hong Kong and Japan), and a self-help format (mainland China).