Innovations in Practice: Adapting a specialized ADHD parenting programme for use with 'hard to reach' and 'difficult to treat' preschool children.

BACKGROUND: Effective implementation of parent training programmes for preschool Attention-Deficit/Hyperactivity Disorder type is constrained by barriers limiting take-up and effective engagement by 'hard to reach' and 'difficult to treat' families. METHOD: We describe an evidence-driven adaptation and piloting of an existing empirically supported preschool ADHD parenting programme to address these problems. RESULTS: The New Forest Parenting programme was changed substantially in terms of length; content and delivery on the basis of information gathered from the literature, from parents and practitioners, further modifications were made after the pilot study. CONCLUSIONS: The adapted-NFPP is currently being assessed for efficacy in a large multicentre randomized controlled trial.

The effect of early confirmation of hearing loss on the behaviour in middle childhood of children with bilateral hearing impairment.

AIM: To determine if the benefit of early confirmation of permanent childhood hearing impairment (PCHI) on children's receptive language development is associated with fewer behavioural problems. METHOD: Follow-up of a total population cohort of 120 children with PCHI of moderate or greater severity (≥ 40 decibels relative to hearing threshold level) (67 males, 53 females; mean age 7 y 11 mo, range 5 y 5 mo-11 y 8 mo) and 63 hearing children (37 males, 26 females; mean age 8 y 1 mo, range 6 y 4 mo-9 y 10 mo). The main outcome measures were the Strengths and Difficulties Questionnaire (SDQ) completed by teachers and parents and the Vineland Adaptive Behaviour Scales (VABS) which are completed on the basis of a parental interview. RESULTS: Children with PCHI had lower standard scores than hearing children on the Daily Living Skills (p=0.001) and the Socialisation (p=0.001) scales of the VABS. They had significantly higher Total Behaviour Problem scores on the parent-rated (p=0.002) and teacher-rated SDQ (p=0.03). Children for whom PCHI was confirmed by 9 months did not have significantly fewer problems on the behavioural measures than those confirmed after that age (p=0.635 and p=0.196). INTERPRETATION: Early confirmation has a beneficial effect on receptive language development but no significant impact in reducing behavioural problems in children with PCHI.

The relationship between language development and behaviour problems in children with hearing loss.

BACKGROUND: There are well-replicated findings that link poor development on a range of communication skills with increased behavioural problems. This paper examines this relationship in children with hearing loss. METHOD: One hundred and twenty children with hearing loss (67 boys, 53 girls) and 63 hearing children (37 boys, 26 girls) with a mean age of 8 years from eight districts in Southern England were assessed for receptive and expressive language skills. The relationships between these measures and an aggregate of parent- and teacher-reported behaviour problems in the children were investigated. RESULTS: Children with hearing loss had higher levels of behaviour problems compared to hearing children. Once the language abilities of children with hearing loss are taken into account, the negative effects of hearing loss on behaviour disappear. CONCLUSIONS: Behaviour problems are found more commonly in children with hearing loss and the level of behaviour problems is highest amongst those children with hearing loss with the least developed language capabilities.

Language ability after early detection of permanent childhood hearing impairment.

BACKGROUND: Children with bilateral permanent hearing impairment often have impaired language and speech abilities. However, the effects of universal newborn screening for permanent bilateral childhood hearing impairment and the effects of confirmation of hearing impairment by nine months of age on subsequent verbal abilities are uncertain. METHODS: We studied 120 children with bilateral permanent hearing impairment identified from a large birth cohort in southern England, at a mean of 7.9 years of age. Of the 120 children, 61 were born during periods with universal newborn screening and 57 had hearing impairment that was confirmed by nine months of age. The primary outcomes were language as compared with nonverbal ability and speech expressed as z scores (the number of standard deviations by which the score differed from the mean score among 63 age-matched children with normal hearing), adjusted for the severity of the hearing impairment and for maternal education. RESULTS: Confirmation of hearing impairment by nine months of age was associated with higher adjusted mean z scores for language as compared with nonverbal ability (adjusted mean difference for receptive language, 0.82; 95 percent confidence interval, 0.31 to 1.33; and adjusted mean difference for expressive language, 0.70; 95 percent confidence interval, 0.13 to 1.26). Birth during periods with universal newborn screening was also associated with higher adjusted z scores for receptive language as compared with nonverbal ability (adjusted mean difference, 0.60; 95 percent confidence interval, 0.07 to 1.13), although the z scores for expressive language as compared with nonverbal ability were not significantly higher. Speech scores did not differ significantly between those who were exposed to newborn screening or early confirmation and those who were not. CONCLUSIONS: Early detection of childhood hearing impairment was associated with higher scores for language but not for speech in midchildhood.

