Trial Supports Parent Training for Children with ADHD-Type Behaviors

A small randomized trial reduced child ADHD traits through the promotion of parent training using the Nurtured Heart Approach.

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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.”
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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.”

 

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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).

12 COMMENTS

  1. “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.”

    Please stop misinforming the public by calling it “side effects”. They are EFFECTS.
    “may result in discontinuation”? Who decides?
    I think “not sufficiently monitored” means that people basically either deny that the drugs are bothering Johnny, or they suggest that Johnny will have no future if he does not take his “medication”…which is the same as force.

    I think it is high time to support parents with no drugging of their kids. I’m hoping that the parents chosen for this study were from diverse backgrounds. I wonder what the “instructions” look like.
    We already know that stuttering can go away, in almost magical ways. And usually nothing at all to do with the speech therapy but rather the insight of the parents.

    I think we would have to be very careful about how much we want Johnny to be like others. OOOPS, Johnny is hyperactive again? Will it lead to Johnny not knowing how to ever let loose?

    Can Johnny be “hyperactive” even in “inappropriate” moments?

    • And it is worth mentioning again that 50 years of research have yet to produce any evidence that “medicated” “ADHD” youth have any better long-term outcomes than those who don’t. So why are we exposing young children to the risks of Schedule 2 narcotics when there is no evidence they help for more than a few months at best?

      • And 50 years of research have not shown “what” “it” is. So why drug “it”? That is bad “medicine”. Makes no dif if they turn into perfect angels. There have been no real attempts to make society try and adapt to behavior. No different education systems, no in house help for parenting. No adequate incomes. I’m not talking about obviously affected kids that perhaps might need proper supports forever. Those are indeed a small minority.
        It is not the kid’s fault if society created this very narrow path, but it becomes his problem. WE are all for saving lives, prolonging lives, but we really have no clue of how to ensure quality.
        I’m not imagining some kind of utopia, without suffering. But those who opted for “care jobs” should not participate in harm. I mean how can we talk about child neglect or abuse from ignorant parents and then remove and drug these kids?
        Ridiculous.

        • I agree 100%. But for some reason, this kind of argument flies over most people’s heads. Whereas pointing out that there is no evidence of long-term benefits almost always has some “bite.” Some people get upset about it and try to tell me I’m wrong, others are shocked, but a small few are induced to explore the question further. I’m afraid the idea that “ADHD” exists is too firmly planted in the minds of at least US society that pointing out its spurious nature seems to induce too much “cognitive dissonance” for most people to handle!

          • Exactly Steve.
            Thank god for all the people that encourage thought.
            Labels end conversation, which is rather obvious in many areas.. AND it prevents understanding and knowledge about all the many ways we could try to enrich people and environments.
            People were sold “diagnosis” and “treatments” almost in unison. Unheard of in science 🙂

  2. I read a story about a “hyperactive” boy. He was always tapping his hands and a pencil on his desk. He was severely reprimanded by a teacher for this. He did everything in his power to not tap his hands, including sitting on them, but he couldn’t help it.

    One day, another teacher approached him about it. He was afraid he would get in trouble again. Instead, this teacher asked him if he had ever considered playing the drums. He went on to learn how to play drums and ended up playing drums in a rock band.

    This idea that all children (or adults) should be nearly or totally identical in behavior is ludicrous. Even if doctors don’t stoop to the level of putting children on drugs, saying that any childhood behavior that deviates from some arbitrary norm is a problem fails to see the unique value in every child, and may prevent someone from becoming a rock star drummer.

  3. ” 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. ”

    More realistically, they go on to develop the common sense negative effects of amphetamines and become irritable, hostile, volatile, restless, obsessive, etc. and go on to receive new diagnoses such as “bipolar disorder” or “oppositional defiance disorder” or “mood dysregulation disorder” and are ordered to take neuroleptics. This is unless things have changed since I last knew what was happening in the trenches of child psychiatry. Unfortunately, it is medical, and involving children, so privacy curtains are erected as shields to keep society from “violating” the “privacy rights” of children and families.

    With what is known about psychiatry and psychiatric drugs, absolute transparency should be mandatory.

    • Of course they go on to receive lots of other diagnosis.
      Being people is now a disorder. I once drove home after
      a visit with a therapist, and a lightbulb went off.
      That I was in a sea of crazy, because I could no longer tell
      the difference between me, my neighbor, my GP, my therapist,
      the grocer. There were some differences like the one where
      people pretty much think they are normal.

      • “Being people is now a disorder.” Lol, except I’m pretty certain that’s what the psychiatrists and psychologists believe. I’ve read much of their DSM, it’s absurd.

        I agree with others here, all children are forced to “take your medicine.” And we need the forced and coerced (including with lies, like the “chemical imbalance theory”) neurotoxic poisoning of children (and adults) to end.

  4. When I was at school in the1970s in Ireland the French teacher (in her twenties) encouraged a very boisterous class. There was one particular boy who was extremely boisterous and I wouldn’t repeat (even now) some of the jokes he made in the class (and got away with).

    I bumped into him again years ago, in a bar in Ireland. He was drinking beer and he was a lot bigger. He was very friendly and he told me he was living in New York and working in the Bronx as a teacher.

  5. Instead of the word “training”, perhaps “collaboration and support” sounds less like a
    doggy lesson. Even the child can help with the collaboration. After all, as we raise kids,
    they raise us.
    Definitely no one is the subject. We learn SO much ourselves everytime
    we try to train or educate even.

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