• 45.1 efficacy and cost-effectiveness of individual versus group-based parent training for preschool attention-deficit/hyperactivity disorder: A multi-center randomized controlled trial

      Daley, David (2016)
      Objectives: The goal of this presentation is to compare the efficacy and cost effectiveness of New Forest Parenting Programme (NFPP)-an individually delivered approach-with a group-based approach (incredible years, IY) and treatment as usual (TAU) in a sample group of preschool children with ADHD. Methods: The Comparison of Preschool Parenting Interventions (COPPI) trial was a three-arm parallel group, randomized controlled trial. The trial recruited 307 preschool children that met standard ADHD diagnostic criteria. Children were block-randomized to NFPP, IY, or TAU on a 3:3:1 ratio. NFPP is a specialist parent-training (PT) program for parents of preschool children with ADHD delivered on a one-to-one basis. The toddler version of IY is a group-based PT program delivered over 12-weekly sessions designed to address problems of challenging and oppositional conduct in young children. Results: In total, 307 participants were randomized (NFPP: N = 134; IY: N = 131; TAU: N = 42). The sample group included a high proportion of single parents (30 percent), low-income families, children with language difficulties (50 percent), and parents with mental health problems (77 percent). No statistically significant differences between NFPP and IY were observed in parent-assessed ADHD symptoms at T2 (primary end point: mean for NFPP, 1.715; mean for IY, 1.724; mean difference, -0.009; 95% CI -0.191 to 0.173; p = 0.921) or T3 or in other secondary or healthrelated outcomes at either T2 or T3. Small benefits of NFPP over TAU were seen for parent-rated ADHD (adjusted mean, 1.693 for NFPP and 1.881 for TAU; mean difference, -0.189; 95% CI -0.380 to 0.003; p = 0.053) and conduct problems (p < 0.05). NFPP was significantly less costly than IY (mean total cost per patient, 1,509 vs. 2,103), with the difference being attributed to higher intervention-related costs of IY. Cost utility analysis, in terms of incremental cost/quality-adjusted life-year (QALY) gained, showed that NFPP was dominant over IY and thus likely to be cost-effective, albeit based on small QALY gain differences. Conclusions: High-quality, group-based PT may be more expensive to deliver than some forms of individually delivered equally efficacious PT programs. Both formats should be available to families.
    • A qualitative process evaluation of a randomised controlled trial of a parenting intervention in community (school) settings for children at risk of attention deficit hyperactivity disorder (ADHD)

      Valentine, Althea Z.; Sayal, Kapil (2015)
      BACKGROUND: Interventions for parents of children experiencing emotional and/or behavioural difficulties can help to improve their children's health, educational and social outcomes. However, the desirability and acceptability of screening and offering such interventions for attention-deficit hyperactivity disorder (ADHD)-type problems are currently unclear. This article is a qualitative process evaluation of a pragmatic cluster randomised controlled trial (Trial registration: ISRCTN87634685; reported elsewhere) to assess the feasibility and acceptability of a school-based parenting intervention programme for parents and teachers of children with high levels of ADHD symptoms.
    • A small-scale randomized controlled trial of the self-help version of the New Forest Parent Training Programme for children with ADHD symptoms

      Daley, David (2013)
      The efficacy of a self-help parent training programme for children with attention deficit hyperactivity disorder (ADHD) was evaluated. The New Forest Parenting Programme Self-help (NFPP-SH) is a 6-week written self-help psychological intervention designed to treat childhood ADHD. Forty-three children were randomised to either NFPP-SH intervention or a waiting list control group. Outcomes were child ADHD symptoms measured using questionnaires and direct observation, self-reported parental mental health, parenting competence, and the quality of parent-child interaction. Measures of child symptoms and parental outcomes were assessed before and after the intervention. ADHD symptoms were reduced, and parental competence was increased by self-help intervention. Forty-five percent of intervention children showed clinically significant reductions in ADHD symptoms. Self-help intervention did not lead to improvements in parental mental health or parent-child interaction. Findings provide support for the efficacy of self-help intervention for a clinical sample of children with ADHD symptoms. Self-help may provide a potentially cost-effective method of increasing access to evidence-based interventions for clinical populations.
    • Academic outcomes following a school-based RCT for ADHD: 6-year follow-up

