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Acknowledgements.3List of Authors/Contributors.3Executive Summary.4 1.1 The aetiology and impact of ADHD.71.2 Treatment of ADHD.81.3 The Incredible Years Intervention Series.101.4 The Incredible Years Ireland Study: An overview.15 2.1 Study design.172.2 Participant Recruitment.172.3 The intervention.182.4 Measures .19 3.1 Participant characteristics.173.2 Treatment attendance.193.3 Intervention outcomes.19 SECTION FOUR: PARENTS’ EXPERIENCES AND VIEWS: A QUALITATIVE SUB-STUDY.23 4.1 One-to-One interviews with parents.234.2 Focus group findings (Facilitators).31 5.1 Parent and child outcomes.365.2 Key issues.37 1 Proving the Power of Positive Parenting Acknowledgements
List of Authors/Contributors
The research team would like to extend their warmest thanks to all of Dr Sinéad McGilloway, Principal Investigator, Incredible Years
the parents who so generously gave of their time to take part in this re- Ireland Study, and Director, Mental Health and Social Research search and without whom this study would not have been possible. Unit, Department of Psychology, NUI Maynooth.
We acknowledge the continued commitment of all the Archways staff Dr Gráinne Ní Mháille, Research Fellow, Mental Health and Social
to this research. In particular, we would like to thank Ms Aileen Research Unit, Department of Psychology, NUI Maynooth.
O’Donoghue (CEO of Archways) and Dr Sean McDonnell (DeputyCEO and Research and Training Manager) for their support and help Yvonne Leckey, Project Co-Ordinator, Mental Health and Social
Research Unit, Department of Psychology, NUI Maynooth.
We would also like to thank all of the community-based organisations Paul Kelly, Data Manager, Mental Health and Social Research Unit,
and individuals for their help in identifying and referring prospective Department of Psychology, NUI Maynooth.
research participants to the study including, in particular, the TallaghtFamily Resource Centre and the Deansrath Family Centre, Clondalkin. Mairead Bracken, Research Assistant, Mental Health and Social
Research Unit, Department of Psychology, NUI Maynooth.
A note of gratitude is due to all of the parent group and Dina facilita-tors for their hard work in delivering the programmes and for their dili- Website: www.iyirelandstudy.ie
gent help and co-operation throughout this stage of the research. In addition, we extend our sincere thanks to Dr Tracey Bywater, YorkUniversity and Dr Michael Donnelly, Queen’s University Belfast, fortheir support and guidance in the planning of this study. We also ac-knowledge with thanks, the invaluable and continuing support and ad-vice that we have received from Dr Mark Dynarski (formerly ofMathematica) and Professor Judy Hutchings, Bangor University,Wales. Lastly, we extend our thanks to Ms Mairead Furlong and Ms LyndaHyland for their help in conducting this study. Executive Summary
Key Findings
At baseline, all index children displayed high levels of child
hyperactivity and attention deficit problems, as well as externalising,
aggressive and oppositional behaviours. More than two-thirds of This summary report presents the short-term findings from an parents were socio-economically disadvantaged. The findings exploratory Randomised Controlled Trial (RCT) undertaken to assess highlighted significant differences at the six-month follow-up between the effectiveness of (1) the Incredible Years Basic Parent Programme the PT group and the WLC group on child hyperactivity and pro-social (IYBP) and (2) a combination of the Incredible Years Small Group skills as well as parenting competency. Differences between Dina Programme (Dina) and IYBP for Irish children (aged 3–7 years) the PT+CT group and the WLC group at follow-up were largely with symptoms of Attention Deficit Hyperactivity Disorder (ADHD).
non-significant with the exception of the SDQ impact scale, on which Recent research conducted in the US, suggests that the combined IYBP parents reported significantly lower post-intervention levels of and child Dina programmes can lead to improvements in child child distress and social impairment due to conduct problems and behaviour and hyperactivity (Webster-Stratton et al., 2011).
hyperactivity post-intervention, when compared to the control group.
Furthermore, while some research has demonstrated the positive These results suggest that, whilst the IYBP was effective in tackling effects of the IYBP on the core symptoms of ADHD (Jones et al., 2007; some core ADHD symptoms, the combined treatment (PT+CT) Carlson & Ogg, 2009), little is known about the effectiveness of did not produce any added benefit for child hyperactive/inattentive the IYBP and, in particular, the Dina programme, for children with behaviour post-intervention, at least as recorded on study measures.
ADHD. The principal aim of this study was to assess the extent to Conversely, the qualitative findings suggest that the combined which the combined IYBP and IY Dina training programmes led to programme was viewed very favourably by both parents and children improvements in ADHD-type behaviours in children, when compared and had led to marked improvements in child behaviour. to IYBP alone and a waiting list control group. Design/Methods
The findings from the IYBP appear promising for this particularly This study involved 45 children with symptoms of ADHD and their vulnerable clinical sub-group of children and their parents, whilst parents who were randomly allocated to: (1) a Dina child training plus the subjective reports of parents also indicated improvements in parent training intervention group (PT+CT, n=12); (2) parent training parent and child behaviour as a result of the combined IYBP and group only (PT, n=19); or (3) a wait-list control group (WLC, n=14).
Small Group Dina treatment. However, several factors, which are Assessments of child and parent adjustment were carried out using discussed later in this report, may have contributed to less parent- parent-report measures at baseline and at six months post intervention.
reported improvement than anticipated with regard to the combined Three parents (7%) did not complete assessments at the six-month treatment, as recorded on study measures. Further research is needed follow-up. One-to-one post-intervention interviews were also to explore the effectiveness and cost-effectiveness of the combined conducted with a small number of parents (n=8) who had received the IYBP and Dina programmes for children with ADHD symptoms combined intervention, as well as a focus group with Dina programme The Intervention
An extended 20-week version of the Incredible Years BASIC
Preschool/Early School Years Parent Training programme (IYBP)
was delivered to parents of children with ADHD symptoms. This
is designed to improve social and emotional functioning, and
supplementary sessions place a greater emphasis than the usual
14-week IYBP on problem solving, praise and incentives, limit
setting, anger management, parental stress and fostering appropriate
child emotional regulation.
The small group Dina Child Training Programme (Dina) was delivered in 2-hour weekly Small Group sessions (6 children pergroup) during a period of 18 weeks and, in this instance, was offered in conjunction with the weekly parent group sessions. The programme is designed to strengthen children’s social and emotional competencies and to address areas such as understanding and communicating feelings, child problem solving, anger regulation and prosocial skills. Additional sessions include practising friendship, conversational and self-regulatory skills.
Key Findings and their Implications
The collective findings from this study demonstrate that: ❑ Significant positive outcomes were found amongst children in the parent training group in terms of reduced levels of ❑ Children of parents in the parent training group displayed significantly higher levels of prosocial behaviour post-intervention. ❑ Parents in the parent training group used significantly fewer forms of harsh discipline and improved parental instruction. ❑ There were no significant differences on study measures between the combined treatment group (IYBP and Dina programme) and the IYBP-only group six months post-intervention. However, parent interviews revealed many positive effects of thecombined treatment on child and parent behaviour. The parent training programme alone was effective in improving hyperactive/inattentive behaviour amongst children, whilst also improving parenting skills and behaviour. However, contrary to expectation, child training as an adjunct to the parent training programme did not result in benefits for either parents or children in the short-term, as recorded on study measures. This may be due to: the small sample size (which may have reduced the statistical power of the analysis); the focus only on short-term outcomes; the age range of the children in the Dina group; and variations in the nature and extent of parent-facilitator collaboration and feedback in the Dina groups. Research has indicated that, whilst medication alone has been shown to help with some symptoms of ADHD, there are persistent ethical and other considerations regarding the long-term use of such medication with young children. The findings reported here suggest that the IYBP may help to reduce hyperactivity and inattentiveness in children with ADHD or ADHD-type symptoms, whilst also tackling critical secondary issues, such as behavioural problems and parent child relationships. The National Institute of Health and Clinical Excellence (NICE) (2008) recommends parent training programmes as a first-line intervention for children with ADHD and recognises the value of such programmes in managing ADHD symptoms. Given the commitment by the Irish government to early intervention and prevention for children, there is a clear need to invest in further research on evidence-based programmes (e.g. the IY parenting programmes) for vulnerable groups of children such as those with ADHD (or ADHD-type symptoms) and children in care. Future research should explore, in particular, the impact of combined psychosocial treatments with larger sample sizes as well as the long-term outcomes of such interventions. Attention Deficit Hyperactivity Disorder (ADHD) is a chronic and Children with ADHD can also experience antisocial behaviour debilitating behavioural disorder that emerges in early childhood and delinquency, criminal behaviour, personality dysfunction, marital and is characterised by maladaptively high levels of inattention, instability, employment difficulties and substance abuse/misuse, hyperactivity and impulsivity. ADHD is a common reason for in later life, as well as (Barkley, 2002; Dalsgaard, 2002). Family referral to mental health services in childhood. For a diagnosis of distress and disruption to family interaction are also common ADHD to be given, a child’s behaviour must exhibit a pervasive (Tettenborn et al., 2008). Aside from the personal, family and societal pattern of inattention and hyperactivity, excessive restlessness, lack costs, the treatment of ADHD places a significant burden on health, of sustained effort/attention and unusually high levels of movement social and special educational services. For example, the NICE (2008) and acting without thinking and across different settings, such as report on ADHD highlights annual costs in the UK of £66m including home and school. Symptoms must be evident before the age of 7, £23m for specialist assessment for ADHD, £14m for follow-up be present for at least 6 months and lead to significant impairment care, and a further £29m on prescribed psychostimulant medication. Worryingly, it is estimated that these costs will increase substantially In recent times, there has been an increasing recognition of the into the future due to increasing diagnosis and prescribing rates (NICE, disorder and a growing number of children are presenting with 2008). Furthermore, in the US, these costs are much higher at $31.6 ADHD-type symptoms and subsequently being formally diagnosed billion (in 2000) whilst it was estimated, in 2005, that the annual cost with ADHD (National Institute for Health and Clinical Excellence of ADHD per individual was $14,576 (Pelham et al., 2007). (NICE), 2009). It is estimated that ADHD affects up to 5% of all children (Polanczyk, 2007), although boys have an increased risk of 1.2 Treatment of ADHD
developing the disorder, with male to female ratios ranging from 4:1 Considerable progress has been made in recent years, in to 9:1 (Gold, 1997). Some evidence also suggests that the condition is understanding the aetiology of ADHD (Barkley & Murphy, 2006) underdiagnosed and undertreated (Tettenborn et al., 2003). Research and neuropsychological and genetic theories are now widely accepted.
