Effectiveness of the Prevention Program for Externalizing Problem Behavior (PEP) in Preschoolers with Severe and No or Mild ADHD Symptoms
Abstract
Abstract. Zusammenfassung: Fragestellung: Das Präventionsprogramm für Expansives Problemverhalten (PEP), entwickelt für Eltern (EL) und ErzieherInnen (ER) von Vorschulkindern, zeigte in beiden Modulen (PEP-EL und PEP-ER) in der Routineversorgung positive Effekte. Das Ziel dieser Sekundäranalyse war die Untersuchung der Effekte beider Module bezogen auf Vorschulkinder mit hoch ausgeprägter ADHS-Symptomatik im Vergleich zu Kindern mit keiner oder wenig ausgeprägter ADHS-Symptomatik. Methodik: In einem Eigenkontrollgruppendesign werden die Veränderungen der Symptomatik und des Problemverhaltens der Kinder in spezifischen Situationen zu Hause und in der Schule in einer Wartephase mit den Veränderungen in einer Interventionsphase verglichen (jeweils 3 Monate). Ergebnisse: Durch das Elterntraining reduzieren sich für Kinder mit hoch ausgeprägter ADHS-Symptomatik die spezifischen Problemsituationen zu Hause (HSQ-D) und durch das ErzieherInnentraining zeigen sich signifikante Effekte für oppositionell-aggressives Verhalten und im Gesamtscore des Fragebogen für ErzieherInnen von Klein- und Vorschulkindern (C-TRF 1½-5). Kinder mit keiner oder weniger ausgeprägter ADHS-Symptomatik zeigen Veränderungen im HSQ-D, im oppositionell-aggressiven Verhalten und im Gesamtwert des Elternfragebogen für Klein- und Vorschulkinder (CBCL 1½-5), während sich für das ErzieherInnentraining in allen Zielvariablen signifikante Effekte zeigen. Schussfolgerungen: Die Befunde, dass sich Effekte auf unterschiedlichen Dimensionen von Problemverhalten zeigen, legen nahe, dass die Kombination beider Trainingsmodule eine potentielle präventive Strategie für Vorschulkinder mit ADHS darstellt.
Zusammenfassung. Abstract: Objective: The prevention program for externalizing problem behavior (PEP), developed for parents and teachers of preschool children, showed the effectiveness of both modules (PEP-PA and PEP-TE) under routine care conditions in two separate studies. This secondary analysis examined the effects of both modules on preschool children with severe attention deficit/hyperactivity disorder (ADHD) symptoms compared with children with no or mild ADHD symptoms. Methods: In the within-subject control group, design changes in child symptoms and problem behavior in specific situations at home and school during the waiting period were compared with changes during the intervention period (3 months each). Results: For children with severe ADHD, parent training reduced specific problem situations at home (HSQ-D[please provide full name here]), and teacher training showed significant effects on oppositional-aggressive behavior as well as the total problem score of the Caregiver Teacher Report Form (C-TRF). Children with no or mild ADHD benefited from parent training on the HSQ-D score, oppositional-aggressive behavior and the total problem score of the Child Behavior Checklist (CBCL), while teacher training had significant effects on all outcomes assessed. Conclusion: Our results suggest that parent training reduces mainly specific behavior problems at home in children with severe ADHD symptoms and with no/mild ADHD symptoms, while teacher training reduces ADHD symptoms and ODD[please provide full name here] symptoms including specific behavior problems in the kindergarten in children with no/mild ADHD symptoms. However, in children with severe ADHD only overall problems and ODD symptoms were significantly reduced by teacher training.
Introduction
Attention deficit/hyperactivity disorder (ADHD) is one of the most common and extensively studied mental disorders of childhood and adolescence. It is characterized by increased motor activity, impulsivity, and inattention (Döpfner, Frölich, & Lehmkuhl, 2013a). The diagnostic criteria of ICD-10 and DSM-IV/5 have been well studied for preschool children (Breuer & Döpfner, 2008). However, only a few international studies have been performed on the prevalence of ADHD in preschool children (Connor, 2002). The estimated prevalence of elevated ADHD symptoms in German preschoolers is 11.3 % based on the parents’ assessment and 6.6 % based on teachers’ ratings when assessed during regular preventive medical examinations (U8/U9 check-ups) (Breuer & Döpfner, 2006).
