ADHD Parent Training and Classroom interventions

ADHD Parent Training and Classroom interventions Prof. M. Danckaerts UZ-KULeuven

Drive for behavioural interventions • Children with ADHD have negative interactions: • 1 / min with parents • 2 / min with teachers/peers in school • 0.7 /min with peers outside school = enormous potential learning history of negative behaviour Danforth ea 2006, Abikoff ea 1993, Pelham & Bender 1982

Parent training and classroom interventions • What is the evidence ? • In practice

History • Behavioural interventions • since > 40 years for children with “disruptive disorders” • Since > 30 years for children with ADHD • 3 types: directed to • Parents • School • Child / adolescent

Family-based interventions Pelham e.a. 1998 • Behavioural parent training barely meets criteria for well-established treatment • Outpatient based, 8-20 sessions • Manualized training protocols teaching standard behavioural techniques (contingency management, time-out) • Studies heterogeneous in design • Various combinations with other interventions • Average effect inferior to medication

School-based interventions • Classroom behaviour management • Academic interventions (= manipulation of instructions or materials) • DRC (Daily Report Card) • Nearly all single case studies and intensive contingency management • Effect sizes in the range of 1.4 on child behaviour (= targeted behaviour) DuPaul and Eckert, 1997, Pelham et al. 1998

History - 2 • Review Pelham et al. 1998: • Behavioural parent training & classroom intervention are empirically supported treatments for ADHD • Cognitive treatment of child : not efficacious • Enhancement of self-control • Enhancement of problem-solving

ADHD Psychosocial treatments • Recent landmark comparative treatment studies played down the importance of psychosocial treatments in the management of ADHD

MTA-study Month 0 14 24 36 22-m Follow- up After Treatment 10-m Follow- up After Treatment 14-m Treatment Stage Medication Only 144 Subjects Random Assignment Psychosocial (Behavioral) Treatment Only 144 Subjects Combined Medication & Behavioral Treatment 145 Subjects 579 ADHD Subjects Community Controls No Treatment from Study 146 Subjects Follow-up (24 m) Mid- treatment (9 m) End Treatment (14 m) 36 m FU Early Treatment (3 m) Recruitment of LNCG Cohort Jensen et al 1999

MTA-psychosocial treatment • 30 parent sessions • 20 school visits and teacher training sessions • 2-month individual summer treatment program • Part-time classroom aid

MTA-outcome 14-monthTeacher SNAP inattention Average Score Assessment Point (Days) Jensen et al 1999

MTA-outcomeTeacher SNAP Hyp-Imp Average Score Assessment Point (Days) Jensen et al 1999

MTA-outcome: Normalization 88% 68% 56% 34% 25% MTA N = 579 Classroom Cntrls N = 288 Swanson et al. for the MTA Cooperative Group

Montreal-study 2 year comparison of methylphenidate only and methylphenidate + multimodal treatment (in MPH-responders) • Significant short-term benefits on behaviour, academic achievement and social behaviour maintained over 2 years • No support for adding psychosocial interventions, academic support or social skills training for medication responsive children Abikoff et al. 2004

The Netherlands 10 weeks • Both treatments yielded significant improvement on all domains (ADHD, ODD/CD, social skills, parenting stress, anxiety, self-worth • NO significant differences MPH mgt Randomized: 50 Parent training: 10 sessions (Barkley) Teacher training: 1 session (Pelham) Child cognitive-behaviour therapy: 10 sessions MPH mgt + brief multimodal treatment Vanden Oord ea 2007

History - 3 Conclusion after these results: • If a child responds well to medication: not much extra gain to be expected from behavioural treatment • If a child does not respond well to behavioural treatment: still a lot of gain to be expected from adding medication

Is there a need for psychosocial treatments ? • Some children are effectively treated with psychosocial interventions only • For certain comorbid subgroups they have the largest effects • Medication is not effective in every child • Medication is not always effective every hour of the day • Improvement on medication does not always mean normalization • There may be intolerable side effects • Medication may be unacceptable or ethically objected against (e.g. very young children) • Compliance to medication is far from optimal

Is there a need for psychosocial treatments ? - 2 • Medication results in positive effects in structured situations, but families with ADHD are often highly unstructured • Medication effects on academic, social and family functioning are smaller in effect size • Uncertainty about long-term effects and side-effects of medication • Comparison of effects on Quality of Life is still lacking • Developmentally important opportunities for enduring change may be missed