in Ireland has indicated that the most commonly reported primary ADHD is thought to arise from abnormalities in the structure diagnosis of all children in contact with mental health services, and functioning of the prefrontal cortex, which gives rise to the is hyperkinetic disorders/problems (including ADHD and other behavioural inhibition and poor executive functioning that is central attention disorders) (29% of cases; N=6,629) (Child and Adolescent to ADHD symptomatology (Barkley, 1997). Recent groundbreaking research involving researchers at the Department of Psychology, NUI Maynooth, has also shown that a disruption of the circadian 1.1 The aetiology and impact of ADHD
rhythms may be implicated (Baird et al., 2012). However, the disorder ADHD has a pervasive and significant effect on many aspects of a tends to be defined at the behavioural level and a diagnosis of ADHD child’s life, including family, school and social environments (Harpin, does not imply the presence of a neurological or medical disease 2004). Along with the core symptoms of hyperactivity, inattention (NICE, 2009). Several psychosocial risk factors have also been and impulsivity, children with ADHD often present with co-morbidi- identified, including severe socioeconomic disadvantage, disrupted ties. For example, more than 40% are also diagnosed with and discordant parent-child relationships and harsh or aversive Oppositional Defiance Disorder (ODD) and Conduct Disorder (CD), parenting behaviours, such as critical and negative comments, whilst 10% to 20% suffer from internalising symptoms and mood hostility and negative disciplining (Purdie, Hattie & Carroll, 2002; disorders; Tourettes and Autistic Spectrum Disorder symptoms have also been noted, as well as global and specific learning difficulties(NICE, 2009). In total, approximately, 65% of ADHD individuals Effective treatment and interventions for children with ADHD have at least one comorbid condition and behavioural difficulties and their families are crucial in order to improve child outcomes are particularly common. Children with ADHD frequently exhibit across home, school and social environments (Tettenborn et al., 2008), non-compliant behaviour, aggression, and mood swings, as well whilst improvements in the quality of life of both parents and as low levels of self-esteem and confidence (NICE, 2009). teachers are also viewed as essential in helping to manage the Externalising and reckless behaviours are also common. Children with behaviour of ADHD children (NICE, 2009). Typical interventions ADHD are at increased risk of academic failure and experience for ADHD include pharmacological treatment and psychosocial difficulties with literacy as well as other learning problems (Polderman interventions. However, the needs of children with ADHD and et al., 2010). In school, ADHD children display high rates of off-task their families are frequently complex and, due to the early onset behaviour and tend to be disruptive and noisy. These behaviours of ADHD and its extended course, individuals and their families increase the likelihood of social rejection (deBoo & Prins, 2007), may require intervention over many years (Goldman et al., 1998). and social adjustment and interpersonal difficulties in children withADHD are common (Nixon, 2001). Traditionally, pharmacological treatment/management has been Research on Irish children with ADHD has also shown that the most commonly reported intervention for children with ADHD both parents and children experience feelings of stigma which can and it has been estimated that approximately 85% of ADHD significantly impact on their lives (McIntyre & Hennessy, 2011), children are prescribed psychostimulants (e.g. atomoxetine, whilst 91% of parents of children with ADHD also report considerable dexamfetamine and methylphenidate) in order to treat their core stress and worry about their child’s life (NICE, 2009). symptoms and to improve overall functioning (Olfson et al., 2003). Whilst there is good evidence for the short-term efficacy of 1.2.1 Parent-training as an intervention for children with ADHD psychopharmacological treatments (MTA, 1999; NICE, 2006; Chronis et al., 2006), it has been found that psychostimulants are Group-based parent training programmes, in particular, are frequently not effective for approximately 20%-30% of all ADHD children. recommended as the first course of action for families, and these Furthermore, there have been a number of recent questions treatments may be supplemented with additional child-focused and concerns regarding the longer term effectiveness of programmes. Parenting behaviours and the ability of parents to psychopharmacological treatment of ADHD in childhood (NICE, manage and cope with the symptoms of ADHD, play a crucial role 2009; Webster-Stratton et al., 2011). These are outlined below. in determining the extent to which ADHD is problematic (NICE,2009). Parent training programmes aim to improve parent-child There have been ethical concerns regarding the long-term relationships and to provide parents with appropriate skills to use of psychotropic medication, particularly with young manage aversive behaviour and reinforce positive behaviour (Barlow children (Purdie et al., 2002) and the potentially adverse side- & Parsons, 1998). A growing body of research suggests that those effects include insomnia, stomach aches, irritability and, in the programmes which are based on behavioural and social learning long term, decreased physical growth and liver dysfunction may principles, are likely to result in the most positive outcomes for both the child and the parent (e.g. Purdie et al., 2002; Barkley et al.,2002; Jones et al.,2007; Webster-Stratton et al., 2011). Other concerns relate to the lack of generalisation of effects beyond treatment and the narrow benefits derived from medical However, while there is some evidence in support of the effectiveness intervention. For example, there is only limited evidence of parent training for children with ADHD, the findings from many showing long-term academic gains, or meaningful changes in reviews are mixed. For instance, some reviewers argue that parent negative peer behaviour with children on ADHD medication training helps to improve child compliance, parent-child relationships (Purdie et al., 2002; Chronis et al., 2006). and parent well-being, but does not produce significant changes in the core symptoms of ADHD. Likewise, it has been suggested that While core symptoms may be reduced, psychopharmacological parent training is less effective than pharmacological interventions in interventions do not tackle critical secondary issues, such as tackling the incidence of hyperactivity, inattention and impulsivity behavioural difficulties, peer problems, child social skills, (Brown et al., 2005). Nevertheless, parent-child relationships are emotional regulation, family dysfunction, parent-child frequently impaired in families where a child exhibits ADHD and interactions, parental stress and depression and parenting skills. parent training interventions can help to tackle family processes that Notably, findings from the MTA longitudinal study of ADHD, exacerbate and maintain negative behaviours as well as improving highlighted that the largest reductions in behavioural problems parental and family well-being (Pelham, Wheeler & Chronis, 1998). were noted when psychostimulant medication was A significant body of research links parent behaviours, particularly supplemented with a psychosocial intervention for parents, lax and ineffective discipline and harsh parenting, to the incidence of conduct disordered and oppositional behaviours in impulsive children(Collins et al., 2000), whilst negative parenting behaviours may also Currently, in the UK, psychopharmacological treatment is moderate the outcomes of pharmacological treatments (Hinshaw et al., no longer recommended as the first-line of intervention for 2000). More generally, parenting programmes have been found to be children with ADHD; the UK NICE guidelines (2009) stipulate highly effective in the treatment of behavioural problems in young that drug treatment ought to be reserved for those children who children more generally (e.g. Hutchings et al., 2007; Larsson et al., suffer with severe ADHD symptoms and for those who refuse 2008; Barlow et al., 2010; McGilloway et al., 2012; Furlong et al., other forms of treatment. Consequently, psychosocial interventions are now recommended as the first-line of treatment for children with ADHD and their families (NICE, 1.2.2 Child- focused interventions for ADHD: Social Skills
2008). These include cognitive behavioural therapies (e.g. child Training
social skills training and parent training), family therapy, school- Children with ADHD tend to have significant deficits in self-regulation based programmes and psychoeducational interventions. of behaviour and social interaction (Nixon, 2001). Thus, from a Importantly, these aim to improve the quality of life of children theoretical perspective, children with ADHD symptoms should and their families (Barbaresi & Olsen, 1998). However, the benefit from any treatment that focuses on improving cognitive, evidence, to date, on the effectiveness of psychosocial emotional and behavioural skills. Child-focused interventions that treatments is mixed and more research is required to investigate aim to improve self-regulation skills and social competence, have been optimal treatment strategies for this important sub-group. widely used with positive results in children with anti-social and aggressive behaviours (e.g. Brestan & Eyberg, 1998). Notably, deBoo 1.3.1 The Incredible Years Basic Parent Training Programme