Meta-analyses have shown the effectiveness of parent trainings and school-based interventions in children with ADHD (Fabiano et al., 2009). A meta-analysis of randomized controlled trials found weak but statistically significant effects when analyzing the most proximal assessments (i. e., ratings made by raters, often unblinded, who were closest to the therapeutic setting) (Sonuga-Barke et al., 2013). In another meta-analysis, behavioral trainings for parents of preschool children with disruptive behavior including ADHD had a mean effect size of d = 0.68, whereas combined parent and preschool or kindergarten training yielded inconsistent results (Charach et al., 2013). In German-speaking countries, day-patient treatment and guided self-help for parents of children with externalizing disorders have been shown to be effective treatments (Döpfner, Berner, & Schmidt, 1989; Kierfeld, Ise, Hanisch, Görtz-Dorten, & Döpfner, 2013). Barkley et al. (2000) reported greater effects on child behavioral symptoms with kindergarten teacher-based interventions than with parent management training, which was associated with a high rate of parental dropout. The results of Reid and colleagues (Reid, Webster-Stratton, & Hammond, 2007) suggest that a combination of parent and teacher training on the prevention of externalizing problem behavior in preschool or kindergarten children may be advantageous. In their study, mothers reported significantly less externalizing behavior in children where both a classroom intervention and parent training was applied, compared to classroom intervention alone. The teachers’ reports did not support this finding, but showed more supportive and less critical behavior of the mothers if parent training was added (Reid et al., 2007).
The indicated prevention program for externalizing problem behavior (PEP; Plück, Wieczorrek, Wolff Metternich, & Döpfner, 2006) was developed from the German “Therapieprogramm für Kinder mit hyperkinetischem und oppositionellem Problemverhalten – THOP” (Döpfner, Schürmann, & Frölich, 2013b) and the self-help book “Wackelpeter und Trotzkopf” (Döpfner, Schürmann, & Lehmkuhl, 2011), which proved to be effective in several trials (e. g., Döpfner et al., 2004; Kierfeld et al., 2006, 2013; Ise, Kierfeld & Döpfner, 2015). Two parallel trainings were developed aimed at parents (PEP-PA) and teachers (PEP-TE) of preschool children (aged 3 to 6 years) with externalizing behavior problems. The goals of the training are to modify the parent-child or teacher-child interaction, and to improve the parent and teacher stress management as well as their management skills in dealing with difficult situations and problem behavior in the children. During up to 12 group sessions, basic strategies for managing specific child behaviors in defined problem situations are developed with the participants.
Efficacy of the combined use of parent and teacher training modules was tested in a randomized controlled trial in a sample of preschool children with externalizing behavior problems (Hanisch, Freund-Braier et al., 2010a; Hanisch, Hautmann, Eichelberger, Plück, & Döpfner, 2010b). The participating families were recruited using a screening questionnaire administered to a representative sample (Plück et al., 2008, 2010). Short-term effects in favor of the intervention group (compared with a control group) were detected for parenting behavior and child externalizing behavior problems (Hanisch et al., 2006; Hanisch, Freund-Braier et al., 2010a). Although the improvement in these two outcome measures stabilized over 2 years of follow-up, there were no differences between the control group and intervention group at 2-year follow-up. However, the child externalizing problem behavior had decreased earlier in the intervention group than in the control group (Hanisch, Hautmann et al., 2010b). In addition, reduction of dysfunctional parenting behavior in conflict situations was found to be an important mediator of the reduction in child externalizing problem behaviors (Hanisch, Hautmann, Plück, Eichelberger, & Döpfner, 2014).
