Remote assessment of ADHD in children and adolescents: recommendations from the European ADHD Guidelines Group following the clinical experience during the COVID-19 pandemic.

The COVID-19 pandemic led ADHD services to modify the clinical practice to reduce in-person contact as much as possible to minimise viral spread. This had far-reaching effects on day-to-day clinical practice as remote assessments were widely adopted. Despite the attenuation of the acute threat from COVID, many clinical services are retaining some remote practices. The lack of clear evidence-based guidance about the most appropriate way to conduct remote assessments meant that these changes were typically implemented in a localised, ad hoc, and un-coordinated way. Here, the European ADHD Guidelines Group (EAGG) discusses the strengths and weaknesses of remote assessment methods of children and adolescents with ADHD in a narrative review based on available data and expert opinions to highlight key recommendations for future studies and clinical practice. We conclude that going forward, despite remote working in clinical services functioning adequately during the pandemic, all required components of ADHD assessment should still be completed following national/international guidelines; however, the process may need adaptation. Social restrictions, including changes in education provision, can either mask or exacerbate features associated with ADHD and therefore assessment should carefully chart symptom profile and impairment prior to, as well as during an ongoing pandemic. While remote assessments are valuable in allowing clinical services to continue despite restrictions and may have benefits for routine care in the post-pandemic world, particular attention must be paid to those who may be at high risk but not be able to use/access remote technologies and prioritize these groups for conventional face-to-face assessments.

Systematic Review and Meta-Analysis of the Effectiveness of Teacher Delivered Interventions for Externalizing Behaviors.

This systematic review and meta-analysis explores the effectiveness of teacher interventions supporting children with externalizing behaviors based on teacher and child outcomes. A systematic search was conducted using 5 electronic databases. From 5714 papers, 31 papers that included interventions delivered directly to teachers and aimed to benefit either teachers and/or children with externalizing behaviors were included. The review focused on qualified teachers working with children aged 2-13. The results of the current meta-analysis revealed a positive effect of teacher intervention on teacher and child outcomes, including the increased use of teacher-appropriate strategies, as well as significant and moderate improvements in teacher-child closeness, and small reductions in teacher-child conflict. For child outcomes, the interventions reduced externalizing behavior problems and ADHD symptoms and enhanced prosocial behavior. Only one fully blinded analysis for conduct problems was possible and revealed a moderate but significant reduction in favor of intervention. These findings provide evidence to support the role of teacher interventions for both teachers and children with externalizing behaviors. Future research should include more PBLIND measurements so that MPROX findings can be confirmed. More research should be done to evaluate the influence of teacher interventions on teachers' well-being.

Development and evaluation of an online education tool on attention deficit hyperactivity disorder for general practitioners: the important contribution of co-production.

BACKGROUND: Attention deficit hyperactivity disorder (ADHD) is underdiagnosed in the UK and the assessment and diagnosis pathway often involves a general practitioner (GP) referral to secondary care services. GPs' levels of knowledge and understanding about ADHD is often a significant barrier in patients accessing care. The development of an online education resource could improve GPs knowledge of ADHD and optimise appropriate referrals. Involving end-users in co-creating interventions may enhance their clinical utility and impact routine clinical practice. However, there is limited published evidence describing how to meaningfully involve stakeholders in both the design and development components of co-production. METHOD: We report a step wise, co-production approach towards developing an online ADHD education intervention for GPs. Preparatory work highlighted the relevant topics to be included in the intervention, from which educational videos were then developed. Workshops were then conducted with GPs, leading to further refinement of the video content and subsequently the final intervention. A pilot usability study (n = 10 GPs) was then conducted to assess the intervention's acceptability, feasibility and accessibility. RESULTS: The development of the online intervention was greatly facilitated by the involvement of GPs. Having a co-production development process ensured the consistent adaptation of the intervention to meet GPs' needs. The usability study showed that the content of the intervention was suitable, easily accessible, engaging and delivered at an acceptable level of intensity, validating the development approach taken. CONCLUSION: While further studies are needed to evaluate the efficacy of the developed intervention, preliminary findings demonstrated that it was acceptable and well received. The importance of co-development was highlighted in developing an intervention that addresses specific needs for GPs. This development approach may be useful for other researchers and developers of clinical interventions.