      Sayal, Kapil (2015)
      OBJECTIVE: For children with high levels of ADHD symptoms, to investigate the impact of early school-based interventions on academic outcomes in mid-childhood. METHOD: A 6-year follow-up of 4- to 5-year-olds (N = 52,075) whose schools participated in a cluster randomized controlled trial for children at risk of ADHD. School-level interventions involved the provision of a booklet with evidence-based information (book) and/or feedback of names (identification) of children with high levels of ADHD symptoms. At ages 10 to 11 years, outcome measures were scores in English and mathematics tests. RESULTS: For children with high levels of ADHD symptoms, the interventions had no impact on academic outcomes. When all children were analyzed, the book intervention had a positive impact on mathematics. Baseline inattention was associated with poorer academic outcomes, whereas impulsiveness was associated with better academic outcomes. CONCLUSION: The provision of evidence-based information about helping children with ADHD at school may have wider academic benefits.
    • Adapting an attention-deficit hyperactivity disorder parent training intervention to different cultural contexts: The experience of implementing the New Forest Parenting Programme in China, Denmark, Hong Kong, Japan, and the United Kingdom

      Daley, David (2017)
      The New Forest Parenting Programme (NFPP) is a parenting program developed for parents who have a child with attention-deficit hyperactivity disorder (ADHD). It is a manualized program that is delivered in a parent's home over 8 weeks, or in a group format, or through a self-help manual. Three randomized controlled trials have been carried out in the United Kingdom. The NFPP group has adapted the program according to feedback from parents and therapists, and for use with different populations, both within the United Kingdom and internationally. The first international trial took place in New York, United States. Trials in Denmark, Hong Kong, and Japan followed. More recently, a trial of the self-help manual has been carried out in mainland China. This paper will outline the adaptions that were needed in order to be able to deliver the program in different countries with their own expectations of parenting, culture, and language. Training had to be differently focused; manuals and handouts had to be revised, translated and back-translated; and supervision had to be delivered at a distance to maintain the fidelity of the program. The international group will outline their experience of running trials in their own countries with the NFPP in a face-to-face format (Denmark), a group format (Hong Kong and Japan), and a self-help format (mainland China).
    • Addressing the inverse care law: The role of community paediatric services

      Beeley, Chris (2014)
      Background: Children's health suffers disproportionately from the effects of poverty. The inverse care law states that those who need care the most are the least likely to receive it. Community paediatricians are well placed to address health inequalities in children. Aims: To explore, using routinely collected data, whether we address health inequalities and the inverse care law, particularly for certain conditions targeted by our specialty. Methods: Five years of data were analysed, during which health equity audits have led to service changes in order to tackle inequities. The data include postcodes, allowing each child to be assigned to a deprivation quintile, and a range of diagnoses, including five sentinel conditions: attention deficit hyperactivity disorder (ADHD) on medication, autistic spectrum disorder (ASD), epilepsy, cerebral palsy and Down's syndrome. This allowed analysis of the caseload by deprivation index for these conditions, comparison with the background population and exploration of time trends. Results: The number of children on the caseload and their distribution across the quintiles remained stable. The proportion of deprived children (i.e. in the lowest two quintiles) on the caseload over the last five years taken together is 56%, compared to 44% in the background population. The numbers of children with ADHD on medication has almost quadrupled in deprived quintiles and doubled in the least deprived quintile, while the numbers of children with this diagnosis in the most deprived is four times that in the least deprived. Numbers of children with ASD have also increased in each quintile. In contrast, the number of children with epilepsy and cerebral palsy did not show much variation, but those from deprived quintiles made up a greater proportion of the caseload. Conclusions: Routine data collection demonstrates that inequalities are addressed using all four quality domains of service provision and sentinel conditions more likely to affect deprived children are targeted. We believe it is possible for all services to collect and analyse data thus with minimal effort, thereby providing a foundation from which to address the inverse care law.
    • ADHD and transitions to adult mental health services: A scoping review