Both training components (PEP-PA and PEP-TE) were also investigated in two separate effectiveness studies using a within-subject control-group design under routine care conditions (Hautmann, Hanisch, Mayer, Plück, & Döpfner, 2008; Plueck et al., 2015). Outcome parameters were assessed at five time points: 3 months (pre1) and immediately before (pre2) the intervention, at the end of the intervention (post), and at 3 months (fu1) and 12 months after the end of the intervention (fu2). In the effectiveness analyses for PEP-PA, up to 270 families were included with children aged 3 to 10 years with externalizing behavior problems from different care facilities (Hautmann et al., 2008). Short-term effectiveness was found for the child behavior problems and the parenting behavior (0.24 ≤ d ≤ 0.38), and long-term stability could be shown for both outcome parameters (Hautmann, Hoijtink et al., 2009). The reduction in child behavior problems was also clinically significant: At the beginning of the study, 32.6 % to 60.7 % of children were classified as clinical cases on three different outcome parameters; and at 3 months after the intervention, 24.8 % to 60.4 % of the children were classified as normal (Hautmann, Stein et al., 2009). Differential effects of PEP-PA were examined in two additional analyses (Hautmann et al., 2010, 2011). Both studies indicated that the most severely impaired children benefited the most from the parent training. A comparison of the ratings made by parents who participated in the training with those of the nonparticipating partners gave no evidence of a distorting effect; there was no overestimation of the effects due to effort justification of the parents participating in the training (Hautmann et al., 2012).
The effectiveness study of PEP-TE under routine care conditions included 144 teachers in public preschools (Plueck et al., 2015). The teachers selected a target child with externalizing behavior and applied the strategies developed during the group teacher training sessions. The results showed the effectiveness of the intervention, with short-term effects in both child behavior and teacher behavior and burden (0.44 ≤ d ≤ 0.83); the treatment effects were stable at 3- and 12-month follow-up in the subsample that remained at preschool (Plueck et al., 2015).
With one randomized controlled efficacy study and two effectiveness studies, PEP is the best evaluated indicated prevention programs for children with externalizing problem behavior in Germany. These studies were conducted in samples of children with externalizing problem behaviors as rated by their parents or teachers, and included children with mild to severe symptoms of ADHD. Recent meta-analyses questioned the effects of parent trainings in children with ADHD, especially the effects of such interventions on ADHD symptoms (Sonuga-Barke et al., 2013). Therefore, the aim of this secondary analysis of the two effectiveness studies is to assess the effects of parent and teacher trainings on preschool children with severe symptoms of ADHD and of children with no or mild symptoms of ADHD.
Methods
Study Design
For this analysis, we used data from the two studies of effectiveness of the PEP-PA and PEP-TE; these studies had a within-subject control-group design as described above and as reported previously (Hautmann et al., 2008, Plueck et al., 2015). Both studies were approved by the Ethics Committee of the University Hospital Cologne. In the PEP-PA-study, families were informed by the trainer about the study design, and informed consent was obtained prior to study participation. In particular, families were informed about the 3-month pretreatment assessment period. In the PEP-TE-study written consent was not obtained from the parents of children assessed in this study because (a) the children’s behavior was being observed by teachers in the normal school setting, and (b) this allowed the anonymity of the child and their family to be maintained throughout the study even from the project staff performing the data analysis. The ethics committee agreed that teachers can participate in different kinds of vocational trainings and talk about problems with children anonymously.
Assessments
For both study samples, the mothers (PA) or teachers (TE) provided ratings of ADHD symptoms and comorbid behavioral and emotional problems. The assessment scales used are described below and were tested for their internal consistency using Cronbach’s U+03B1.
The Symptom Checklist for Attention Deficit and Hyperactivity Disorder (FBB-ADHD, Döpfner, Görtz-Dorten, & Lehmkuhl, 2008b) assesses the diagnostic criteria of DSM-IV and ICD-10 for ADHD and is part of the diagnostic system for mental disorders (DISYPS-II; Döpfner et al., 2008b). Analyses were carried out using the subscales Inattention (U+03B1(PA/ TE) = .88/.87) and Hyperactivity-Impulsivity (U+03B1(PA/ TE) = .91/.88). The Symptom Checklist for Disruptive Behavior Disorder (FBB-SSV) comes from the same system. Because of the age group and preventive nature of the study, only the scale Oppositional-Aggressive behavior was considered (U+03B1(PA/ TE) = .91/.87).
