bone health articleClinicians and parents are often reluctant to give medication to pre-school children showing symptoms of ADHD, but psychosocial alternatives may provide an answer. Mary Salmon reports:

Although usually diagnosed at about age seven, attention deficit hyperactivity disorder (ADHD) symptoms often show up by age three. While medication can be prescribed to pre-schoolers, increasingly psychosocial interventions are showing promising results.

The core symptoms of the condition, which include hyperactivity, inattention and impulsivity, can make family life stressful.

When left untreated, there are huge consequences for the child, who may go on to have trouble academically and socially. Often there is exclusion from school, and perhaps criminal behaviour and/or substance abuse further down the line.

Due to concerns about the long-term safety of ADHD drugs on the developing brain, clinicians and parents are often hesitant to give medication to very young children. But there are alternatives.

New Forest Parenting Programme
One of the main non-pharmacological programmes for pre-schoolers in the UK is the New Forest Parenting Programme (NFPP), where parents of children with ADHD-like symptoms learn how to guide the child towards becoming more calm and focused.

“Many of the parents who are referred to our ADHD clinic say they knew early on that something was different about their child. Typically these children can’t sit still, don’t sleep well and are irritable, impulsive and forgetful,” says Cathy Laver-Bradbury, a Southampton-based consultant nurse specialising in ADHD.

“While we don’t make a formal diagnosis of ADHD in pre-schoolers, we call it ‘pre-school type ADHD problems,’ a term which the parents generally don’t feel overwhelmed by.”

There is thought to be a heritable component to ADHD, but many researchers believe that other factors are just as important. One significant influence is parent–child socialisation and the negative responses the child’s behaviour elicits from others. It is thought that the cycle of challenging behaviour in the child coupled with parental disapproval and criticism amplifies dysregulated neurological pathways to which the child’s temperament may have predisposed them.

The model behind the programme is based on developmental literature relating to the important role played by constructive and reciprocal parent–child interactions during the pre-school years which naturally helps the child to pay attention, focus, and eventually self-organise.

“The idea behind starting a psychosocial programme with pre-schoolers is that the plasticity of the brain is much greater at this age than when children are older, so there is real potential to influence how the brain is wired for the future,” adds Laver-Bradbury, who is also pathway leader for child and adolescent mental health services at the University of Southampton, and one of the founders of NFPP.

“With hyperactivity especially, if it is left unchecked during the pre-school years it can be harder to correct as the child gets older. Also, when young children are helped to focus and concentrate, they can really build on it so that by the time they start school, they can cope much better.”

While there are several parenting programmes available, NFPP is the only researched course that is designed to specifically help children with ADHD and the neuro-psychological deficits that occur, while also tackling behavioural issues.

Research evidence
So far there are three published studies looking at its effectiveness. The first study, (Sonuga-Barke et al, 2001) carried out on 78 three-year-old children, found that compared with parent counselling support or a waiting list control group, the NFPP group demonstrated a clinically significant decrease in ADHD symptoms, while the other groups did not.

Another small-scale study of 41 children also found that the training programme was highly effective (Thompson et al, 2009). In both studies, the effect size for the programme was as good as stimulant drugs, the most commonly prescribed medication for ADHD. In practice, drugs can be used in tandem, especially if the ADHD is severe.

A third study suggests that children do better when the programme is delivered by a highly-trained specialist, as opposed to a non-specialist such as a health visitor (Sonuga-Barke et al, 2004).

However, clinical evidence suggests that when the mother has ADHD, the impact of the programme may not be as good as when mothers score low on ADHD symptoms. This is thought to be due to the difficulties a parent with ADHD may have in being consistent with the programme.

American researchers have been so impressed with the studies and clinical feedback that a larger trial involving 170 children was carried out recently at the New York University Child Study Centre. The results are expected in 2014.

Meanwhile, European scientists have also shown an interest and another trial involving more than 200 children recently began in Denmark.

So far, research has focused on when the programme is delivered on a one-to-one basis to parents in their own home over eight sessions. Group sessions are also available and clinical evidence suggests it is effective. In addition, there is a self-help book for parents (Laver-Bradbury et al, 2010).

The programme has several elements and begins with the parents learning about ADHD. They then learn how to ‘scope’ their child by noticing the particular ways the condition affects them. A list of strengths is also made.

The parents then learn how to ‘scaffold’ their child by helping them to improve on areas they are weak at, such as concentration, patience and self-control, while also working on less hyperactivity and better social skills. A diary is kept so that the parent can keep track of progress.

“The parents do not have to be super-human as all it takes sometimes is around 10 minutes a day focused on helping the child,” says Dr Margaret Thompson, an honorary reader in child and adolescent psychiatry and clinical director at the Institute of Delay, Impulsivity and Attention at the University of Southampton.

“Simple games such as Snap, I Spy and Simon Says all help improve working memory and concentration as well as helping the child to wait to take turns.

“Routine is also important for children with ADHD and parents are encouraged to set firm behavioural boundaries and household rules.”

Praise
Another important aspect is to turn around the negative patterns that might have set in – parents may find it hard to see the positive in their child as they have a stressful time parenting them.

“Giving praise when the child gets something right is important as children with ADHD are often criticised. Praise increases their self-esteem which encourages them to behave better, and in turn this is encouraging for the parents,” adds Laver-Bradbury.

“Parents can also make up simple social stories suited to their child’s problems – for example, if the child has problems keeping friends, the parents can tell a story about how their child could keep friends doing things like smiling, keeping calm and waiting for their turn.”

As children with ADHD can throw temper tantrums more often than their peers, one technique parents learn is to give choices that avoid a ‘no’ answer, such as: ‘would you like to play cards now or after lunch?’

Helping a child improve their communication skills and vocabulary is also encouraged as verbalising frustration, anger and disappointment can help diffuse difficult situations.

“So far, our one follow-up study, although not yet published, is encouraging,” adds Thompson. “When we looked at outcomes seven years on from one of the studies, there were often some symptoms of ADHD in the children, but it was at the level where they were coping most of the time and did not need medication. Parents were also less stressed and felt they had really benefited from the programme.”

For more information or to enrol on a training course to deliver the NFPP, please email Josephine Surmun on Joesphine.surmun@solent.nhs.uk.

This feature originally appeared in the November/December edition of Mental Health Today magazine - click here to subscribe. 

References:
Laver-Bradbury C, Thompson M, Weeks A, Daley D & Sonuga-Barke EJ (2010). Step by Step Help for Children with ADHD: A self-help manual for parents. Jessica Kingsley Publishers.
Sonuga-Barke EJ et al (2001) Parent-based therapies for pre-school attention-deficit/hyperactivity disorder: a randomized, controlled trial with a community sample. Journal of the American Academy of Child and Adolescent Psychiatry 40 (4) 402–8.
Sonuga-Barke EJ et al (2004) Parent training for attention deficit/hyperactivity disorder: is it as effective when delivered as routine rather than as specialist care? British Journal of Clinical Psychology 43 449–57.
Thompson MJ et al (2009) A small-scale randomized controlled trial of the revised New Forest Parenting Programme for pre-schoolers with attention deficit hyperactivity disorder. European Child and Adolescent Psychiatry 18 (10) 605–16.