Is there a need for psychosocial treatments ? YES Important questions: • Are they efficacious ? Are they effective ? • On which domains / aspects do they exert their effect ? • Which factors moderate / mediate the effect ? • Which ingredient is most important ? • Further issues

History - 4 • Recent revival of interest in psychosocial therapies: reviews: • Chronis et al. 2004: Enhancements to the behavioural parent training paradigm for families of children with ADHD: review & future directions • Chronis et al. 2006: Evidence-based psychosocial treatments for children and adolescents with ADHD • Daly et al. 2007: Psychosocial treatments for children with ADHD

History - 5 • Pelham & Fabiano 2008: Evidence-based psychosocial treatments for ADHD • Parent training: 22 new studies • Behavioral Classroom Management: 23 new studies Both are now well-established • Behavioural Peer Interventions: • Traditional group-based, weekly: minimal effects • Summer-treatment programs (5-8 weeks; 200-400 hours): effective , but costly and difficult to implement

Effect sizes Pelham & Fabiano 2008

Is there a need for psychosocial treatments ? YES Important questions: • Are they efficacious ? • On which domains / aspects do they exert their effect ? • Which factors moderate / mediate the effect ? • Which ingredient is most important ? • Further issues

MTA-outcome DOMAIN C vs Cc? M vs Cc? B vs Cc? ADHD Symptoms Yes Yes Oppos./Aggress. Yes Yes Anxiety Yes Social Skills Yes Yes Academics Yes P-C Relations Yes Yes MTA Cooperative Group, 1999

MTA-outcomeParent-child arguing Average Score Assessment Point (Days)

MTA-outcomeNegative-ineffective discipline Average Score Assessment Point (Days) Wells et al., for the MTA Cooperative Group

Parent training effects Routine Clinical Care = Family support + pharmaco-therapy if appropriate 4-12y Behavioural symptoms: RCC + PT > RCC Internalizing symptoms: RCC + PT > RCC ADHD, parental stress RCC + PT= RCC + parent training N=42 RCC continued N=47 Regardless of medication status 6 months Van den Hoofdakker ea 2007

Parenting training effects • Larger effects on • Compliance with parental requests • Rule-following • Defiant-aggressive behaviour • Parenting skills (< negative/ineffective parenting practices) • Than on • Specific ADHD behaviours

Which outcomes should we address ? • Symptom reduction • Compliance, less disruptive behaviour • Modify behaviour to • Classroom rules, classroom norm • Individualized norm • Conflict reduction • Parent-child • Teacher-child • Peer-child • Self-esteem, contentment, happiness, QoL • Functional improvement • Completion of classroom assignments • School results • Parent, teacher satisfaction

Moderators of success ? - 1 • Age: mixed results • Less effective on ADHD with age • Equally effective on negative behaviour(Lundahl ea 2006) • Sex: 1 study: no effect • Comorbidity: • Comorbid aggression in ADHD: no difference • Comorbid ADHD in CD predicts better response in ½ studies • Comorbid anxiety in ADHD predicts better response (MTA) Summary: comorbidity has NO negative effect !

Parent-training effects on ADHD behaviours Sensitive period for altering the progression of the developmental course ? PRESCHOOL PRIMARY SCHOOL ADOLESCENTS Incredible years Jones ea 2007 New Forest PT Sonuga-Barke Ea 2001 Inconsistent results on ADHD behaviour + possible rater bias Barkley 1992 Statist but not clinically sign. Triple P Bor ea 2002 Barkley 2001 double number sessions: idem 50-80 % Clinically sign effect

Moderators of success ? - 4 • Comorbidity MTA, Jensen ea 2001

Moderators of success ? - 2 • Parental mental health • Maternal ADHD associated with poorer outcome in parent training (Sonuga-Barke ea 2002) • Maternal depressive symptoms associated with poorer outcome for MedMgt & Comb MTA groups (Owens ea 2003) • Negative parental cognitions • about themselves, their children and their parenting associated with poorer response to all MTA-treatments (Hoza ea 2000) • Who is attending • Only 4/32 report on fathers (Fabiano 2007) • No information on independent effect of father involvement