The German translation of the Child Behavior Checklist (CBCL/ 4–18; Arbeitsgruppe Deutsche Child Behavior Checklist, 1998; Döpfner, Plück, & Kinnen für die Arbeitsgruppe Deutsche Child Behavior Checklist, 2014) was used; it encompasses a wide range of mental and behavioral symptoms in children and adolescents. For this analysis, we used the total problem score, which had an internal consistency of U+03B1PA = .93 in this sample.
The Caregiver Teacher Report Form (C-TRF) was originally developed by Achenbach and Rescorla (2000) and translated from the Arbeitsgruppe Deutsche Child Behavior Checklist (2002). It covers behavioral symptoms, emotional problems, and somatic complaints of young and preschool children. The current analyses are based on the total problem score (U+03B1TE = .91).
We also used a German translation (Döpfner, Schürmann, & Frölich, 2013b) of the Home Situation Questionnaire (HSQ-D; originally developed by Barkley, 1987). It consists of 16 items and contains a list of different problem situations at home. The internal consistency of the total score is U+03B1PA = .80. The Kindergarten Situation Questionnaire (KSF) was developed for this study based on the HSQ. It comprises 15 problem situations in the kindergarten and is assessed by teachers. The internal consistency of the total score is U+03B1TE = .78.
The main outcome variables for this analysis were the ADHD dimensions (Inattention, Hyperactivity/Impulsivity) and oppositional-aggressive behavior. The total scores of the CBCL/4–18 and the C-TRF were used as indicators of a wide range of emotional and behavioral problems. The total scores of HSQ-D or KSF assessed problem behavior in specific problem situations at home and in the kindergarten, respectively.
Samples
The samples analyzed here originate from the two effectiveness studies under routine care conditions of the PEP-PA parent training (n = 270) and PEP-TE teacher training (n = 144). In order to allow for direct comparison of the results from the two studies, we limited the sample for the parent training to preschool children (≤ 6 years at baseline) for the main analysis. PEP-PA data were available for 121 children and PEP-TE data for 142 children. As in the published main analyses of the effectiveness studies, the symptom courses during the waiting phase and intervention phase were compared to assess the effects of the trainings. The current approach contrasts the effects of PEP in children with no or mild ADHD symptoms with those who have severe ADHD symptoms, as rated by their mother or teacher, respectively within the questionnaires. Children were classified as “severe” if two of three criteria were fulfilled: (1) inattention (at least six of nine symptoms rated “true” or “very true”), (2) hyperactivity/impulsivity (at least six of ten symptoms rated “true” or “very true”) or (3) the burden of the child caused by these symptoms (at least two of three items rated “true” or “very true”). This approach is similar to the criteria mandated by DSM-IV (American Psychiatric Association, 2000), but can only be understood as an approximation to a clinical diagnosis.
Table 1 presents a descriptive summary of the two samples analyzed. In the PEP-PA sample, the mothers of children with severe ADHD symptoms had a lower level of professional education than the mothers of children with no/mild ADHD symptoms (p = .04). In PEP-TE sample, there were no significant differences between the two samples based on ADHD symptoms. In both samples with no/mild ADHD symptoms, the mean scores for the inattention and hyperactivity-impulsivity scales correspond with a stanine value of at least 6 (61st–77th percentile) on parent ratings and of at least 7 (78th–89th percentile) on teacher ratings.
Statistical analyses
Data were analyzed using multilevel modeling in the different groups. This strategy was chosen because of its capacity to handle missing data. While incomplete cases are excluded from repeated measures analysis of variance, they are used in multilevel analyses to calculate growth rates (Maas & Snijders, 2003). In general, our results were considered significant if the alpha error was equal to or below U+03B1 = .01, while values of U+03B1 ≤ .05 were considered as a trend. For each group the growth rates for the waiting period (pre1 to pre2) were compared directly with those for intervention period (pre2 to post). Therefore, person (level 1) over time (level 2) was analyzed. Moreover, the model tested was identified by random intercept (accepting differences in the individual level of the outcome variables) with a fixed slope for each interval (assuming a common tendency in the growth rate within the sample). The size of effects (net effect) was calculated as slope difference between the two intervals using the standard deviation of pre1 (Feingold, 2009). The effects were classified as “small” (0.20 ≤ d < 0.50), “medium” (0.50 ≤ d < 0.80), or “large” (0.80 ≥ d) (Cohen, 1988). Power calculations indicated that medium effects could be detected with the sample sizes described in Table 2.
