Early Intervention for Young Children
with ADHD: 24-Month Outcomes
1
AGENDA
  Background information
  Overview of early intervention project
  Parent education component
  Home-based functional assessment component
  Preschool-based intervention component
  Two-year outcomes
  Q & A/Discussion
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Background Information
  Symptoms of ADHD emerge at a very young age
(Egger et al., 2006; Wolraich, 2006)
  ADHD tends to be chronic for ~75 to 85% of young
children with early symptoms (Lahey et al., 2004)
  Approx. 2% of 3-4 year-olds are diagnosed with
ADHD
  Symptoms in young children associated with
significant behavioral, social, and pre-academic
impairment (DuPaul et al., 2001; Lahey et al., 1998; PATS study,
2007)
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Egger et al. (2006)
  Comprehensive literature review re: children ages
2 to 5 yrs old
  ADHD symptoms:
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Can be reliably assessed
Associated with significant impairment
Mirror those of older children with respect to
 
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Prevalence
Subtypes
Gender differences
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Preschool Children with ADHD
  High level of chronicity of symptoms
 
70 to 80% exhibit significant ADHD symptoms in elementary school
(Lahey et al., 2004)
  At high risk for comorbidity, especially ODD, communication
disorders, & anxiety disorders (~70% of PATS sample; Greenhill et
al., 2006)
  Associated with academic & social deficits
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Enter schools behind peers in pre-academic skills
3x as likely to be placed in special education
Nearly 90% of Lahey et al.’s sample fell short of being considered
well-adjusted as adolescents
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Preschool Children with ADHD
  Greater than average risk for injuries and accidental
poisonings
 
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7x as likely to sustain injuries (Lahey et al., 2004)
Injuries more likely to be severe (DiScala et al., 1998)
Strongest risk for those with HI subtype and/or aggressive behavior
(Lahey et al., 1998)
  Increased use psychotropic medication
 
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1.7 to 3.1fold increase in MPH through 1990’s (Zito et al., 2000)
17% of Lahey et al., 2004 sample prescribed stimulants, grew to 48%
w/in 3 yrs
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Strong Rationale for Early Intervention
  Directly address ADHD & comorbid symptoms
  Reduce risk for development of more severe
antisocial behavior (interrupt coercive cycle)
  Reduce risk for injury
  Enhance academic & social functioning so children
enter school ready to learn
  Delay or avoid use of psychotropic medication, if
possible
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Treatment of Young Children with ADHD
  Same approaches as with older children?
 
Stimulants and other psychotropics
 
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PATS study (Greenhill et al., 2006) showed similar levels of efficacy
but also higher frequency of side-effects and lower acceptability by
parents
Behavioral strategies
 
Several studies showing positive effects of behavioral parent
training (e.g., Webster-Stratton, Sonuga-Barke) & preschool-based
behavioral programming (e.g., McGoey et al., 2005)
  Few, if any, studies have examined multi-component
early intervention programs to address cross-setting and
multiple difficulties experienced by young children with
ADHD
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Early Intervention Project Overview
  Purpose:
 
Examine two types of early intervention for preschool age
children with or at risk for ADHD
  Funded by NIMH (Grant R01-MH61563)
  Co-PIs: George DuPaul and Lee Kern
 
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Co-Investigators: John Van Brakle, Rob Volpe
Project Coordinator: Lauren Arbolino
  http://www.lehigh.edu/education/adhd/
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Early Intervention Goals
  Reduce problem behaviors (especially ODD and CD
related)
  Improve early academic skills
  Reduce accidents and injuries
  Prevent or delay use of psychotropic medication
  Evaluate support needed to maintain initial gains
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Participants & Groups
  Total: 137
  Characteristics:
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Age 3-5
78% male; 69% Caucasian
Multi-tiered screening process
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Symptoms of ADHD (any subtype) determined by preschool teacher and
parent standardized ratings (above 93rd percentile)
Excluded children with autism, cognitive delays, or conduct disorder
63% combined, 26.5% hyperactive-impulsive, 10.5% inattentive
76% comorbid ODD
  Random assignment to:
1. Multi-component Early Intervention Group (MCI; n = 73)
2. Parent Education Group (PE; n = 64)
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Multi-Component Intervention Group
(MCI)
  Parent education classes
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General information about ADHD
Focus on behavioral function
Instruction in safety issues
Used lessons from the Community Education Program (COPE;
Cunningham et al., 1998)
  In-home functional analyses and individualized support plan
  Pre-academic instruction
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Literacy
Numeracy
  Pre-school functional assessment and support individualized
plan
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Parent Education Intervention Group
(PE)
  Parent education classes
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General information related to child development – health,
nutrition, & safety
General information about ADHD
General intervention strategies for parents
Used lessons from the Early Childhood Systematic
Training for Effective Parenting (STEP; Dinkmeyer et al.,
1997)
  Allowed to obtain other community services as
needed
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Parent Education Overview
  20 – Two-hour sessions
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MCI – Every 2 weeks
PE – Monthly (12 sessions) & Every 6 weeks (8 sessions)
  Manualized treatment with fidelity checks
  Initial group size
 