Awareness of ADHD in primary care: stakeholder perspectives.

BACKGROUND: Attention Deficit Hyperactivity Disorder (ADHD) is underdiagnosed in many European countries and the process of accessing care and diagnosis is complex and variable. In many countries, general practitioners (GPs) refer on to secondary care where individuals receive an assessment and, if appropriate, a diagnosis and access to care. It is therefore essential that GPs have a clear understanding of the disorder and its care pathways. While previous studies have highlighted potential barriers in GPs' ADHD awareness, this qualitative study aims to further explore individual stakeholders' experiences. METHODS: Semi-structured interviews explored the views of multiple stakeholders- GPs (n = 5), healthcare specialists (n = 5), patients (adults with ADHD n = 5) and parents (n = 5) with experience of the presentation and management of ADHD in primary care. These interviews were analysed using thematic analyses and following principles of grounded theory. RESULTS: Stakeholders described ADHD assessment, diagnosis and treatment as an intricate process. Many factors affected this process such as complex pathways, lack of services, limited GP recognition and knowledge, and communicative difficulties between and within multiple stakeholders. CONCLUSION: This analysis underlines the significant impact that receiving (or not) a diagnosis can have, and further explores muddled ADHD care pathways, highlighting key issues around GP identification and the shortage of adult services. Implications for practice and future research are discussed, suggesting a strong need for more commissioned pathways and GP specific educational programs.

Barriers and facilitators to understanding of ADHD in primary care: a mixed-method systematic review.

Attention deficit hyperactivity disorder (ADHD) is a developmental disorder affecting up to 5% of children and adults and is underdiagnosed in many European countries. The process of access to care for this disorder is complex and variable across countries. In general, those affected, or their caregiver, will seek help through their primary care practitioners who are then often responsible for referral to other professionals for diagnosis and provision of treatment. Previous studies have highlighted that many barriers to recognition exist in primary care settings (such as misconceptions, lack of education or lack of resources), preventing access to care for this population and potentially affecting diagnosis rate. This systematic review aims to establish the barriers and facilitators with regard to attitudes, beliefs and experiences of ADHD within primary care. Electronic searches of multiple databases identified 3898 articles of which 48 met our inclusion criteria-primary care professionals from any country, understanding, knowledge, awareness, attitude and recognition of ADHD. Four main themes were identified: (1) need for education, (2) misconceptions and stigma, (3) constraints with recognition, management and treatment, and (4) multidisciplinary approach. The findings suggest many interacting factors are at play in the recognition of ADHD by primary care practitioners with a strong recurring theme of a significant need for better education on ADHD. Implications for research and practice are discussed, suggesting that educational interventions for primary care practitioners could improve the recognition of ADHD in this setting.

The Effectiveness of a Psychoeducation Intervention delivered via WhatsApp for mothers of children with Autism Spectrum Disorder (ASD) in the Kingdom of Saudi Arabia: A randomized controlled trial.