      Swift, Katie D.; Sayal, Kapil; Hollis, Chris P. (2014)
      There is increased awareness that attention deficit hyperactivity disorder (ADHD) continues into adulthood. Thus, health services are faced with a new challenge in providing a 'smooth' transition to adult services appropriate for young people with ADHD. This scoping review sought to identify the literature addressing transition for young people with ADHD to adult mental health services (AMHS). A scoping review, in which the search terms 'ADHD' and 'Transition' or 'Transfer' were entered into eight healthcare publication databases facilitated by NHS Evidence to identify both published and unpublished papers between 2000 and June 2013. Additional informal searches were also undertaken. Twenty-three papers were selected for this review. This review confirms the lack of research explicitly tracking transition from Paediatrics/Child and Adolescent Mental Health Services (CAMHS) to AMHS for young people with ADHD. Only four papers directly studying transition for ADHD patients were identified. Three further studies surveyed clinician perspectives. Taken together, the studies address a number of issues in relation to transition, including the developmental course of ADHD symptoms, appropriate adult care, knowledge and communication, unmet need, comorbidities, environmental demands and medication cessation/dosage during the transition period. While literature surrounding transition exists, the scope of the evidence showing successful and unsuccessful transition activity from Paediatric and CAMHS to AMHS for young people with ADHD is limited. Future quality research in the form of audits, longitudinal tracking studies and service evaluations are required if we are truly to understand and identify what is needed and currently available for successful transition to an appropriate adult service for ADHD patients.; © 2013 John Wiley & Sons Ltd.
    • ADHD in children and young people: Prevalence, care pathways, and service provision

      Sayal, Kapil; Prasad, Vibhore; Daley, David (2017)
      Attention-deficit hyperactivity disorder (ADHD) is a common childhood behavioural disorder. Systematic reviews indicate that the community prevalence globally is between 2% and 7%, with an average of around 5%. At least a further 5% of children have substantial difficulties with overactivity, inattention, and impulsivity that are just under the threshold to meet full diagnostic criteria for ADHD. Estimates of the administrative prevalence (clinically diagnosed or recorded) vary worldwide, and have been increasing over time. However, ADHD is still relatively under-recognised and underdiagnosed in most countries, particularly in girls and older children. ADHD often persists into adulthood and is a risk factor for other mental health disorders and negative outcomes, including educational underachievement, difficulties with employment and relationships, and criminality. The timely recognition and treatment of children with ADHD-type difficulties provides an opportunity to improve long-term outcomes. This Review includes a systematic review of the community and administrative prevalence of ADHD in children and adolescents, an overview of barriers to accessing care, a description of associated costs, and a discussion of evidence-based pathways for the delivery of clinical care, including a focus on key issues for two specific age groups-younger children (aged ≤6 years) and adolescents requiring transition of care from child to adult services. © 2017 Elsevier Ltd.
    • ADHD management during the COVID-19 pandemic: guidance from the European ADHD Guidelines Group

      Cortese, Samuele; Daley, David; Hollis, Chris P. (2020)
      The coronavirus disease 2019 (COVID-19) pandemic is creating unprecedented challenges at every level of society. Individuals with neurodevelopmental disorders, such as attention-deficit hyperactivity disorder (ADHD), are particularly vulnerable to the distress caused by the pandemic and physical distancing measures, and they might display increased behavioural problems. The crisis also poses several important questions for clinicians on how best to deliver care within the new restrictions. Therefore, the European ADHD Guidelines Group (EAGG) has developed guidance on the assessment and management of ADHD during the COVID-19 virus pandemic (see full guidance in the appendix).
    • Attention deficit hyperactivity disorder is associated with poorer academic performance

