Dr David Daley So, it’s a very interesting  question, and it has both a very simple and a   very complex answer. The simple answer, when we  look at results from a myriad of meta-analyses,   they definitely show us that behavioural  interventions for ADHD clearly do reduce   both ADHD symptoms in the child, but  also, key associated other problems,   such as conduct problems. So, we know that these  interventions work, that’s the simple answer. The more complicated answer is that the  degree to which they work is very much   influenced by who the informant is. If we focus  on what we call the most proximal informant,   so that would be the person who actually  comes to the intervention, then generally,   most proximal informants report quite large  changes in the child’s behaviour. When you focus   on what we call probably blinded informants, so  these wouldn’t have been people who were present   at the intervention, they could be Teachers,  for example, or it could be blinded assessments   using computerised tests or observations. When we  look at that data, we get a very mixed picture. For ADHD symptoms, you usually don’t find  corroboration in probably blinded outcomes. So,   the parents who engage in the intervention say the  child’s ADHD symptoms are substantially reduced,   the probably blinded informants don’t  see it. When we look at conduct problems,   there’s more consistency. The parents say that  conduct problems are substantially reduced,   and the probably blinded informants do see  change in the child’s behaviour. To date,   we don’t have a satisfactory  explanation for that distinction. When we look at other outcomes, particularly  important ones around parental behaviour,   such as changes in parenting style – and changes  in parenting style are what mediates the change   in the child’s ADHD symptoms, when we look  at changes in parenting, then you get a very   consistent picture. Parents report, you know, huge  improvements in their positive parenting style,   massive reductions in their negative parenting  style, and probably blinded informants agree.   They also see huge differences in  the parents’ parenting style. So,   the only real discrepancy is with ADHD symptom  outcomes, where the parents report significant   reductions in the child’s symptoms, and those  probably blinded informants don’t see them. A caveat to that is that, in most studies,   these probably blinded informant reports are  taken immediately after the end of treatment,   and it could be if they were taken at a much  longer follow-up point, perhaps the probably   blinded informants might see the change. The  jury’s still out on that unfortunately [pause]. That’s a really interesting question, and it  has both a very simple answer and a slightly   more complicated answer. But the simple answer  is yes, when we look at the results of various   different meta-analyses, we see compelling  evidence that behavioural interventions reduce   both ADHD symptoms in the child, but also, other  important comorbidities, such as conduct problems. The slightly more complicated answer is that  it does depend on who the informant it. So,   when we look again at those meta-analyses,  when you look at what we call the most   proximal informant, that is the person  who actually comes to the treatment, then   they always report substantial reductions in the  child’s ADHD symptoms or their conduct problems.   When we look at what’s known as probably blinded  informants, and that could be a Teacher rating,   or it could be a more objective measure, such  as a computerised test or an observation,   there, we see very little corroboration of  the parents’ reports for ADHD symptoms. So,   the parents who come to treatment say that the  interventions reduce their child’s ADHD symptoms.   The probably blinded informants, they don’t  see the change in the child’s ADHD symptoms. More bizarrely, when we look at  something like conduct problems,   the parents report that the interventions also  improve their child’s conduct problems, and here,   the probably in – probably blinded informants  do see the change in the child’s behaviour. So,   they don’t report it for ADHD, they  do see it for conduct problems.  More importantly, when we focus on parental  behaviours, and in particular, on parenting,   for a lot of these interventions, parents  report substantial improvements in their   parenting, increases in positive parenting,  reductions in negative parenting, and here,   the probably blinded informants, that are often  blinded observations of the parents’ behaviour,   also agree. They also see substantial improvements  in the parents’ parenting. So, it’s only for ADHD   symptoms where the parents report improvements  and the probably blinded informants don’t see it. We don’t yet fully know how to explain  that discrepancy. For most studies,   those probably blinded informant reports are  taken immediately after the end of treatment,   and it may be if they were taken at a  much later point in time, then perhaps   those probably blinded informants might see  the change that the parents are reporting,   but as yet, the jury’s still out  on