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.

A small-scale randomized controlled trial of the revised new forest parenting programme for preschoolers with attention deficit hyperactivity disorder.

The revised new forest parenting programme (NFPP) is an 8-week psychological intervention designed to treat ADHD in preschool children by targeting, amongst other things, both underlying impairments in self-regulation and the quality of mother-child interactions. Forty-one children were randomized to either the revised NFPP or treatment as usual conditions. Outcomes were ADHD and ODD symptoms measured using questionnaires and direct observation, mothers' mental health and the quality of mother-child interactions. Effects of the revised NFPP on ADHD symptoms were large (effect size >1) and significant and effects persisted for 9 weeks post-intervention. Effects on ODD symptoms were less marked. There were no improvements in maternal mental health or parenting behavior during mother-child interaction although there was a drop in mothers' negative and an increase in their positive comments during a 5-min speech sample. The small-scale trial, although limited in power and generalizability, provides support for the efficacy of the revised NFPP. The findings need to be replicated in a larger more diverse sample.

The Moderating Effect of Self-Reported State and Trait Anxiety on the Late Positive Potential to Emotional Faces in 6-11-Year-Old Children.

Introduction: The emergence of anxiety during childhood is accompanied by the development of attentional biases to threat. However, the neural mechanisms underlying these biases are poorly understood. In addition, previous research has not examined whether state and trait anxiety are independently associated with threat-related biases. Methods: We compared ERP waveforms during the processing of emotional faces in a population sample of 58 6-11-year-olds who completed self-reported measures of trait and state anxiety and depression. Results: The results showed that the P1 was larger to angry than neutral faces in the left hemisphere, though early components (P1, N170) were not strongly associated with child anxiety or depression. In contrast, Late Positive Potential (LPP) amplitudes to angry (vs. neutral) faces were significantly and positively associated with symptoms of anxiety/depression. In addition, the difference between LPPs for angry (vs. neutral) faces was independently associated with state and trait anxiety symptoms. Discussion: The results showed that neural responses to facial emotion in children with elevated symptoms of anxiety and depression were most evident at later processing stages characterized as evaluative and effortful. The findings support cognitive models of threat perception in anxiety and indicate that trait elements of anxiety and more transitory fluctuations in anxious affect are important in understanding individual variation in the neural response to threat in late childhood.

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).

Emotion-recognition abilities and behavior problem dimensions in preschoolers: evidence for a specific role for childhood hyperactivity.

Facial emotion-recognition difficulties have been reported in school-aged children with behavior problems; little is known, however, about either this association in preschool children or with regard to vocal emotion recognition. The current study explored the association between facial and vocal emotion recognition and behavior problems in a sample of 3 to 6-year-old children. A sample of 57 children enriched for risk of behavior problems (41 were recruited from the general population while 16 had been referred for behavior problems to local clinics) were each presented with a series of vocal and facial stimuli expressing different emotions (i.e., angry, happy, and sad) of low and high intensity. Parents rated children's externalizing and internalizing behavior problems. Vocal and facial emotion recognition accuracy was negatively correlated with externalizing but not internalizing behavior problems independent of emotion type. The effects with the externalizing domain were independently associated with hyperactivity rather than conduct problems. The results highlight the importance of using vocal as well as facial stimuli when studying the relationship between emotion-recognition and behavior problems. Future studies should test the hypothesis that difficulties in responding to adult instructions and commands seen in children with attention deficit/hyperactivity disorder (ADHD) may be due to deficits in the processing of vocal emotions.

Evaluation of a Mental Health Service for Young Children: Development, Outcome and Satisfaction.

