Parent Training for ADHD: No Generalization of Effects From Clinical to Neuropsychological Outcomes in a Randomized Controlled Trial.

OBJECTIVE: We examined whether neuropsychological function in ADHD can be improved by the New Forest Parenting Programme (NFPP), that combines standard parenting strategies with self-regulatory skills training, or predict ADHD and quality of life (QoL) treatment effects. METHOD: Participants were 93 medication-naive preschool children with ADHD (3-7 years) randomized to either NFPP (n = 49) or treatment as usual (TAU; n = 44) in a recent randomized trial. Laboratory measures of executive function, reaction time variability, and delay of gratification were collected along with parent ratings of ADHD and QoL at baseline and post treatment. Ratings were collected again at 3-month follow-up. RESULTS: NFPP did not improve neuropsychological function (compared to TAU), and baseline neuropsychological function did not predict treatment-related ADHD or QoL effects. CONCLUSION: Although NFPP includes a neuropsychological training element and has been shown to improve several clinical outcomes, it did not improve the neuropsychological functions it targets.

Functional somatic symptoms in preschool attention-deficit/hyperactivity disorder: a secondary analysis of data from a randomized controlled trial of parent training.

Children with attention-deficit/hyperactivity disorder (ADHD) can be more stress-vulnerable, and thereby, it has been suggested, prone to develop functional somatic symptoms (FSS) compared to their peers. In this paper, using data from 160 children aged 3-7 years with ADHD from the D'SNAPP study, a randomized controlled trial testing a parent training intervention, we addressed a number of questions about the role of FSS in ADHD. First, are FSS levels higher in an ADHD sample than in the children of the general population. Second, do FSS levels predict psychopathology and health-related quality of life (HRQoL) in ADHD samples. Third, does FSS levels moderate the effect of parent training on ADHD symptoms. We found that preschoolers with ADHD experienced more severe FSS than a general population-based sample (18.80% vs. 2.11%). Severe FSS were associated with increased psychopathology and impaired daily function and lower HRQoL. Level of baseline FSS did not moderate the effect of parent training on ADHD. FSS in preschool children with ADHD is associated with impaired daily functioning, but further research is warranted to determine the clinical impact of FSS in children with ADHD.

Effect of Parent Training on Health-Related Quality of Life in Preschool Children With Attention-Deficit/Hyperactivity Disorder: A Secondary Analysis of Data From a Randomized Controlled Trial.

OBJECTIVE: School-age children with attention-deficit/hyperactivity disorder (ADHD) have reduced health-related quality of life (HRQoL), but it is unclear whether this is also true for preschool children. It is unknown whether parent training (PT) improves HRQoL. This study compared HRQoL in preschool children with ADHD with age-matched children from the general population; examined whether PT improves HRQoL; and tested if treatment-related changes in HRQoL were mediated by improvements in ADHD, parent efficacy, and family stress. METHOD: Parents of 164 children age 3-7 years with an ADHD diagnosis participated in a randomized controlled trial comparing the New Forest Parenting Programme and treatment as usual. Measures of HRQoL, ADHD, parent efficacy, and family stress were completed at baseline, posttreatment, and 36-week follow-up. Child baseline HRQoL was compared with 2 general population-based reference groups. PT effects were analyzed using linear models and mediation analyses. RESULTS: Preschoolers with ADHD had lower HRQoL than the reference groups. The New Forest Parenting Programme, but not treatment as usual, was associated with improvement in psychosocial HRQoL at posttreatment (change 2.28, 95% CI [0.78, 3.77]) and at 36-week follow-up (change 2.05, 95% CI [0.56, 3.54]). This difference between treatment arms was not statistically significant. Parent efficacy and family stress scores at posttreatment significantly mediated improvements in HRQoL at 36-week follow-up; ADHD scores at posttreatment did not. CONCLUSION: ADHD negatively impacts HRQoL in early childhood. PT for ADHD has the potential to improve HRQoL independently of its effects on ADHD symptoms. CLINICAL TRIAL REGISTRATION INFORMATION: A Controlled Study of Parent Training in the Treatment of ADHD in Young Children (D'SNAPP); http://clinicaltrial.gov/; NCT01684644.

Treatment of ADHD in adults - prevalence of discontinuation and associated factors - results from a cross-sectional analysis of Danish register data.