BACKGROUND: Mothers of children with autism spectrum disorder (ASD) report high levels of stress and lower levels of well-being than parents of typically developing children. Current interventions for ASD typically focus on working with the child rather than delivering strategies to help support parents. OBJECTIVE: To evaluate the effectiveness of a psychoeducation intervention developed to support mothers of children with ASD in Saudi Arabia. METHOD: Sixty-two mothers (23-52 years) of children (26-78 months) were recruited to a multisite randomized controlled trials of the intervention. The intervention consisted of one face-to-face session (60 min) and four virtual sessions (30 min each) delivered using WhatsApp. Parenting stress was the primary outcome, with secondary outcomes focusing on maternal depression, anxiety, and happiness, and child behaviour problems and ASD symptoms. Data were collected at baseline T1, immediately postintervention T2 and 8-week follow-up T3. RESULTS: One-way analysis of covariance was used at T2 and T3 with T1 scores entered as a covariate. Improvements were found at T2 for stress (F = 234.34, p = .00, and d = -1.52) and depression (F = 195.70, p = .00, and d = -2.14) but not anxiety, and these results were maintained at T3. Changes in child behaviour problems were limited to improvements in hyperactivity at T2 (F = 133.66, p = .00, and d = -1.54). Although changes in stress and depression were statistically significant, change to clinically normal levels was limited to depression. None of the participants had recovered after the intervention (Parent Stress Index Short Form stress scores), whereas 23 mothers (71.87%) in the intervention group had recovered at T2 and 22 (68.75%) at T3 (Hospital Anxiety and Depression Scale depression scores). CONCLUSION: This intervention with WhatsApp support is beneficial but may need to be augmented with other forms of support for mothers of children with ASD including more condensed sessions on stress and interventions targeting anxiety.

Effectiveness and cost-effectiveness of a brief school-based group programme for parents of children at risk of ADHD: a cluster randomised controlled trial.

BACKGROUND: National Institute for Health and Care Excellence guidelines recommend a stepped care approach for the identification and management of children with, or at risk of, attention-deficit/hyperactivity disorder (ADHD). We investigated the effectiveness, cost-effectiveness and acceptability of a group parenting intervention programme (+/- a teacher session) for children at risk of ADHD. METHODS: In a three-arm cluster randomised controlled trial, 12 primary schools were randomly assigned to control, parent-only and combined (parent + teacher) intervention arms. Eligible children had high levels of parent-rated hyperactivity/inattention (n = 199). At 6 month follow-up, the primary outcome measure was the parent-completed Conners' Rating Scale - Revised (ADHD index). Secondary outcomes included the Conners' sub-scales (hyperactivity, cognitive problems/inattention and oppositional behaviour), the teacher-completed Conners' Rating Scale - Revised, child health-related quality of life, parental burden and parental mental health. The cost-effectiveness analyses reflected a health and personal social services perspective. TRIAL REGISTRATION: ISRCTN87634685. RESULTS: Follow-up data were obtained from 76 parents and 169 teachers. There was no effect of the parent-only (mean difference = -1.1, 95% CI -5.1,2.9; p = 0.57) or combined interventions (mean difference = -2.1, 95% CI -6.4,2.1; p = 0.31) on the ADHD index. The combined intervention was associated with reduced parent-reported hyperactivity symptoms (mean difference = -5.3; 95% CI -10.5,-0.01; p = 0.05) and the parent-only intervention with improved parental mental health (mean difference = -1.9; 95% CI -3.2,-0.5; p = 0.009). The incremental costs of the parent-only and the combined interventions were £73 and £123, respectively. Above a willingness-to-pay of £31 per one-point improvement in the ADHD index, the parent-only programme had the highest probability of cost-effectiveness. Participants found the interventions acceptable. CONCLUSIONS: For children at risk of ADHD, this school-based parenting programme was not associated with improvement in core ADHD symptoms. Secondary analyses suggested a possible reduction in parent-reported hyperactivity and parental mental health problems. Future research should compare targeted interventions against watchful waiting and specialist referral.

Beyond symptom control for attention-deficit hyperactivity disorder (ADHD): what can parents do to improve outcomes?

