More effective psychosocial treatments for children with ADHD or hyperactive behaviour, their parents and teachers, is what the consortium PAINT (Psychosocial ADHD interventions) wanted to realise with its studies. The results obtained provide many possibilities to improve the existing care, says project leader Prof. Barbara van den Hoofdakker.
Schools, parents and municipalities currently have a knowledge deficit regarding effective treatment methods for ADHD and hyperactive behaviour, says Van den Hoofdakker. ‘That is a clear conclusion from our consortium. Much use is made of training and treatment programmes for which we either do not know the effectiveness or the effectiveness has not been investigated. That means the knowledge we have acquired can have a considerable impact.’
Existing interventions with a proven effectiveness are mainly training courses for parents and teachers. These combine behavioural therapy techniques to prevent problem behaviour among children with ADHD and to influence the behaviour in retrospect. In professional jargon: they work with both stimulus control and contingency management. Examples of stimulus control techniques are: providing more structure, setting clear rules and trying out a different sequence of activities. Contingency management concerns skills such as praising or ignoring behaviour
The existing training programmes often require a lot of time. So, sometimes parents do not start such programmes or they fail to complete them, says Van den Hoofdakker. That is a shame, because an American study has shown that early psychosocial intervention can lead to less medication use. Van den Hoofdakker was therefore pleased when research results from PAINT revealed how effective short interventions can be.
Researchers developed these interventions by separating the techniques for stimulus control and for contingency management from interventions with a proven effectiveness. They incorporated both techniques individually into two short behavioural therapy training courses for parents and teachers, respectively, and tested these techniques in micro-trials. ‘For both parents and teachers, we examined which techniques were more effective’, explains Van der Hoofdakker. ‘And we discovered that they both work really well! Independently of each other, they are possibly just as effective as the longer training courses offered.’
Schools, parents and municipalities currently have a knowledge deficit regarding effective treatment methods for ADHD
Lianne van der Veen, a therapist at Accare, helped to devise the composition of the training courses for the trial and gave the training courses for parents. She found it an interesting and instructive experience. ‘It made me think carefully about what I do in the sessions.’
The accepted parents could follow the training course of two two-hour sessions immediately after the intake, before medication or more intensive psychosocial treatment came in view. Nearly all of the parents offered the training wanted to participate. ‘The parents decided which problem behaviour of their child they wanted to work on in which daily situation. Parents often stated dawdling and disobedience in the morning’, says Van der Veen. ‘Together, we came up with an approach that they could directly use in practice. We rehearsed this during the sessions. And that worked. The parents were also very satisfied.’ Only 4% withdrew from the training sessions early.
‘With the trial, we wanted to determine which type of techniques work best’, notes Van den Hoofdakker. ‘Now, we effectively have two mini-interventions that both give very good results.’ A meta-analysis revealed that practising with the parents and teachers during the session contributes to the effectiveness’, she says. ‘That is also an important insight.’
The researchers also wanted to know whether providing one technique in addition to the other had any added value. Therefore a small number of parents and teachers could follow a training course that contained both the stimulus control and the contingency management techniques. The data from the so-called single case study are now being analysed, says Van den Hoofdakker.
Now we effectively have two mini-interventions that both give very good results.
As a final step, Van den Hoofdakker wants to combine the two clusters of techniques into a single intervention of two sessions of two hours. Follow-up research is needed to demonstrate the effectiveness of this. ‘Once the research has been completed, we will examine together with the parents whether the intervention was effective enough’, says Van der Veen. ‘It could be that some parents find two sessions enough, whereas others need more time. Once we know that, then we can offer extra training to this group.’
The short, targeted approach can lead to a better throughput and therefore faster help for children and their parents and teachers. And also to less medication use, hopes Van den Hoofdakker. ‘We would like to test that.’
The project leader praises the ongoing collaboration that has arisen through the consortium. ‘It is now much easier to find parties who are willing to take part in a follow-up study’, she says. ‘We have also built up a strong international network through the setting up and realisation of an Individual Patient Data Meta-Analysis (IPDMA). This combines the data from previous studies. As a result of this, we now know, for example, that the behaviour of children with severe problems can deteriorate if you do not offer treatment straight away. That is vital information for policymakers. Thanks to the IPDMA, we now have a large database, also for future advanced analysis. Yet another fantastic result from the consortium.’
The researchers have also drawn up decision trees for the Care Standard ADHD [in Dutch].
Most of the consortium’s results have not been published yet. It is expected that several articles will be published during the course of 2020. In 2019, an article from the consortium was published in the Dutch journal Kind en Adolescent Praktijk.
In the consortia Effectiveness of Psychosocial Interventions Youth, researchers and youth care organisations are exploring new possibilities for seven larger substantive themes related to growing up and parenting. The research provides knowledge about which (aspects of) interventions can best be used when, for who and by which persons. The key elements of interventions with proven effectiveness are the starting point for these interventions. Through innovative impact studies, the consortia provide answers to questions such as: What actually makes an intervention effective? Are there effective factors that can be found in all interventions? How can the care provider exert an influence on the impact? And: which interventions or aspects of these are cost-effective? Realising impact studies in an appropriate form is a challenge. Each consortium takes a different approach, but they work together to ensure that their approaches are well aligned with each other. The research from the consortia must improve the interventions and enable professionals and municipalities to choose an effective approach. The outcomes will make it possible to improve the effectiveness of professional practice and provide better help to children and families.
The consortia Effectiveness of Psychosocial Interventions Youth are working on these seven themes:
In the consortia, key elements of interventions will be investigated. But what exactly are those key elements? Key elements are the things that a care provider can do to teach desired behaviour to young people or their parents, guardians or carers. Or to diminish undesirable behaviour. This is given various names in the literature (e.g. components, elements, ingredients, kernels and techniques). We have chosen the term “key element” because this is used by most of the consortia and ties in well with the literature. As it is often not yet clear whether the element actually works, we ought to use the term “potentially effective key elements”. However, that is quite a mouthful. A collection of these key elements defines an intervention. Structural elements also play a role in defining an intervention. For example, the sequence, frequency and intensity of the key elements involved.
The consortium Psychosocial ADHD Interventions (PAINT) was established to acquire more knowledge about the effective treatment of ADHD and hyperactive behaviour so that the help provided to these children can be improved. Therefore the researchers have described the current practice of care and education for children with ADHD and hyperactive behaviour in the Netherlands. To what extent are interventions and guidelines used that have proven to be effective? Which factors influence the choices made? A second sub-study concerned the usefulness of various elements in interventions of proven effectiveness, which usually relate to training courses for teachers and parents. Are certain elements or methods perhaps more effective than others? In the third sub-study, the researchers determined whether there are subgroups of children or parents for which it is clear that certain interventions work well or, conversely, do not work so well. Finally, the balance between the effectiveness and the costs of interventions was investigated to analyse their cost-effectiveness.
The data collection has been completed for most PAINT studies. Good use can be made of the research results to improve the help provided to children with ADHD and hyperactive behaviour. The studies provide insight into the current practice of care and education for children with ADHD and hyperactive behaviour and contain recommendations for improving these. In the future, the knowledge acquired about the effectiveness of elements of parent and teacher training courses can contribute to improving and shortening existing training courses. Knowledge about the effectiveness of interventions of certain subgroups can help municipalities and care institutions to provide more tailored care. Finally, insight into the cost-benefit ratio of interventions can facilitate cost-effective choices in care.
Text Veronique Huijbregts. Translation Dave Thomas. Portrait Barbara Martin de Bouter. Photography header Studio Oostrum.