Artiklen er udgivet i 2018
Parenting training interventions for children with or at risk of Attention Deficit Hyperactivity Disorder (ADHD)
Parenting training interventions are recommended as part of a multimodal treatment approach for school-aged children with ADHD1. Based on social learning principles, parenting interventions include strategies for parents aimed at increasing the frequency of adaptive child behaviours whilst reducing the occurrence of non-compliant or disruptive behaviour.
Current UK guidelines recommend that programmes are delivered to parents in a group format by trained therapists. However, their efficacy as treatments for ADHD has been questioned recently in a meta-analysis using outcome data from objective informants ‘probably blind’ to treatment allocation2. Despite this, behavioural interventions, such as parenting programmes, may be better viewed as treatments with the ability to target some of the more distal functioning deficits associated with ADHD3,4,5. The core aims of this presentation is to explore four areas relating to the empirical and clinical evidence relating to parenting interventions for ADHD.
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What is the mechanism through which behavioural interventions might impact on ADHD behaviour?
What do we know about the underlying endophenotypes of ADHD, the processes that mediate the relationship between the genetic liability associated with ADHD and the behaviours and the symptoms and impairments that are so obvious in most children with ADHD6? How does the evidence from endophenotypes map onto current intervention content in terms of potential treatment targets?
What is the evidence base to support behavioural interventions for ADHD symptom reduction and other outcomes?
Based on recent meta-analyses which have applied rigorous methods to overcome biases in previous analyses, findings suggest that behavioural interventions (most of which were parent focused) lead to significant reductions in ADHD reported interventions as reported by the most proximal rater (ie the person who attended the intervention) but no change according to probably blinded informants, which were a mix of teacher ratings and objective measures of ADHD1. The situation was clearer when out outcomes beyond symptom control for ADHD were explored, evidence suggested that parenting interventions were associated with a reduction in conduct problems, and an improvement in parenting, finding which were corroborated by probably blinded informants.3
Who should we target? Is there value in combining parent-focused interventions with school-focused or patient-focused behavioural interventions?
A recent meta-analysis7 of treatments for adolescents with ADHD has demonstrated that behavioural interventions (which were mostly adolescent focused but were sometimes augmented with teacher and/or parent components) were associated with robust improvements in mostly parent rated academic and organizational skills, such as homework completion and planner use. Although studies have shown the effectiveness of integrated school/home programmes compared to control groups only one study has systematically assessed the additive value of school intervention (and a child skills training) to parent training in a sample of children with the inattentive subtype of ADHD8. Results showed superior effects of integrated home-school treatment as compared to parent training alone on unblinded teacher-reports at post-treatment. However, at follow-up during the subsequent school year, differences in teacher-reported outcomes were not statistically significant. Although several treatment studies have combined child-focused and parent focused elements (and reported positive results, few studies have systematically assessed the additional value of a child-focused element to parent training. Some early studies combined parent training with child-focused treatment (targeting child self-control) and assessed the separate and combined effects. In these studies there was no evidence for additive effects of child-focused problem solving treatment on ADHD and conduct problems5.
What mode of delivery should we use i.e. group versus individual treatment?
There is little available evidence to support one delivery structure (individual versus group) over another. General engagement and drop-out rates for group-based programmes for children with conduct problems are high and usually between 25 and 40%9. A recent study comparing home-based individual parent training versus a group based parent training programme delivered in non-home-based settings showed no difference between the two interventions in terms of ADHD or conduct problem outcomes but the home based individual programme was associated with lower levels of participants drop-out and cost less than the group programme. In this study cost differences were due to expensive facility costs (crèches, halls and refreshments and travel costs) and higher preparation/supervision and training costs for the group-based approach10.
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References
1. Sonuga-Barke, E., et al., Non-pharmacological interventions for attention-deficit/hyperactivityvdisorder: systematic review and meta-analyses of randomised controlled trials of dietary and psychological treatments. Am J Psychiatr, 2013.
2. Sonuga-Barke, E.J., et al., Nonpharmacological interventions for preschoolers with ADHD: the case for specialized parent training. Infants & Young Children, 2006. 19(2): p. 142-153.
3. Daley, D., et al., Behavioral Interventions in Attention-Deficit/Hyperactivity Disorder: A Meta-Analysis of Randomized Controlled Trials Across Multiple Outcome Domains. Journal of the American Academy of Child & Adolescent Psychiatry, 2014. 53(8): p. 835-847.e5.
4. Group, M.C., A 14-month randomized clinical trial of treatment strategies for attentiondeficit/ hyperactivity disorder. Archives of General Psychiatry, 1999. 56(12): p. 1073.
5. Daley, D et al Practitioner Review: Current best practice in the use of parent training and other behavioural interventions in the treatment of children and adolescents with ADHD. Journal of Child Psychology and Psychiatry (2018) DOI: 10.1111/jcpp.12825
6. Sonuga-Barke, E. J. S. & Halperin, J. M. (2010). Developmental phenotypes and causal pathways in attention deficit/hyperactivity disorder: potential targets for early intervention? Journal of Child Psychology and Psychiatry, 51, 368-389.
7. Chan, E., Fogler, J. M. & Hammerness, P. G. (2016). Treatment of Attention-Deficit/Hyperactivity Disorder in Adolescents: A Systematic Review. JAMA, 315, 1997-2008.
8. Pfiffner, L. J., Hinshaw, S. P., Owens, E., Zalecki, C., Kaiser, N. M., Villodas, M., & McBurnett, K. (2014). A two-site randomized clinical trial of integrated psychosocial treatment for ADHD inattentive type. Journal of Consulting and Clinical Psychology, 82(6), 1115–1127. doi:10.1037/a003688
9. Koerting, J., Smith, E., Knowles, M. M., Latter, S., Elsey, H., Mccann, D. C., Thompson, M. & Sonuga-Barke, E. J. S. (2013). Barriers to, and facilitators of, parenting programmes for childhood behaviour problems: a qualitative synthesis of studies of parents’ and professionals’ perceptions. European Child & Adolescent Psychiatry, 22, 653-670.
10. Sonuga-barke, E.J.S., Barton, J., Daley, D., Hutchings, J., Maishman, T., Raftery, J., Stanton, L., Laver-bradbury, C., Chorozoglou, M., Coghill, D., Little, L., Ruddock, M., Radford, M., Guiqing, L.Y., Lee, L., Gould, L., Shipway, L, Markomichali, P., McGuirk, J., Lowe, M., Perez, E., Lockwood, J., & Thompson, M. (2018) Efficacy and cost-effectiveness of individual versus group-based parent training for preschool attention-deficit/hyperactivity disorder: A multi-centre, randomised controlled trial.
