Parent training (PT) and parent counseling and support (PC&S) techniques were compared in the management of a community sample of preschool 3-year-old children with attention-deficit/hyperactivity disorder (ADHD) followed in the Department of Psychology, University of Southampton, UK. Of 78 children with a preschool equivalent of ADHD, 30 were randomly assigned to the PT group, 28 to the PC&S group, and 20 to a “waiting-list” control (WLC) untreated group. The core symptoms of preschool ADHD and conduct/oppositional disorders were assessed and scored in a structured interview - PACS (Parental Account of Childhood Symptoms) [1]. A group of non-ADHD controls were selected at random from those whose PACS scores fell below the cutoffs for inclusion in the study. The mean PACS scores for ADHD children and non-ADHD controls were 20.94 and 13.25, respectively (P=.0001). A PACS score lower than 15.65 was the criterion for “recovery” after treatment intervention. An “observation” measure during 10-minutes of solo-child play with a multipurpose toy (“Fun-Park”) was also employed. PT involved advice and coaching of mothers on behavioral strategies to modify behavior and establish positive family relationships (eg: importance of praise, clear messages, routine, boundaries, and limit-setting; use of a behavioral diary; avoidance of confrontation and threats; concepts of time out and quiet time). PC&S was a nondirective support and counseling session without training in specific behavioral strategies. Maternal well-being and parental sense of competence were assessed by validated questionnaires. All measures were taken before (Tl) and on completion of intervention at eight 1-hour weekly visits to the client’s home by one of two trained health visitor therapists (T2). Measures were repeated during week 23 (T3) at follow-up. WLC children received no treatment for the 23 weeks, and no child had contact with therapists between T2 and T3. None received psychostimulant medication at any time.

Children with ADHD differed significantly from non-ADHD controls on all measures. In children with ADHD, 53% of the PT group showed clinical improvement, compared to 38% of PC&S, and 25% of WLC groups. Only PT produced significant levels of improvement (p=.048). Analysed separately, both interview and direct observation measures showed significant PT benefits (p<.001 and p<.05, respectively). PT also benefited conduct problems (p=.029). Scores for PC&S did not differ from those in WLC groups (p=.6). Maternal adjustment measures also showed significant improvements with PT relative to PC&S and WLC groups. [2]

COMMENT. Maternal parent training and coaching on child-management techniques can be a valuable intervention for preschool children with ADHD whose age is a limiting factor for use of psychostimulant medication. Methylphenidate is not usually recommended nor approved for treatment of children less than 5 years of age, except in carefully monitored experimental studies. Controlled studies of the benefits and adverse effects of stimulant medications in this age group are incomplete.

Parent training techniques may provide a welcome alternative to drugs, especially in preschool children and for professionals and parents who have ethical objections to the “medicalization” of behavior and learning [3]. For parent training to be effective, the coaching must be specific and constructive regarding behavioral management techniques. A nondirect method of parent counseling and support, without training in behavioral strategies, is largely ineffective. The completion of a weekly behavior diary by the parent is an essential adjunct to regular reviews of results of intervention and identification of problems.

In the recent NIMH Collaborative Multisite Multimodal Treatment Study (MTS) of grade school children with ADHD, intensive psychosocial intervention alone was much less effective than psychostimulant medication and no more effective than routine community-based care. In combination with medication, psychosocial intervention was only slightly additive in benefit (see Ped Neur Briefs Jan 2000;14:3-4) [4]. Parent training techniques are time consuming, requiring frequent follow-up and reinforcement. The practical disadvantages of PT compared to medical treatment would need to be addressed, for this form of intervention to be generally successful. For children under 5 years of age, when treatment with stimulant medication is not appropriate, a trial of PT is especially indicated.

In the UK where the above study was conducted, the recognition and treatment of ADHD with medication is not as readily accepted as in the US [5]. Many UK parents will opt for no therapy or for behavioral training, despite the obvious superior benefits of methylphenidate demonstrated in the MTS study.