Dr Blandine French David, in  terms of parenting intervention,   when you talked about the outcomes of it,  you mentioned that people who don’t take   part in the intervention do not report many  changes, such as Teachers, for example. So,   if other people cannot see the changes in  the children, then does it really work? Dr David Daley It’s actually quite difficult  to answer that question, because unhelpfully,   the answer is we don’t know. So, what I was  referring to there was a number of findings   from meta-analyses, and so meta-analyses are  where people look across the outcomes of lots   of different studies and they, kind of, average  out the findings to get – to, kind of, get the   average picture. And in meta-analyses, when you  look at the impact of behavioural interventions   on ADHD symptom reduction, the people who attend  the intervention, which is usually the parents,   report that they are effective, and the effect  sizes are generally about .4. And people who   are probably blinded to interventions, so  those who don’t engage in the intervention,   and who haven’t been told the  child’s treatment allocation,   so whether the child was in the intervention  arm or the control arm, they generally don’t   see anything at all. The effect size is – can  be as low as 0.02, which may as well be zero. There are lots of possible explanations for  this. The most obvious one is that if you’re   comparing Teachers again – Teachers  ratings’ against parents’ ratings,   well, Teachers see children in very  different environments to the parents. So,   Teachers generally see ADHD children in  very structured environments and parents   see children in less structured environments,  ‘cause the child’s relaxing at home. So,   that’s one possibility, that it’s just  different contexts that confuse the rater. There are lots of other problems with  this methodology. Quite often in trials,   even if you’re taking a Teacher rating, it’s  not the same Teacher before and afterwards. So,   that also doesn’t help, it adds extra noise,  because we know from the literature that have   looked at how, you know, two Teachers teaching the  one child, so Teachers that might do a job share,   for instance, they wouldn’t necessarily rate  the child’s behaviour the same either. So,   there are lots of methodological  problems that might confuse the   situation and make it harder for us  to work out what’s actually going on. What is interesting from those meta-analyses  is that when you look at conduct problems,   there is a much higher level of agreement. So,  for conduct problems, the person who comes to   the intervention, which is usually the parent,  says, “Yes, you know, they help reduce conduct   problems,” and the effect sizes are between .3 and  .4. And there, the probably blinded informants,   again, who are usually Teachers, do  see change in the child’s behaviour. Now, another possibility is that in this  meta-analytic work, we only look at the   differences between these two types of  raters before and after intervention,   and if you were to look at it in the longer  term, perhaps those probably blinded informants   would begin – would see change in ADHD  symptoms. So, it may be, for instance,   that in these interventions, conduct  type problems respond much more quickly   to the parents’ use of strategies and ADHD type  problems take longer for the child to respond. I’ve always been of two minds about what this  data actually tells us. So, as a Scientist,   I want to absolutely make sure that we double  check and verify every finding. That’s part of my   scientific training. But clinically, especially  these days here in the UK, we almost entirely   rely on parents’ reports for everything,  including assessment and diagnosis. So,   the Clinician part of me is a little less worried  that we don’t get independent corroboration of the   success of the intervention, whereas the  Scientist part of me remains concerned. Dr Blandine French And in terms of long-term  impacts, you mentioned there is very little   longitudinal data on the effect of parenting  intervention, but what do we know in terms of,   you know, the long-term changes? Do we notice  changing – you know, what does the data say,   does it show changes a year down the line,  two years down the line, five years? You know,   how long do these kind of changes or improvement  in the child’s improvement last? What do we know? Dr David Daley Very little, unfortunately.  So, most trial designs would look at – would   compare the impact of intervention over some  form of control. In the last five or ten years,   that control is usually treatment as usual. Going  back a little further back in the literature,   it was quite often wait-list control. But we’d  normally look at the effects of intervention   over control before the start of intervention, at  the end of intervention and at a follow-up point,   that could be anywhere between four weeks and  24 weeks. There are very few studies that have   gone beyond 24 weeks. I can only think of  one or two in the entire literature that   have gone as far as 52 weeks or a year,  and virtually nothing later than that. And one of the problems with this evidence  base is that in those early trials,   where you were comparing intervention to  wait-list, as soon as you finished the trial,   you offered the intervention  to those on the wait-list. So,   that then meant you couldn’t follow them up  anymore because everyone had had intervention,   and the only difference between the two groups  was the time at which they’d had the intervention.   