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.

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).

Preschool hyperactivity specifically elevates long-term mental health risks more strongly in males than females: a prospective longitudinal study through to young adulthood

Evidence of continuities between preschool hyperactivity and adult mental health problems highlights the potential value of targeting early identification and intervention strategies. However, specific risk factors are currently unclear. This large-scale prospective longitudinal study aimed to identify which hyperactive preschoolers are at the greatest long-term risk of poor mental health. One hundred and seventy children (89 females) rated as hyperactive by their parents, and 88 non-hyperactive controls (48 females) were identified from a community sample of 4215 3-year-olds. Baseline data relating to behavioral/emotional problems and background characteristics were collected. Follow-up mental health and functional impairment outcomes were collected between 14 and 25 years of age. At age 3 years, males and females in the hyperactive group had similarly raised levels of hyperactivity and other behavior problems. In adolescence/young adulthood, these individuals showed elevated symptoms of ADHD, conduct disorder, mood disorder, anxiety and autism, as well as functional impairment. Preschool hyperactivity was strongly predictive of poor adolescent/adult outcomes for males across domains with effects being specifically driven by hyperactivity. For females, the effects of preschool hyperactivity were smaller and dropped to non-significant levels when other preschool problems were taken into account. Environmental risk factors also differed between the sexes, although these may also have been mediated by genetic risk. In conclusion, these results demonstrate marked sex differences in preschool predictors of later adolescent/adult mental health problems. Future research should include a measure of preschool inattention as well as hyperactivity. The findings highlight the potential value of tailored approaches to early identification strategies.

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.

Parent training for preschool ADHD: a randomized controlled trial of specialized and generic programs

BACKGROUND

The 'New Forest Parenting Package' (NFPP), an 8-week home-based intervention for parents of preschoolers with attention-deficit/hyperactivity disorder (ADHD), fosters constructive parenting to target ADHD-related dysfunctions in attention and impulse control. Although NFPP has improved parent and laboratory measures of ADHD in community samples of children with ADHD-like problems, its efficacy in a clinical sample, and relative to an active treatment comparator, is unknown. The aims are to evaluate the short- and long-term efficacy and generalization effects of NFPP compared to an established clinic-based parenting intervention for treating noncompliant behavior ['Helping the Noncompliant Child' (HNC)] in young children with ADHD.

METHODS

A randomized controlled trial with three parallel arms was the design for this study. A total of 164 3-4-year-olds, 73.8% male, meeting DSM-IV ADHD diagnostic criteria were randomized to NFPP (N = 67), HNC (N = 63), or wait-list control (WL, N = 34). All participants were assessed at post-treatment. NFPP and HNC participants were assessed at follow-up in the next school year. Primary outcomes were ADHD ratings by teachers blind to and uninvolved in treatment, and by parents. Secondary ADHD outcomes included clinician assessments, and laboratory measures of on-task behavior and delay of gratification. Other outcomes included parent and teacher ratings of oppositional behavior, and parenting measures. (Trial name: Home-Based Parent Training in ADHD Preschoolers; Registry: ClinicalTrials.gov Identifier: NCT01320098; URL: http://www/clinicaltrials.gov/ct2/show/NCT01320098).

RESULTS

In both treatment groups, children's ADHD and ODD behaviors, as well as aspects of parenting, were rated improved by parents at the end of treatment compared to controls. Most of these gains in the children's behavior and in some parenting practices were sustained at follow-up. However, these parent-reported improvements were not corroborated by teacher ratings or objective observations. NFPP was not significantly better, and on a few outcomes significantly less effective, than HNC.

CONCLUSIONS

The results do not support the claim that NFPP addresses putative dysfunctions underlying ADHD, bringing about generalized change in ADHD, and its underpinning self-regulatory processes. The findings support documented difficulties in achieving generalization across nontargeted settings, and the importance of using blinded measures to provide meaningful assessments of treatment effects.

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.