& Prins (2007) concluded, from their systematic review of Social The Incredible Years Basic Parent Training Programme (IYBP; Skills Training (SST), that this approach was effective for ADHD Webster-Stratton, 1989) is a brief, group-based intervention guided children, although several limitations to the potential benefits of by the principles of behavioural and social learning theory. The SST for children with ADHD should also be noted. Firstly, whilst programme has been extensively evaluated as an intervention for many children with ADHD exhibit high levels of socially aversive children (aged 3-7 years) with conduct problems (Webster-Stratton & behaviours, they may also have high levels of positive behaviour, Hancock, 1998; Reid & Webster-Stratton, 2001) and its effectiveness thereby reducing the likelihood of any benefits from SST (Nixon, is now well-established (Scott et al., 2001; Mihalic et al., 2002; 2001). Secondly, the quality of parent-child relationships and parental Gardner et al., 2006; Hutchings et al., 2007; Larsson et al., 2008; discipline style are critical to child social, emotional and behavioural Bywater et al., 2010; McGilloway et al, 2012). Research also health and child-parent interactions are heavily influenced by ADHD indicates that the IYBP can reduce the incidence of hyperactivity and symptoms and associated disruptive behaviour (Gibbs et al., 2003; inattention in children with conduct problems (Hutchings et al., 2007; Frick, 2004). Frequently, any conflict between parent and child Larsson et al., 2008), while Hartman and colleagues (2003) found that can persist in spite of SST, thereby limiting its benefits. Similar issues comorbid attention deficits and hyperactivity did not preclude conduct may be evident in the child’s classroom environment. Therefore, while disordered children from deriving benefits from the IYBP. SST training for children with ADHD can lead to important reductionsin aversive behaviours and help to improve the child’s social skills, Despite these positive findings, the effectiveness of the IYBP with it may be more effective when used alongside additional interventions ADHD children has received little research attention. Jones and such as parent training and classroom management interventions. colleagues (2007; 2008) conducted an RCT evaluation of the IY programme for parents of children with ADHD and reported long-term Webster-Stratton and colleagues (2011) demonstrated the efficacy of positive effects on ADHD symptoms of inattention and hyperactivity, a combined parent and child training programme intervention for as well as child deviance and parenting behaviour. A number of other improving social competence and problem-solving in children with small-scale studies (Carlson & Ogg, 2009 [n= 3]; Walcott, Carlson & ADHD, as well as attendant improvements in child behaviour. Beamon, 2009[n = 4]; Lees & Ronan, 2008 [n=4]) have also reportedPrevious research has also supported the effectiveness of significant improvements in child behaviour and parental well-beingsimultaneous parent and child combined treatments amongst conduct post IYBP-training. This, albeit limited research, suggests that the IY disordered children (Webster-Stratton et al., 2001; Webster-Stratton programme may be a useful intervention for children with ADHD. et al., 2004), including children with high levels of hyperactive-inattentive behaviours (Hartman et al., 2003). 1.3.2 The Incredible Years Small Group Dina programme
The Incredible Years small group Dina Programme is an evidence-
1.3 The Incredible Years Intervention Series
based child social skills training programme which, like the IYBP, is The Webster-Stratton Incredible Years (IY) Parent, Teacher and Child based on behavioural and social learning theory. The aim of the Training Series was designed for the early treatment and prevention programme is to improve child emotional regulation, pro-social of conduct disorders in childhood (Webster-Stratton & Hancock, behaviour, problem solving and friendship skills (Webster-Stratton, 1998). The IY series comprises a suite of comprehensive, specially 2005). To date, the Dina programme has been evaluated in combina- designed programmes, which target children aged 0-12 yrs, and their tion with the IYBP and the Incredible Years Teacher Classroom parents and teachers, with a view to improving social and emotional Management (TCM) Programme (Webster-Stratton & Hammond, functioning and reducing or preventing emotional and behavioural 1997; Webster-Stratton, Reid & Hammond, 2004; Webster-Stratton, Reid & Stoolmiller, 2008). The findings from these studies suggestthat children who receive such training programmes can show improved problem-solving and conflict resolution skills, as well as reduced peer problems in school when compared to parent-training interventions alone. Moreover, the addition of child training may increase the generalisation of treatment effects beyond the home, aswell as increasing the likelihood that such effects are maintained in thelonger term (Webster-Stratton et al., 2004). Little is known about the effectiveness of the Small Group Dina programme for children with ADHD. Larsson and colleagues (2008)explored the effectiveness of the combined IY parent and child programmes for children with conduct disorder when compared to Figure 1: The Incredible Years Series
parent training alone, or a control condition. The research, which was Both of the above RCTs were supported by 12-month conducted in a clinical setting, demonstrated significant reductions in follow-up evaluations which demonstrated the likelihood of conduct problems in the combined condition relative to the other longer-term benefits of both parent- and teacher-training groups, as well as greater generalisation of behavioural improvements interventions for tackling childhood adjustment problems in the across different contexts. However, there was little additional benefit of combining parent training with child training, when compared toparent training alone (Larsson et al., 2008). Webster-Stratton and Nested within each of the above RCTs, were other studies colleagues (2011) carried out an RCT evaluation of the combined IY undertaken in parallel, in order to examine the processes by parent and Dina programmes in children (aged 4-6 years) diagnosed which the different interventions worked (i.e. process with ADHD (n=99). The findings suggest significant pre- to post-in- evaluations) as well as their cost effectiveness (i.e. economic tervention improvements in child externalising and conduct disordered behaviour, hyperactivity and inattention. Pre-to post intervention improvements in parenting behaviours were also found. However, The third RCT is described in this report. differences between groups on most measures of child conduct disordered behaviour and parental adjustment, were not detected and, 1.4.1 The current study
in general, improvements in child behaviour did not generalise to The third and final evaluation was an exploratory RCT examining the the child’s school environment. Nevertheless, significant between effect of the IYBP plus the combined effects of the IYBP and the child group differences in child problem-solving skills were found, which Dina programme for children with symptoms of ADHD. A small suggests that child social skills training can result in some additional qualitative sub-study was also undertaken to explore the experiences benefits for child outcomes and, overall, the study illustrates some and views of parent participants and Dina facilitators. A small promising effects of combined parent and child training for number of children (aged 3-7 years) with symptoms of ADHD, and their families, agreed to take part in the study; most were living in socially disadvantaged areas. 1.4 The Incredible Years Ireland Study: An overview
The implementation of the Incredible Years programmes in several
The specific research questions were as follows: community-based agencies and schools in Ireland began in 2004 andwas aimed at preventing and treating socioemotional and behavioural To what extent does the Small Group Dina programme impact difficulties in Irish children identified as high risk for conduct on the behaviour of young children (aged 3-6 years) who disorders; this work was spearheaded at that time by Archways, the have been assessed as having symptoms of ADHD? national co-ordinator of the IY programme in Ireland and led to anArchways’ commissioned national evaluation of the programme - the To what extent does the combination of the IYBP and Small Incredible Years Ireland Study (IYIS) led by researchers in the Group Dina training lead to improvements in behaviour of Department of Psychology at NUI Maynooth. The IYIS involves a young children (aged 3-7 years) who have been assessed as comprehensive and methodologically rigorous, community-based evaluation of the effectiveness of different elements of the IY suite of programmes. This has involved three experimental studies or To what extent does the IYBP as a stand-alone intervention, or Randomised Controlled Trials (RCTs) designed to investigate the key when combined with the IY Dina training lead to improvements components of the Incredible Years programme (see below). in parenting competencies and parental stress in parents with children with symptoms of ADHD? What is the impact of each The first RCT evaluation highlighted the effectiveness of the intervention on parent-child relationships? Incredible Years BASIC Preschool/Early School Years Parent Training programme as an intervention for early childhood What are the experiences and views of parent participants? behavioural problems in disadvantaged community-based settings in Ireland (McGilloway et al., 2009; Furlong & McGilloway, 2011, McGilloway et al, 2012;). The second RCT involved an evaluation of the IY Teacher Classroom Management (TCM) programme and indicated that the teacher-focused programme was effective in providing teachers with the appropriate skills and strategies to reinforce positive child behaviour and to promote appropriate classroom behaviour (McGilloway et al., 2010; McGilloway et al., in submission). 2.1 Study design
2.3.1 Parent Training: The Incredible Years Basic Parenting
The study involved two elements: (1) an exploratory, pragmatic Programme
randomised controlled trial (RCT); and (2) a small qualitative The IYBP (Webster-Stratton, 1989; 2005) comprises 20 weekly sub-study. The latter is described in the next section. Participants in sessions, each of which lasts for 2 to 2.5 hours. Sessions are attended the RCT were blindly allocated to one of the following groups: (1) the by 10-12 participants and partners are encouraged to attend. The IYBP Dina child training plus parent training intervention group (CT+PT; is a collaborative, group-based intervention which uses group n=12); (2) the parent-training only group (PT; n=19); or (3) a waiting- discussions and role plays in combination with video material to list control group (WLC; n=14). The unit of randomisation was the illustrate various parenting and discipline strategies. Programme parent-child dyad. Randomisation was carried out on a 2:1 basis topics include play, attention and involvement, listening, problem- using a random number generator. This allowed for the inclusion of solving, praise and incentives, and limit setting and other non-aversive a larger intervention group (i.e. PT+CT or PT) and ensured that discipline strategies. The programme promotes positive parenting fewer people were placed on a waiting list. It was recommended that techniques, such as child-directed play and encouragement to foster children who were participating in the same Dina group were broadly child cooperation and to strengthen parent-child relationships. Child comparable in age and randomisation was restricted, therefore, by problem behaviours are addressed by encouraging parents to reinforce child age; in other words, participating families were divided into (i) positive pro-social behavior and to use non-aversive discipline pre-school or (ii) primary school. Due to limited resources, it was strategies (e.g. time-out) in order to tackle aversive or inappropriate possible to allocate only a maximum of 12 children to one of two behaviors. Parents practise the new tasks and techniques at home and Dina training groups - a pre-school group (n=6) and a primary school provide feedback at the next weekly session. Parents also received a weekly support call from the group leader throughout the course andfollow-up sessions were delivered where feasible.