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MCI – mean of 9.7 families represented (range: 4 - 19)
PE – mean of 8.1 families represented (range: 6-11)
  Convenient location (schools & hospitals)
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MCI
PE
1.  Opening (purpose and overview)
Opening (purpose and overview)
2.  Introduction to ADHD
Introduction to ADHD
3.  Attending and Rewards (COPE)
Understanding Your Child’s Behavior
(STEP)
4.  Functional Behavioral Assessment I:
Finding the Problem
Home Safety
5.  Functional Behavioral Assessment II:
Identifying Patterns
Self-Esteem (STEP)
6.  Functional Behavioral Assessment III:
Developing a Plan
Parent Self-Care
7.  Home Safety
Healthy Child Overview
8.  Teaching Early Literacy
Listening and Talking (STEP)
9.  Teaching Early Numeracy
Learning to Cooperate (STEP)
10.  Balanced Attending and Planned
Ignoring (COPE)
Preparing Your Child for School
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MCI
PE
11.  Transitional Warnings and When-Then
Statements (COPE)
Discipline (STEP)
12.  Planning Ahead I (COPE)
School Readiness
13.  Time Out from Reinforcement (COPE) Discipline Discussion
14.  Point Systems I (COPE)
Language Development
15.  Point Systems II (COPE)
Social and Emotional Development (STEP)
16.  Planning Ahead II (COPE)
Cognitive Development
17.  Home-School Communication (COPE) Healthy Child Overview (part 2)
18.  Problem Solving (COPE)
Review and Application of STEP Sessions
19.  Transitioning to Kindergarten
Review and Application of all Sessions
20.  Closing
Closing
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MCI Parent Education:
Focus on FBA
  Finding the Problem (session 4)
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Define and provide examples of triggers, behaviors, & responses (TBR)
Identify “why” behaviors occur & “what” makes behavior continue
View video tapes & role plays to practice identifying TBR
Review use of information collection forms to identify TBR (homework)
  Identifying Patterns (session 5)
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Review TBR data collection forms (homework)
Describe & provide examples of summary statements
Guided practice developing summary statements (large group activity)
Independent practice developing summary statements (homework)
  Developing a Plan (session 6)
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Describe importance of developing multicomponent intervention plans
Describe purpose of preventive, instructive, & consequence-based interventions
Guided practice identifying and using different types of interventions
Identify strategies to assess the effectiveness of intervention plans
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Home-based Functional Assessment (FA)
  Limited study of FBA in home settings
 
Evidence that parents can be trained in this strategy (Feldman &
Werner, 2002; McNeill, Watson, Henington, & Meeks, 2002)
  Components of the assessment include a PII, Direct
observations, & Functional Analysis (FA)
  Importance of FA:
 
