Which factors determine clinicians' policy and attitudes towards medication and parent training for children with Attention-Deficit/Hyperactivity Disorder?

The short- and longer-term effects of brief behavioral parent training versus care as usual in children with behavioral difficulties: study protocol for a randomized controlled trial

BACKGROUND

The access to and uptake of evidence-based behavioral parent training for children with behavioral difficulties (i.e., oppositional, defiant, aggressive, hyperactive, impulsive, and inattentive behavior) are currently limited because of a scarcity of certified therapists and long waiting lists. These problems are in part due to the long and sometimes perceived as rigid nature of most evidence-based programs and result in few families starting behavioral parent training and high dropout rates. Brief and individually tailored parenting interventions may reduce these problems and make behavioral parent training more accessible. This protocol paper describes a two-arm, multi-center, randomized controlled trial on the short- and longer-term effectiveness and cost-effectiveness of a brief, individually tailored behavioral parent training program for children with behavioral difficulties.

METHODS

Parents of children aged 2-12 years referred to a child mental healthcare center are randomized to (i) three sessions of behavioral parent training with optional booster sessions or (ii) care as usual. To evaluate effectiveness, our primary outcome is the mean severity of five daily ratings by parents of four selected behavioral difficulties. Secondary outcomes include measures of parent and child behavior, well-being, and parent-child interaction. We explore whether child and parent characteristics moderate intervention effects. To evaluate cost-effectiveness, the use and costs of mental healthcare and utilities are measured. Finally, parents' and therapists' satisfaction with the brief program are explored. Measurements take place at baseline (T0), one week after the brief parent training, or eight weeks after baseline (in case of care as usual) (T1), and six months (T2) and twelve months (T3) after T1.

DISCUSSION

The results of this trial could have meaningful societal implications for children with behavioral difficulties and their parents. If we find the brief behavioral parent training to be more (cost-)effective than care as usual, it could be used in clinical practice to make parent training more accessible.

TRIAL REGISTRATION

The trial is prospectively registered at ClinicalTrials.gov (NCT05591820) on October 24th, 2022 and updated throughout the trial.

Variation in attitudes toward diagnosis and medication of ADHD: a survey among clinicians in the Norwegian child and adolescent mental health services

Prevalence and medication rates of ADHD vary geographically, both between and within countries. No absolute cutoff exists between ADHD and normal behavior, making clinician attitudes (leading to local practice cultures) a potential explanation for the observed variation in diagnosis and medication rates. The objective of this study was to describe variation in attitudes toward diagnosis and medication of ADHD among clinicians working in child and adolescent mental health services (CAMHS). We hypothesized that attitudes would vary along a spectrum from "restrictive" to "liberal". We also explored whether differences in attitudes between clinicians were related to professional background and workplace (clinic). A survey in the form of a web-based questionnaire was developed. All CAMHS outpatient clinics in Norway were invited. Potential respondents were all clinicians involved in diagnosing and treating children and adolescents with ADHD. To investigate the existence of attitudes toward diagnosis and medication as latent constructs, we applied confirmatory factor analysis (CFA). We further examined how much of variance in attitudes could be ascribed to profession and clinics by estimating intraclass correlation coefficients. In total, 674 respondents representing 77 (88%) of the clinics participated. We confirmed variation in attitudes with average responses leaning toward the "restrictive" end of the spectrum. CFA supported "attitude toward diagnosis" and "attitude toward medication" as separate, and moderately correlated (r = 0.4) latent variables, representing a scale from restrictive to liberal. Professional background and workplace explained only a small part of variance in these attitudes.

Geographical variation in ADHD: do diagnoses reflect symptom levels?

Rates of ADHD diagnosis vary across regions in many countries. However, no prior study has investigated how much within-country geographic variation in ADHD diagnoses is explained by variation in ADHD symptom levels. We examine whether ADHD symptom levels explain variation in ADHD diagnoses among children and adolescents using nationwide survey and register data in Norway. Geographical variation in incidence of ADHD diagnosis was measured using Norwegian registry data from the child and adolescent mental health services for 2011-2016. Geographical variation in ADHD symptom levels in clinics' catchment areas was measured using data from the Norwegian mother, father and child cohort study for 2011-2016 (n = 39,850). Cross-sectional associations between ADHD symptom levels and the incidence of ADHD diagnoses were assessed with fractional response models. Geographical variation in ADHD diagnosis rates is much larger than what can be explained by geographical variation in ADHD symptoms levels. Treatment in the Norwegian child and adolescent mental health services is free, universally available upon referral, and practically without competition from the private sector. Factors beyond health care access and unequal symptom levels seem responsible for the geographical variation in ADHD diagnosis.

Using a Design Thinking Approach to Develop a Social Media-Based Parenting Program for Parents of Children With Attention-Deficit/Hyperactivity Disorder: Mixed Methods Study

Background: Parenting programs have proven effective in improving the behavior of children with attention-deficit/hyperactivity disorder (ADHD). However, barriers such as job and transportation constraints hinder parents from attending face-to-face therapy appointments. The COVID-19 pandemic has further exacerbated these challenges. Objective: This study aimed to develop and test the feasibility of a social media-based parenting program for parents of children with ADHD, considering both the pre-existing challenges faced by parents and the additional barriers imposed by the COVID-19 pandemic. Methods: This study used a 5-stage design thinking process, encompassing empathizing with parents, defining their needs, ideating innovative solutions, prototyping the program, and testing the program with parents. Qualitative interviews were conducted with 18 parents of children with ADHD to understand their unique needs and values. Brainstorming techniques were used to generate creative ideas, leading to the creation of a prototype that was tested with 32 parents. Participants' engagement with the program was measured, and posttraining feedback was collected to assess the program's effectiveness. Results: Parents of children with ADHD encounter specific challenges, including managing impulsive behavior and difficulties in emotion regulation. The social media-based parenting program was delivered through the LINE app (Line Corporation) and consisted of 7 modules addressing topics related to ADHD management and effective parenting strategies. The program exhibited a high completion rate, with 84% (27/32) of participants successfully finishing it. Program provider-participant interaction peaked during the first week and gradually decreased over time. Qualitative feedback indicated that the program was feasible, accessible, and well received by participants. The LINE app was found to be convenient and helpful, and participants preferred content delivery once or twice per week, expressing acceptance for various content formats. Conclusions: This study emphasizes the significance of adopting a human-centered design thinking approach to develop parenting programs that cater to the unique needs and values of parents. By leveraging social media platforms, such as LINE, a parenting program can overcome the challenges posed by the COVID-19 pandemic and other constraints faced by parents. LINE offers a viable and feasible option for supporting parents of children with ADHD, with the potential for customization and widespread dissemination beyond the pandemic context.