When you then do trials that look at comparing  intervention to treatment as usual, then usually   those trials show that the intervention is  more positive than treatment as usual, and so,   the intervention then gets adopted as treatment  as usual, which then makes it harder to follow   all these children up, as well. So, there  are lots of limitations to our understanding,   and we honestly know very little about the  long, long-term impact of these interventions. I’ve recently been involved in a really  large trial of an intervention called the   New Forest Parenting Program in Denmark,  that we completed in 2018. We – because   we conducted the trial in Denmark, in Denmark  every bit of clinical information for children   gets put onto these national research  registers, called the Danish Registers,   and so we will have the opportunity to follow  these children up naturalistically in the future   using the Danish Registers. And that may allow  us to say something helpful about whether these   interventions are more effective in the longer  term or not, but for now, the jury really is out.  Dr Blandine French And in terms  of behaviour, as I understand it,   the parenting strategies work with certain  difficulties of behaviour, but do we see a   transfer across other behaviours? So, if we  are trying to work with recruiting attention,   for example, and we’re working on the  attention, do we see any changes in loads   of different aspect of attention, such  as, concentration, or things like that? Dr David Daley So, when you look at  the evidence base for evaluation of   these behavioural interventions, then you  certainly do see that these interventions,   they target parents’ parenting style or  parenting practices. We certainly know   that you see changes in parents’ parenting  style. So, the meta-analyses very clearly   show that receipt of these interventions reduce  your negative parenting practices and increase   your positive parenting practices. And  you see effect sizes of, you know, .7,   .8, and those effect sizes are about the same  magnitude of change that you get from medication   on ADHD children’s symptom reduction. So,  they’re very large effect size changes. So, we know that these interventions change  parenting, and when we look at child outcomes,   we know that they do change aspects of the child’s  ADHD symptom profile. So, we see improvements in   attention, you see reductions in impulsivity and  reductions in hyperactivity for younger children,   but crucially, it’s mostly done by parent report.  So, in the trials, where very sensibly Researchers   have added in tests of attention, so, computerised  tests of attention, or computerised measures of   impulsivity, or observational measures  of impulsive behaviour in children, they   usually don’t see significant changes in those  – what we would call those “objective tests.” And the reason for that is that when parents  report them on questionnaires, they tend to be   talking – they tend to report at a very global  level. So, “Over the last three months,” you   “know, has your child’s impulsive behaviours  reduced?” And the parents think about it,   and they think, actually, you know what, in the  last three months they have, they been a lot less   impulsive. Whereas in those trials, with those  objective measures, tests or observations, they’re   quite often focusing on impulsive behaviours  for maybe ten or 15 minutes in a testing room in   some strange university building, where the child  isn’t necessarily comfortable or being themselves. So, there are also lots of methodological  challenges that limit our ability to   accurately and ecologically capture objective  change in some of those core ADHD behaviours.   But certainly when you talk to parents,  these interventions do change multiple   aspects of the child’s ADHD symptoms,  but, also, other important aspects. So,   they reduced conduct problems, they increase  peer relationships, and that’s very important,   because quite often, ADHD children struggle to  make friends. So, we know these interventions   actually help these children increase their  peer group, and that’s very important. And there’s some evidence that they can be  beneficial in terms of increasing academic   attainment, but the measures for that  are often quite messy. So, for instance,   we’ve never had a trial that’s looked  at whether the child’s – here in the   UK, whet – that’s increased the child’s  scores at their SATs, for instance. So,   when I say they increase academic ability,  they increase estimates of academic ability   that research trials take, such as,  you know, reading level, for instance. Dr Blandine French Thank you. So,  these resource that you describe,   are they the same across all  different party interventions,   or are there some differences between  the type of intervention that you do? Dr David Daley So, generally, funders are not  too keen in funding large, expensive trials   that compare two psychological interventions  head-to-head. I can only think of two trials that   have actually done that. So, one was conducted in  the United States, and it compared the New Forest   Parenting Program to Helping the Noncompliant  Child, for pre-school children, and it generally   found that both interventions were effective, but  one intervention wasn’t better than the other,   but both of them were better than wait-list  control, across a range of different outcomes. There was a second trial that was done here in  