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Determining function
Confirming hypothesis by manipulating conditions directly
Completing in the natural setting with natural change agent
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Conditions & Links to Interventions
  Conditions: (Wacker, Berg, Harding, & Asmus, 1996)
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Escape, Attention, Tangible, & Play/Control
5 minutes each with 2 minute breaks between conditions
Replicate problematic condition(s)
  Links to interventions:
  Transitional warnings/
Timer
  When-then
  Choice
  Reminder of future access
  Redirection
  Substitute object
  Specific praise
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Type of Problem Behavior
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Functions of Problem Behavior
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Frequency of Problem Behavior
Across FA Conditions
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Primary Behavioral Function by Age
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Primary Behavioral Function by Gender
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Primary Behavioral Function by
ADHD Subtype
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Preschool-based Intervention
  FBA conducted by consultant
  Increase teacher acceptability & integrity of Behavior
Intervention Plan (BIP) implementation
  Ecological Inventory
  Development of a school plan
  Monitor academic, social & behavioral changes
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2-year Outcomes: Outcome Measures
  Behavioral Functioning:
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ADHD Rating Scale - IV (ADHD RS-IV: Home) & (ADHD RS-IV: School)
Child Behavior Checklist (CBCL/6-18) & Teacher Report Form (TRF)
Conners Parent Rating Scale – Revised (CPRS-R) & Conners Teacher Rating Scale –
Revised (CTRS-R)
Social Skills Rating System – Parent (SSRS-P) & Teacher (SSRS-T), Elementary level
Direct observations of preschool behavior (structured & free play)
Direct observations of parent-child interactions in the home
  Pre-academic Functioning:
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Dynamic Indicators of Basic Early Literacy Skills (DIBELS)
Early Numeracy Skills Assessment (ENSA)
Bracken Basic Concepts Scale-Revised (BBCS-R)
Woodcock-Johnson III – Tests of Achievement (WJ-III ACH)
  Measures collected every 6 months for 2.5 years
  Intent-to-treat methodology employed
  Results analyzed for 2-year outcomes
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Summary of 2-year Outcomes
  HLM (growth modeling) analyses conducted separately for 46
dependent measures
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Key indices were slope for MCI and slope differences between groups
(linear and quadratic)
Intercept (baseline score) significantly greater than 0 for MCI and no
group difference in intercept for 44 of 46 measures
Significant growth (slope) for 30 of 46 dependent measures (p < .01)
Group differences in slope (favoring MCI) found for 9 variables
Significant reduction in clinically significant ADHD & ODD in both
groups
Some increase in medication and CD symptoms but below typical
levels for this population
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Variables with Slope < 0
(p < .05)
  Parent & teacher ratings of IA and HI symptoms
(ADHD RS-IV, CPRS-R/CTRS-R, & CBCL/TRF)
  Parent & teacher ratings of ODD symptoms
(CPRS-R/CTRS-R & CBCL/TRF)
  Parent & teacher ratings of CD symptoms (CBCL/TRF)
  Home observations: Negative social behavior (child) & Alpha
commands (parent)
  Structured preschool setting: Off-task, Noncompliance, &
Physical aggression
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Variables with Slopes > 0
(p < .05)
  Parent & teacher ratings of social skills
  Parent ratings of actions to prevent injuries
  Parent ratings of seeking spiritual support
  DIBELS: Initial sound fluency, Phoneme
segmentation fluency, & Letter naming fluency
  WJ-III ACH: Letter-word identification &
Calculations
  Bracken: Total Test standard score
  ENSA: Quantity Concepts score
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Variables with Slopes
That Differed Between Groups
  Preschool structured setting: Noncompliance
  Preschool structured setting: Off-task (Quad)
  Preschool unstructured setting: Positive social (Quad)
  Home: Positive social (Linear & Quad)
  Teacher ratings of ODD (Quad)
  Parent ratings of distress (Linear & Quad), Parent-child
dysfunctional interaction (Quad), & Difficult child (Linear &
Quad)
  Parent ratings of mobilizing family to help (Linear & Quad)
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Teacher ODD Rating
Trajectories Across Groups
80.000
70.000
60.000
50.000
MSI
40.000
CI
30.000
20.000
10.000
0.000
0m
6m
12m
18m
24m
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Off-Task Trajectories Across Group
7.000
6.000
5.000
4.000
MSI
3.000
CI
2.000
1.000
0.000
0m
6m
12m
18m
24m
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DISC ADHD Diagnosis
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Children Meeting Symptom +
Impairment Criteria
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Children Meeting Initial Inclusion Criteria
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Impairment Ratings Across Studies
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Mean ADHD Inattentive
Symptom Scores-Parent
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Mean ADHD Hyperactive-Impulsive
Symptom Scores-Parent
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Mean ADHD Inattention
Symptom Scores-Teacher
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Mean ADHD Hyperactive-Impulsive
Symptom Scores-Teacher
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ODD Diagnosis Across Groups
42
Conduct Disorder Diagnosis
Across Groups
43
Receipt of Psychotropic Medication
Across Groups
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Initial Conclusions
  Significant growth in behavior control & pre-academic
functioning over 2 years regardless of intervention group
  Some differences favoring MCI particularly with respect to
maintenance of improvements in 2nd year in school setting
  Unclear whether growth is due to tx or other variables (e.g.,
maturation)
  Impact of participant attrition, parent attendance, & tx
integrity?
  Positive effects of assessment-based interventions on specific
target behaviors
  Further analyses of predictors and moderators of tx outcome
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For Further Information
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