Click the article title to be taken to the full story.
Behavioral intervention for preschool children with ADHD is better than treatment as usual in routine Danish Child and Adolescent Mental Health Services.
A major research project from Aarhus University and the Centre for Child
and Adolescent Psychiatry, Risskov, in collaboration with the University of
Copenhagen, University of Nottingham, UK and Kings College London is
published August 1th in the Journal of the American Academy of Child and
The study highlights that individual behavioural treatment and support for parents who have preschool children with ADHD is significantly better than what is currently routinely offered in Danish Child and Adolescent Mental Health Services.
The researchers examined the effectiveness of parent training for preschool ADHD in three routine specialist clinics in Denmark. The study recruited 164 children aged 3 to 7 years, and randomly allocated them to receive the New Forest Parenting Programme (NFPP) or an intensive treatment as usual intervention. Results showed that parents who received the New Forest Programme reported their children's ADHD symptoms significantly lower after intervention and at a 48-week follow-up compared to the treatment as usual group. Parents who received the New Forest Parenting Programme also reported higher levels of parenting self-esteem and lower levels of strain with in the family compared to the treatment as usual group.
"ADHD in the preschool years is associated with a range of negative outcomes that warrant intervention, but very little is known about the effect of behavioural parenting interventions when implemented in routine health care systems. Investigating the effects of treatment in the everyday settings where children are routinely seen is important for improving the outcomes for young children with ADHD and their parents. This study shows that evidence-based parent training is effective when implemented in the real-life settings where young children with ADHD receive their care"
"The New Forest Parenting Programme provides parents with techniques to
train their child's attention and concentration, improve their ability to
deal with waiting and frustration but is also designed to help ensure an
easier day-to-day life for children with ADHD and their families."
This is according to Anne-Mette Lange, clinical psychologist at the Centre for Child and Adolescent Psychiatry at Aarhus University Hospital, Risskov, and Aarhus University, and first author of the paper.
About the study
164 children aged between three and seven and their parents took part in the study. The children were referred through the usual referral system and assessed and diagnosed with ADHD. The families were then asked whether they wished to participate in the project. Some children were selected for the project, while others received the usual treatment.
The individual method of delivery in the New Forest Parenting Programme means that the intervention can be tailored to parent's specific needs.
The study started in 2012 and has included 1,300 children in a control group. The control group was used to examine whether the 164 children were representative for children with ADHD.
The study is a collaboration between Aarhus University Hospital, Copenhagen University Hospital in Denmark as well at the University of Nottingham and Kings College London in the UK.
By using the Danish National Registers to establish a comparison group that represents all the other preschool children in Denmark who received a diagnosis of ADHD during the study, this study was able to show that the children and parents included in the trial were very representative of preschool children and their families in contact with Danish Child and Adolescent Mental Health Services during the same time.
Exploratory examinations of moderators of outcome showed that child gender, family socio-economic status, parental ADHD symptoms and children's level of conduct problems had no influence on outcome, suggesting that the intervention can be effective irrespective of family and child characteristics.
Each month, the journal selects an article to be highlighted in a Podcast. In August, Anne-Mette Lange is the interviewee and she talks about the Danish study and parental training and ADHD.
Each month, the journal also selects one article to be included in an online programme for further education and training of child and adolescent psychiatrists and related professionals. The article on parent training has been designated as the article of the month for this programme.
About preschool ADHD
Preschool Attention-deficit hyperactivity disorder (ADHD) is a prevalent neuro-developmental disorder with substantial impact on daily functioning. It runs a relatively stable and chronic course and is predictive of functional impairment through adolescence, despite treatment with medication. Preschool ADHD is associated with long-term burden to families and health, social, education and criminal justice systems. More effective ADHD interventions are needed for this age group.
Anne-Mette Lange, David Daley, Morten Frydenberg, Tine Houmann, Lene Juel Kristensen, Charlotte Rask, Edmund Sonuga-Barke, Signe Søndergaard-Baden, Aparna Udupi, Per Hove Thomsen. Parent Training for Preschool ADHD in Routine, Specialist Care: A Randomized Controlled Trial. Journal of the American Academy of Child & Adolescent Psychiatry, 2018; 57 (8): 593 DOI: 10.1016/j.jaac.2018.04.014
What doctors and parents should discuss about medicating a child for A.D.H.D., anxiety or depression.
Whenever I write about children getting medications for anxiety, for depression, or especially for attention deficit hyperactivity disorder, a certain number of readers respond with anger and suspicion, accusing me of being part of a conspiracy to medicate children for behaviors that are either part of the normal range of childhood or else the direct result of bad schools, bad environments or bad parenting.
Others suggest that doctors who prescribe such medications are in the corrupt grip of the drug companies. And there are parents with stories of unexpected side effects and doctors who didn’t listen. (Of course, there are also parents who write to say that the right medication at the right moment really helped, or adults regretting that no one offered them something that might have helped back when they were struggling.)