Results
Table 2 summarizes the means (and standard deviations) of the outcome variables at the three assessment points (pre1, pre2 and post), together with the p-values for the comparison of the course during the treatment phase (pre2 to post) versus the course during the waiting phase (pre1 to pre2), and the net effect sizes. In illustration of the time courses, Figure 1 shows the course for selected outcome parameters for parent and teacher training – oppositional behavior (FBB-SSV) with PEP-TE and behavior problems in specific family situations (HSQ-D) with PEP-PA, in children with no/mild and severe ADHD symptoms.
For PEP-PA in the group with severe ADHD symptoms, only the reduction in the HSQ-D during the intervention phase was significantly greater than that seen in the waiting phase (Table 2). In terms of effect sizes, the difference was considered large. There was a medium effect size for the inattention ADHD subscale, but the comparison between the intervention and waiting phases was not statistically significant. In the sample with no/mild ADHD symptoms, the parent training was also significantly effective on the HSQ-D (d = –0.55; p = .004)
For PEP-TE, the group with severe ADHD symptoms showed a significantly larger reduction on the oppositionalbehavior scale score (medium effect) and on the total problem score (large effect) during the intervention phase compared with that seen during the waiting phase. In the group with no/mild ADHD symptoms, significant effects were observed for all outcome variables (Table 2).
For the PEP-PA, comparison of the percentage of children meeting DSM-IV symptom criteria for ADHD at pre1 (35 %) and pre2 (23 %) showed a reduction of 12 % during the waiting phase. There was only a 5 % reduction during the following intervention period to Post (18 %), which was less than half that seen during the waiting phase. For PEP-TE at the three assessment points, 44 %, 35 % and 20 % of children fulfilled the symptom criteria of ADHD, showing a larger reduction during the intervention phase.
Discussion
The overall effectiveness of the PEP parent and teacher training in samples of children with elevated externalizing problem behavior has been demonstrated in a randomized control-group study and in two effectiveness studies under routine care conditions (Hanisch, Freund-Braier et al., 2010a; Hanisch, Hautmann et al., 2010b; Hautmann, Hoijtink et al., 2009; Hautmann, Stein et al., 2009; 2011; Plueck et al., 2015). The present secondary analysis investigated the effectiveness of parent and teacher training in groups of preschool children with severe ADHD symptoms and in groups of preschool children with no/mild ADHD. As expected, compared to the normal sample (Döpfner et al., 2008b), the mean scores for the different outcome measures were higher not only in the group with severe ADHD, but also in the sample with no/mild ADHD symptoms. Therefore, a decrease of ADHD-symptoms could also be expected for the latter group.
As seen in Table 1, the distribution of ADHD diagnoses in both study samples (PEP-PA and PEP-TE) shows that only a small proportion of children had the predominantly inattentive type, which corresponds with both clinical experience and empirical studies (Breuer & Döpfner, 2006; Lahey et al., 1998). As expected, higher symptom scores were found on all outcome parameters in the group of children with severe ADHD, as seen in Table 2. For children with no/mild ADHD symptoms (the traditional target group for prevention), the intervention led to significant effects on most of the outcome parameters in both samples; this can only be partly explained by the larger sample size of the group of children with no/mild ADHD, since the different outcome measures also had larger effect sizes compared with the severe ADHD group. However, no effects could be detected in PEP-PA on rating scales assessing ADHD symptoms according to ICD-10/DSM-IV. In both groups of children with severe ADHD symptoms and no/mild symptoms, the strongest effects were seen in the reduction of problem behavior in specific problem situations in the family as assessed by the HSQ-D. This effect was especially strong in the group with severe ADHD symptoms and may represent a specific training effect, because parent training focuses on the reduction of child externalizing behavior problems in specific problem situations. The HSQ-D reflects both ADHD symptoms and symptoms of oppositional behavior in specific problem situations.