Attention-deficit hyperactivity disorder (ADHD) and its associated behavioural manifestations develop and progress as the result of complex gene-environment interactions. Parents exert a substantial influence and play a major role in their child's social environment. Despite this, recent evidence has suggested that adapting the child's environment via parenting interventions has minimal effects on child ADHD symptoms when analysing data from informants who are probably blind to treatment allocation. However, adverse parenting and family environments may act as a source of environmental risk for a number of child outcomes beyond ADHD symptoms. This is a narrative review that critically discusses whether parenting interventions are beneficial for alternative functioning outcomes in ADHD including neuropsychological, academic and social functioning and disruptive behaviour and how parenting and familial environments may be associated with these outcomes. In addition, the review explores how parental depression and parenting efficacy impact on capacity for optimal parenting and whether parenting interventions benefit parents too. A review of the evidence suggests that with modification, parenting interventions are beneficial for a number of outcomes other than ADHD symptom reduction. Improving the parent-child relationship may have indirect benefits for disruptive behaviour. Furthermore, parenting behaviours may directly benefit child neuropsychological, academic and social functioning. Parenting interventions can have therapeutic benefits for parents as well as children, which is important as parent and child well-being is likely to have a transactional relationship. Evaluation of the clinical success of parenting interventions should focus on a wider range of outcomes in order to aid understanding of the multifaceted benefits that they may be able to offer. Parenting interventions should not be seen as a redundant adjunct to medication in multi-modal treatment approaches for ADHD; they have the potential to target outcomes that, at present, medication seems less able to improve.

Adherence therapy improves medication adherence and quality of life in people with Parkinson's disease: a randomised controlled trial.

BACKGROUND: Many factors are associated with medication non-adherence in Parkinson's disease (PD), including complex treatment regimens, mood disorders and impaired cognition. However, interventions to improve adherence which acknowledge such factors are lacking. A phase II randomised controlled trial was conducted investigating whether Adherence Therapy (AT) improves medication adherence and quality of life (QoL) compared with routine care (RC) in PD. METHODS: Eligible PD patients and their spouse/carers were randomised to intervention (RC plus AT) or control (RC alone). Primary outcomes were change in adherence (Morisky Medication Adherence Scale) and QoL (Parkinson's Disease Questionnaire-39) from baseline to week-12 follow up. Secondary outcomes were MDS-UPDRS (part I, II, IV), Beliefs about Medication Questionnaire (BMQ), EuroQol (EQ-5D) and the Caregiving Distress Scale. Blinded data were analysed using logistic and linear regression models based on the intention-to-treat principle. RESULTS: Seventy-six patients and 46 spouse/carers completed the study (intervention: n = 38 patients, n = 24 spouse/carers). At week-12 AT significantly improved adherence compared with RC (OR 8.2; 95% CI: 2.8, 24.3). Numbers needed to treat (NNT) were 2.2 (CI: 1.6, 3.9). Compared with RC, AT significantly improved PDQ-39 (-9.0 CI: -12.2, -5.8), BMQ general harm (-1.0 CI: -1.9, -0.2) and MDS-UPDRS part II (-4.8 CI: -8.1, -1.4). No significant interaction was observed between the presence of a spouse/carer and the effect of AT. CONCLUSION: Adherence Therapy improved self-reported adherence and QoL in a PD sample. The small NNT suggests AT may be cost-effective. A larger pragmatic trial to test the efficacy and cost-effectiveness of AT by multiple therapists is required.

Attention-deficit hyperactivity disorder (ADHD): an updated review of the essential facts.

Attention-deficit hyperactivity disorder (ADHD) is a complex disorder that can affect individuals across the lifespan. It is associated with substantial heterogeneity in terms of aetiology, clinical presentation and treatment outcome and is the subject of extensive research. Because of this, it can be difficult for clinicians to stay up to date with the most relevant findings and know how best to respond to parents' questions and concerns about the disorder and interventions. This is a narrative review that aims to summarize key findings from recent research into ADHD and its treatment that clinicians can share with families in order to increase their knowledge about ADHD and intervention options. ADHD develops as a result of complex interplay between interdependent genetic and non-genetic factors. The disorder is associated with substantial impairments in functioning and poor long-term outcomes. Pharmacological and non-pharmacological treatment options are available for symptom management and to improve function, but functioning outcomes often fail to normalize in children with ADHD. Despite extensive advances in understanding this complex disorder, it is clear that there is still a long way to go. In particular, we address the need for future non-pharmacological interventions to be more specifically targeted for ADHD symptoms and its commonly associated functioning deficits in order to ensure the best long-term outcomes for children with ADHD.

