Early Intervention For Young Children With Adhd: 24-month Outcomes 1

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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 2 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) 3 Egger et al. (2006)   Comprehensive literature review re: children ages 2 to 5 yrs old   ADHD symptoms:       Can be reliably assessed Associated with significant impairment Mirror those of older children with respect to       Prevalence Subtypes Gender differences 4 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       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 5 Preschool Children with ADHD   Greater than average risk for injuries and accidental poisonings       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     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 6 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 7 Treatment of Young Children with ADHD   Same approaches as with older children?   Stimulants and other psychotropics     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 8 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     Co-Investigators: John Van Brakle, Rob Volpe Project Coordinator: Lauren Arbolino   http://www.lehigh.edu/education/adhd/ 9 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 10 Participants & Groups   Total: 137   Characteristics:       Age 3-5 78% male; 69% Caucasian Multi-tiered screening process         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) 11 Multi-Component Intervention Group (MCI)   Parent education classes         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     Literacy Numeracy   Pre-school functional assessment and support individualized plan 12 Parent Education Intervention Group (PE)   Parent education classes         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 13 Parent Education Overview   20 – Two-hour sessions     MCI – Every 2 weeks PE – Monthly (12 sessions) & Every 6 weeks (8 sessions)   Manualized treatment with fidelity checks   Initial group size     MCI – mean of 9.7 families represented (range: 4 - 19) PE – mean of 8.1 families represented (range: 6-11)   Convenient location (schools & hospitals) 14 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 15 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 16 MCI Parent Education: Focus on FBA   Finding the Problem (session 4)         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)         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)         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 17 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:       Determining function Confirming hypothesis by manipulating conditions directly Completing in the natural setting with natural change agent 18 Conditions & Links to Interventions   Conditions: (Wacker, Berg, Harding, & Asmus, 1996)       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 19 Type of Problem Behavior 20 Functions of Problem Behavior 21 Frequency of Problem Behavior Across FA Conditions 22 Primary Behavioral Function by Age 23 Primary Behavioral Function by Gender 24 Primary Behavioral Function by ADHD Subtype 25 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 26 2-year Outcomes: Outcome Measures   Behavioral Functioning:             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:         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 27 Summary of 2-year Outcomes   HLM (growth modeling) analyses conducted separately for 46 dependent measures             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 28 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 29 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 30 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) 31 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 32 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 33 DISC ADHD Diagnosis 34 Children Meeting Symptom + Impairment Criteria 35 Children Meeting Initial Inclusion Criteria 36 Impairment Ratings Across Studies 37 Mean ADHD Inattentive Symptom Scores-Parent 38 Mean ADHD Hyperactive-Impulsive Symptom Scores-Parent 39 Mean ADHD Inattention Symptom Scores-Teacher 40 Mean ADHD Hyperactive-Impulsive Symptom Scores-Teacher 41 ODD Diagnosis Across Groups 42 Conduct Disorder Diagnosis Across Groups 43 Receipt of Psychotropic Medication Across Groups 44 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 45 For Further Information 46