Four-year-old Owen struggled to sit still or stay on task. He was impulsive and loud, unable to regulate his noise level. While he spent hours playing with blocks or Legos, when bored or uninterested in a task he was disruptive and inattentive.
Owen’s parents, Barbara and Jeffery Barthold, signed on to participate in a pilot randomized controlled trial led by Lehigh researchers to study whether a 10-week training session for parents of young children at-risk for attention deficit hyperactivity disorder (ADHD) would impact children’s behavior—and how an online version of the training compared to a face-to-face format. The Bartholds participated in the in-person program.
Lehigh researchers George DuPaul, professor of school psychology, and Lee Kern, professor of special education, found that brief online or in-person behavioral therapy for parents was equally effective in improving children’s behavior and parental knowledge. The discovery is a potential game changer for parents strapped for time and resources to help children whose inattention, distractibility and impulsiveness affects school and home.
Kern and DuPaul reported their findings in a recent paper in The Journal of Clinical Child & Adolescent Psychology, “Face-to-Face vs. Online Behavioral Parent Training for Young Children At-Risk for ADHD: Treatment Engagement and Outcomes.” The research is the first to look at online ADHD behavior therapies in this age group (3-5 years old). It was conducted with a $1.2 million grant from the Institute of Education Sciences, the research arm of the U.S. Department of Education.
“Parents learned effective ways to anticipate and prevent child behavior problems, teach their children better ways to communicate their needs, and how to best reinforce their children’s positive behaviors with about 15 hours of parent education that can be delivered equally successfully in a typical face-to-face format or online,” DuPaul said. “The fact that parents can learn these strategies on their own schedule via an online platform has the potential to significantly improve current practice and present savings in terms of time and cost to families for whom access is an issue.”
For the study, researchers created a program of parent education and support that was shorter in duration than most similar trainings. They recruited 47 families in the Lehigh Valley region of Pennsylvania who had 3- to 5-year-old children who met diagnostic criteria for ADHD. Families were randomly assigned to one of three groups (face-to-face parent education, online parent education or a wait-list control group), with parents taking part in 10 weekly education sessions.
“We collected parent questionnaires, tested parent knowledge and observed parent-child interactions in family homes before and after parent education was delivered to evaluate whether our program made a difference relative to families who did not receive parent education,” DuPaul said.
In addition to finding online training was similarly effective to face-to-face training, researchers found parents participating in the streamlined 10-week format were more likely to be engaged and to complete training than those participating in longer formats. Both in-person and online training formats had high attendance and significantly improved parent knowledge of interventions and adherence to treatment protocols.
In addition, children in the study were better able to regulate their behavior, demonstrating reduced restlessness and impulsivity and improved self-control, affect and mood compared to the control group.
“When we started introducing the things we learned, [Owen] was more self-regulated and responded very well to a routine/schedule,” Barbara Barthold said of her son, now 8. “You could tell he was proud of himself for accomplishing tasks and not getting frustrated.” In addition, understanding her son’s triggers gave her and her husband the ability help him succeed, she said. “I also feel we gained more trust and respect between one another due to having routines, clear expectations and reward systems,” she said.
Though behavioral parent training is known to have positive results for children with ADHD, fewer parents and mental health and medical practitioners know about it than medication prescribed for ADHD, which can come with side effects and is not recommended as a first-line treatment for preschool-age children, DuPaul said.
In fact, while the American Academy of Pediatrics recommends behavior therapy support as the first line of treatment for preschool-age children with ADHD, limited availability of clinicians, cost and challenges in transportation and child care—as well as reliance on pharmacological drugs—mean few families access such therapy for themselves and their children. A 2016 report from the Centers for Disease Control found that about 75 percent of young children with ADHD received medicine as treatment and only about 50 percent of young children with ADHD with Medicaid and 40 percent with employer-sponsored insurance got psychological services, which may include behavior therapy. ADHD occurs in 2 to 15 percent of young children, with 11 percent of children in the U.S. receiving an ADHD diagnosis at some point in their lives.
Thus the study provides options both relative to medication and among behavioral therapy in terms of the effectiveness of both in-person and electronically delivered formats.
“I hope these findings add to the existing evidence that behavioral parent training is an effective approach for young kids with ADHD even when applied over a relatively short time, and show that both in-person and online formats can be effective in parent and child behavior change,” said DuPaul, who hopes the research also spurs more development of alternative ways of delivering interventions to parents.
“The implications are substantial given barriers that many families experience with face-to-face behavioral parent training,” the study states.
In addition to parents, the findings will be useful for others who interact with young children at risk for ADHD, from mental health practitioners and pediatricians to preschool teachers and early childhood education professionals, DuPaul said.
Hearing that other families experienced similar struggles and the opportunity to work closely with advocates for additional support was a valuable asset, Barbara Barthold added. “Simple changes in our lifestyle, parenting skills and family routines made a world of difference,” she said. “The program also gave families the opportunity to share their stories, gain more knowledge about ADHD and expand your little book of tricks to help your children succeed.”