Researchers were blind to randomisation in order to minimise any potential bias. The data for the study reported here, were collected at 2.3.2 Child Training: The Incredible Years Dina Programme
two time points: baseline (prior to intervention) and six months later.
The IY Dina programme (Webster-Stratton, 2005) targets children Randomisation took place after baseline assessment. Parents and with conduct disordered behaviour; however, Webster-Stratton and children in the PT+CT and PT groups received the intervention during Reid (2008) outlined several adaptations to the Dina programme the six-month interim period between data collection points. Parents designed to address the individual behavioural and emotional needs allocated to the WLC group were offered the parent programme after of children, including those who exhibit high levels of hyperactivity the six-month follow-up. At the six-month assessment stage, three and inattention. The group-based programme comprises 18 weekly parents (7%) were lost to follow-up (97% retention rate). sessions, each of which lasts 2 hours, and includes group discussions,coaching, life-sized puppets, video vignettes and homework 2.2 Participant recruitment
assignments to illustrate various socioemotional and self-regulatory Participants were of primarily low or middle income status and the skills to children. The programme content includes: building majority were living in areas designated as socially disadvantaged.
friendship skills; teaching problem-solving strategies; enhancing Families were referred to the IY programmes through Health Board emotional literacy and anger management; and enhancing school waiting lists, Child and Adolescent Mental Health Services (CAMHS), performance. Parents also receive weekly letters and phone calls. The information from local school and community-based family centres, methods and structure of the programme are tailored to the specific needs of children with ADHD symptoms to facilitate a more limited capacity for sustained attention and increased hyperactivity. For Inclusion criteria
example, additional hands-on practical activities and role-plays are Participants were included in the trial if: (a) the person was the used and additional space is provided to allow the child room primary caregiver of the child and was willing to participate in the for movement if needed. Parents in the combined arm of the trial training and the research; (b) the child was aged 3-7 years; (c) the attended the IYBP while their child attended the Dina programme. primary referral reason related to persistent hyperactivity, inattentionand/or impulsive behaviours; (d) the child scored above the cut-off(≥17) on the screening measure (see below); (e) the child was not receiving any ADHD medication and was not to receive any medication if at all possible during the period of the research; and (f)the parent or child had not previously attended any IY programmes.
2.3 The Intervention
The interventions were delivered in several community-based
organisations in south-west Dublin. All participating organisations
have a regular and routine engagement with families seeking support
for children with ADHD (or ADHD symptoms).
2.3.3 Treatment delivery
writing or doing homework, does the child talk too much?” This All training programmes were delivered by at least two facilitators who scale was used for screening eligible participants and a cut-off had received extensive training in the context and techniques of the score of 17 or more was used to select child participants who intervention. The leaders had varied backgrounds which included psychology, counselling and education or related fields. Leaders adhered closely to the treatment manual for each session and 2.4.2 Parent behaviour and well being measures
completed weekly protocol checklists of group sessions in order to The Parenting Scale (Arnold et al., 1993) was used to measure monitor treatment integrity and document group development. During (self-report) parenting competencies. The scale comprises 30 course delivery, the group leaders received regular supervision items and assesses dysfunctional discipline strategies. and support from a certified independent IY trainer and attendedweekly meetings to assess progress and address issues which may The Parenting Stress Index-Short Form (PSI-SF; Abidin, 1995) have arisen during group sessions. Group sessions were held at a was used to obtain an overall measure of parent stress and time and a place that suited participants. Free transportation, crèche functioning ( =0.93). The scale comprises 36 items which facilities or financial reimbursement for childcare and refreshments measure the distress experienced by parents in their parenting were provided for all participants to help overcome barriers to role as well as dysfunctional parent-child interactions.
2.4 Measures
A battery of well known and widely used psychometric measures was
used in order to provide a comprehensive and rigorous assessment
of key outcomes including child conduct problems and social
competencies (e.g. interpersonal skills), as well as parent competencies
(e.g. positive communication) and psychological well-being. All
measures have good reliability and validity. Demographic and
background information on parents and children was collected at
baseline using a Profile Questionnaire (PQ). Further information is
provided below.
2.4.1 Child behaviour measures
Several measures were used to assess the nature and severity of child
hyperactivity, inattention and impulsivity, as well as the extent of
conduct disordered behaviour and socioemotional difficulties. These
included the following:
The Werry-Weiss-Peters Activity Rating Scale (WWPARS; Werry, 1968) was the primary outcome measure. This widely used parent-report inventory consists of 27 items which assess child hyperactive behaviour in home and school settings. Typical items include: “When at play, does the child keep going from one toy to another?” or “When drawing, colouring, The Conners Parent Rating Scale (3rd Edition) Short Form (CPRS-SF;Conners, 2008) was also used to provide an assessment of hyperac-tive, inattentive and impulsive behaviours, including restlessness, over-activity, emotional reactivity and inattention. The Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997) was used to assess general emotional and behavioural difficulties. This 25-item measure consists of five subscales that assess emotional symptoms, conduct problems, hyperactivity, peer problems and pro-social behavior. The scores on each subscale (except the ‘Pro-social’ scale) may be summed to generate a ‘Total Difficulties’ score. 3.1 Participant Characteristics
The number of risk factors to which a child is exposed, has a The baseline demographic characteristics of participants are shown cumulative effect and also tends to correlate strongly with the in Table 1. The index children were predominately male (78%) development of serious behavioural problems. Factors which increase with a mean age of 57 months (SD=15.6). Study parents included 42 the risk of conduct disorder include: single parenthood; teenage mothers and 3 fathers, most of whom were married (28/45; 62%). parenthood; parental depression; family poverty; and parental history A high proportion of families were socioeconomically disadvantaged of drug abuse or criminality (Webster-Stratton, 1998). A risk factor and approximately 69% of the total sample were at risk of poverty, score ranging from 0 to 5 was calculated on the basis of the above as based on income and family size. A socioeconomic disadvantage derived from the PQ data obtained in the study. It was found that, score was also calculated using demographic data relating to: in total, 73% of child participants experienced 2 or more risk factors employment status; parental status (lone parent versus married/co- for Conduct Disorder (M=2.6, SD=1.1); this is considerably higher habiting); size of family; parental education; quality of housing; and than in the general population (CSO, 2006). A significant proportion levels of criminality in the participant’s area of residence. In total, of children in the study were deemed to have an increased risk 44% (20/45) of participants obtained a socioeconomic disadvantage of serious psychological distress, including conduct disordered score of 2 or more (M=1.5, SD=0.9). Overall, the proportion of families in Ireland who are at risk of poverty is 17% whilst 8% of thepopulation experience two or more indicators of socio-economic At baseline, parents reported high levels of child hyperactivity and disadvantage (Central Statistics Office [CSO], 2006). Thus, this attention deficit problems, as well as externalising, aggressive sample was considerably above the norm in this respect. and oppositional behaviors (see Table 2). Parents also reported high levels of parenting-related stress (see Table 3). There were no significant differences between participants in the three experimentalconditions with respect to either demographic characteristics or scores on psychometric measures. Table 1: Demographic Characteristics at Baseline (unless otherwise noted, numbers are frequencies (%))
No. (%) boys
Single parent
Large family (≥ 3 kids)
History of Depression
At risk of poverty
Primary carer left school before finishing secondary
Mean (SD) age of primary care giver (years)
at birth of first child
24.2 (6.2)
24.6 (5.7)
26.1 (4.7)
Mean age (SD) of child in months (SD)
58.8 (16.5)
57.1 (17.1)
56.4 (13.7)
Socio economic disadvantage score a
Risk factors for Conduct Disorder b
Note: No significant differences between groupsa) Employment status; parental status (lone versus married/co-habiting); size of family; parental education; quality of housing; and levels of criminality in the participant’s area of residence.
b) Single parenthood; teenage parenthood; parental depression; family poverty; and parental history of drug abuse or criminality.
3.2 Treatment attendance
According to parent-report, children in the PT group also demonstrated PT group (n=19): The average number of sessions attended by the 19
significantly higher post-intervention levels of pro-social behaviour parents in the PT group was 10.05 (SD=7.7). In total, 56% of parents when compared to the WLC group as well as significantly more (11/19) attended 10 or more sessions. Five parents did not attend any empathy and social competence (as measured by the SDQ Pro-social sessions. The average number of sessions attended by partners was 3.18 (SD=6.1).