In the PEP-TE sample, the group of children with no/mild ADHD symptoms improved on all outcome parameters with effect sizes in the medium range. In the group with severe ADHD symptoms, the reductions in oppositional behavior and total problem score were statistically significant. In this group, the ADHD core symptoms decreased during both the waiting and intervention phases, and we did not observe a stronger improvement during the intervention phase compared to the waiting phase. A possible reason for these findings may be that the teachers specifically used their newly acquired skills to address oppositional behavior problems in the children and, therefore, stronger reductions were found in this area.
In contrast, Hautmann et al. (2008) found significant effects for ADHD symptoms and oppositional behavior in their larger total sample, which included school-age children. However, similar to the current analysis, the effect sizes were also in the small range. The analyses for PEP-TE in the total group showed significant effects on ADHD symptoms and oppositional behavior during the intervention phase, with medium effect sizes (Plueck et al., 2015) over and above the developmental effects seen during the waiting phase.
Our results are consistent with recent meta-analyses of randomized controlled trials on the efficacy of behavioral interventions for children with ADHD, which also found somewhat weaker effects on the ADHD core symptoms (Sonuga-Barke et al., 2013). However, the meta-analysis of Charach et al. (2013) showed medium effects not only in the reduction of externalizing symptoms (d = 0.75) but also in the specific reduction of ADHD symptoms (d = 0.77) in controlled studies of parent training with preschool children with externalizing behavior problems.
Our results suggest that children who have already clear signs of ADHD benefit from this intervention (at least on some outcome parameters); on most parameters, the effects are as strong as or even stronger in the group with severe ADHD symptoms. This corresponds to recent findings of Azevedo and colleagues (Azevedo, Seabra-Santos, Gaspar, & Homem; 2015) in their reanalysis of an application of the Incredible Years Basic Parent Program (Webster-Stratton, 1990) on Portuguese preschoolers with high vs low hyperactive behaviors over one year.
Limitations
Because the present study is a secondary analysis of subgroups of children by ADHD symptom severity, the statistical power is limited. Also, analyses of follow-up data could not be performed because the sample sizes would have been further reduced.
The chosen outcome measures were exclusively based on questionnaire data and captured only the perspective of the parents and teachers participating in the training process. This restricts the interpretation of the results, as no independent perspective is available. Moreover, observational data are not free from subjective bias (Patterson & Forgatch, 1995). However, Hautmann and colleagues (2012) showed treatment effects of the parent training based on the ratings of parents not involved in the training. The perceived improvement can also be regarded as decisive, since it is assumed that this leads to an increase of competence and self-efficacy, which affects the educational strategies and, therefore, the child’s behavior (Crnic & Low, 2002; Rubin & Burgess, 2002). This mediating process has already been confirmed for PEP in the analyses of the efficacy study (Hanisch et al., 2014).
The study was conducted as an effectiveness study under routine care conditions. Therefore, experimental control was carried out in a within-subject analysis by contrasting the changes during the waiting phase with those during the intervention phase. The premise of these analyses is the equality of the spontaneous changes during the waiting and treatment phase. However, it can be presumed that regression effects due to the high pre1 scores, especially during the waiting phase, overestimate the spontaneous changes during the intervention phase. This may mask real effects of the intervention. Such a regression to the mean applies especially to the group with severe ADHD symptoms, as the highest pre1-scores are reported here. However, the efficacy of PEP was also shown in a study using a randomized control group design (Hanisch, Freund-Braier et al., 2010a).
Acknowledgments
The study was funded by the Deutsche Forschungsgemeinschaft Grant DO 620/2. We kindly thank Deirdre Elmhirst for carefully reading an earlier version of this article. We thank all the families and teachers who participated in training, and all the institutions and trainers who offered the training.
Conflicts of interest: Manfred Döpfner and Julia Plück are authors of the PEP. Manfred Döpfner is director of the Ausbildungsinstitut für Kinder- und Jugendlichenpsychotherapie (AKiP, Training Institute for Child and Adolescent Psychotherapy) at the University Hospital of Cologne, which offers training in PEP.
Julia Plück conducts workshops in PEP. The other authors have no potential conflicts of interest.
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