Assessing the effectiveness of the 'Incredible Years(®) parent training' to parents of young children with ADHD symptoms - a preliminary report

Parent training for 842 families experiencing disruptive child behavior across 19 Danish community sites: A benchmark effectiveness study

Interactional processes between child and parents, in particular harsh and coercive parenting practices, have been established as important factors maintaining and shaping the developmental trajectory of disruptive child behavior. The Incredible Years Parent Training (IYPT) is a well-established evidence-based program targeting negative parent-child interactions in families with children exhibiting high levels of disruptive behaviors. There are, however, few studies investigating the effectiveness of the IYPT when implemented in established practice settings independently from research environments. Also, very little evidence exists for the program's effectiveness for school-aged children. The IYPT was administered to consecutive groups of parents (N = 842) across 19 Danish community sites during the period from 2012 to 2019. Pre and post data were collected using the Eyberg Child Behavior Inventory (ECBI). By means of a benchmark approach, the effectiveness of the intervention was compared with that of two European effectiveness randomized controlled trials. Large effect sizes were seen from pre to post for both parent-reported number of problematic disruptive child behaviors (ECBI Problem subscale; d = 1.51, p = 0.000, 95% CI [9.06-10.01]) and frequency of these behaviors (ECBI Intensity subscale; d = 1.15, p = 0.000, 95% CI [29.33-32.73]). Treatment effects found in this study are comparable to or larger than those found in previous effectiveness studies and show the IYPT to be an effective intervention when implemented across a range of different community settings in a large community sample of children across an age span of 2 to 12 years.

Contemporary diagnosis and treatment of conduct disorder in youth

INTRODUCTION

Conduct disorder (CD) is characterized by repetitive and persistent antisocial behaviors, being among the most frequently reported reasons of referral in youth. CD is a highly heterogeneous disorder, with possible specifiers defined according to age at onset, Limited Prosocial Emotions (LPE) otherwise known as Callous-Unemotional (CU) traits, Emotional Dysregulation (ED), and patterns of comorbidity, each with its own specific developmental trajectories.

AREAS COVERED

The authors review the evidence from published literature on the clinical presentations, diagnostic procedures, psychotherapeutic and psychoeducational approaches, and pharmacological interventions from RCT and naturalistic studies in youth. Evidence from studies including youths with LPE/CU traits, ED and aggression are also reviewed, as response moderators.

EXPERT OPINION

Due to its clinical heterogeneity, relevant subtypes of CD should be carefully characterized to gain reliable information on prognosis and treatments. Thus, disentangling this broad category in subtypes is crucial as a first step in diagnosis. Psychosocial interventions are the first option, possibly improving LPE/CU traits and ED, especially if implemented early during development. Instead, limited information, based on low-quality studies, supports pharmacological options. Second-generation antipsychotics, mood stabilizers, and stimulants are first-line medications, according to different target symptoms, such as aggression and emotional reactivity. Developmental pathways including ADHD suggest a specific role of psychostimulants.

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.

Executive Function Training for Preschool Children With ADHD: A Randomized Controlled Trial

OBJECTIVE

This randomized controlled study explored the efficacy, feasibility, and acceptability of executive function training (EFT) for preschool children with ADHD.

METHOD

The current study design was an 8 week randomized parallel groups, single-blinded trial, using EFT-P. A total of 96 children with an ADHD diagnosis at age 4 to 5 years old were randomized into the intervention group and waitlist group. In the intervention group, 46 out of 50 participants completed the 8-week program, compared with 39 out of 46 in the waiting group. The level of ADHD symptoms and the executive function (EF) were evaluated by both neuropsychological tests from NEPSY Second Edition (NEPSY-II) and Behavior Rating Inventory of Executive Function Preschool version (BRIEF-P).

RESULTS

The EFT is feasible to administer and is acceptable for preschool children, with a 93% retention rate. Results showed that following the intervention, the visual-motor precision (p = .024), ADHD diagnostic state (p = .01), and oppositional defiant symptoms (p = .023) improved significantly in preschool children. However, the symptoms of ADHD and other EF evaluations were found to be insignificant.

CONCLUSION

The EFT is feasible, acceptable, and potentially effective to reduce symptoms and improve EF for preschool children with ADHD. The next step is to extend the program time and provide more frequent practice of activities between the children and the therapist and/or parent, to improve the effectiveness.

