|
An Effective Behavioral Intervention for Preschoolers with ADHD |
|
|
Some of you may recall
a controversy that emerged last year around the increasing use of stimulant
medication treatment in preschool children.
This controversy erupted in response to an article published in the
Journal of the American Medical Association that documented 200-300%
increases in stimulant prescribing to preschool children between 1991 and
1995. Although the percentage of
preschool children treated with stimulants was still less than 1%, there were
understandable concerns about this large rate of increase. These concerns
reflect the fact that the efficacy of stimulant medication treatment for
preschoolers is more variable than in older children, and the rate of side
effects appears to be higher. In
addition, some professionals have noted that little is known about the
possible impact of stimulant medication on the neurological development of
children when started at such a young age and continued over many years.
Because of these issues, treatment guidelines published recently by the
American Academy of Child and Adolescent Psychiatry indicate that stimulant
medication should "only be used in the more severe cases or when parent
training and placement in a highly structured, well-staffed preschool program
have been unsuccessful or are not possible." In light of this recommendation, it is
unfortunate that good studies on the effectiveness of behavioral treatment
for preschoolers manifesting symptoms of ADHD are few and far between. How well such interventions actually work
with preschoolers is thus largely unknown.
Because ADHD symptoms often emerge at such an early age, and can
create significant difficulties in a child's early development, it is
especially important to develop and document effective treatments for
preschoolers with ADHD. A
study published in a recent issue of the Journal of the Parents
of children scoring above a certain level on the screening were informed
about the study and offered a more thorough evaluation for their child. When parents agreed, and the subsequent
evaluation was consistent with an ADHD diagnosis, the families were assigned
at random to one of three different groups.
Parents in two of these groups received an active treatment while the
third group was a waiting-list control group.
This design enabled the researchers to examine the impact of the 2
different treatments compared (see below for a description of each treatment)
and whether parents and children who received treatment were doing better at
follow-up than those in the waiting list control group. Mothers were the recipients of the
treatment in all cases. No explanation
is provided for why fathers were not included. The parent-training group was
an eight-week program in which participants were educated about ADHD and
introduced to a range of behavioral strategies for increasing attention and
reducing defiant behavior. All
meetings occurred during one-hour weekly visits conducted in participants'
homes. In most meetings, the therapist worked directly with the mother and
child. The behavioral techniques covered in this program included teaching
parents how to effectively praise their child, ignoring minor misbehaviors,
giving clear and effective commands, using distraction effectively, avoiding
threats, etc. In addition, parents
were instructed to complete a behavior diary for their child so that their
efforts to implement new strategies could be reviewed each week. Parents
assigned to the other treatment group received no direct training in
behavioral strategies as discussed above.
Instead, they were given the opportunity to discuss issues of concern
to them and the impact of their child's behavior problems on family life, in
a supportive and non-threatening atmosphere.
Thus, rather than being taught specific skills that could be used to
manage their child's behavior, they were simply provided the opportunity to
discuss their concerns with an empathic listener. This also occurred over eight weekly
meetings conducted in the parents' homes. Results Two
types of outcome measures were obtained at the end of the eight-week
treatments, and again 15 weeks later.
One set of outcome measures focused on ADHD symptoms and conduct
problems in the preschoolers. This was
obtained both through a structured interview with each mother and through
observing each child engaging in a solitary play activity. During the observation of the children at
play, the researchers focused on patterns of attention to, and switching
from, one activity to another. Based
on this observation, an index of attention/engagement was computed for each
child indicating the child's ability to stay focused and engaged during play
activities (as opposed to "bouncing" from one incomplete activity
to another). The second type of
outcome data collected concerned measures of maternal well-being. Of primary concern here were maternal
reports of depressed moods and their sense of competence/effectiveness and
satisfaction as a parent. Collecting
these data enabled the researchers to examine whether either treatment
improved mothers' perception of their parenting abilities, in addition to
simply noting whether changes occurred in child behavior as a result of
treatment. Because parenting a
preschooler with ADHD can be such a difficult experience, mothers' moods and
their satisfaction with parenting are important types of data to
collect. Preliminary analysis
indicated that, prior to the treatment, there were no differences in the
preschoolers' behavior or maternal ratings of well-being, parental efficacy,
or parental satisfaction. At the
conclusion of the eight-week treatment period, however, mothers in the
parent-training group reported that their children showed significantly fewer
ADHD symptoms and conduct problems than did the mothers receiving supportive
treatment or the mothers in the waiting-list control group. These changes were consistent with ratings
made by blind observers of the children's behavior during = the free-play
observation-preschoolers of mothers receiving parent-training intervention
were seen as more attentive and engaged than the other preschoolers. Even more impressive is the fact that these
changes noted immediately following treatment were still evident 15 weeks
later. This was true even though there
had been no additional contact with the mothers or children during this
time. Overall, 53% of preschoolers in
the parent-training group were rated as having made a clinically significant
recovery, compared to only 38% of those in the supportive treatment group and
25% from the no-treatment control group.