Should fathers participate • Fathers report impairment in their relationship with the ADHD child AND the mother • Fathers contribute to many developmental aspects of the child: • Emotion regulation • Social cognition • Focused attention • Peer relationships • Specific contribution to • Participation in organized sports • Academic achievement BUT: they are less likely to attend PMT programs and do not view their parenting as in need for intervention Fabiano 2007

Moderators of success ? - 3 • Setting • Possibly more pos. effects in academic than in recreational settting at school (Kolko ea 1999) • SES • Poorer treatment compliance to parent training (McMahon ea 1981) • MTA: white collar families incremental benefit of Beh over Med on ADHD symptoms • MTA: blue collar families incremental benefit of Beh over Med on ODD symptoms (Rieppi ea 2002) • Ethnic minorities • Less likely to seek help • Equal effects once in training (Reid ea. 2002) • In MTA: minority: pos. effect on outcome

Mediators of success ? - 4 • Format: • Individual/clinic based versus group/community based: lower threshold in the latter (Cunningham ea 1995) • Didactic versus collaborative or using videotaping: latter more effective in behaviour problems, but not demonstrated in ADHD. • Incredible Years (Webster-Stratton 1996) • Community Parent Education Program –COPE (Cunningham ea 1995) • NFPT (Thompson ea 2001) • Motivation & Skills of provider

Mediators of success ? - 4 • Intensity of treatment • Contingency mgt > low intensity behav. intervention (eg. DRC) in single case studies (Pelham ea 1998) • Fabiano ea 2007: • low intensity closer to high intensity than to no behavioural intervention (Fabiano ea 2007) • High intensity some additional, but non-significant effect over low-intensity • Low dose Med + BI = High dose medication • Duration ? • Delay interval ? • Nature of antecedent control ? • Treatment setting • Each component seems necessary to bring about change in the targeted domain (i.e. lack of generalizability)

Intensity of treatment • Comparison of low/high intensity and low/high doses of medication Fabiano ea 2007

Moderators / Mediators of effect • MTA: • In the Comb group: enhanced outcome for positive social skills at school was mediated by reduced Negative/Ineffective Discipline at home • Comb treatment moderated the way in which Negative/Ineffective Discipline was associated with reductions in school-based disruptive behaviour Thus: the effects of pharmacological treatment were at least partially explained by psychological processes

Which ingredient is most important ? Active ingredients ? • Modification of antecedents • Commands, rules, expectations • Modification of consequences • Prudent negative consequences (verbal reprimands, backed up with time-out ? • Positive consequences ?

Which ingredient is most important ? • Prudent negative consequences superior to contingent praise alone • Response cost programs more effective than reward programs in controlled classroom settings • MTA: Changes in Positive parental involvement did not mediate outcome whereas changes in Negative/Ineffective Parenting did. Abramowitz ea 1987, Fabiano ea 2004, pfiffner & O’Leary 1987

Further Issues - 1 • Few studies have shown maintenance effects beyond a few months after the active treatment: long term management plans ? • Substantial proportion of children fail to improve and improvement is not always complete • Efficacy depends on motivation and capabilities of the significant adults • Efficacy versus effectiveness in real world ? Eg. Most consumers favor behavioural interventions

Further issues - 2 • Cost-effectiveness relative to medication treatment ? • Dismantle separate effect of BPT, BCM, BPI • Sequence of interventions

Current Clinical Guidelines • European: • BI first choice unless severe and pervasively impairing ADHD • APA: • Treatment recommendation for medication (strong) and for behaviour therapy (fair) • AACAP: • If no robust response to either of 3 FDA-approved medications: try behaviour therapy or non-approved medication

Parent training and classroom interventions • What is the evidence ? • In practice

Disruptive Behaviour Patterson (1976) Forehand & Mc Mahon (1981) Triple P (2001) www.health.nsw.gov.au The incredible years www.incredibleyears.com ADHD Barkley (1987) Pelham and Hoza (1996) COPE (Cunningham) (1997) New Forest PT (Thompson 2001) School Challenging Horizons Program TM (Evans 1999) Combined STP: Summer Treatment Program (Pelham ea) Available Manuals http://ccf.buffalo.edu

ADHD Parent Training and Classroom interventions

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