the UK that compared the New Forest Parenting   Program to the Incredible Years Programme,  again, for pre-school children. In this trial,   there is an added complication because the  New Forest Parenting Program is an individual   home-based programme and Incredible  Years is a group-based programme. So,   that was actually a really messy trial,  wonderfully pragmatic, but very messy. And again,   there wasn’t a – there wasn’t clear evidence  that one intervention was better than the   other. There were some very small trends,  but they were very difficult to interpret. The interesting thing that came out of that  trial was the health economic evaluation,   that showed that the individual home-based  programme, New Forest Program, was actually   cheaper to deliver than Incredible Years, the  group-based programme. And that was surprising,   because most people had assumed that  group delivery is cheaper than individual,   but in that trial, that turned out not to  the case. Because when you’re delivering a   group-based intervention for parents of children  with ADHD, who are often quite busy and chaotic,   if a parent doesn’t come to the group, you have  to try and catch up with that parent some stage   during that week, to share the information  with them that they missed in the group. So,   that when they come back to the group  next week, they’re not at a disadvantage. And so, for behavioural interventions delivered in  a group format for parents of children with ADHD,   you often end up running both an individual  programme and a group programme in parallel, and   so, it’s actually cheaper just to scrap the group,  and deliver an individual programme, where week on   week, you can vary the day and the time that you  meet the parent, to, kind of, meet their needs. Dr Blandine French So, you  mentioned the Incredible Years,   and the New Forest Parenting Program, what are  the names of the most common and successful   intervention? If I wanted to implement them  in my practice, what do I need to look for? Dr David Daley I think different people are  looking for different things. You should – as   a Clinician, you should be seeking to implement  evidence-based interventions, although a lot of   Clinicians do struggle to understand exactly what  makes an evidence-based intervention. The New   Forest Parenting Program, for instance, I think,  has at least eight positive randomised controlled   trials around the world, including three or four  here in the UK. Some other interventions only have   one positive randomised controlled trial. And so,  there are – there’s no accepted understanding of   exactly what is an evidence-based intervention,  but there should be at least some evidence,   some strong research evidence, that the  intervention is going to be effective   for the problem that you want to address and  for the people that you’re trying to support. And then it’s more about availability. So, for  instance, I mentioned Helping the Noncompliant   Child, which was one of the two interventions in  that head-to-head trial run in the United States.   I don’t think it’s possible to access training  in Helping the Noncompliant Child here in the UK,   at the moment. So, once you choose an intervention  that is evidence-based, the next question is,   is it possible for me to access training and  access supervision while I practice delivery?   And certainly, for the New Forest Parenting  Program, Incredible Years Programme and Triple P,   I am aware that it is possible to access  training and supervision here in the UK, and,   also, generally, all of those interventions are  more widely available internationally, as well. So, once you’ve thought about evidence-based and  whether I can actually access training or not,   you then get down to the pragmatics of how long  are those interventions? So, Incredible Years is   a group-based intervention, Triple P is – can  be either individual or group, and New Forest   can be individual or group, as well, but it’s  usually delivered as an individual programme. And then the last thing is how long does it  take to deliver these interventions? So, there’s   actually quite a wide variation in the duration of  some of these interventions. So, when Incredible   Years is delivered for conduct problems, it’s  usually delivered as a 13-session group programme,   but when it was trialled for ADHD, they increased  it to 20 to 22 sessions. So, if you want to use   Incredible Years as an evidence-based intervention  for chil – for parents of children with ADHD, you   need to be willing to deliver 20 to 22 sessions,  which is quite a lot. 20 to 22 weeks doesn’t fit   into any time in the year. You can’t do it between  September and Christmas, or New Year and Easter,   and it’s – that’s quite a lot of commitment,  both from the parents and the Therapists. The New Forest Parenting Program, on the other  hand, is eight one-hour sessions. So, it is a   lot – it’s a briefer, and it’s more focused, and  for some Therapists, they know that it’s harder   to get much more extensive longer interventions  commissioned in their local areas. So, they may   be better off going for something that is still  very evidence-based, but is a shorter commitment,   and therefore, Clinicians are able to treat more  families with the available time and resources. Dr Blandine French And in terms of delivery,  you mentioned that one-on-one reduces bias   to taking part in intervention and is somewhat  cheaper, but what about outcomes? Is there any   evidence that group delivery versus one-on-one  have better outcomes, one way or another? Dr David Daley There’s nothing conclusive  that would allow me to answer that question,   the evidence doesn’t exist. The small number  of studies that have looked at head-to-head   comparisons have not shown any definitive  advantage of one intervention over another,   so it’s down to preference. We do need to remember  that lots of parents are looking for individual   intervention, but not all. Some parents would  rather be in a group, for various reasons. When I deliver behavioural interventions, I like  to do it individually and I like to do it at home.   