      Sayal, Kapil (2008)
      Question:Is attention deficit hyperactivity disorder (ADHD) associated with poorer academic outcomes?Population:From a large birth cohort for whom school records were available through a contractual agreement with the city, 370 adolescents fulfilling criteria for ADHD (mean age 10.4 years; 75% male), and 740 age and gender matched controls (two for each case) without ADHD or any other psychiatric disorder were selected. Medical records for these participants were available through the Rochester Epidemiology Project. DSM-IV exclusion criteria: severe mental retardation, developmental disorder, schizophrenia or other psychiatric disorder.Setting:Rochester, Minnesota, USA. Participants enrolled in the January 1976 to December 1982 birth cohort.Prognostic factors:ADHD.Outcomes:Reading achievement (percentile rank on the California Achievement Score, measured every 2 years to mean age 13 years), absenteeism (percentage days absent per school grade level for each subject), grade retention (need to repeat one or more grades), and dropout from school prior to graduation, taken from school records.METHODSDesign: Retrospective cohort study.Follow-up period: From age 5 years until emigration, death, school graduation, or dropout.MAIN RESULTSBoth boys and girls with ADHD had significantly lower reading scores (measured on California Achievement Test) than controls (mean CAT score: 45 with ADHD vs 73 for controls; p<0.001) and significantly more days absent than controls across grade levels (p<0.001). Those with ADHD were significantly more likely than controls to have repeated a grade (HR 3; 95% CI 2.1 to 4.4; p<0.001) and to have dropped out from school (HR 2.7; 95% CI 1.8 to 3.9; p<0.001). Findings were similar with adjustment for age and gender.CONCLUSIONSADHD affects academic performance. Adolescents with ADHD have lower standardised reading achievement scores and higher rates of school absenteeism, school dropout and grade retention compared to matched controls.
    • Atypical electrophysiological indices of eyes-open and eyes-closed resting-state in children and adolescents with ADHD and autism

      Bellato, Alessio; Arora, Iti; Kochhar, Puja; Hollis, Chris P.; Groom, Madeleine J. (2020)
      Investigating electrophysiological measures during resting-state might be useful to investigate brain functioning and responsivity in individuals under diagnostic assessment for attention deficit hyperactivity disorder (ADHD) and autism. EEG was recorded in 43 children with or without ADHD and autism, during a 4-min-long resting-state session which included an eyes-closed and an eyes-open condition. We calculated and analyzed occipital absolute and relative spectral power in the alpha frequency band (8-12 Hz), and alpha reactivity, conceptualized as the difference in alpha power between eyes-closed and eyes-open conditions. Alpha power was increased during eyes-closed compared to eyes-open resting-state. While absolute alpha power was reduced in children with autism, relative alpha power was reduced in children with ADHD, especially during the eyes-closed condition. Reduced relative alpha reactivity was mainly associated with lower IQ and not with ADHD or autism. Atypical brain functioning during resting-state seems differently associated with ADHD and autism, however further studies replicating these results are needed; we therefore suggest involving research groups worldwide by creating a shared and publicly available repository of resting-state EEG data collected in people with different psychological, psychiatric, or neurodevelopmental conditions, including ADHD and autism.
    • Automatic detection of ADHD and ASD from expressive behaviour in RGBD data

      Gillott, Alinda; Daley, David (2017)
      Attention Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD) are neurodevelopmental conditions which impact on a significant number of children and adults. Currently, the diagnosis of such disorders is done by experts who employ standard questionnaires and look for certain behavioural markers through manual observation. Such methods for their diagnosis are not only subjective, difficult to repeat, and costly but also extremely time consuming. In this work, we present a novel methodology to aid diagnostic predictions about the presence/absence of ADHD and ASD by automatic visual analysis of a persons behaviour. To do so, we conduct the questionnaires in a computer-mediated way while recording participants with modern RGBD (Colour+Depth) sensors. In contrast to previous automatic approaches which have focussed only on detecting certain behavioural markers, our approach provides a fully automatic end-to-end system to directly predict ADHD and ASD in adults. Using state of the art facial expression analysis based on Dynamic Deep Learning and 3D analysis of behaviour, we attain classification rates of 96% for Controls vs Condition (ADHD/ASD) groups and 94% for Comorbid (ADHD+ASD) vs ASD only group. We show that our system is a potentially useful time saving contribution to the clinical diagnosis of ADHD and ASD. © 2017 IEEE.
    • Awareness of ADHD in primary care: Stakeholder perspectives