PT+CT group (n=12): Children who participated in the Dina
PT+CT v WLC: There were significant differences in post-
programme, on average, attended 13 of the 18 sessions (SD=6.3).
intervention scores on the SDQ ‘Impact supplemental subscale’ Three-quarters (75%; 9/12) attended 9 or more sessions. The average between the combined PT+CT group when compared to the number of parent training sessions attended by parents in the PT+CT WLC (p=0.05). This indicates that parents in the PT+CT group group was 15.17 (SD=5.9). Compliance with the intervention was reported significantly lower levels of child distress and social deemed to be acceptable if parents had attended 10 of the 20 sessions impairment as a result of conduct problems and hyperactivity and, in total, 83% of parents had done so. All parents and children post-intervention, when compared to the control group. attended at least one session. The average number of sessions attended However, whilst parents in the PT reported lower SDQ scores when compared to the control group, these differences were not statistically significant. No further significant differences were 3.3 Intervention outcomes
found on child outcome measures between the PT+CT and the WLC groups (Table 2). 3.3.1 Child outcomes
The findings highlighted a number of statistically
PT+CT v PT: There was a statistically significant difference
significant differences at follow-up between the PT group and between the PT and PT+CT groups with respect to the WLC group on child ADHD-type behaviours, as well as social hyperactivity (as measured on the SDQ Hyperactivity subscale), adjustment (Table 2). Statistically, the PT intervention effects on indicating lower post-intervention hyperactivity scores amongst the Conners Total score indicated that parents rated their child’s children in the PT only group. Thus, children in the PT-only behaviour as less inattentive, hyperactive and oppositional when group fared better at the six-month follow-up than their peers compared to the control group. This finding was corroborated by who also received the child training intervention, although no additional statistically significant between-group differences on the other statistically significant differences between the groups SDQ Hyperactivity and the Conners ADHD index subscales. Although there were no between group differences on the primary outcomemeasure (the WWPARS), children in the PT group showed lower levels of hyperactive behaviour at the six-month follow-up. Overall,these findings indicate that the IYBP helped parents to better manageand improve their children’s impulsivity and overall hyperactive/inat-tentive behaviours.
Table 2: Summary of Child Measures at Baseline and Six-Month Follow-up
WLC (n=14)
PT (n=19)
PT+CT (n=12)
Effect size (d)
PT+CT vs
PT vs
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
vs WLC
SDQ=Strengths and Difficulties Questionnaire;
WWPARS=Werry-Weiss-Peters Activity Rating Scale; Conners=Conners Parent Rating Scale-Short Form (3rd Ed)
Parent Outcomes
PT+CT v WLC: The analyses did not reveal any statistically
PT v WLC: There were a number of significant differences between
significant effects of the PT+CT intervention on parent-reports the PT and WLC groups on self-reported parenting practices and use of disciplining strategies or parental well-being. However, there of discipline (as measured by the Parenting scale) at the six-month fol- were some, albeit non-significant, declines in self-reported use low-up (Table 3). These findings indicate that, when compared to the of lax parenting techniques, as well as overall improvements in WLC group, parents in the PT group used fewer harsh disciplining parenting behaviour, as indicated by moderate effect sizes. There measures and improved parental instruction when dealing with their were no significant changes in parental distress at follow-up, child. The findings also showed that the group-based parenting inter- amongst parents in the PT+CT group (PSI subscale) (see Table vention had a positive effect on parent-child verbal interactions, with results from the PT vs WLC comparisons demonstrating significantlybetter post-intervention scores on self-reported parental responses to PT+CT v PT: Comparisons between the PT +CT and PT-only
child misbehaviour for parents in the PT group. The use of lax parental groups did not reveal any significant differences between the disciplining was also significantly lower amongst parents in the PT groups, suggesting that there were no additional benefits for group when compared to their WLC counterparts, thereby indicating parents from the combined treatment; neither did the combined that the former used less permissive and inconsistent discipline tech- intervention result in any additional improvements in overall parenting behaviour, parental well-being or parent-child relationships. Indeed, the combined group had significantly There were no post-intervention differences between the PT and WLC higher levels of hyperactivity at follow-up than the parent groups on measures of parental distress (as measured by the PSI). Nev- ertheless, in contrast to the control group, there was a slight improve-ment in parent reports of stress experienced in the role of parenting inthe PT group, indicating some, albeit non-significant, improvements inparent competency and functioning, and parent-child relationships. Table 3: Summary of Parent Measures at Baseline and Six-month Follow-up
WLC (n=14)
PT (n=19)
PT+CT (n=12)
Effect size (d)
PT+CT vs
PT vs
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
Mean (SD)
vs WLC
Parents’ Experiences and Views: A Qualitative Sub-Study A small qualitative ‘add-on’ study was undertaken several months after course was also described by others as both “valuable” and “helpful” the RCT had been completed, in order to explore the views and whilst one mother of a six-year-old son commented that “the more you experiences of parents who had taken part in the parent training and put into it, definitely the more you get out of it.” One parent expressed whose children had simultaneously received the Dina intervention.
a concern that it is sometimes difficult to find 15 minutes to engage in One-to-one semi-structured interviews were conducted with 8 parents one-to-one play with her child each day, but despite this, she expressed whilst a focus group was also conducted with all facilitators (n=5) of a very positive attitude towards the programme and was “very the IY Dina programme. All participants were furnished with an information sheet and asked to provide their written informed consent.
The interviews and focus group were recorded (with consent), Some parents highlighted specific aspects of the parent training transcribed verbatim and analysed using standard thematic analysis. programme which they particularly enjoyed. These included: learningto play; positive praise; interaction with other parents with similar 4.1 One-to-one interviews with parents
experiences; question and answer sessions; video clips; techniques to Four key themes were identified from the analysis of the one-to-one control child’s behaviour; and advice and explanations by group interviews, each of which is summarised below.
leaders. Parents especially enjoyed the group-based format and thesense of togetherness that this engendered; they were reassured when Theme 1: Experience and views of the Parent Training
they learned that other parents were experiencing similar problems Overall, parents were very positive about the parent training with their children. This sense of togetherness also extended to the programme (see Box One). For example, one mother of a five-year-old development of friendships between parents. Group leaders in the boy commented that “I think overall it was a very good experience, it parent training programme were also viewed very positively by parents was well worth doing. I think it should be offered to more people.” The and the general consensus was that group leaders were “fantastic”. Box One: Selection of comments on the Parent Training
“Overall, I absolutely loved the Incredible Years programme. I got so much parenting skills.” (Mother of 6-year-old boy) “It made me more aware of what was going on for a child. It just makes you more aware of what the child wants and maybe that is whythe child gets angry and aggressive. By the time I left, it was like I was getting a new child going home.” (Mother of 6-year-old girl) “I thought it was very good. It helped me. I honestly found the whole programme, as a whole, very valuable to me. I think it was a greatcourse and I am always saying it to my friends, I really thought it was very good. It was very valuable to myself because I am a singleparent and at times I would have been pulling my hair out.” (Mother of 5-year-old boy) “I found it very helpful I have to say; it was very good, very helpful I have to say. I would have been 100% satisfied, I couldn't fault it.
Like I have done other courses and they wouldn't have covered things or explained things as good as this one did.”
(Mother of 6-year-old boy) I loved learning how to play again, learning how to allow my child to lead the play. I loved learning about the positive praise, the praiseworked so well in this house. They showed us what way we can talk them around positively - how we can stop squabbling betweensiblings; stuff like that was really, really good.”(Mother of 6-year-old boy) Parents also agreed that it was relatively easy to attend the programme Theme 2: Experience and general views of the Dina programme
on a regular basis and all had attended most, if not all, of the sessions.
The second major theme related broadly to the parents’ general views Reasons for missing sessions included having other appointments, and the experience of the Dina as a stand-alone programme. The having a sick child(ren) and an inability to organise attendance for consensus amongst participants was that their children had thoroughly various other reasons. Interestingly, one parent suggested that the enjoyed participating in the Dina programme. For example, one programme should be longer, whilst another stated “it is every week mother said that her six-year-old son “absolutely loved the Dina school and it is so long” (mother of six-year-old son), but acknowledged that and still talks about it”. The participants were also very positive about the course duration was necessary in order to cover all materials. the programme itself and the perceived benefits for their child (see Despite these different views, all parents were very positive about Box Two). Interestingly, two parents highlighted their child’s love attending the course on a regular basis. Importantly, it was also of the puppets used in the programme, whilst several also mentioned acknowledged that it is crucial to attend most if not all of the course that their child particularly enjoyed the reward system whereby sessions in order to properly benefit from the programme.
they were rewarded with small gifts for good behaviour. Importantly,they also reported that their child’s participation in the Dina programme had led to many improvements in the behaviour of theirchild (see on). Box Two : Selection of Parents’ Comments on the Dina Programme
“[He] gained so much in Dina school. He learned so many skills that he will need to bring with him going forward in the future.
It has made a huge impact on [his] life. He is like a different child.”