These data indicate that, although a certain number of preschoolers
meeting the criteria for ADHD will show improved behavior over time even when
no intervention is received, the parent-training intervention tested in this
study more than doubled the number of children for whom this was the
case. The magnitude of the improvement
reported for preschoolers in this group was comparable to what has been
reported for stimulant medication treatment in this age group. Similar
results were obtained for maternal ratings of well-being, sense of parental
efficacy, and feelings of satisfaction as a parent. Compared to mothers in the supportive
treatment and waiting-list control group, mothers who learned specific
parenting skills reported greater feelings of well-being, parental efficacy,
and parental satisfaction immediately following treatment. Although there was some decline in all
three areas over the next 15 weeks, they were still doing better than the other
mothers at this time. Mothers who
received supportive treatment, although not doing as well as those who
learned specific parenting skills, also tended to be feeling somewhat better
than mothers in the control group at the end of treatment. However, this did
not persist. Summary and Implications The
results of this study clearly indicate that behavioral interventions in which
parents are taught specific strategies/skills for managing the difficult
behavior of preschoolers with ADHD can produce significant improvements for a
large percentage of these children.
The gains that can be expected include: reductions in core ADHD
symptoms, reduced oppositional behavior, and greater feelings of well-being,
sense of parental efficacy, and sense of parental satisfaction in the mothers
of these children. These results are
important for several reasons. First,
they provide a firm basis for the recommendation that behavioral intervention
- rather than stimulant medication - is an appropriate first line treatment
for preschoolers with ADHD. When done well,
it appears that many ADHD preschoolers may improve to the point where the use
of stimulants is no longer necessary.
Second, it is especially encouraging, I think, that the program used
to produce these gains could be realistically available on a widespread
basis. Remember that the gains
reported were for a program that consisted of eight weekly one-hour home
visits. This truly is the type of
intervention that could be made available in many communities. In contrast, the behavioral intervention
used in the MTA study (see link below) has been criticized on the basis that
it was so comprehensive that it really could not be realistically implemented
outside of the research setting. Perhaps significant gains from behavioral
treatment using a relatively brief intervention are more easily obtained when
children are younger and more malleable. As
with any study, there are some caveats that are important to note. First, although the parent-training
intervention resulted in clinically significant improvement in 53% of the
preschoolers, still nearly half did not obtain such benefit. This represents a large number of
preschoolers with ADHD for whom additional interventions would be required.
Perhaps a longer and more intensive behavioral approach would have promoted
gains in this group. Or, this may be a
group for whom treatment with stimulant medication turns out to be an
appropriate option. (Note: There currently is a large-scale study
underway of stimulant medication in preschoolers with ADHD. In this study, a course of behavioral
treatment similar to what was used here will first be implemented with all
participants, and medication will only be tried for children who do not
respond to the behavioral approach. This
study thus promises to shed important light on the efficacy and safety of
stimulant medication for ADHD preschoolers who are not helped significantly
by behavioral treatment alone. It is
likely to be several years, however, before the results of this study are
available.) |
|
|
Home | ADD | Diagnostics | Treatments | Workshops FAQ | Clinics | Resources | Tests | Testimonials |
|
|
Copyright © 2005 ADD Treatment Centers All rights reserved. |
|