      French, Blandine; Perez Vallejos, Elvira; Sayal, Kapil; Daley, David (2020)
      Background: Attention Deficit Hyperactivity Disorder (ADHD) is underdiagnosed in many European countries and the process of accessing care and diagnosis is complex and variable. In many countries, general practitioners (GPs) refer on to secondary care where individuals receive an assessment and, if appropriate, a diagnosis and access to care. It is therefore essential that GPs have a clear understanding of the disorder and its care pathways. While previous studies have highlighted potential barriers in GPs' ADHD awareness, this qualitative study aims to further explore individual stakeholders' experiences. Methods: Semi-structured interviews explored the views of multiple stakeholders- GPs (n = 5), healthcare specialists (n = 5), patients (adults with ADHD n = 5) and parents (n = 5) with experience of the presentation and management of ADHD in primary care. These interviews were analysed using thematic analyses and following principles of grounded theory. Results: Stakeholders described ADHD assessment, diagnosis and treatment as an intricate process. Many factors affected this process such as complex pathways, lack of services, limited GP recognition and knowledge, and communicative difficulties between and within multiple stakeholders. Conclusion: This analysis underlines the significant impact that receiving (or not) a diagnosis can have, and further explores muddled ADHD care pathways, highlighting key issues around GP identification and the shortage of adult services. Implications for practice and future research are discussed, suggesting a strong need for more commissioned pathways and GP specific educational programs. © 2020 The Author(s).
    • Barriers and facilitators to understanding of ADHD in primary care: A mixed-method systematic review

      French, Blandine; Sayal, Kapil; Daley, David (2018)
      Attention deficit hyperactivity disorder (ADHD) is a developmental disorder affecting up to 5% of children and adults and is underdiagnosed in many European countries. The process of access to care for this disorder is complex and variable across countries. In general, those affected, or their caregiver, will seek help through their primary care practitioners who are then often responsible for referral to other professionals for diagnosis and provision of treatment. Previous studies have highlighted that many barriers to recognition exist in primary care settings (such as misconceptions, lack of education or lack of resources), preventing access to care for this population and potentially affecting diagnosis rate. This systematic review aims to establish the barriers and facilitators with regard to attitudes, beliefs and experiences of ADHD within primary care. Electronic searches of multiple databases identified 3898 articles of which 48 met our inclusion criteria-primary care professionals from any country, understanding, knowledge, awareness, attitude and recognition of ADHD. Four main themes were identified: (1) need for education, (2) misconceptions and stigma, (3) constraints with recognition, management and treatment, and (4) multidisciplinary approach. The findings suggest many interacting factors are at play in the recognition of ADHD by primary care practitioners with a strong recurring theme of a significant need for better education on ADHD. Implications for research and practice are discussed, suggesting that educational interventions for primary care practitioners could improve the recognition of ADHD in this setting.
    • Barriers to medication entitlements after diagnosis of ADHD - Authors' reply

      Sayal, Kapil; Prasad, Vibhore; Daley, David (2018)
      We thank John Hayden and colleagues for their helpful comments on our paper. We are also pleased that a resolution was found in Ireland for the particular problem that had been limiting access to care for those with attention-deficit hyperactivity disorder (ADHD). We agree that it is important to consider and address barriers to care that might exist post-diagnosis and thank them for highlighting this issue. There is considerable variation in the way that reimbursement for medications is handled within different health-care systems as well as disparity in how rules are applied for different disorders.
    • Behavioral interventions in attention-deficit/hyperactivity disorder: A meta-analysis of randomized controlled trials across multiple outcome domains

      Daley, David; Cortese, Samuele (2014)
      OBJECTIVE: Behavioral interventions are recommended as attention-deficit/hyperactivity disorder (ADHD) treatments. However, a recent meta-analysis found no effects on core ADHD symptoms when raters were probably blind to treatment allocation. The present analysis is extended to a broader range of child and parent outcomes.
    • Beyond symptom control for attention-deficit hyperactivity disorder (ADHD): What can parents do to improve outcomes?

