Beyond symptom control for attention-deficit hyperactivity disorder: what can parents do to improve outcomes?

• J Tarver, D Daley and K Sayal
• Child: Care, Health and Development Vol 41, (2015)

Attention-deficit hyperactivity disorder (ADHD) is a developmental disorder, characterised by hyperactivity, impulsivity and inattention. It is both genetically and environmentally caused.

The effectiveness of parenting interventions to treat ADHD has previously been supported by research (Fabiano et al, 2009). However, Sonuga-Barke et al (2013) showed that the evidence base may not be as strong as previously thought. This narrative review of literature published between March 1998 and March 2013 aimed to highlight the need for more quality research in this area and potential alternative benefits of parenting interventions.

Executive function

This describes cognitive functions that are used to drive goal-directed behaviour. Little research has directly explored the relationship between parenting and executive function in children with ADHD but setting realistic goals and helping the child to achieve them is advantageous for child development (parents of children with ADHD partake in less effective "scaffolding" like this compared with parents of typically developing children).

Scaffolding of developmental skills for younger children with ADHD is a key component of the New Forest Parenting Program and the Training Executive, Attention, and Motor Skills intervention. The latter encourages parental engagement in activities aimed at developing:

• Inhibitory control (eg "Simon says")
• Working memory (eg searching for hidden items)
• Planning (eg packing for a picnic)
• Motor control (eg skipping, jumping).

Reward processing

Some children with ADHD prefer smaller, immediate rewards over larger, later rewards. No studies have specifically assessed the effects of parenting interventions on processing in children with ADHD. However, one found that interventions emphasising reward frequency could be beneficial for children with abnormal processing and another has shown that frequent and immediate reinforcement has a comparable effect on brain function as medication in children with ADHD: parental praise and affection may be sufficient.

Temporal processing

Parents often report that children with ADHD interrupt and seem unable to wait their turn. These behaviours may be due to deficits in temporal processing.

No studies have assessed the effects of parenting interventions on processing in children with ADHD but this does improve for children with reinforcement. Using a timer or clock during activities may help the child develop an understanding of time.

Academic functioning

Children with ADHD experience lower academic achievement relative to others. While medication improves productivity it is unable to normalise achievement.

The evidence is unclear whether parenting interventions alongside medication benefit academic functioning. However, one study into The Family-School Success model, suggests that encouraging collaboration between family and school may benefit academic outcomes for children with ADHD.

There is also little research exploring the relationship between parental involvement in learning and academic outcomes in children with ADHD. Nonetheless, parental involvement and encouragement is generally recommended as is practical support with homework management, such as keeping a diary.

Social and peer functioning

Children with ADHD experience substantial social functioning impairment. As this predicts adverse development it should be seen as a vital intervention target.

When used with medication, parenting interventions may not offer any additional benefit for social functioning. However, interventions targeted at parental behaviours related to child social performance hold promise. An adapted Parental Friendship Coaching intervention encourages parents to create social opportunities for their child and provide constructive feedback on their social skills, both of which parents of children with ADHD have been shown to be less likely to do.

Co-morbid oppositional/conduct disorders

It is estimated that up to half of children with ADHD also have a disruptive behavioural disorder (DBD) including conduct disorder (CD).

Currently, it is unclear whether parenting interventions alongside medication provide additional benefit for co-morbid DBD compared with medication alone. However, there is evidence that children with ADHD are less likely to develop CD when parents are warm, encouraging and praise their child. Parenting interventions that encourage pro-active, positive parenting skills may therefore protect against the development of behaviour problems in ADHD, particularly during the pre-school years.

Implications for practice

While these findings may spark concern about the efficacy of parenting interventions in the treatment of ADHD, this review suggests that:

• Parents' reports of symptoms should be supplemented with reports from independent sources in the assessment of ADHD.
• Parenting is associated with a wide range of outcomes in children with ADHD.
• Adapted parenting interventions thus have the potential to benefit functioning outcomes that medication may be less able to.
  
  

IN NUMBERS

900,000 children (7% of total) have a disability (1)

40% of disabled children live in poverty (2)

1 in 13 disabled children receive a council support service (3)

410,000 of 0-19 year olds have a learning disability (4)

Sources: 1. DWP, July 2014; 2. The Children's Society, 2011; 3. NHS Information Centre, 2013; 4. Mind

FURTHER READING

Related resources:

• The Views and Experiences of Children in Residential Special Schools: Overview Report
• Child Sexual Abuse and Exploitation: Understanding Risk and Vulnerability
• "They Still Need to Listen More": A Report About Disabled Children and Young People's Right's in England
• Overcoming Barriers to Effective Early Parenting Interventions for Attention-Deficit Hyperactivity Disorder: Parent And Practitioner Views

Related resources by Research in Practice:

• Voice of the Child: Evidence Review
• Communicating With Children and Young People With Speech, Language and Communication Needs and/or Developmental Delay: Frontline Briefing
• Lifespan Personalisation: Strategic Briefing
• Capturing and Recording the Views and Experience of Children and Young People (Including Disability): Practice Tool
  
  

The research section for this special report is based on a selection of academic studies which have been explored and summarised by Research in Practice, part of the Dartington Hall Trust.

This article is part of CYP Now's special report on special educational needs and disabilities. Click here for more