BACKGROUND: Over a 10-year period (1984-1996) a child guidance clinic developed a service in the community for parents with young children with mental health problems. This included support for primary care staff and training courses. The clinical input to the young children developed from a clinic within the child guidance clinic (1984-87), to a specialist clinic for under fives (1990-91) to a service run by a nurse in the community (1994-95), with nurses referring to colleagues only the more complicated cases. METHOD: The work in 1990-91 was compared with the work in 1994-95. The family and clinic scored the outcome of the work, by recording the severity of the problem, separately, on unanchored 5-point Likert scales before and after treatment. For the evaluation in 1994-95 a satisfaction questionnaire was also developed. The cost of running the two different clinics was calculated. RESULTS: The results indicated that there was a slight fall in the effect size for the clinical work in 1994-95, but this method of working was two-thirds of the cost of the previous clinic. The parents were satisfied with both services. The post-contact parental satisfaction questionnaire had face validity, construct validity and internal consistency. CONCLUSIONS: Nurses working on their own in the community can be a cost effective method for working with families with young children. Some families will need to be referred on to specialist teams and more work needs to be done to establish which families and when referral is appropriate. The questionnaire was shown to be a valid and reliable way of assessing family satisfaction.

Isolating N400 as neural marker of vocal anger processing in 6-11-year old children.

INTRODUCTION: Vocal anger is a salient social signal serving adaptive functions in typical child development. Despite recent advances in the developmental neuroscience of emotion processing with regard to visual stimuli, little remains known about the neural correlates of vocal anger processing in childhood. This study represents the first attempt to isolate a neural marker of vocal anger processing in children using electrophysiological methods. METHODS: We compared ERP wave forms during the processing of non-word emotional vocal stimuli in a population sample of 55 6-11-year-old typically developing children. Children listened to three types of stimuli expressing angry, happy, and neutral prosody and completed an emotion identification task with three response options (angry, happy and neutral/'ok'). RESULTS: A distinctive N400 component which was modulated by emotional content of vocal stimulus was observed in children over parietal and occipital scalp regions-amplitudes were significantly attenuated to angry compared to happy and neutral voices. DISCUSSION: Findings of the present study regarding the N400 are compatible with adult studies showing reduced N400 amplitudes to negative compared to neutral emotional stimuli. Implications for studies of the neural basis of vocal anger processing in children are discussed.

Parenting behaviour described by mothers in a general population sample.

OBJECTIVES: To collect mothers' reports of the range of behaviours used by them in the management of their children's difficult behaviour. DESIGN: A cross-sectional study using an interview with both semi-structured and open-ended question routes. SAMPLING FRAME: The population of mothers with 10-year-old children living in the New Forest region of Hampshire, UK. METHODS: Mothers (n=67), selected from the sampling frame, were interviewed about the range of parenting behaviours they used in the management of their children's difficult behaviour. RESULTS: Mothers reported a wide range of behaviours. Both authoritative (e.g. reasoning was mentioned by 42%) and authoritarian (e.g. the use of physical punishment was mentioned by 37%) behaviours were mentioned frequently. Although the different behaviours within these domains were intercorrelated, there was little overlap between the two domains. The use of praise for good behaviour seemed to be independent of other behaviours. There was no association between mothers' parenting behaviours and the behaviour problems of their children. CONCLUSIONS: These data suggest that parenting takes many forms, with variations of behaviour across the 'normal' range being unlikely to represent a significant risk to children's development. Public funding for parenting education should be targeted at those children who are at significant risk from extreme forms of parenting.

Profiles, co-morbidity and their relationship to treatment of 191 children with AD/HD and their families.

BACKGROUND: This study was set up to re-audit our use of a protocol for the assessment and treatment for children on psycho-stimulant medication within a community clinic for children with Attention Deficit/Hyperactive Disorder (AD/HD) and to examine the profile of children and their families referred to the clinic in order to consider their assessment and treatment needs. METHOD: A questionnaire based on results from previous studies was completed for 191 patients from a case note audit, and by questioning clinicians. Key areas examined were symptomatology and child and family variables, which included learning difficulties, medical problems, psychosocial factors and side-effects of medication. RESULTS: The protocol was used appropriately with the majority of children. Children with AD/HD referred to the clinic often presented with co-morbid psychopathology, e. g. conduct disorder, low self-esteem, and frequently experienced family and psychosocial difficulties. CONCLUSIONS: Protocols in clinics are useful as this should maintain good practice and allow on-going monitoring, but they need precise use. Also, as many children with AD/HD present with co-morbid psychopathology and complicated family dynamics to Child and Adolescent Mental Health Services, this will influence assessment and treatment needs and require increased resources.