BACKGROUND: A growing number of adults are receiving pharmacological treatment for ADHD but a sizable proportion also discontinues or have gaps in treatment. The primary aims of this study were to identify how many patients treated for ADHD in adulthood, have at least one event of discontinuation in treatment and to identify possible associated variables. METHODS: Within the Danish population aged 18-60 years on the 1st of January 2013, we identified the number of individuals who had been prescribed ADHD-medication at least once during the 1st of January 2002-31st of December 2013 using Danish register data. Among those who filed more than one prescription, treatment discontinuation was defined as having more than 211 days between two prescriptions. In crude and adjusted logistic regression analysis, we explored potential associations to discontinuation for variables such as gender and age at treatment initiation. RESULTS: In a population, if N = 3,165,844 individuals, n = 42,892 had received at least one prescription for ADHD medication. Among those with more than one prescription (N = 38,289), 29.4% had discontinued their treatment at least once, according to our definition of treatment discontinuation. ADHD treatment discontinuation was associated with being male, unemployment, lower educational attainment, receiving incapacity benefits and younger age at treatment initiation (p < 0.001). CONCLUSIONS: A large proportion of individuals treated for ADHD had at least one discontinuation of treatment according to our definition. Although the present study does not allow for investigating the direction of these effects, nor whether some patients later resumed treatment, having at least one discontinuation was associated with a range of variables relating to e.g. age and gender, and provides an emerging profile for clinicians of patients more likely to discontinue.

[ADHD in preschoolers and early parent training interventions].

ADHD is a prevalent neuro-developmental disorder, and with onset often occurring in early childhood. It impacts daily functioning across a range of domains and is predictive of long-term burden to families as well as health, social, education and criminal justice systems. Parent training (PT) is recommended as first-line treatment for pre-school children with ADHD. This review outlines the clinical presentation of preschool ADHD and presents the evidence for three different PT programmes available in Denmark and evaluated in RCTs with preschoolers.

An examination of the psychometric properties of scores on the Family Strain Index (FSI) in a general community sample.

Given the potentially harmful effects of parenting stress on parents, children, and their relationship, it is critical to have a reliable and valid measure of parenting stress in clinical and community samples. The Family Strain Index (FSI) is a brief questionnaire designed to measure stress and demand on parents of children with ADHD. The present study is the first to evaluate the psychometric properties of scores on the FSI in a general community sample. Parents (89% mothers) of 550 preschool children (aged 2-5 years; 50% boys) sampled through 17 kindergartens located in Danish cities and villages completed the FSI, the ADHD Rating Scale (RS)-IV Preschool Version, and a background questionnaire. FSI scores were characterized by restricted range and floor effects. The scale's construct validity was not supported and the measurement repeatability after 1 month was low. The scale did have convergent validity as levels of parenting stress were associated with perceived ADHD behavior in off-spring, but overall, results did not encourage the use of the FSI as a measure of parenting stress in the general population. Measures that include more normative events may be more appropriate when attempting to capture parenting stress in general community samples.

Parent Training for Preschool ADHD in Routine, Specialist Care: A Randomized Controlled Trial.

OBJECTIVE: Parent training is recommended for attention-deficit/hyperactivity disorder (ADHD) in preschool children. Evidence-based interventions are important, but only if they produce better outcomes than usual care. METHOD: The authors conducted a multicenter, 2-arm, parallel-group, randomized controlled trial in routine specialist ADHD clinics in the Danish Child and Adolescent Mental Health Services. Children (N = 164, 3-7 years old) with ADHD received a well-established parent training program (New Forest Parenting Programme; n = 88) or treatment as usual (n = 76). The primary outcome was parent ratings of child ADHD symptoms. Secondary outcomes included teacher ratings and direct observations of ADHD symptoms. Outcomes were measured at baseline, after treatment, and at follow-up (36 weeks later). Representativeness of participants was evaluated against the total national cohort of children (N = 1,378, 3-7 years old) diagnosed with ADHD during the same period using the Danish Civil Registration System. Statistical analysis used a repeated measure model. RESULTS: After treatment, the parent training program was superior to treatment as usual on parent-rated ADHD symptoms (p = .009; effect size d = 0.30) and on parenting self-efficacy and family strain. Effects persisted to 36 weeks after treatment. There were no effects on teacher ratings or direct observations of ADHD or on ratings of conduct problems or parenting. The clinical sample was similar to the national cohort of young children with ADHD. CONCLUSION: Evidence-based parent training has value as an intervention for preschool ADHD in routine clinical settings. As in previous trials, effects were restricted to parent-reported outcomes. Surprisingly, there were no effects on child conduct problems. CLINICAL TRIAL REGISTRATION INFORMATION: A Controlled Study of Parent Training in the Treatment of ADHD in Young Children (D'SNAPP). http://clinicaltrial.gov/;NCT01684644.