Genome-wide association study of body mass index in 23 000 individuals with and without asthma.

BACKGROUND: Both asthma and obesity are complex disorders that are influenced by environmental and genetic factors. Shared genetic factors between asthma and obesity have been proposed to partly explain epidemiological findings of co-morbidity between these conditions. OBJECTIVE: To identify genetic variants that are associated with body mass index (BMI) in asthmatic children and adults, and to evaluate if there are differences between the genetics of BMI in asthmatics and healthy individuals. METHODS: In total, 19 studies contributed with genome-wide analysis study (GWAS) data from more than 23 000 individuals with predominantly European descent, of whom 8165 are asthmatics. RESULTS: We report associations between several DENND1B variants (P = 2.2 × 10(-7) for rs4915551) on chromosome 1q31 and BMI from a meta-analysis of GWAS data using 2691 asthmatic children (screening data). The top DENND1B single nucleotide polymorphisms(SNPs) were next evaluated in seven independent replication data sets comprising 2014 asthmatics, and rs4915551 was nominally replicated (P < 0.05) in two of the seven studies and of borderline significance in one (P = 0.059). However, strong evidence of effect heterogeneity was observed and overall, the association between rs4915551 and BMI was not significant in the total replication data set, P = 0.71. Using a random effects model, BMI was overall estimated to increase by 0.30 kg/m(2) (P = 0.01 for combined screening and replication data sets, N = 4705) per additional G allele of this DENND1BSNP. FTO was confirmed as an important gene for adult and childhood BMI regardless of asthma status. CONCLUSIONS AND CLINICAL RELEVANCE: DENND1B was recently identified as an asthma susceptibility gene in a GWAS on children, and here, we find evidence that DENND1B variants may also be associated with BMI in asthmatic children. However, the association was overall not replicated in the independent data sets and the heterogeneous effect of DENND1B points to complex associations with the studied diseases that deserve further study.

Association between parent reports of attention deficit hyperactivity disorder behaviours and child impulsivity in children with severe intellectual disability.

BACKGROUND: Although children with intellectual disability (ID) seemed to be at increased risk for Attention deficit hyperactivity disorder (ADHD)/hyperactivity problems when assessed with parent report questionnaires and clinical interviews, there has been little attention to the associations between parent reports and observed child behaviours. The purpose of the present study was to compare clinical symptoms and observed impulsivity in children with ID whose parents reported them as being relatively high and low in ADHD symptoms, and to examine whether any differences were associated with developmental level. METHODS: Parents of 28 children with ID completed a behaviour rating scale of hyperactivity symptoms. Parents were also interviewed using a robust clinical interview tool focused on hyperactivity symptoms. The children were all tested by an experimenter to measure their impulsive behaviour. RESULTS: Those children with clinical range scores on parent questionnaire ratings were also reported by parents to have more ADHD symptoms using a parent report clinical interview. Although these children were also more impulsive on an experimental task, when children's developmental ages were statistically controlled impulsivity differences disappeared. CONCLUSIONS: Parent reports of ADHD symptoms in children with ID may be positively associated with data derived using clinical interview methods, but they may be less sensitive to developmental expectations when compared with observed child behaviour. Practical implications include the need for multiple sources of information and normative data for children with ID on simple experimental tasks that can be used to aid diagnosis of ADHD in clinical settings.

Development of a recovery manual for suicidal patients with schizophrenia: consumer feedback.

A recovery-oriented manual was developed for patients with schizophrenia and suicidality. It included psychoeducational information, vignettes, "workbook" sections and was reviewed by experts in suicidology, recovery, patient education, manual development and psychosocial interventions. The revised version was tested in 22 consumers with schizophrenia and a history of suicidality. Consumer-based focus groups yielded five key themes which were used to further refine the manual. A satisfaction survey indicated that 85% stated the manual was 'somewhat easy', 'easy' or 'very easy to read.' All stated it was 'very useful', 'useful' or 'somewhat useful. Thus, the manual appears to be acceptable and useful.