Efficacy of the parenting support program on child behavior problems

The study aimed to examine the efficacy of the Parenting Support Program (PSP) for reducing problem behaviors and increasing adaptive behaviors in young children aged 3 to 6. The PSP focuses on effective parenting skills and building positive interactions between parents and their children. Parents of children (n = 18 mothers and 11 fathers) were randomly assigned to an experiment group (EG) and a wait-list (WL) group. The EG attended a total of 12 individually delivered sessions. Data was gathered via parent and teacher report measures, observation and semi-structured interviews. The PSP was effective in increasing adaptive behaviors and decreasing behavior problems in children. The change in the children's score which fulfills the Reliable Change Index criteria in the EG was found to be higher than the WL group. However, fathers reported fewer improvements than mothers in the EG. Qualitative data supported the experimental study results demonstrating the efficacy of the PSP, and met the expectations of parents. Consequently, the PSP could be used as an intervention tool to decrease behavior problems and increase adaptive behaviors in young children.

Dialogical Family Guidance (dfg)-Development and implementation of an intervention for families with a child with neurodevelopmental disorders

Aim

To describe the development and implementation of a Dialogical Family Guidance (DFG) intervention, aimed at families with a child with neurodevelopmental disorders (NDD).

Design

The DFG components are presented and the content of a DFG training course. Professionals' experiences after the DFG training were evaluated.

Methods

Dialogical Family Guidance development phases and implementation process are examined. The Revised Standards for Quality Improvement Reporting Excellence checklist (SQUIRE 2.0) was used to provide a framework for reporting new knowledge.

Results

The DFG training course seemed to increase possibilities of a more independent role as a nurse to deliver the DFG family intervention. The project showed that the use of dialogue can be difficult for some professionals. Analysis of the questionnaire completed after DFG training reported a high level of satisfaction. DFG training offered a new approach to deliver knowledge and understanding to families using dialogue, including tailored psychoeducation and emotional and practical guidance.

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.

Evidence Base Update for Measures of Social Skills and Social Competence in Clinical Samples of Youth

Social skills and social competence are key transdiagnostic processes in developmental psychopathology and are the focus of an array of clinical interventions. In this Evidence Base Update, we evaluated the psychometric properties of measures of social skills and social competence used with clinical samples of children and adolescents. A systematic literature search yielded eight widely used measures of social skills and one measure of social competence. Applying the criteria identified by Youngstrom et al. (2017), we found that, with some exceptions, these measures had adequate to excellent norms, internal consistency, and test-retest reliability. There was at least adequate evidence of construct validity and treatment sensitivity in clinical samples for nearly all measures assessed. Many of the scales included items assessing constructs other than social skills and competence (e.g., emotion regulation). Development of updated tools to assess youth's effectiveness in key interpersonal situations, including those occurring online, may yield clinical dividends.

Parent and facilitator experiences of an intensive parent and infant programme delivered in routine community settings

AIM

The aims of this study were to (1) assess the initial experiences of parenthood amongst mainly disadvantaged mothers; (2) explore their views on the extent to which they felt they had benefitted (or not) from participating in a newly developed, intensive mother and baby support programme in the community; and (3) explore the perspectives of those who delivered the programme (i.e., facilitators), most of whom were Public Health Nurses (PHNs).

BACKGROUND

Positive parent-child interactions and appropriate levels of infant stimulation are essential to promoting a child's well-being and laying a foundation in the early years for positive developmental outcomes. It is important, therefore, to examine participants' experiences of community-based, family-focused, early prevention and intervention programmes.

METHODS

This study was undertaken as part of a larger evaluation of a newly developed parent and infant (PIN) programme which was delivered in two disadvantaged areas in Ireland. One-to-one interviews were conducted with both mothers (n = 22) and facilitators (n = 8) (including three PHNs) plus six focus groups with an additional sub-group of facilitators (n = 17).

FINDINGS

The collective findings suggest that mothers found the programme helpful in promoting a greater understanding of their infants' behaviour and needs, and in alleviating stress and concerns associated with motherhood. Mothers described feeling more knowledgeable about the importance of regular and appropriate infant interaction to encourage learning and development. Facilitators, specifically PHNs, also reported a greater awareness of the value of infant socioemotional development for their clinical practice and observed greater positive communication between mothers and infants.

CONCLUSION

These findings suggest that a community-based, intensive mother and baby programme can help to promote parental competence and enhance infant learning and development. Additional benefits in terms of early intervention and positive changes to public health nursing practice are also discussed.

Parental predictors of children's executive functioning from ages 6 to 10

According to prominent models of child development, parental factors may contribute to individual differences in children's executive functioning (EF). Here, we examine the relative importance of parents' socio-economic status, mental health, and parenting as predictors of EF development, drawing on a large (n = 1,070) community sample of Norwegian children who received biennial EF assessments from 6 to 10 years of age. We measure EF by means of the Behavior Rating Inventory of Executive Function. We assess parenting through observer ratings of parent-child interactions and parental mental health via the Beck Anxiety Inventory, Beck Depression Inventory, and Hopkins Symptom Checklist. When we adjust for all time-invariant unmeasured confounders, higher parental education predicts superior EF development, whereas harsh parenting forecasts poorer EF development. However, parenting does not mediate the effect of parental education. These results indicate that harsh parenting should be targeted in interventions aimed at improving EF. Statement of contribution What is already known on this subject? Parental factors seem to affect child development of executive functions (EF). Specifically, parental socio-economic status, mental health, and their parenting seem to influence the developmental course of child EF. What does this study add? To what degree the parental influence on EF development is likely to be driven by time-invariant factors, for example, genetics. The relative influence of positive and negative parenting on EF development.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Preschool children's response to behavioural parent training and parental predictors of outcome in routine clinical care

OBJECTIVE

To investigate the effectiveness of behavioral parent training (BPT) for preschool children with disruptive behaviours and to explore parental predictors of response.