The ADHD rating scale-IV preschool version: Factor structure, reliability, validity, and standardisation in a Danish community sample.

BACKGROUND: ADHD is a debilitating disorder with symptoms often appearing in early childhood. To facilitate early identification, developmentally appropriate and validated assessment tools for the preschool-age are needed. AIMS: The current study aims to examine the psychometric properties of the ADHD Rating Scale (RS)-IV Preschool Version (-P) in a Danish community sample and provide national standardisation data. METHODS AND PROCEDURES: Parents (n = 916) and kindergarten teachers (n = 275) of preschool children, aged 3-5 years, completed the ADHD RS-IV-P. OUTCOMES AND RESULTS: Confirmatory factor analysis indicated that a three-factor model (inattention, hyperactivity, and impulsivity) best fit the data regardless of rater. Scales generally showed acceptable internal consistency, test-retest reliability, inter-rater reliability, and criterion validity. Boys received higher ratings on the ADHD RS-IV-P than girls and younger preschool children were rated as more inattentive than older preschool children. CONCLUSIONS AND IMPLICATIONS: Our findings support the reliability and validity of the ADHD RS-IV-P and a three-factor model of ADHD. However, high factor correlations and similarity in model fit suggest that more research is needed to clarify the organisation of ADHD symptoms in preschool children. Furthermore, the external validity of separate ADHD dimensions at this age should be examined.

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).

The Effectiveness of Parent Training as a Treatment for Preschool Attention-Deficit/Hyperactivity Disorder: Study Protocol for a Randomized Controlled, Multicenter Trial of the New Forest Parenting Program in Everyday Clinical Practice.

BACKGROUND: Parent training is recommended as the first-line treatment for attention-deficit/hyperactivity disorder (ADHD) in preschool children. The New Forest Parenting Programme (NFPP) is an evidence-based parenting program developed specifically to target preschool ADHD. OBJECTIVE: The objective of this trial is to investigate whether the NFPP can be effectively delivered for children referred through official community pathways in everyday clinical practice. METHODS: A multicenter randomized controlled parallel arm trial design is employed. There are two treatment arms, NFPP and treatment as usual. NFPP consists of eight individually delivered parenting sessions, where the child attends during three of the sessions. Outcomes are examined at three time points (T1, T2, T3): T1 (baseline), T2 (week 12, post intervention), and T3 (6 month follow/up). 140 children between the ages of 3-7, with a clinical diagnosis of ADHD, informed by the Development and Well Being Assessment, and recruited from three child and adolescent psychiatry departments in Denmark will take part. Randomization is on a 1:1 basis, stratified for age and gender. RESULTS: The primary endpoint is change in ADHD symptoms as measured by the Preschool ADHD-Rating Scale (ADHD-RS) by T2. Secondary outcome measures include: effects on this measure at T3 and T2 and T3 measures of teacher reported Preschool ADHD-RS scores, parent and teacher rated scores on the Strength & Difficulties Questionnaire, direct observation of ADHD behaviors during Child's Solo Play, observation of parent-child interaction, parent sense of competence, and family stress. Results will be reported using the standards set out in the Consolidated Standards of Reporting Trials Statement for Randomized Controlled Trials of nonpharmacological treatments. CONCLUSIONS: The trial will provide evidence as to whether NFPP is a more effective treatment for preschool ADHD than the treatment usually offered in everyday clinical practice. TRIAL REGISTRATION: ClinicalTrials.gov NCT01684644; https://clinicaltrials.gov/ct2/show/NCT01684644?term= NCT01684644&rank=1 (Archived by WebCite at http://www.webcitation/6eOOAe8Qe).