I feel there’s an enormous clinical advantage  to actually seeing the environment you’re trying   to modify. It’s really, really helpful to go and  visit the parents at home, and you get an idea of   what home life might be like for the child you’re  trying to help. So, is the home environment really   cluttered and chaotic, or is it incredibly clean  and tidy, in a way that my house would never be?   And it gives you an idea of what family life  will be – is like for that child, in a way   that you can never get from meeting the parents,  either individually or in group, in the clinic. Dr Blandine French So, are  interventions alone enough,   or is it better to mix with  medication, for example? Dr David Daley Okay, so certainly here in the UK,  Clinicians should be guided by the recommendations   from NICE. So, most Clinicians will be aware that  it’s rare to offer medication to children under   the age of six, because there’s very few trials  that have looked at the efficacy of medication   in younger children. And the small number of  trials that have done that, in places like the   United States, tend to report smaller effect  sizes and much higher rates of side effects   or adverse events in the use of ADHD medication  in younger children. So, for younger children,   we should be offering behavioural interventions  as a first offer. For older children,   I think the evidence internationally is  that combined intervention is best. So,   adding in both medication, which can have a  rapid effect on the child’s symptoms, and then,   also, making sure that parents are offered  access to a behavioural intervention, as well. I think what’s really important to remember is  that when we look at the evidence base from many   evaluations of ADHD medications, they’re  very good at targeting core ADHD symptoms,   such as inattention or impulsivity, but  they’re less good at targeting other   outcomes that are really important for  the child and important for the parent,   such as, helping the child do better at school,  helping the child make more friends. And so,   for that reason, as well, it’s important  to combine these interventions together,   to use both medication and behavioural  interventions, so that we’re offering   a more global solution for the myriad of  difficulties that ADHD cause for the child. Dr Blandine French And in terms  of psychological intervention,   you talked a little bit about cognitive training.  Can you explain to us what cognitive training is? Dr David Daley Sure. So, cognitive training  is all about training aspects of the child’s   executive functioning. So, we know from research  trials that a lot of children with ADHD have   difficulties with executive functioning. Not  all children with ADHD have difficulties,   but lots of children with ADHD have difficulties  with executive functioning. So, for instance,   they may have difficulties planning  or organisation, or working memory,   or inhibitory control. And cognitive training  is all – is about finding innovative ways to   practice these aspects of executive functioning.  So, it’s usually computer type games that children   can do again and again and again, that would  practice aspects of executive functioning. And until recently, there was very little  evidence that cognitive training impacted   on core ADHD symptoms. So, there’s a lot  of evidence, going back at least 20 years,   for what we call near transfer. So,  if you practice inhibitory control,   you might see that the child’s working  memory system gets a little bit better. So,   near transfer from one aspect of cognitive  training to another. But what’s been lacking   is any evidence of far transfer from practising  working memory to actually reductions in AD – to   improvements in ADHD symptoms, and that  evidence is beginning to change a little bit. So, until recently, the literature was saying,  “Actually, cognitive training doesn’t really work,   at all,” but now there may be some suggestions  that there may be some limited benefits in terms   of ADHD symptom improvement from  cognitive training. The challenge,   as always, is that it’s quite hard to do.  You – the child has to do a lot of it,   and although they’re presented as computer  type games, they’re often not very enjoyable   or entertaining, and so, often, parents struggle  to get children to do the cognitive training in   a – in as intensive a way as is necessary  in order for the child to see the benefits. Dr Blandine French So, we  mentioned cognitive training,   neurofeedback and we discussed  about parenting intervention. Is   there any other forms of non-pharmaceutical  intervention that we haven’t mentioned yet? Dr David Daley There’s no other core  psychological intervention that we   haven’t mentioned. There are other forms of  intervention that have some evidence for ADHD,   but most of them would be dietary, so they  wouldn’t be psychological interventions.