Putting children, especially young children, on psychotropic medications is scary for parents, sometimes scary for children and also, often, scary for the doctors who do the prescribing. As a pediatrician, I have often had occasion to be grateful to colleagues with more experience and training who could help a family figure out the right medication, dosing and follow-up.
It is a big deal, and there are side effects to worry about and doctors should listen to families’ concerns. But when a child is suffering and struggling, families need help, and medications are often part of the discussion. And so, without presuming to judge what should be done for any specific child, I want to talk about the discussion that needs to take place around medicating a child in distress, and how the doctor and the family should monitor medications when they are prescribed.
Parents worry that medications will affect their children’s personalities, said Dr. Doris Greenberg, a developmental pediatrician in Savannah, Ga., who is associate clinical professor of pediatrics at Mercer University School of Medicine. She can see the message in their faces: “my child has a spirit and a sparkle, and we don’t want this taken away.” She faces this directly: “I ask them, what are you worried about, what horror stories have you heard?”
The family probably has been dealing with a very symptomatic child for a while before they get to her, and “when they come in, they’re kind of wounded.” Before talking about medication, she said, it’s important to understand – and to be sure the family understands – how the diagnosis is being made, and why medicine is even being considered. “We don’t treat people who aren’t impaired – just because the kid wiggles,” she said.
Dr. Timothy Wilens, the chief of the division of child and adolescent psychiatry at Massachusetts General Hospital, said, “The issue of medicine itself stamps that your kid has a behavioral health issue – they have a disorder that’s requiring treatment.” Dr. Wilens, the author of the standard recommended book on psychiatric medications for children, has faced criticism in the past about ties to pharmaceutical companies; he regards it as an academic obligation to work with the industry, he said, and discloses that directly to parents.
Dr. Wilens said that at that first visit, it’s especially important to discuss the diagnosis with parents, and be sure that they are in agreement about what the problem is. “I stop and say to the parents, Is this what you’re seeing? Does this make sense to you?” he said. “And I talk to the kid. This is what I think it is, does this feel like this is what you have?”
Medication isn’t always appropriate. For anxiety, he said, “I’m probably not going to recommend you go right on medication, I’m going to talk to you about cognitive behavioral therapy.”
When medication is indicated, Dr. Wilens said, parents need a little
space and time to think about it, and it may take more than one visit to get
to the point of actually writing a prescription.
What parents are most worried about, of course, is safety. “I go right to their worst fears,” Dr. Wilens said. “Is this going to hurt my kid, what are the side effects, what are the worst things that can happen?”
Dr. Greenberg said that she sometimes talks about the Milwaukee study that followed children with A.D.H.D. as they grew up, and suggested that those whose A.D.H.D. was treated when young had fewer problems with drug and alcohol abuse. “I emphasize that this isn’t just a school problem, it’s a life problem,” Dr. Greenberg said. Dr. Wilens cited a 2017 study that also found that A.D.H.D. treatment was associated with less substance abuse later on.
The doctor should also talk directly to the child, even if the child is young, Dr. Greenberg said, explaining the plan, and answering questions, and getting the child’s assent to treatment. Don’t promise that medication will do the impossible: “It doesn’t cure anything, but it fixes the problem,” she said. “I explain, we’re going to make their brains work better – it won’t get you a girlfriend, you won’t dance.”
Prescribing psychotropic medicines for children involves close attention to the child’s rhythms and patterns. “I want to know about their eating habits,” Dr. Greenberg said, since some A.D.H.D. medicines can reduce appetite. It’s important to know whether they are night eaters or breakfast eaters and to time the dosing so that it interferes as little as possible – and then to monitor the child’s growth carefully.
And the doctor should check regularly on issues of sleep; sometimes a child can’t tolerate an afternoon dose of a stimulant without sleep problems. Good sleep hygiene is important, and it’s often helpful for children with A.D.H.D. to wake up at the same time consistently, weekdays and weekends, Dr. Wilens said.
Doctors should explain how the dosing works, Dr. Greenberg said. “I always explain what the therapeutic range is – some people are fast metabolizers, some are not, and we always start low and work up.” Families need to understand the pharmacology, and what to do if you miss a dose.
“Side effects matter a lot,” Dr. Wilens said. “I tell parents it’s like the old radio dial of an analog tuner, you get to the station and have to tune it perfectly.”
And no one should start a child on any of these medications without follow-up – parents need a number to call immediately if they have any questions, and the child needs to come back at regular intervals. For A.D.H.D. medications, Dr. Greenberg said, she usually sees children every three or four months during the school year to check that they are doing well, to check growth, and then in the summer to plan for the next school year.
These medicines affect the mind, but the mind is very much part of the body. “We do a very complete physical just about every time they come in,” Dr. Greenberg said, to make sure the medicine is safe.
Follow-up also gives parents a chance to report on what they see. Parents can tell whether the medicines are working and they get very good at knowing when doses need to be adjusted. “When parents feel that they are really part of the treatment team,” Dr. Wilens said, “you lose that hopelessness and helplessness a lot of people come in with when their kids have a behavioral health issue,” and that helps everyone take better care of the child.
By Perri Klass
30 July 2018