Cystic fibrosis modifier genes related to Pseudomonas aeruginosa infection.

Cystic fibrosis (CF) is one of the most common life-shortening genetic disorders, and the CF transmembrane conductance regulator (CFTR) is the major causal gene. However, a substantial clinical variability among patients with identical CFTR genotypes suggests the presence of modifier genes. We tested the effect of four genes involved in Pseudomonas aeruginosa infection. Analysis of a primary cohort detected eight candidate polymorphisms that were genotyped in the secondary cohort of 1579 patients; lung function and age at first infection with P. aeruginosa were considered as the phenotypes. Both additive and codominant models were considered, adjusting for confounding variables but not for multiple comparisons. In the secondary cohort, heme oxygenase-1 (HMOX1) rs2071749 had the most significant effect on lung function in the pediatric group (P=0.01; P(corrected)=0.03), and complement factor 3 (C3) rs11569393 and HMOX1 rs2071746 in the adult groups (P=0.03 for both variants; P(corrected)=0.16, 0.09). No polymorphism of complement factor B (CFB) or toll-like receptor 4 (TLR4) had a significant modifying effect on lung function in either group. We have identified two genes that showed nominal association with disease severity among CF patients. However, because of the multiple comparisons made, further studies are required to confirm the interaction between these modifying genes and CFTR.

Self-help parenting interventions for childhood behaviour disorders: a review of the evidence.

The use of self-help interventions for parents of children with behaviour problems is becoming more prevalent. This review critically evaluated the evidence supporting the efficacy of such programmes for children with behaviour problems. Using a systematic literature search, two modes of delivery were evaluated, namely bibliotherapy and multimedia. Programmes that included minimal therapist support were also included. Overall, there is good evidence supporting the efficacy of self-help programmes in improving child behaviour, over the short and longer term. Self-help programmes led to outcomes similar to those achieved with more intensive therapist input. Including minimal levels of therapist support in addition to self-help materials enhances child and parent outcomes. Parents view self-help favourably but significantly less so than programmes including some form of therapist input. The future directions for self-help parent programmes include the need for longer-term follow-ups, the identification of moderators of outcome and economic evaluations of self-help programmes.

Incredible Years parent training support for foster carers in Wales: a multi-centre feasibility study.

BACKGROUND: the incidence of conduct disorder in young children is 10% in the general population and 37% among fostered children. Up to 40% of untreated children diagnosed with conduct disorder develop problems later in life including drug misuse, criminal and violent behaviour. There are more than 80,000 looked after children in the UK, with 5000 in Wales. Challenging child behaviour is the main reason for placement breakdown and has huge cost implications as challenging children cost up to 10 times more in service use than children without conduct disorder. The Incredible Years (IY) evidence-based parenting programme is an effective, low cost solution in improving child behaviour and social competence in 'conventional' families and thus has the potential to support foster carers in managing difficult behaviours. Our main aims were to establish: • The feasibility of delivery and the effectiveness of the IY parenting programme in supporting carers in managing difficult behaviour in looked after children. • Service use costs for foster carers and looked after child. METHODS: This was a 12-month trial platform study with 46 foster carers in three authorities in Wales. Carers were allocated 2:1 intervention to waiting-list control. Validated measures were used to assess 'parenting' competency, carers' depression levels, child behaviour and service use. Measures were administered at baseline and 6-month follow-up. Intervention carers received the programme between baseline and follow-up. RESULTS: Analyses showed a significant reduction in child problem behaviour and improvement in carers' depression levels for intervention families at follow-up, compared with control. Unexpectedly, there was a significant improvement in control carers' self-reported 'parenting' strategies. Special education was the greatest service cost for looked after children. CONCLUSIONS: Initial foster carer training could incorporate the IY programme to support carers in establishing positive relationships and managing difficult child behaviour. Programme participation may lead to reduced service use and improved placement stability.