(Mother of 6-year- old boy) “He loved it. Generally it helped him, the different techniques for calming down because that is one of his main problems. Youcouldn't get him out of it, he didn't want to leave. It was very good for him - it taught him a lot.” (Mother of 5-year-old boy) “He loved it, he thought there was nothing like it - he loved going to it every week and the fact that all the kids in the group allhad their own problems - he wasn't standing out.” (Mother of 7-year-old boy) “He just looked so forward to going to it; it was his little time as well. I would have been very satisfied with it because it learned[taught] him to calm himself down. So he learned to listen to me a lot more and learned to respect what I'd say to him.” (Mother of 5-year-old boy) Although all parents were satisfied with the Dina programme, some Theme 3: The combined (perceived) effects of the parent and Dina
concerns were also raised. For example, one mother reported that training
her child was “very bold and hyper” following participation in the The third key theme related to the perceived effectiveness of the com- programme. However, this parent indicated that she had been told bined parent and Dina training. All but one of the participants (n=7) to expect such behaviour because her son was learning new things alluded to the link between the parent and Dina training programmes and would try to “push the boundaries”; her son’s behaviour and felt that it was beneficial to engage in both training programmes subsequently improved during the post-intervention period. Two simultaneously. Only one parent, a mother of a four-year-old daughter, parents expressed a concern that their child may have been too felt that there was no useful link between the two programmes, although this may have been due to a perceived lack of feedback tothis parent, on how well her child was doing in the programme. A “I think she was too small for that [the Dina programme] in my selection of illustrative comments is provided in Box Three.
opinion. I couldn't get any information out of her what they were doingthere, what kind of techniques they were using.” (Mother of 4- The greatest benefits identified in terms of the combined parent training and Dina programmes were behavioural changes in the child,changes in the parent child relationship, and changes in the parents “I think he might have been a bit young to understand what they were themselves (self perceptions and behavioural changes). Each of doing.” (Mother of 4-year-old boy) these is discussed in more detail below. One of the above parents felt that her child did not derive as much (a) Beneficial techniques and development of parental
benefit as she might otherwise have done, had she been a little older competencies
(e.g. 4.5 years) and better able to express herself verbally. Despite this, Many parents reported that post-intervention, they were still using the this parent still felt that her child had benefited from the programme.
skills they had learnt in the Dina school and the parent training in their It is worth noting here that the age range of the children also emerged day-to-day lives, particularly during play. This included: ‘listening as a sub-theme in the facilitator focus group (see on). ears’ (n=1); puppets (n=1); rewards (n=2); sticker/star chart (n=4);‘emotional thermometer’ (n=1); and the ‘bold step’ (n=1). The find- Parents were generally positive about the Dina group leaders; for ings suggest that the use of sticker and star charts following training example, half of the group felt that the leaders were “very was especially popular, with many using this in tandem with a reward approachable” and provided appropriate feedback to them at the end system. One parent also reported that she regularly referred to the of each session. However, it was suggested by one parent that course materials to help her in challenging situations. Important there was a need for further feedback on the Dina programme, changes in parents’ behaviour included increased use of positive praise possibly in the form of written notes. Another parent reported that (n=3), and being positive with their child more generally (n=2). The she did not have much contact with group leaders, although she had techniques learned through the programmes also helped parents in received substantial feedback during the programme delivery. “coping much better” (Mother of 7-year-old son) with their child. Fiveparents reported that, since completing both programmes, they were Although parents were overwhelmingly positive about the Incredible better better able to not “lose their cool” and to remain calm in Years suite of programmes, a number of suggestions for improvement dealing with their child’s behaviour, whilst three alluded to the were made. Importantly, half of the participants suggested that it would fact that they felt much calmer and less stressed since completing be useful to have some form of follow-on from the training, such as a the course. Two parents further stated that they had experienced refresher course and a review of progress, or follow-up contact with an increase in their confidence since programme completion. course facilitators. For example, one mother of a four-year-old girl, re-ported that “when the course was finished, I didn’t have the feeling I Other common changes in parents included: use of more realistic was finished”. Notably, and in line with the comments above, there punishments (n=2); clearer boundaries in place (n=1); “giving in” less was also a suggestion to reduce the age gap between children taking (n=1); and a feeling that they could better manage challenging part in the Dina programme as one parent felt that the gap between her situations (n=1). Four parents also reported changes in their overall four-year-old daughter and the oldest child in her child’s group was thinking/attitude which included: realising that they need to spend too large as they had “a completely different set of problems”.
more time with their child; being more realistic with their expectationsof their child’s behaviour; thinking before reacting; and a greaterawareness of the verbal interaction with their child. Interestingly, one parent enjoyed the course to the extent that they have since decided to return to education to complete a course in the area.
Box Three: Selection of comments on the combined effects of both programmes
“The changes in [him] have been absolutely fantastic with the parenting programme and the Dina school running together, both of them.
It is like he got a double whammy, and the skills that he learned and the skills that I learned have just worked so well together for bothof us.”
(Mother of 6-year-old boy) “Between the Dina and the parenting group, I don't know if one without the other would have been as good because I wouldn’t havebeen able to carry it on at home and we would have lost it pretty quick.” (Mother of 5-year-old ) “The two of us were going to our programme and he was learning what he had to do and I was learning so we were all putting it together. It was kind of coming together then. I think me doing it and [him] doing it at the same time helped the two of us.”(Mother of 5-year-old) “I know some people maybe don't need a parenting programme, but I found doing a parenting programme while he was in the Dinaworked because both of us was getting taught at the same time. I do think that you needed the two together.” (Mother of 7-year-old) There was also a realisation on the part of some parents that they were The specific kinds of positive behavioural changes in the children “part of the problem” (Mother of 5-year-old son), that perhaps they included: less tantrums (n=2) and lashing out (n=1); improvements were not spending sufficient one-on-one time with their child and that in social behaviour (n=2); calmer more relaxed and less agitated they “should put by 15 minutes of just sitting down and playing with behaviour (n=5); a greater ability to follow instructions (n=2); them or sitting down and talking with them” (Mother of 7-year-old increased confidence and overall happiness (n=1); improvements son). Two participants had found the programme to be beneficial in in behaviour at school (n=3); and improvements in emotional establishing a better routine for both themselves and their child. For expression (n=1). One mother also highlighted the importance of now example, one parent stated that her five-year-old son “…was more being able to recognise when her five-year-old son was going to lose structured because he knew what was happening” Likewise, another his temper and to be able to “nip things in the bud”. Despite these parent commented that the programme allowed them to establish improvements, three parents indicated that their child’s behaviour, boundaries with their child which, in turn, had led to significant although still better than before the programme, had disimproved for benefits. In two cases, participants reported that their child’s teacher a period thereafter, due mainly to decreases in play sessions (n=1) and had tried to incorporate some of the basic teaching principles/methods a major upheaval in the child’s life (n=2). However, only one parent used in the Dina programme into their classroom and that this also had felt that the behaviour of her four-year-old daughter had remained “up and down” since completing the programme and that the main behavioural issues had not been satisfactorily resolved. (b) Changes in child behaviour
The most commonly reported pre-intervention behavioural difficulties
were crying, arguing and temper tantrums (n=4) as well as aggressive
and violent behaviour (n=3). Other more isolated problems for the
children included: feeling stressed and agitated (n=1); struggling in
social settings (n=2); poor concentration (n=2); difficulty in
empathising with others (n=1); and not following instructions (n=1).
All but one parent (n=7) felt that their child’s behaviour with respect
to the above, had improved considerably as a result of completing
the programme. For example, one mother described the behaviour
of her six-year-old after the course as “fantastic” whilst another
felt that her six-year-old daughter had “come on in leaps and bounds”.
Positive behavioural changes, in some cases, were evident to such
an extent that parents felt they had a “different child” following
the programme (n=3), or that their child’s behaviour was at the
“opposite [better] end of the scale’’ (n=2).
Changes in the parent child relationship
Goals and reward charts were highlighted as useful techniques in man- Improvements in the parent-child relationship following completion aging hyperactivity (n=2), as well as one-on-one play sessions (n=2), of the programme were noted by all but one parent. For example, one use of time out from the stressful situation (n=2) and ignoring mother of a six-year-old boy, described her relationship with her son the child’s behaviour (n=1). Some techniques previously employed before the programme as “quite strained” and “very stressed” with a by parents to manage hyperactivity (e.g. engaging the child in transformation to “fantastic” after the programme. She continued: numerous activities to “wear him out”) were discarded following “We laugh so much, we joke so much. I am less stressed so he is less the programme, as parents learned more information about how stressed. I am less agitated so he is less agitated.” The strain on the best to manage their child’s behaviour. A small number of parent-child relationship caused by the child’s behavioural difficulties parents (n=2) were unclear as to whether the training programmes was also noted by a number of parents who alluded to a lack of dealt with hyperactivity specifically, but they felt that they had bonding (n=1) and frequent screaming (n=2): benefited from learning techniques to cope and deal more successfully with hyperactive behaviour as well as their child’s other “We are much happier now that we are not screaming and shouting” problem behaviours. Another parent commented that she found it more difficult to manage her child’s aggression (rather than hyperactivity) prior to completing the programme. Interestingly, the Other positive parent-child relationship improvements were noted mothers of two boys aged five and seven respectively, alluded to what with regard to: child listening; child-parent communication; they saw as the limitations of training programmes such as the parent-child play; and an increase in the child’s helpful behaviour. Incredible Years in dealing with ADHD-type behaviours. For It is also interesting to note that the positive changes in the relationship example, the first thought that they “can only go so far” in addressing between one mother and her child had generalised to her second these issues whilst the other commented: “I don’t know if he is child and that this three-way relationship had also improved as a result ever going to be right with the amount of problems he has.” Reassuringly however, both acknowledged that the programmes had provided them with useful techniques to improve their children’s Theme 4: Perceived utility of the programme in managing
behaviour in, for example, calming them down and helping to hyperactivity/inattention
All but one of the parents (n=7) felt that the programmes had improvedtheir child’s hyperactive and inattentive behaviours. For example, two Theme 5: The role of the Dina group leaders
participants felt that their child was “much calmer” and “less agi- The parents were generally very positive towards the Dina group tated” as a result of completing the programme, whilst another indi- leaders (Box Four). However, there were some differences of opinion cated that the programme had been useful in teaching parents how to with regard to the nature and extent of feedback provided by “channel their attention to things that maybe they like” (Mother of 6- group leaders to parents. Half of the parents indicated that the group year-old son) and to use games which were more ‘toned down’ and leaders were “very approachable” and provided information to less competitive with their child. Another mother of a five-year-old them at the end of every session. However, it was suggested by boy felt that her child was “still hyperactive but it is not as extreme” one parent that there is a need for further feedback on the Dina and she described improvements in her son’s behaviour in terms of programme, possibly in the form of parent notes: relaxing and sitting still. A similar view was expressed by another parent who felt that her six-year-old son was still quite hyperactive, “I think it was lacking that a little bit, like the feedback, I wasn't sure but with small post-intervention improvements in evidence: what they were actually doing in the class. Parent notes, that wouldbe better (Mother of 4-year-old girl). “I think with his condition he is just hyper; he is always going to be hyper more so than normal children.” A second parent also indicated that she did not have much contact with group leaders, although she felt that substantial feedback had been provided to parents generally during this time.