Food additives and hyperactive behaviour in 3-year-old and 8/9-year-old children in the community: a randomised, double-blinded, placebo-controlled trial.

BACKGROUND: We undertook a randomised, double-blinded, placebo-controlled, crossover trial to test whether intake of artificial food colour and additives (AFCA) affected childhood behaviour. METHODS: 153 3-year-old and 144 8/9-year-old children were included in the study. The challenge drink contained sodium benzoate and one of two AFCA mixes (A or B) or a placebo mix. The main outcome measure was a global hyperactivity aggregate (GHA), based on aggregated z-scores of observed behaviours and ratings by teachers and parents, plus, for 8/9-year-old children, a computerised test of attention. This clinical trial is registered with Current Controlled Trials (registration number ISRCTN74481308). Analysis was per protocol. FINDINGS: 16 3-year-old children and 14 8/9-year-old children did not complete the study, for reasons unrelated to childhood behaviour. Mix A had a significantly adverse effect compared with placebo in GHA for all 3-year-old children (effect size 0.20 [95% CI 0.01-0.39], p=0.044) but not mix B versus placebo. This result persisted when analysis was restricted to 3-year-old children who consumed more than 85% of juice and had no missing data (0.32 [0.05-0.60], p=0.02). 8/9-year-old children showed a significantly adverse effect when given mix A (0.12 [0.02-0.23], p=0.023) or mix B (0.17 [0.07-0.28], p=0.001) when analysis was restricted to those children consuming at least 85% of drinks with no missing data. INTERPRETATION: Artificial colours or a sodium benzoate preservative (or both) in the diet result in increased hyperactivity in 3-year-old and 8/9-year-old children in the general population.

Universal newborn screening for permanent childhood hearing impairment: an 8-year follow-up of a controlled trial.

An 8-year follow-up study of the birth cohort of babies enrolled in the Wessex controlled trial of universal newborn screening (UNS) for permanent childhood hearing impairment (PCHI) was undertaken to establish whether UNS would increase the proportion of all true cases of PCHI in children aged 7-9 years who are referred early. The proportion referred before 6 months of age increased from 11 of 35 (31%) children with true PCHI born during periods without UNS to 23 of 31 (74%) born during periods with UNS (difference 43%, 95% CI 19-60). UNS leads to early referral of PCHI.

Study protocol for a randomized controlled trial comparing the efficacy of a specialist and a generic parenting programme for the treatment of preschool ADHD.

BACKGROUND: The New Forest Parenting Programme (NFPP) is a home-delivered, evidence-based parenting programme to target symptoms of attention-deficit/hyperactivity disorder (ADHD) in preschool children. It has been adapted for use with 'hard-to-reach' or 'difficult-to-treat' children. This trial will compare the adapted-NFPP with a generic parenting group-based programme, Incredible Years (IY), which has been recommended for children with preschool-type ADHD symptoms. METHODS/DESIGN: This multicentre randomized controlled trial comprises three arms: adapted-NFPP, IY and treatment as usual (TAU). A sample of 329 parents of preschool-aged children with a research diagnosis of ADHD enriched for hard-to-reach and potentially treatment-resistant children will be allocated to the arms in the ratio 3:3:1. Participants in the adapted-NFPP and IY arms receive an induction visit followed by 12 weekly parenting sessions of 1½ hours (adapted-NFPP) or 2½ hours (IY) over 2.5 years. Adapted-NFPP will be delivered as a one-to-one home-based intervention; IY, as a group-based intervention. TAU participants are offered a parenting programme at the end of the study. The primary objective is to test whether the adapted-NFPP produces beneficial effects in terms of core ADHD symptoms. Secondary objectives include examination of the treatment impact on secondary outcomes, a study of cost-effectiveness and examination of the mediating role of treatment-induced changes in parenting behaviour and neuropsychological function. The primary outcome is change in ADHD symptoms, as measured by the parent-completed version of the SNAP-IV questionnaire, adjusted for pretreatment SNAP-IV score. Secondary outcome measures are: a validated index of behaviour during child's solo play; teacher-reported SNAP-IV (ADHD scale); teacher and parent SNAP-IV (ODD) Scale; Eyberg Child Behaviour Inventory - Oppositional Defiant Disorder scale; Revised Client Service Receipt Inventory - Health Economics Costs measure and EuroQol (EQ5D) health-related quality-of-life measure. Follow-up measures will be collected 6 months after treatment for participants allocated to adapted-NFPP and IY. DISCUSSION: This trial will provide evidence as to whether the adapted-NFPP is more effective and cost-effective than the recommended treatment and TAU. It will also provide information about mediating factors (improved parenting and neuropsychological function) and moderating factors (parent and child genetic factors) in any increased benefit. TRIAL REGISTRATION: Current Controlled Trials, ISRCTN39288126.