that one, I’m afraid [pause]. I think the major barrier to engagement in  interventions is the parents finding the time   to engage. We know that parents of children  with ADHD are very busy. We know that home   life can be a little bit chaotic, because it’s  quite difficult to parent a child with ADHD,   and in modern life, we know that parents are  trying to juggle parenting and working and   running the house and trying to keep on top  of the bills. And in addition, we’re now also   asking them to make time to engage in some sort  of intervention, so that’s the major barrier. How we overcome that is very much about  how we offer the intervention to them. So,   some evidence-based behavioural interventions  for ADHD are group-based, and they can be quite   difficult for parents to engage in. So, they  may be running in a church hall somewhere,   or in a hospital clinic, and they run at a set  time, and the parents would be offered a slot,   “Come on a Tuesday at 11 o’clock,” and it  might not be a day or a time that really   suits the parent. And we know clinically that  when services run group-based interventions,   they may have to invite 50 or 60 parents in  order to get ten or 12 parents into a group. There are other interventions that are conducted  individually, and they’re usually also run in the   parents’ home, and that is a really great way to  try and reduce barriers. So, the Therapist would   come to see the parents at home on a day and  at a time that suited the parents, and it could   be that each week the day and time change, and  just goes with the natural needs of the parents,   the fact that things come up at short moment, and  those appointments can be very easily rescheduled. The additional advantage of individual home-based  interventions is that the Therapists get to see   the environment they’re trying to modify. Is the  house really, really disorganised and chaotic,   or is it incredibly OCD tidy? What is that’s going  on at home? And that information can be really,   really helpful for the parents to further tailor  the intervention to the needs of the parents. There’s also some UK-based evidence from a 2018  randomised controlled trial, that compared a   individual home-based intervention for ADHD  against group-based intervention, and conducted   a health economic analysis. And those findings  showed that individual home-based treatment   was cheaper to deliver than group-based. Now,  that might sound a little bit counterintuitive,   because most people run groups because they assume  that they’re cheaper, but if you’re going to run   an intervention in an evidence-based way, then you  need to deliver the evi – you need to deliver the   intervention in the way that it was delivered in  the research trial that generated the evidence. And for group-based interventions, if  parents don’t come to a group session,   you really need to offer that parent some sort  of catch-up session before the group session   the following week, ‘cause otherwise, if they  turn up next week, they’ll be lost because they   missed the previous session. And so, what  we find for parents of children with ADHD,   when we run group-based interventions, we actually  end up running both a group-based intervention and   an individual intervention in parallel, trying to  help all the people who didn’t come to the group   catchup in time for the next week’s session. And  so, that helps us understand why, actually, if you   just decide to do it as an individual programme,  it often can end up being cheaper [pause]. So, when we’re thinking about behavioural  interventions for ADHD, there is no particular   qualification that’s needed in order to be able  to deliver these interventions. You don’t need to   be a Psychologist or a Psychiatrist to be able  to deliver these interventions. I think you do   need to have some simple, limited clinical  experience. You need to have some experience   of working with families, some experience of  working with parents of children with ADHD,   and it – I think it helps if you have a working  understanding of some key behavioural strategies.   But for most individuals, most of the skills  can be gained by engaging in the training,   and usually, training for these interventions is  three or four days long, and also acquired through   supervision while you deliver the intervention  in a practice format to some families. For me, I think what’s fundamentally important is  that we train people who are in a position to use   these interventions and who are able to deliver  these interventions in a timely way to parents   when they need them. And so, for that reason, in  the past, I’ve always found it incredibly helpful   to train Health Visitors, Family Support Workers  and CAMHS Nurses, because they’re all really in   a position where they constantly meet families of  children with ADHD, can easily identify families   who are in need of intervention, and usually  have some degree of flexibility in their diary   to be able to deliver the intervention. For  me, I think that’s much more important than   training Psychologists or Psychiatrists  to deliver these interventions [pause]. So, when we deliver the psychoeducation element of  most of these behavioural interventions for ADHD,   fundamentally, we’re trying to help parents  understand why their child with ADHD behaves   in the way that they do. And we’re also trying to  help parents separate out behaviours that are a   result of the child’s ADHD from behaviours  that might be the result of the child,   basically, trying it on, trying to get one  over the parent, trying to get their own way,   trying to ensure they have another  biscuit or a second chocolate. And when you’re parenting a child with ADHD, it’s  very difficult to separate those two out. You just   see a child who, you know, who’s engaging in a  behaviour that maybe you don’t feel you have the   time or the resources to cope with right now, but  is it due to their ADHD symptoms, or is it just   your child, you know, trying to make your life  difficult? And the psychoeducation element of   most of these interventions really helps parents  to equip them to understand the difference. So,   for example, a lot of these interventions will  teach parents to recruit their child’s attention,   using various different kinds of techniques.  And in some ways, it’s very important for these   interventions to teach parents how to recruit  their child’s attention, because if you don’t   recruit your child’s attention, it, kind of  doesn’t matter what you do next, ‘cause they’re   not listening. You could be demonstrating the best  parenting ever, but if your child’s not listening,   they’re not benefiting from all that  fabulous parenting that you’re doing. And so, quite often, when children have  tantrums, the parents don’t know whether   the child is having a tantrum because they’re  trying to exert control over the parent,   or the child’s having a tantrum because  they don’t know what’s expected of them,   or they’ve forgotten what has been requested. And  so, by explaining this to parents, and by teaching   them how to recruit the child’s attention, and  by teaching them how to deliver very short,   simple messages to the child, that really  helps clarify for the parents the fact that   they have recruited the child’s attention and  given a very simple and reasonable request. And now, if the child is refusing to follow  that request, then the parent feels like   they’re on quite strong ground to issue a  sanction. The sanction is warranted. But if   you don’t recruit the child’s attention,  and you don’t give a very simple, clear,   reasonable request, then the parents don’t know  whether, is the parent’s behaviour unreasonable,   is the child’s behaviour unreasonable?  It’s all very unclear. And so,   what we’re trying to do here is give  very simple education and strategies   to parents so that they feel more confident  if they have to use something like sanctions,   and they will use them with more authority, and  they will use them more consistently [pause]. Well, I think the really key thing for a lot of  these behavioural interventions is that before   parents engage in these interventions, they  are parenting in the best way that they can,   and often, it’s not really working. It’s  worth remembering that nobody teaches   us how to parent. We often just make it  up as you go along. I remember going to   parenting craft classes when my – before my  daughter was born, and she was recently 21,   and I remember the classes ending with the “And  you leave the hospital with your lovely, smiling   baby.” And I remember leaving the hospital with my  wife and the baby, and getting home and thinking,   now what do we do? It’s very unclear. So, we often  make it up as we go along, and for most parents,   they’re able to navigate that. They have children  who respond to strategies, they do similar things,   you know, their – they see their friends  doing things and they copy them and they work. For parents of children with ADHD, they  do all of that and it doesn’t work. So,   they see their friends parenting,  simply doing things, just asking   their children to put their shoes away,  and their children put their shoes away,   and they ask their child to put their shoes  away and the child has a massive tantrum,   and it goes on all afternoon. And so,  after a while, it’s only natural that   those parents should internalise all of that  and think, I’m really no good at parenting. And that’s actually not the case, and,  often, parents of children with ADHD   who have more than one child, where one  child has ADHD and one child doesn’t,   they begin to realise that it’s not just  them. Because they use those simple parenting   techniques with their non-ADHD child,  and they see generally that they work,   and they try them with their ADHD child, and  they see that they generally don’t work. And so,   that helps parents to realise it’s not just  me. It’s also about the needs of this child. And so, these interventions help parents  to understand, a) that they’re actually   not a terrible parent at all, and b)  that actually for a child with ADHD,   you do need to do things differently. And  so, once parents realise that for children   with ADHD they need to parent