      Tarver, Joanne; Daley, David; Sayal, Kapil (2015)
      Attention-deficit hyperactivity disorder (ADHD) and its associated behavioural manifestations develop and progress as the result of complex gene-environment interactions. Parents exert a substantial influence and play a major role in their child's social environment. Despite this, recent evidence has suggested that adapting the child's environment via parenting interventions has minimal effects on child ADHD symptoms when analysing data from informants who are probably blind to treatment allocation. However, adverse parenting and family environments may act as a source of environmental risk for a number of child outcomes beyond ADHD symptoms. This is a narrative review that critically discusses whether parenting interventions are beneficial for alternative functioning outcomes in ADHD including neuropsychological, academic and social functioning and disruptive behaviour and how parenting and familial environments may be associated with these outcomes. In addition, the review explores how parental depression and parenting efficacy impact on capacity for optimal parenting and whether parenting interventions benefit parents too. A review of the evidence suggests that with modification, parenting interventions are beneficial for a number of outcomes other than ADHD symptom reduction. Improving the parent-child relationship may have indirect benefits for disruptive behaviour. Furthermore, parenting behaviours may directly benefit child neuropsychological, academic and social functioning. Parenting interventions can have therapeutic benefits for parents as well as children, which is important as parent and child well-being is likely to have a transactional relationship. Evaluation of the clinical success of parenting interventions should focus on a wider range of outcomes in order to aid understanding of the multifaceted benefits that they may be able to offer. Parenting interventions should not be seen as a redundant adjunct to medication in multi-modal treatment approaches for ADHD; they have the potential to target outcomes that, at present, medication seems less able to improve. Copyright © 2014 John Wiley & Sons Ltd.
    • Bibliometric review: Classroom management in ADHD-Is there a communication gap concerning knowledge between the scientific fields psychiatry/psychology and education?

      French, Blandine; Groom, Madeleine J. (2020)
      Many students with ADHD experience educational attainment difficulties. Nevertheless, evidence-based classroom management strategies (CMS) are seldom used. This science-practitioner gap might be due to a lack of shared knowledge between the scientific fields of psychology/psychiatry and education. This review uses science mapping to explore the basis of the current stock of knowledge in each of the two scientific fields, compares current approaches, and examines whether implementation methods and related barriers are investigated topics. We conducted a systematic search of the literature to identify articles on CMS in ADHD. We then conducted co-citation analyses and bibliographic coupling analysis. The former revealed six clusters of psychology/psychiatry and five clusters of education. Bibliographic coupling analysis resulted in eight clusters, with literature from both fields. The majority of the research is conducted in the field of psychology/psychiatry; teachers' perspectives are focused only in the field of education. The number of studies on implementation and potential barriers is small. There was thus relatively little communication between the sciences, but the scientific fields have seemed to converge recently. Connecting the scientific fields more and concentrating on implementation methods and barriers is strongly needed to close the science-practitioner gap. © 2020 by the authors.
    • Cardiovascular effects of stimulant and non-stimulant medication for children and adolescents with ADHD: A systematic review and meta-analysis of trials of methylphenidate, amphetamines and atomoxetine

      Hollis, Chris P. (2017)
      This article presents a review to evaluate potential cardiovascular effects of these treatments, the authors conducted a systematic review and meta-analysis of the effects of methylphenidate (MPH), amphetamines (AMP), and atomoxetine (ATX) on diastolic and systolic blood pressure (DBP, SBP) and heart rate (HR) in children and adolescents with attention deficit/hyperactivity disorder (ADHD). The authors conducted systematic searches in electronic databases (PsychINFO, EMBASE and Medline) to identify published trials which involved individuals who were (i) diagnosed with ADHD and were aged between 0–18 years; (ii) treated with MPH, AMP or ATX and (iii ) had their DBP and SBP and/or HR measured at baseline (pre) and the endpoint (post) of the study treatment. Eighteen clinical trials met the inclusion criteria (10 for MPH, 5 for AMP, and 7 for ATX) with data from 5837 participants (80.7% boys) and average duration of 28.7 weeks (range 4–96 weeks). Statistically significant pre–post increases of SBP, DBP and HR were associated with AMP and ATX treatment in children and adolescents with ADHD, while MPH treatment had a statistically significant effect only on SBP in these patients. These increases may be clinically significant for a significant minority of individuals that experience larger increases. Since increased BP and HR in general are considered risk factors for cardiovascular morbidity and mortality during adult life, pediatric patients using ADHD medication should be monitored closely and regularly for HR and BP. (PsycINFO Database Record (c) 2017 APA, all rights reserved)