In a recent randomized study published in Ethical Human Psychology and Psychiatry, a team of researchers based in Arizona and led by Velia Leybas Nuño, Ph.D., explored the efficacy of a family-centered, non-pharmacological approach to supporting children with ADHD-type behaviors.
Nuño and colleagues evaluated this technique, the Nurtured Heart Approach (NHA), by dividing parents of children with ADHD diagnoses (n = 104) into two groups, an intervention, and delayed intervention (control) group, and exposing parents in the intervention group to weekly NHA training sessions for a total of six weeks.
Intervention effects were primarily evaluated according to parent reports of their child’s expressions of ADHD related behaviors. Results indicated that parents in the NHA intervention condition reported decreases in their child’s inattentive and hyperactive/impulsive behaviors, whereas those in the control condition did not.
Despite the relatively small sample of families included in this study, Nuño and colleagues’ work provides preliminary evidence for positive effects associated with the NHA intervention to reduce ADHD-type behaviors by cultivating parent-child connection. They write:
“Our study presents an approach to working with children with ADD and ADHD (from here forward referred to as ADHD) behaviors which focuses on modifying behaviors through a parenting approach.”
Diagnostic criteria for ADHD outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) comprise observable behavioral characteristics. There are no biomarkers or physiological characteristics included in diagnostic determinations about ADHD – a label typically first assigned to children by their primary care providers (PCPs; responsible for 53% of initial diagnoses). Some research has revealed variability in diagnostic approaches across pediatric providers.
Nuño and team point out that although school and home-based behavioral supports accompany pharmacological intervention in the American Academy of Pediatrics’ guidelines for treatment, FDA-approved medications for ADHD represent the most popular course of intervention implemented. Specifically, 62% of children with ADHD diagnoses are prescribed medication for it. Yet, more than half of children prescribed medication for ADHD experience adverse side effects.
Side effects, though sometimes minor, may result in discontinuation for some children prescribed. An additional concern surrounding pharmacological intervention for ADHD is that associated progress or symptoms may not always be sufficiently monitored.
According to one study published in 2015, there was a 43% increase in ADHD diagnoses among school-aged children in the US between 2003 and 2011. In materials designed for children to learn about ADHD, there seems to be an emphasis on biomedical intervention compared to behavioral, community-oriented support. This bias reflects trends in treatment despite ample evidence for lifestyle and behaviorally-oriented strategies to promote change.
“The Nurtured Heart Approach is a parent training program that addresses challenging behaviors in children such as inattention, hyperactivity, and impulsivity, irrespective of the cause.”
With small-scale research support dating back to 1997, the NHA introduces parents and guardians to a novel framework for conceptualizing and responding to their child’s ADHD-type behaviors. Based on evidence that ADHD-type behaviors, regardless of cause, may be reinforced through patterns of intense negative attention, the NHA “guides parents into an intentionally and energetically aligned way of uplifting the child for the good choices made[…].”
The NHA is made up of “Three Stands” – tenets guiding parent training. Stand One relates to suppressing the compulsion to engage in negative interactions surrounding inattentive and hyperactive/impulsive behaviors with one’s child, Stand Two has to do with celebrating moments of success and behaviors consistent with expectations, and Stand Three emphasizes clarity in rules and consequences.
Nuño and colleagues’ study here described the first randomized controlled trial designed to evaluate the NHA’s impact on parent-reported child behaviors. Their sample of parent participants comprised predominately White (85%) mothers (96%) with children (primarily sons; 73%) aged six to eight with ADHD diagnoses or suspected ADHD.
Intervention group participants (n = 52) were exposed to the NHA training (including synchronous and asynchronous activities) weekly for six weeks total, while control group participants (n = 52) received delayed exposure to the NHA (post-intervention). Both groups completed simultaneous pre- and post-measures associated with child ADHD-type behaviors, parenting stress, and self-perceived parenting competency. Study procedures, including training, were exclusively conducted online.
“Inattention, hyperactivity, and impulsivity are the primary reasons parents and educators refer children for evaluations and the resultant ADHD diagnosis. Our study found significant improvements in ADHD behaviors as reported by parents. Other parent trainings and behavioral interventions have also shown success in improving inattention and/or hyperactivity/impulsivity.”
In addition to reductions in their child’s ADHD-type behaviors, researchers identified parent-reported reductions in learning problems and increases in executive functioning abilities post-intervention among those who had received the NHA trainings. Improvements were also identified in self-reported parental stress, but not in relation to self-perceived parenting competency.
The scope and narrow demographic profile of participants limit the generalizability of Nuño and team’s findings. However, this study supports the growing body of literature presenting benefits associated with behavioral strategies to stimulate the reduction of ADHD-type behaviors among children. The online training delivery described by the authors represents an additional strength.
“In light of the COVID-19 pandemic, parents and practitioners may be looking for ways to learn new approaches while keeping their families safe and healthy. The NHA showed improvement by training parents, rather than a direct child-focused treatment approach, and thus could be diffused throughout the family, potentially yielding benefits for other children within the household.”
Nuno, VL., Wertheim, B., Murphy, B., Glasser, H., Wahl, R., Roe, D. (2020). The Online Nurtured Heart Approach to Parenting: A Randomized Study to Improve ADHD Behaviors in Children Ages 6–8. Ethical Human Psychology and Psychiatry. 22 (1).