html5-img
1 / 73

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

gillian-thomas
Télécharger la présentation

ADHD Parent Training and Classroom interventions

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

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

  2. 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

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

  4. 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

  5. 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

  6. 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

  7. 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

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

  9. 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

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

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

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

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

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. 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

  21. 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

  22. Effect sizes Pelham & Fabiano 2008

  23. 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

  24. 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

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

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

  27. 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

  28. 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

  29. 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

  30. 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

  31. 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 !

  32. 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

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

  34. 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

  35. 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

  36. 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

  37. 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

  38. 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)

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

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

  41. 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

  42. 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

  43. 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 ?

  44. 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

  45. 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

  46. 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

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

  48. 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

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

  50. 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

More Related