Box Four: Selection of comments on the Dina Group Leaders
“The three ladies that ran the Dina programme, they were lovely. No matter what you went to them with, nothing was too much. It wasreally fantastic that everyone was just so helpful, so understanding, so committed to helping you and your child.” (Mother of 6-year-old boy) “They were lovely, he really liked them; they were very good with him. They were very patient and very calm with him and that is the kind of thing he responds to. And if they needed to be firm with him they were, they weren't all airy fairy. He always talked about themand he really liked them.” (Mother of 5-year-old boy) “They were very good, they were very helpful. He really did love going to the club and meeting the two leaders.” (Mother of 5-year-old) “You could approach them, you could ask them questions; they were very helpful. They were very approachable and they were very good with the kids.” (Mother of 7-year-old) Other issues
Theme 1: Perceived impact of the programme
It is important to note some other factors which may have influenced The duration of the programme was discussed at the outset. Some the extent to which children and their parents benefited from the felt that 18 weeks was not long enough, whilst others emphasised programme. For example, some of the children had other that it is difficult to secure the commitment of parents to an 18-week underlying conditions, some of which were only diagnosed post programme without expanding it further. Interestingly, those who intervention; it is possible that these may have influenced their felt the course duration should be increased, were those who were outcomes. For instance, two children were diagnosed with Asperger delivering the programme in a school setting. Attendance rates Syndrome. The mother of one of these children felt that, because were described generally as “good”, or “excellent” and only a very of his diagnosis, her six-year-old son “scored high on paper” with small number of children had ‘missed’ sessions. The importance respect to behavioural problems following the programme and of regular attendance was also highlighted. In particular, one that her child suffered more with socio-behavioural problems than interviewee alluded to the changes in the group dynamic that hyperactivity. The second child who had been diagnosed with often occur both when a child is missing and also when that child the same condition, had presented with other co-morbid disorders including dyspraxia and a sensory processing disorder, whilst he wasalso being assessed for ADHD at the time of the interview. Four other Interviewees reported that the effects of the Dina programme parents indicated that, at the time of the interview, their child was improved dramatically when the child’s parent also completed undergoing an assessment for ADHD, one of whom was also being the IY parent training programme. For example, one facilitator assessed for an Autistic Spectrum Disorder. Another parent had spo- commented: “It does work really well when the parent is doing it” ken to her GP in relation to having her child assessed for ADHD and and outlined that the parent is then more aware of the language and had been advised that her child was too young for this assessment. concepts used in the Dina programme. The behaviour of children Importantly, none of the children of the parents who participated in during the programme was described by interviewees as “very interviews, had been prescribed medication for their behavioural mixed” with some children being “quite vocal” and others very problems either during, or since completing, the IY programmes.
quiet. A “honeymoon period” was also described, whereby the behaviour of children on commencement of the programme was 4.2 FOCUS GROUP FINDINGS (FACILITATORS)
initially very restrained and, on balance, quite good but as time Two of the five facilitators had been delivering the Dina programme passed, a number of issues begin to emerge as “their little for more than six years while two had been delivering for one year.
personalities show through.” At certain points in programme The final interviewee was not a Dina facilitator, but instead, worked delivery, one facilitator felt that child behaviour was disimproving as a manager of the Family Resource Centre where the Dina whilst in other cases, any behavioural improvements waxed and programme was being delivered to some of the children. Each facili- waned through the duration of the programme. However, at the end tator had four or five children in their group and the programme ran of the programme, one participant commented that “near the end for a period of 18 weeks. None of the interviewees was involved in you didn’t really have to repeat things” as the children were better facilitating any other similar training programmes. Two overarching themes were identified, each of which is described below. Theme 2: Challenges
Age of children in the group
It was evident from the findings, that the facilitators had experienced A sub-theme that emerged here, related to the different ages of the many different types of challenging behaviour from children who had children who took part in the Dina programme. Overall, this appeared taken part in the programme. For example, one interviewee described to present a number of challenges for facilitators. For example, one an extreme incident in which one child threw a tantrum and “smashed interviewee felt that the child whom she believed to have shown the stuff in the room.” Another challenge related to their hyperactivity and most progress as a result of the programme, was the youngest child here it was highlighted that, although the children were easy to in the group. Conversely, another interviewee who had facilitated the engage on an individual basis, it was often challenging to engage Dina programme with a very young group of children (the oldest child in the group was four) indicated that the group were “quite out of control” at the start of the programme, but that this was due, at least “When they are very active and they are moving around a lot and it in part, to the fact that the children did not have the skills necessary to is very difficult to engage them as a group.” listen to, and follow directions and were not used to engaging in groupsof children. Another two facilitators added that this younger group Importantly, one interviewee felt that “a lot of children of their age of children were “very quick to copy each other’s behaviour” and that even without ADHD or without any problems, would have difficulties this was a difficult issue in a group of children who were already listening to each other.” One child described by a facilitator as progressing well in the programme, had a diagnosis of autism spectrum disorder and “was the worst coming in” but “was actually the Two other interviewees had facilitated a Dina group with older children best coming out.” Another child had often became overwhelmed and aged 5.5 to 7 years and one alluded to the fact that the oldest child in would leave the group “just go around the corner and climb under the this group felt ‘bigger’ than the other children and “he’d be scrunch- coats” in order to calm down.
ing down in the chair to make himself smaller.” The pros and cons ofyounger versus older children within the group were discussed at Two interviewees described a particularly problematic child, but stated length by interviewees. The Dina programme is generally recom- that “by the end of it he did well considering how he was when he mended for children aged 3 to 8 years, but there were some differences first came in.” When describing the changes in another child as a in opinion with regard to the effectiveness of puppet training with result of the programme, two facilitators alluded to the significant level children of different ages. For example, one interviewee felt that of change and upset in the child’s home life while completing the older children do not respond as well to the puppets used in the programme. They felt that, in some ways, this child had made the least programme whilst another commented: “You’d wonder about the progress, but pointed out that, in other ways, “you could say he progressed the most because of all he was going through.” Another interviewee described how the behaviour of one child, although A third interviewee felt that the puppets worked better with younger he made considerable progress in the initial weeks of the programme, children who had “the imagination” for this, whilst others felt that older had deteriorated significantly in the final weeks of the programme. children were more engaged in the puppets as they were more of a According to the interviewee, this was due in large part to the fact “novelty” to them. It also appeared from some of the comments that that the child’s parents were not as consistent as they ought to have the older children were more apprehensive about leaving their parents and joining the group; despite this, only a small number of childrendemonstrated any kind of separation anxiety. Collectively, these Group work proved popular amongst children within the group; for comments suggest considerable uncertainty around the optimal age example, one activity involved completing a large floor jigsaw for children participating in the programme. together. The findings here suggest that the children were generallyvery well behaved in group activity and that the nature and amount Theme 3: Parent-facilitator collaboration
of group interaction amongst children had improved throughout In general, there was a consensus that parents perceived the IY Dina the programme. One interviewee described one child who “was programme positively. For instance, one interviewee commented such a bright kid” and how, as a facilitator, she had to devise different that she had received very positive feedback from the parent of one ways of presenting information and problems to keep the child five-year-old boy who had taken part in the Dina programme: “The feedback that we would have got from his Mam was very Interviewees felt that children responded well to the programme content and principles, although they understood and learned some ofthese more effectively than others. For instance, participants generally However, others felt that many parents were unfamiliar with the Dina felt that the reward principle worked well with the children and so programme content and concepts and suggested that it would be much so, that one interviewee, for example, felt that towards the end useful for parents to see the programme ‘in action’ in order to better of the programme, the prize earned after the accumulation of chips was understand it. Furthermore, the nature and extent of parent-facilitator not as important as the initial pleasure experienced when earning each interaction and collaboration emerged as an important issue. There appeared to be some differences amongst facilitators with re- The importance of facilitator flexibility in delivering the programme gard to the amount of information they had provided to, and received was highlighted by a number of interviewees, particularly in relation from, parents of children attending the programme. For example, two to ongoing adaptations and changes to the schedule or programme in had delivered an information morning to parents (as a group) in ad- order to keep children sufficiently engaged. For example, one partici- vance, whilst two others indicated that they had only seen parents for pant stated: “You have to change quickly very fast.” It was also re- the first time when they had brought their children to the programme ported that things did not always run according to plan. For instance, on the first day. The interaction between facilitators and parents prior not all of the children in each of the groups, found the vignettes equally to commencement of the programme was seen by most to be important interesting, whilst children on the autistic spectrum had a particularly and those parents who had not attended an information evening, felt keen interest in these. One facilitator also stated that she sometimes that this was a disadvantage. Parents were provided with a small spent longer than recommended on specific course modules if she felt amount of feedback after each session, but they had varied in their re- they were particularly difficult. Thus, the facilitators, to some extent, sponses to this; for example, some interviewees were provided with had to adapt programme delivery to fit with the needs of the children. very little information from parents in relation to how they felt about With regard to possible improvements, one suggestion was to deliver the course, whilst others “couldn’t get them [the parents] out the an information session for teachers on the Dina programme, although door!.” These differences may be due, at least in part, to the setting at the same time, it was acknowledged that accessing teachers for such in which the programme was facilitated; two interviewees had deliv- training is often very difficult. Another suggestion was to update the ered the programme in a school and had only limited time for interac- video clips perhaps using a cartoon format. It was also suggested that tion with parents after each session; other interviewees had facilitated it would be useful, in the future, for facilitators to be provided with the programme in a local Family Resource Centre where they appeared some background information on children prior to their entry into the to have more time and flexibility to interact with parents. Theme 4: Programme delivery for children with ADHD symptoms
Lastly, participants were asked for their views on the findings from the For two facilitators, it was the first time that they had delivered the quantitative element of the research and particularly with regard to the programme and also their first time delivering the programme to chil- lack of changes in those who had taken part in the combined parent dren with ADHD symptoms. However, the two other facilitators who and Dina training when compared to the parent training group only.