differently,  what’s really helpful is that there are a   range of interventions out there that they  can access, through CAMHS or Paediatrics,   or even, you know, in the community, that  help the parents work out, what are the   things that I need to do differently in order  to help parent my child with ADHD [pause]? So, there is a lot of research evidence,  mostly coming from meta-regressions,   conducted within meta-analyses, that clearly  show us that children of a younger age benefit   the most from behavioural interventions for  their children with ADHD. So, I think there   is quite a lot of evidence to show that earlier  intervention is better. Theoretically, it also   makes a lot of sense. By intervening early, before  the child’s behaviour becomes associated with   antisocial tendency and school failure, it’s much  easier to change those parents’ parenting style,   and the child’s behaviours are less extreme at  an earlier age, and so, more responsive to the   sorts of strategies that we teach in these various  behavioural interventions. So, both theoretically,   and also, empirically, it makes sense that  early intervention would be more effective. In terms of, do behavioural interventions  reduce long-term risk? I think, theoretically,   absolutely. The theory would suggest that by  intervening early you would change the child’s   developmental trajectory, you would put them on  a different developmental trajectory, a much more   positive one, associated with considerably  lower levels of future risk. The problem is   that there isn’t really a lot of evidence to  support that, and the reason for that is that   when we conduct randomised controlled trials, we  normally only have very short follow-up points. So, you would have – you would test the  child before the start of the intervention,   immediately after the end of intervention,  and then there would be what we call the   long-term follow-up point. And the long-term  follow-up point is not very long at all,   it’s actually very short. It could be as short as  three months. It’s rarely more than six months,   I can think of only one or two trials in the  entire research area that have gone as far as 12   months. And so, we don’t have that robust evidence  to try and show that it changes long-term risk. There have been a number of trials conducted  in the last couple of years in Scandinavia,   including a trial I was involved in, which was  run in Denmark, and those trials in the future,   you do have the ability to find the children  on all of these fabulous Scandinavian national   registers. So, it may be possible in the future  to address the question of whether or not these   interventions change long-term risk, by  doing some registry studies. But for now,   we’ll have to wait for those children to get a bit  older before we can even consider that [pause]. It’s a very complex question, and it  has an equally complex answer. So,   there is emerging evidence of the importance  of cognitive training, although in general,   the cognitive training trials tend to show what we  call near transfer rather than far transfer. So,   cognitive training interventions tend to  enhance other aspects of cognitive function. So,   if you train working memory, you might get  an enhanced effect on planning, but you don’t   always get an effect on ADHD symptoms. So,  you don’t get that far transfer to behaviour. There are a number of behavioural interventions  that try to incorporate elements of cognitive   training into the intervention. So, in particular,  the New Forest Parenting Program teaches NFPP   games that practice aspects of executive  functioning, particularly practising verbal   and auditory working memory. And a recent Danish  study, that added in a battery of cognitive tests   into the randomised controlled trial, did report  no clear evidence that executive or cognitive   control was improved in the children who engaged  in the intervention, even though ADHD symptoms   were significantly reduced in the intervention  arm of the trial. So, it’s difficult to say   that adding in cognitive training to behavioural  interventions would be particularly beneficial. Moving onto neurofeedback. The jury’s  really still out on whether neurofeedback   is particularly effective or not for  ADHD. There are some individual trials   which seem to suggest that neurofeedback  is positive, but at a meta-analytic level,   most meta-analysis struggle to find consistent  evidence that neurofeedback is beneficial,   unlike cognitive training, where it’s easy to  include elements of cognitive training into a   behavioural intervention. As a Clinician, I would  really struggle to know how you would include   neurofeedback into a behavioural intervention.  Neurofeedback is very much a different kind of   intervention. It stands alone, and I couldn’t see  how they could be combined. The only way you could   combine them would be to run them as two separate  interventions for the same group of children. Generally, neurofeedback takes a lot of  time and effort, and the jury’s still out   on whether it’s something that we should  be encouraging parents to use, at all.