Implementation of independent nurse prescribing in UK mental health settings: focus on attention-deficit/hyperactivity disorder

Legislative changes that came into effect in the UK in April 2012 gave nurse independent prescribers (NIPs) the power to prescribe schedule 2-5 controlled drugs. Therefore, suitably qualified UK nurses can now independently prescribe any drug for any medical condition within their clinical competence. The potential benefits of independent nurse prescribing include improved access to medications and more efficient use of skills within the National Health Service workforce. This review explores the published literature (to July 2013) to investigate whether the predicted benefits of NIPs in mental health settings can be supported by empirical evidence, with a specific focus on nurse-led management of patients with attention-deficit/hyperactivity disorder (ADHD). The most common pharmacological treatments for ADHD are controlled drugs. Therefore, the 2012 legislative changes allow nurse-led ADHD services to offer holistic packages of care for patients. Evidence suggests that independent prescribing by UK nurses is safe, clinically appropriate and associated with high levels of patient satisfaction. The quality of the nurse-patient relationship and nurses' ability to provide flexible follow-up services suggests that nurse-led ADHD services are well positioned to enhance the outcomes for patients and their parents/carers. However, the empirical evidence available to support the value of NIPs in mental health settings is limited. There is a need for additional high-quality data to verify scientifically the value of nurse-delivered ADHD care. This evidence will be invaluable in supporting the growth of nurse-led ADHD services and for those who support greater remuneration for the expanded role of NIPs.

A review of the father-child relationship in the development and maintenance of adolescent anorexia and bulimia nervosa

There are disproportionately fewer studies examining the role of the father in the development of child and adolescent psychopathology. This is pertinent in the field of eating disorders, where there is a wealth of research related to family influences and the value of family-based interventions. This article reviews the key themes within the literature around the potential impact of the father-child relationship on the development and maintenance of Anorexia and Bulimia Nervosa in young people. The critical review searched relevant health and social care databases, as well as manually searching key journals in the eating disorder field. In these results, 13 studies met the inclusion/exclusion criteria and were critiqued, with 8 being taken forward for discussion. The 8 studies identified key themes within the relationship of the father and child (particularly daughters) around conflict and communication, parental protection and psychological control, emotional regulation and self-esteem, and self-perfectionism. All of these factors appear to influence the child's level of self-determining autonomy, which in turn can impact maladaptive eating attitudes and psychopathology. Tentative recommendations are made around working with fathers to encourage free expression of ideas and foster a sense of autonomy through compromise and collaboration with their adolescent child. Further research around these themes in relation to other family members is also suggested.

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.

Parent training for Attention Deficit/Hyperactivity Disorder: is it as effective when delivered as routine rather than as specialist care?

BACKGROUND

The effectiveness of parent training (PT) when delivered as part of specialist tier-two services for preschool AD/HD children has been recently demonstrated.

AIMS

To assess the effectiveness of the same PT programme when delivered as part of routine primary care by non-specialist nurses.

METHOD

A sample of 89 3-year-old children with preschool AD/HD took part in a controlled trial of an eight-week (one hour a week), health visitor delivered, PT package. Children, allocated randomly to PT (n = 59) and waiting list control (WLC; n = 30) groups, were compared.

RESULTS

PT did not reduce AD/HD symptoms. Maternal well-being decreased in both PT and WLC groups.

CONCLUSIONS

While PT is an effective intervention for preschool AD/HD when delivered in specialized settings, these benefits do not appear to generalize when programme are delivered as part of routine primary care by non-specialist nurses.

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.

Parent-based therapies for preschool attention-deficit/hyperactivity disorder: a randomized, controlled trial with a community sample

OBJECTIVE

To evaluate two different parent-based therapies for preschool attention-deficit/hyperactivity disorder (ADHD) in a community sample.

METHOD

Three-year-old children displaying a preschool equivalent of ADHD (n = 78) were randomly assigned to either a parent training (PT; n = 30), a parent counseling and support (PCO&S; n = 28), or a waiting-list control group (n = 20). The PT group received coaching in child management techniques. The PC&S group received nondirective support and counseling. Measures of child symptoms and mothers' well-being were taken before and after intervention and at 15 weeks follow-up.

RESULTS

ADHD symptoms were reduced (F2,74 = 11.64; p < .0001) and mothers' sense of well-being was increased by PT relative to both other groups (F2,74 = 10.32; p < .005). Fifty-three percent of children in the PT group displayed clinically significant improvement (chi 2 = 4.08; p = .048).

CONCLUSIONS

PT is a valuable treatment for preschool ADHD. PC&S had little effect on children's behavior. Constructive training in parenting strategies is an important element in the success of parent-based interventions. Psychostimulants are not a necessary component of effective treatment for many children with preschool ADHD.

Behaviour modification in hyperactive children

Behaviour problems in pre-school children can be significantly improved by professionals experienced in child behaviour modification techniques. Reported disobedience, temper tantrums and poor concentration in hyperactive children aged three to three-and-a-half years improved significantly in a treatment group, following eight home visits by research health visitors working in a child and family guidance service.