Early detection and intervention for attention-deficit/hyperactivity disorder.

Attention-deficit/hyperactivity disorder (ADHD) is a high-cost/high-burden disorder. Early detection and intervention may prevent or ameliorate the development of the disorder and reduce its long-term impact. In this article, we set out a rationale for an early detection and intervention program. First, we highlight the costs of the condition and second, we discuss the limitations of the current treatments. We then outline the potential value of an early detection and intervention program. We review evidence on predictors of poor outcomes for early ADHD signs and discuss how these might allow us to target early intervention more cost-effectively. We then examine potential barriers to engagement with at-risk samples. This leads to a discussion of possible intervention approaches and how these could be improved. Finally, we describe the Program for Early Detection and Intervention for ADHD (PEDIA), a 5-year program of research supported by the UK National Institute for Health Research and conducted at the University of Southampton (Southampton, UK), which aims to develop and evaluate a strategy for early intervention.

The role of histamine degradation gene polymorphisms in moderating the effects of food additives on children's ADHD symptoms.

OBJECTIVE: Food additives can exacerbate ADHD symptoms and cause non-immunoglobulin E-dependent histamine release from circulating basophils. However, children vary in the extent to which their ADHD symptoms are exacerbated by the ingestion of food additives. The authors hypothesized that genetic polymorphisms affecting histamine degradation would explain the diversity of responses to additives. METHOD: In a double-blind, placebo-controlled crossover trial, challenges involving two food color additive and sodium benzoate (preservative) mixtures in a fruit drink were administered to a general community sample of 3-year-old children (N = 153) and 8/9-year-old children (N = 144). An aggregate ADHD symptom measure (based on teacher and parent blind ratings of behavior, blind direct observation of behavior in the classroom, and--for 8/9-year-old children only--a computerized measure of attention) was the main outcome variable. RESULTS: The adverse effect of food additives on ADHD symptoms was moderated by histamine degradation gene polymorphisms HNMT T939C and HNMT Thr105Ile in 3- and 8/9-year-old children and by a DAT1 polymorphism (short versus long) in 8/9-year-old children only. There was no evidence that polymorphisms in catecholamine genes COMT Val108Met, ADRA2A C1291G, and DRD4-rs7403703 moderated the effect on ADHD symptoms. CONCLUSIONS: Histamine may mediate the effects of food additives on ADHD symptoms, and variations in genes influencing the action of histamine may explain the inconsistency between previous studies. Genes influencing a range of neurotransmitter systems and their interplay with environmental factors, such as diet, need to be examined to understand genetic influences on ADHD symptoms.

Can schools promote the health of children with asthma?

This report describes the evaluation of a whole-school intervention to improve morbidity and psychosocial well-being in pupils with asthma. In all, 193 children with asthma (7-9 years) from 23 primary/junior schools in the south of England participated. Schools (n = 12) randomly assigned to the intervention group (IV) received a staff asthma training session, advice on asthma policy and practice and an emergency beta(2)-agonist inhaler with spacer. Pupils participated in an asthma lesson. Staff and pupils in non-intervention (NI) schools (n = 11) received no asthma-oriented input. While wheeze reports improved for all children with asthma, only the IV group showed lower requirement for medication (P = 0.01), clinically significant improvement (P < 0.05) in activity related quality of life (QOL) and increased self-esteem (SE: social P = 0.01; athletic P = 0.05; behaviour P = 0.001) in girls. SE decreased for NI girls but there was no change for non-asthmatic peers in NI or IV schools which had similar baseline levels of SE and QOL. There was a marginal improvement in the establishment of asthma policies/practices and no change in school absence or staff knowledge. The significantly increased peer group understanding of asthma seen in the intervention schools may have mediated increased well-being in the IV group. Primary schools are a potentially important context for improving asthma morbidity and psychosocial well-being of children with asthma.

Health status and health-related quality of life preference-based outcomes of children who are aged 7 to 9 years and have bilateral permanent childhood hearing impairment.

