There is evidence to suggest that behavioural parent training (BPT) can be used effectively as a treatment and prevention approach to manage the potential detrimental impact of ADHD and address parental concerns about ADHD. Although BPT is widely accepted, the accessibility of BPT in the US and across Europe is variable, despite the potential positive benefits of BPT in terms of public health spending associated with ADHD. With advocacy organisations becoming increasingly involved with parenting interventions, they are well placed to deliver BPT more widely. However, many existing BPT models are not well suited to the advocacy organisation setting, due to the constraints of clinical skills and the resources available for training and ongoing supervision. To address this, ADHD-foreningen (a Danish non-governmental ADHD advocacy organisation) established Caring in Chaos (CiC). CiC is a BPT intervention* which has been shown to be accessible, effective, efficient and sustainable within the advocacy organisation setting. This study aimed to determine if CiC could improve the most-proximal outcomes of BPT, such as parenting behaviour, parenting sense of competence and parental stress, as well as reducing parent-reported child functional impairments, compared with a wait-list control group.
This randomised controlled trial enrolled† 161 Danish families of children aged 3–9 years (79% male; mean age 7.04 years) for whom there was a concern of ADHD. No formal diagnosis of ADHD was required; however, the majority of individuals had a perceived diagnosis of ADHD by parental report. This approach was taken to better allow the study to reflect effectiveness in a routine community practice setting. Recruited families were randomly assigned to the experimental CiC model either immediately or after a wait-list period (representing the control group). Parents’ ratings of their own behaviour, competence, stress and depressive symptoms, as well as their child’s ADHD symptoms and related functional impairments, were taken before intervention, immediately post-intervention and after 4 months’ follow-up to determine the impact of CiC.
On average, families attended 9.47 of the 12 CiC sessions (standard deviation = 4.00); of the 87% who attended ≥1 session, 97% attended ≥6 sessions, 96% attended ≥9 and 50% attended all 12. Access to CiC showed a significant positive effect, both post-intervention and at follow-up, on parenting behaviour (p<0.001 for both), competence (satisfaction and efficacy subscales; all p<0.001) and depressive symptoms (p<0.001 and p=0.02, respectively). Although parental stress showed a significant improvement post-intervention (p<0.001), this was no longer the case at follow-up (p=0.08). No significant effects on child ADHD symptoms were found post-intervention or at follow-up (p>0.05 for both); however, child functional impairment was significantly improved, both at post-intervention and at follow-up (p<0.001 and p=0.001, respectively).
There are limitations in this study which must be taken into account. These included the use of a wait-list control group and the inability to blind treatment status made it unclear whether alternative treatment models would show similar or better outcomes for children with suspected ADHD and their families, or if the effects observed would be found with more objective measures. No records of baseline or concurrent medications were documented, which may impact the results, although it should be noted that use of medication for the treatment of ADHD in Denmark is relatively low (<5%). In addition, the lack of requirement for a diagnosis of ADHD in this study resulted in a wide range of ADHD symptoms, at least half of which were not above the clinical threshold for ADHD. This may have impacted the ability to determine significant changes in ADHD symptoms following CiC intervention.
This authors concluded that within the advocacy group setting, the CiC model can effectively provide BPT to families with parental concerns about childhood ADHD. The authors suggested that although children with severe ADHD concerns should be directed to speciality mental health care services, children of families with lower-level concerns about ADHD could initially be directed to community-based CiC.
*CiC is a 12-week training programme that was established in 2011 to assist parents in managing children diagnosed with ADHD. It utilises evidence-based BPT and social-learning theory, which have been translated into three core elements: psychoeducation, positive behaviour and tools for managing disruptive behaviour/conflict prevention. Content and language have been simplified to facilitate learning and implementation by people with varying mental health experience
†Participants were recruited via the ADHD-foreningen Internet homepage, and local and national newspapers. Potential participants were required to register themselves and one child who met the inclusion criteria online
Chacko A, Scavenius C. Bending the curve: a community-based behavioral parent training model to address ADHD-related concerns in the voluntary sector in Denmark. J Abnorm Child Psychol 2018; 46: 505-517.