METHODS

Parents of 68 preschool children, aged between 2.7 and 5.9 years, participated in BPT. We evaluated the changes in children's behaviour after BPT with a one group pretest-posttest design, using a waiting period for a double pretest. Outcome was based on parents' reports of the intensity and number of behaviour problems on the Eyberg Child Behavior Inventory. Predictor variables included parents' attention-deficit/hyperactivity disorder symptoms, antisocial behaviours, and alcohol use, and maternal parenting self-efficacy and disciplining.

RESULTS

Mother-reported child behaviour problems did not change in the waiting period but improved significantly after BPT (d = 0.63). High levels of alcohol use by fathers and low levels of maternal ineffective disciplining were each associated with somewhat worse outcome.

CONCLUSIONS

BPT under routine care conditions clearly improves disruptive behaviours in preschool children. Mothers who consider themselves as inadequate in disciplining and mothers whose partners do not consume high levels of alcohol report the largest improvements.

The Incredible Years Parents and Babies Program: A Pilot Randomized Controlled Trial

INTRODUCTION

Infancy is an important period of life; adverse experiences during this stage can have both immediate and lifelong impacts on the child's mental health and well-being. This study evaluates the effects of offering the Incredible Years Parents and Babies (IYPB) program as a universal intervention.

METHOD

We conducted a pragmatic, two-arm, parallel pilot randomized controlled trial; 112 families with newborns were randomized to the IYPB program (76) or usual care (36) with a 2:1 allocation ratio. The primary outcome was parenting confidence at 20 weeks(Karitane Parenting Confidence Scale and Parental Stress Scale). Secondary outcomes include measures of parent health, parent-child relationship, infant development, parent-child activities, and network. Interviewers and data analysts were blind to allocation status. Multiple linear-regression analyses were used for evaluating the effects of the intervention.

RESULTS

There were no intervention effects on the primary outcomes. Only one effect was detected for secondary outcomes, intervention mothers reported a significantly smaller network than control mothers (β = -0.15 [-1.85,-0.28]). When examining the lowest-functioning mothers in moderator analyses, we found that intervention mothers reported significantly higher parent stress (β = 5.33 [0.27,10.38]), lower parenting confidence (β = -2.37 [-4.45,-0.29]), and worse mental health than control mothers (β = -18.62 [-32.40,-4.84]). In contrast, the highest functioning intervention mothers reported significantly lower parent stress post-intervention (β = -6.11 [-11.07,-1.14]).

CONCLUSION

Overall, we found no effects of the IYPB as a universal intervention for parents with infants. The intervention was developed to be used with groups of low functioning families and may need to be adapted to be effective with universal parent groups. The differential outcomes for the lowest and highest functioning families suggest that future research should evaluate the effects of delivering the IYPB intervention to groups of parents who have similar experiences with parenting and mental health.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01931917.

Development and evaluation of an educational intervention in youth mental health for primary care practitioners

OBJECTIVES

Irish adolescents have one of the highest rates of suicide and self-harm in the European Union. Although primary care has been identified as an opportune environment in which to detect and treat mental health problems in adolescents, lack of training among primary care professionals (PCPs) is a barrier to optimum identification and treatment. We describe the development and evaluation of an educational intervention on youth mental health and substance misuse for PCPs.

METHODS

Thirty general practitioners and other PCPs working in the Mid-West region participated in an educational session on youth-friendly consultations, and identification and treatment of mental ill-health and substance use. Learning objectives were addressed through a presentation, video demonstration, small group discussions, role play, question-and-answer sessions with clinical experts, and an information pack. Following the session, participants completed an evaluation form assessing knowledge gain and usefulness of different components of the session.

RESULTS

A total of 71% of participants were involved in the provision of care to young people and 55% had no previous training in youth mental health or substance abuse. Participants rated knowledge gains as highest with regard to understanding the importance of early intervention, and primary care, in youth mental health. The components rated as most useful were case studies/small group discussion, the 'question-and-answer session' with clinical experts, and peer interaction.

CONCLUSIONS

The educational session outlined in this pilot was feasible and acceptable and may represent an effective way to train professionals to help tackle the current crisis in youth mental health.