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An
Effective Behavioral Intervention for Preschoolers with ADHD |
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Some of you may recall
a controversy that emerged a while back 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 These
children were initially identified based on a large-scale screening in an entire
community, rather than by selecting families who had already been referred
for treatment. This is an important strength of the study, in that the
participants are representative of children in the general population who
manifest ADHD symptoms, rather than the relatively small percentage whose
parents seek treatment for their child at such an early age. 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
pre-schoolers. 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.) Second,
we cannot be sure from this study what the longer-term impact of the
behavioral intervention is likely to be.
It would be very informative to follow the children treated
successfully in this study and see how they do over time. One possibility is that they continue to do
well and their symptoms remain manageable.
This would be very exciting indeed, as it would suggest that early
intervention could change the developmental course in children showing early
signs of ADHD. Alternatively, as these
children get older and enter school, their symptoms may become more prominent
and require other treatments to manage them effectively. |
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