had previous delivery experience emphasised that most children re- Here, a number of explanations were offered. One interviewee sug- ferred to the Dina programme tend to have some symptoms of ADHD.
gested that it would be important to measure longer term outcomes as The facilitators indicated further that the way in which the programme completing the programme “is almost like an evangelical experience.” is delivered is important. For example, one commented: Another highlighted a need for implementing follow-up and refreshertraining. It was also suggested that parents’ opinions can vary on a day- “It is just what a child responds to rather than put something different to-day basis and that some parents may have been questioned about in a programme because I do think the content is very good and it does changes in their child’s post-intervention behaviour “on a bad day”.
Another possible explanation was that parents did not sufficiently un-derstand the principles of the Dina programme to implement them in Aspects of the course which were highlighted as particularly useful for their home life and that more interaction between facilitators and par- children with ADHD symptoms were learning about feelings, praise, ents may have helped to increase the positive behavioural change of and problem solving. Two facilitators felt that some of the language children participating in the Dina programme, as parents are then en- used within the programme was a little complex for the children within abled to perceive the child’s behaviour differently and to use tech- their group and that they omitted some difficult terms when facilitat- niques from the programme in the home. It was further indicated that ing the programme with younger children. It was also highlighted that it might be useful to focus parents’ attention on changing one behav- children with co-morbid diagnoses, particularly those on the autistic iour at a time, so that any changes can be identified more easily and as- spectrum, often displayed behaviours more difficult to manage than sessed and monitored on an ongoing basis. Lastly, it was suggested those of other children. This mirrors the findings outlined earlier from that it would be helpful to increase linkages between the parent and child training by increasing references to the Dina programme withinthe parent training, in order to familiarise parents with relevant con-cepts and techniques.
The principal aim of this study was to examine the short-term combined parent-training and child-training programmes as an inter- effectiveness of the IYBP and the combined IYBP and child Dina vention for children specifically with ADHD (or with ADHD programmes on ADHD symptoms and ADHD-type behaviours, as well as overall behavioural and socio-emotional adjustment. Interven-tion effects on parenting behaviour and parental well-being and parent- 5.2 Key issues
In the current study - and contrary to expectation - the findings fromthe RCT do not support the effectiveness of the combined IY Parent 5.1 Parent and child outcomes
and Child training programme for children with ADHD-type symp- The findings in relation to both parent and child outcomes are mixed.
toms and behaviours. Indeed, children in the PT+CT group performed The results suggest, on the one hand, that the IYBP had a significant significantly worse with respect to hyperactivity, than those in the PT beneficial effect on child ADHD-symptoms as well as social skills only condition, thereby suggesting (at least on the basis of this single amongst children in the PT group. However, there were no intervention outcome) that there may be some kind of negative interactions or syn- effects on the other hand, for child behaviour in the combined PT+CT ergies between the combined versus parent-training only programmes.
group as recorded on the study measures. The findings in relation to These findings are all the more surprising given that the parents in the parent outcomes demonstrate a similar pattern. In the PT condition, PT-only group had a lower level of attendance (10 sessions on average statistically significant benefits for parenting competency were ob- during the 20-week programme) when compared to those in the served at the six-month follow-up, but these were not evident in the PT+CT group (15 sessions on average). The children attended, on av- PT+CT condition. However, a moderate effect of the intervention on erage, 13 out of 18 sessions. (Partner attendance was low.) Con- parenting competency was found in the PT+CT condition, which versely, the qualitative results showed many positive comments and demonstrates some, albeit not statistically significant, intervention ef- parent-reported improvements in the behaviour of children who had taken part in the Dina programme and whose parents had also receivedthe parent training in parallel. These changes included improvements Comparisons between the PT and WLC groups also suggest that the in the core ADHD symptoms of hyperactivity and inattentiveness. It is IYBP significantly enhanced parenting skills. Participation in the IYBP difficult, in the absence of further research, to identify the possible rea- programme helped to steer parents towards more positive and more sons for these disparities and unexpected inconsistencies, but there effective disciplining strategies and parents alluded to these at a num- may be a number of methodological and other factors at play which re- ber of junctures during the qualitative interviews. Such improvements in parenting behaviour may help to reduce the risks of conduct disor-der; for example, current research links ineffective and harsh parent- Firstly and perhaps most importantly, the trial was subject to ing to poorer outcomes and the development of co-morbid conduct resource constraints and the small sample size meant that disordered and oppositional behaviour in ADHD children. However, in statistical power (and therefore the likelihood of identifying contrast to our previous research (McGilloway et al., 2009; 2012), statistically significant findings) was low. which was based on, an albeit larger sample and included children withclinically significant conduct problems more generally, the IYBP in For the same reason, we were unable to assess child behaviour this study did not result in improvements to parental well-being (as outside of the home, or to explore child problem-solving and measured by the PSI). Available evidence suggests that parental dis- emotional skills (which may also have benefitted from IY tress can negatively affect parent-child relationships and, in turn, child intervention). Neither were we able to conduct independent behaviour (Hogan et al., 2002; Trapolini et al., 2007). Therefore, it observations. These study limitations are discussed in more may well be the case that parents of children with ADHD symptoms have higher levels of parental stress and may require additional sup-ports in this regard. This is an area that warrants further attention.
On a related point, it was possible to assess only short-term outcomes. Thus, it may not have been possible to capture the true Previous research has demonstrated several positive effects of IY Dina intervention effects of child training on child adjustment and training including: improvements in child behaviour and hyperactivity; behaviour within this short time frame. Indeed, there was a hint the generalisation of treatment effects from home to school (Webster- from the qualitative findings, that some of the children Stratton & Hammond, 1997); the long-term maintenance of treatment disimproved in the immediate post-intervention period - at effects (Webster-Stratton et al., 2004); and significant improvements in which time assessments were conducted - but stabilised emotional literacy and problem solving skills (Webster-Stratton et al., thereafter. This highlights a need for longer term follow-up. 2011). Indeed, a recent study (Webster-Stratton et al., 2011) reportedpromising outcomes from the combined IY Parent and Child training Parental stress and psychopathology may have also attenuated programmes for children with ADHD. However, other independent the effects of the intervention (Reyno & McGrath, 2006). replications (Larsson et al., 2008) have found little support for ad- Notably, parents in the PT+CT group had higher scores (albeit junctive child social skills training with parent training. Therefore, fur- not statistically significantly so) on the Parenting scale and the ther replicative research is required to explore the effectiveness of PSI at baseline, indicating that they were more likely to use more negative, lax and over-reactive disciplining strategies, whilst of fathers in parenting interventions predicted enhanced treatment also experiencing more parenting-related distress prior to the outcomes (Chronis et al., 2004). Overall, accessibility and intervention. These small differences between groups may have engagement are critical to the success of psychosocial interventions, particularly amongst ‘hard-to-reach’ sub-groups (Gardner et al., 2010). An additional two potentially important explanatory factors emergedfrom the qualitative findings. As indicated earlier, other limitations include: the relatively small studysample which may have reduced the statistical power of the analysis Firstly, the age of the children in the Dina group appeared to be and underestimated, to some extent, the clinical effectiveness of the problematic despite the stratification by age at allocation (pre- programme; the short-term (six-month) nature of the findings; and the school versus primary school age bands). Some of the children

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