April 12, 2001 -- While symptoms of Attention-Deficit/Hyperactivity Disorder are seen in children as young as 3 years old, many parents and doctors are reluctant to turn to Ritalin as a treatment. A new study finds that when mothers are coached to learn some alternative parenting techniques, children behave better. Mom's sanity also seems to fare better.
So-called "parent training" classes produced a significant effect on ADHD symptoms -- and on mothers' emotional well-being. "Structured parent training delivered by healthcare professionals can provide an effective vehicle for treating ADHD in this age group," writes Edmund J.S. Sonuga-Barke, PhD, a researcher with the Centre for Research into Psychological Development at the University of Southampton, England. He is the author of a paper appearing in this month's Journal of the American Academy of Child and Adolescent Psychiatry.
If you have questions about ADHD, WebMD has several chat boards to discuss the condition. Go to NewlyDiagnosed, or to the board moderated by Richard Sogn, MD.
In their study, Sonuga-Barke and colleagues enrolled 78 3-year-old children -- all boys -- who, based on information provided by their mothers, had shown symptoms of ADHD in a variety of situations including home, with friends, and in public, over the previous six-month period.
Children were assigned either to a parent-training or parent-counseling-and-support group, or were placed on a waiting list. This served as the comparison group. Treatments consisted of a structured eight-week program involving eight one-hour weekly visits to the mother's home, made by a specially trained therapist.
In the parent-training group, mothers were given background information on ADHD. They were taught a wide range of behavioral strategies to use with their children, to reduce defiant and difficult behavior. These included strategies on how to reward and reinforce good behavior, and ignore bad behavior. In most sessions, therapists worked with both mother and child.
In the parent-counseling-and-support group, mothers received no training in behavioral strategies. They were, however, provided a nonthreatening environment where they could discuss their concerns: their feelings about their child as well as the impact the child had on the family.
The group on the waiting list received no clinical services.
After the parent-training group, the researchers found a significant effect on both ADHD symptoms and mother's mental health. A full 53% of the parent-training group children were "recovered"; 38% of the parent-counseling-and-support group, and 25% of the waiting-list children also met the criteria for recovery. Mothers in the parent-training group also fared better in terms of emotional health, say the authors.
The effects of parent training were still present 15 weeks after the training ended, which is in contrast to other studies that have showed that the effects of medications are short-lived once medication is stopped. "There is little evidence for long-term beneficial effects of medication on either behavior or psychological functioning," writes Sonuga-Barke.
Whether the effects of parent training will be effective in the longer term is unknown, he adds. "It is hoped that by providing a basis for more effective parenting, this treatment would help both the child and the family to cope better with the transition from home to school," he writes.
"Some might take this study as a commentary against medication, but I don't think it is," says Ann Abramowitz, PhD, an associate professor of psychiatry and behavioral science at Emory School of Medicine in Atlanta. "It's more a study about appropriate interventions with preschoolers."
One problem with the study: "Whether all children in the study have true ADHD is not clear," says Abramowitz. "It relied primarily on mothers' reports of symptoms. There was no teacher input, which is critical to diagnosing this disorder. Symptoms must clearly be present in several environments.
"It could be that the 50% of children who showed improvement were simply children with oppositional behavior -- who are defiant, break rules -- whose parents really do need training in parenting techniques," Abramowitz tells WebMD. "Perhaps they improved because their parents were less effective managers to begin with. Studies have already shown parent training to be [effective] with preschool kids who are oppositional."
Those who didn't respond to behavioral therapy quite possibly had true ADHD, says Abramowitz.
Bottom line: "Medicating preschoolers may be appropriate, but I don't think it's as appropriate to do it as a first intervention for preschoolers," Abramowitz tells WebMD. "I think the authors should say they cautiously suggest this intervention should be attempted before medication is prescribed. Some people are too quick to medicate."
From a psychiatrist's viewpoint, "it's unclear whether these children had true ... ADHD or not," William Wetzel, PhD, an associate professor of psychiatry at Duke University School of Medicine tells WebMD. "But I find it hopeful. It's one of the first studies to ever show that a pure psychiatric approach can have some meaningful effect on ADHD ... that for very young children, behavioral therapy may be effective in ameliorating symptoms, whereas in older children this kind of behavioral therapy is not effective."