ADHD and academic performance: why does ADHD impact on academic performance and what can be done to support ADHD children in the classroom?

This paper reviews the relationship between attention deficit hyperactivity disorder (ADHD) and academic performance. First, the relationship at different developmental stages is examined, focusing on pre-schoolers, children, adolescents and adults. Second, the review examines the factors underpinning the relationship between ADHD and academic underperformance: the literature suggests that it is the symptoms of ADHD and underlying cognitive deficits not co-morbid conduct problems that are at the root of academic impairment. The review concludes with an overview of the literature examining strategies that are directed towards remediating the academic impairment of individuals with ADHD.

Essential role of growth hormone in ischemia-induced retinal neovascularization.

Retinal neovascularization is the major cause of untreatable blindness. The role of growth hormone (GH) in ischemia-associated retinal neovascularization was studied in transgenic mice expressing a GH antagonist gene and in normal mice given an inhibitor of GH secretion (MK678). Retinal neovascularization was inhibited in these mice in inverse proportion to serum levels of GH and a downstream effector, insulin-like growth factor-I (IGF-I). Inhibition was reversed with exogenous IGF-I administration. GH inhibition did not diminish hypoxia-stimulated retinal vascular endothelial growth factor (VEGF) or VEGF receptor expression. These data suggest that systemic inhibition of GH or IGF-I, or both, may have therapeutic potential in preventing some forms of retinopathy.

Expressed emotion in children: associations with sibling relationships.

OBJECTIVE: To investigate the reliability and validity of the expressed emotion (EE) measure, the Pre-school Five Minute Speech Sample (PFMSS), in child-to-child sibling relationships. METHOD: A total of 106 boys aged 7-11 were recruited from 12 mainstream primary schools in North Wales. The children completed the PFMSS regarding their sibling and two self-report measures of sibling relationship: the Sibling Relationship Questionnaire (SRQ) and a Child Visual Analogue Scale (CVAS). The parents of 60 participants completed the Strengths and Difficulties Questionnaire regarding the behavioural problems of the participating child and his younger sibling. RESULTS: The PFMSS demonstrated good inter-rater and code-recode reliability. The significant associations between EE dimensions such as relationship, positive comments and critical comments with various components of the SRQ and CVAS provided support for the concurrent validity of the PFMSS. Significantly higher levels of Conflict and Rivalry and significantly lower levels of Warmth/Closeness on the SRQ were reported by children with high EE, demonstrating good discriminant validity for the PFMSS. There was no significant association between the child's EE profile and the behavioural difficulties of both siblings as reported by parents. CONCLUSIONS: The study found that the PFMSS is a valid and reliable measure of child EE. Future research is needed to clarify the concurrent validity of the warmth and initial statement components of the measure as well as the association between EE dimensions and behaviour.

Attention deficit hyperactivity disorder in pre-school children: current findings, recommended interventions and future directions.

This paper outlines the presentation, aetiology and treatment of attention deficit hyperactivity disorder (ADHD) in pre-school children. A review of current parenting training interventions demonstrates that there is good evidence for their efficacy in reducing symptoms of ADHD in pre-school children, and three interventions are evaluated: The new forest parent training programme (NFPP); the triple P - positive parenting programme and the incredible years parent training programme (IY). The evaluation of the NFPP provides strong evidence demonstrating its effectiveness for pre-school children with ADHD, while the efficacy of the Triple - P and the IY programme have, to date, only been demonstrated on children with conduct problems and co-morbid ADHD. It is suggested that parent training should be the first choice treatment for pre-school children presenting signs of ADHD, and medication introduced only for those children where parent training is not effective. Few moderators of outcome have been identified for these interventions, with the exception of parental ADHD. Barriers to intervention and implementation fidelity will need to be addressed to achieve high levels of attendance, completion and efficacy. The IY programme is a good model for addressing fidelity issues and for overcoming barriers to intervention. The future directions for parent training are also discussed.