OBJECTIVE: The objective of this study was to describe the health status and health-related quality of life preference-based outcomes of children with diagnosed bilateral permanent childhood hearing impairment and a comparison group of English-speaking children with normal hearing. METHODS: We studied 120 children who were aged 7 to 9 years and had bilateral permanent childhood hearing impairment of moderate or greater severity, identified from a cohort of 156,733 children who were born in 8 districts of southern England, and 63 English-speaking children with normal hearing and the same place of birth and age at assessment. Principal caregivers were interviewed by using the Health Utilities Index Mark III questionnaire for proxy-assessed usual health status assessment. Levels of function within each of the 8 attributes of the Health Utilities Index Mark III (cognition, vision, hearing, speech, ambulation, dexterity, emotion, and pain) were recorded. RESULTS: Bilateral permanent childhood hearing impairment is associated with significantly increased proportions of suboptimal levels of function and significantly lower single-attribute utility scores in 6 of the 8 attributes of the Health Utilities Index Mark III: vision, hearing, speech, ambulation, dexterity, and cognition. Compared with the children with normal hearing, the mean multiattribute utility score for the children with hearing impairment was significantly lower for both the whole group and the moderate, severe, and profound severity subgroups. The differences in the distributions of the multiattribute utility scores between the children with hearing impairment as a group and the children with normal hearing and between each of the severity subgroups and the children with normal hearing all were statistically significant. CONCLUSIONS: This study provides rigorous evidence of an association between bilateral permanent childhood hearing impairment and diminished health status and health-related quality of life preference-based outcomes during midchildhood.

Language ability in children with permanent hearing impairment: the influence of early management and family participation.

OBJECTIVE: The goal was to examine the relationships between management after confirmation, family participation, and speech and language outcomes in the same group of children with permanent childhood hearing impairment. METHODS: Speech, oral language, and nonverbal abilities, expressed as z scores and adjusted in a regression model, and Family Participation Rating Scale scores were assessed at a mean age of 7.9 years for 120 children with bilateral permanent childhood hearing impairment from a 1992-1997 United Kingdom birth cohort. Ages at institution of management and hearing aid fitting were obtained retrospectively from case notes. RESULTS: Compared with children managed later (> 9 months), those managed early (< or = 9 months) had higher adjusted mean z scores for both receptive and expressive language, relative to nonverbal ability, but not for speech. Compared with children aided later, a smaller group of more-impaired children aided early did not have significantly higher scores for these outcomes. Family Participation Rating Scale scores showed significant positive correlations with language and speech intelligibility scores only for those with confirmation after 9 months and were highest for those with late confirmed, severe/profound, permanent childhood hearing impairment. CONCLUSIONS: Early management of permanent childhood hearing impairment results in improved language. Family participation is also an important factor in cases that are confirmed late, especially for children with severe or profound permanent childhood hearing impairment.

The economic costs of congenital bilateral permanent childhood hearing impairment.

OBJECTIVE: The objective of this study was to estimate the economic costs of bilateral permanent childhood hearing impairment (PCHI) in the preceding year of life for children aged 7 to 9 years. METHODS: A cost analysis was conducted by using a birth cohort of children born between 1992 and 1997 in 8 districts of Southern England, of which half had been born into populations exposed to universal newborn screening (UNS). Unit costs were applied to estimates of health, social, and broader resource use made by 120 hearing-impaired children and 63 children in a normally hearing comparison group. Associations between societal costs per child and severity of hearing impairment, language ability score, exposure to UNS, and age of confirmation were analyzed, including adjustment for potential confounders in a linear regression model. RESULTS: The mean societal cost in the preceding year of life at 7 to 9 years of age was 14092.5 pound sterling for children with PCHI, compared with 4206.8 pound sterling for the normally hearing children, a cost difference of 9885.7 pound sterling. After adjusting for severity and other potential confounders in a linear regression model, mean societal costs among children with PCHI were reduced by 2553 pound sterling for each unit increase in the z score for receptive language. Using similar regression models, exposure to a program of UNS was associated with a smaller cost reduction of 2213.2 pound sterling, whereas costs were similar between children whose PCHI was confirmed at <9 or >9 months. CONCLUSIONS. The study provides rigorous evidence of the annual health, social, and broader societal cost of bilateral PCHI in the preceding year of life at 7 to 9 years of age and shows that it is related to its severity and has an inverse relationship with language abilities after adjustment for severity.

The prevalence and management of asthma in primary-aged schoolchildren in the south of England.

A postal questionnaire survey of headteachers in 149 Infant, Junior and Primary schools (response rate: 63.8%) indicated poor asthma record keeping and a need for regular staff training in asthma. Dealing with an emergency was a major concern of headteachers. In 25 of the schools surveyed, an International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire was distributed to parents of children in Years 3 and 4 (7-9 years). Headteacher-reported asthma prevalence was 11.9% in these schools, while ISAAC parental reports indicated a current or previous diagnosis of asthma in 24.3% children, with 17.8% receiving asthma treatment and 18.9% reporting wheeze in the previous 12 months. Of six wheezing children per Year 3/4 class, one was receiving no treatment for asthma, three had experienced four or more attacks of wheeze in the previous year with one wheezing child per two Year 3/4 classes experiencing more than 12 such attacks. Four in six children experienced exercise-related wheeze, while only one in five schools allowed asthma medication at Physical Education lessons. A whole school policy on asthma together with some regularly updated staff education and training by an asthma-trained nurse would address many of the issues raised in this study.