Dr Blandine French David, you gave an example of children who are really struggling to understand the difference between five minutes and five seconds, and in your example you were saying that, you know, the mother is on an important phone call, and she said to the child, you know, “Give me five minutes,” and the child doesn’t understand. We know that strategies work when parents can focus on addressing different behaviour, and in this example, I’m interested to know how the parent who has to do something really important, deal with the inevitable meltdown or barrage of questions from a child that doesn’t understand his mum has to be on the phone for the next five minutes? Dr David Daley Okay, so that’s a really interesting question. So, I think the first thing that’s really important is that for parents of children with ADHD to realise that a lot of the persistent interrupting that their children do when their parents have asked them to wait, arises because the child doesn’t understand time. And so, when the parent says, “This is a really important phone call, you know, I’ll make you a sandwich in five minutes,” when the child is interrupting after 20 seconds saying, you know, “I’m hungry, where’s the sandwich?” for the parent to realise that actually often the pare – the child thinks they have waited five minutes. And so it’s very good example of where both the parent and the child have the very best of intentions, but they often end up in conflict. The child gets annoyed because they feel like they’ve waited like the parent has asked them to, and the parent gets annoyed because they feel I’ve been really reasonable, I’ve asked them to wait for five minutes, and then after 20 seconds, they’re back interrupting my important phone call, and I’ve now totally forgotten what it is I was saying. So, in this situation, a better way to manage this situation is to have a visual cue for the child. So, for older children, the parent would say, “It’s 320 in the afternoon, so when the clock gets to 325,” you know, either it’s a digital clock or an analogue clock, “when it gets to 325, I’ll make you a sandwich.” For younger children who may not understand time, or be able to tell the time, we encourage parents to have timers, or even sand timers, like, giant egg timers. And you can buy these not just for three minutes, so that you can get the perfect boiled egg, but you can get them in different variations of time. And the parent would take the five minute sand timer, and they would say, “It’s a really important conversation, please don’t interrupt mummy, but when the sand is at the end, then I’ll make you your sandwich.” And so, that helps the parent achieve what they want to do, it helps the child learn to wait, but it also helps the child to follow the instruction, and it gives them a visual representation of time. And now, if the child gets impatient in the interim, rather than interrupt their parent, they just have to go back to the sand timer and think, urgh, actually, I’ve got a lot of time. I though that was five minutes, but most of the sand is still at the top, so that means I’ve got much longer to wait. But now, as a child with ADHD, who struggles to understand time, I have a much better understanding of how much longer it’s going to take until I get my sandwich. Dr Blandine French Thank you, David, that’s very useful. When you talk about parenting intervention, can you clarify, is it for one parent, is it enough for one parent to follow the strategies, or is it for both parents? And I’m, kind of, assuming that it would be better if both parents follow, you know, the strategies to help the child, but what if you are separated, or one parent follows the strategies and one parent doesn’t, does it make a big difference? Dr David Daley So, that’s also a really interesting question. So, of course, not all children have two parents living in the same house, so behavioural interventions are for as many parents who are willing to engage with them as possible. So, if you’re a single parent, then absolutely, it’s still for you, you’re more than welcome, and it will benefit you. When there’s more than one parent in the house, then ideally, we would encourage both parents to engage in the intervention, but that’s also sometimes not possible. You know, you – we have mothers who work, you know, nightshifts, we have dads who work away. Sometimes, you know, it’s just impossible for both parents to get time off work at the same time. So, in the situation where only one parent was available to come to the intervention, we would give resources and encourage and train the parent who attended, train them in how that they could share the key parts of the intervention, the take-home messages, with the other parent. And, generally, as you go through these interventions, we also encourage parents who learn strategies, not just to share the strategies with their partner, but to in – to share the strategies with anybody else who’s important in the child’s life. So, that could be the grandparents, it’s often the Teacher, but also, things like, you know, Soccer Coach, Swim Teacher, Cub Scout Master. Because the aim of psychological interventions for ADHD is to modify the child’s environment. We target parents because, for young children, they are the person who controls most of the child’s environment. When the child goes to school, part of that responsibility then passes to the Teacher, but all of these other people who might be involved in the child’s extracurricular activities also play a role, and so, we would be encouraging parents to also share the strategies with them. When you have parents who don’t agree, and you have one parent who acknowledges and accepts that their child has ADHD and wants to work hard to learn different ways of managing their child’s ADHD behaviour, and a partner who doesn’t, that is a very difficult situation. We still encourage parents to – we still encourage the parent who is help-seeking to engage in intervention, but often, those interventions are less successful. Because one of the aims of psychological interventions for ADHD is to actually enhance consistency in the child’s environment, and when you only have one parent who’s willing to implement the strategies, you end up actually creating extra inconsistency, and so, it sometimes can make things worse rather than better, or it certainly makes it harder for the strategies to work. And so, part of that would be helping – working with the one parent who was on board and helping them to get the other partner to engage. And I think you – and you can engage in lots of ways. So, for example, there are lots of interventions out there for ADHD where one partner might be engaging face-to-face with the Therapist, and the partner who’s less interested or less sure can engage in resources online via the interventions websites, or quite often there are self-help versions of the same intervention. So, with – for me, for example, I quite often work with one parent who will come along and meet with me face-to-face, the other parent, who’s less sure or less interested, might follow the self-help version of the intervention that I was offering. So, they can still engage in some way, and often, that lower level of engagement is better than no engagement at all. Dr Blandine French So, what kind of timeframe would you have to start seeing any benefits from parenting intervention? Is it something that happens quite quickly, or is it something that you’re going to have to practice over a long period of time before seeing any benefits? Dr David Daley Well, of course, all parents come to interventions for ADHD because they’re generally in a point of crisis, they feel like they need help. So, the hope amongst most parents it that everything will – that changes will happen quickly. And some changes do happen quite rapidly, in a couple of weeks. For example, in some interventions the very first strategy is about recruiting the child’s attention. And in the past, parents may have been using lots of really good parenting strategies, but if they haven’t recruited the child’s attention first, it kind – you could be the best parent in the world, it, kind of, doesn’t matter, ‘cause your child’s not listening. So, when you teach the parents to recruit the child’s attention first, there can be quite remarkable improvements in a week or two. However, for most of the other strategies, it does take some time for them to become implemented, and for them to effect change. If – again, if we remember, what we’re trying to do is get the parents to change their parenting style, to modify the child’s environment, and then the change you see in the child’s behaviour is the child’s response to that modified environment. And so, for most parents, I would say, don’t expect too much change in the child’s behaviour for at least six to eight or ten weeks. But you do see changes in parents’ behaviour much more quickly, and because parents are following a much more predictable routine, and they feel as if they have got lots of strategies that allow them to manage their child’s behaviour in lots of different ways, you often see large improvements in parents’ confidence and in their parenting self-esteem. So, even if the child’s behaviour hasn’t change yet, these interventions do make parents enjoy their parenting more, and it makes them feel as if they’re being better parents, and that happens – can happen quite quickly, in a matter of weeks. Dr Blandine French So, you know when you explained that it changes the parents’ way, is it aiming to change the parents’ way in the long-term? So, you just mentioned, for example, recruiting attention. Does it mean that once the parent has learned that, they will have to do it all the time, every time they want their child’s attention? Or is it a matter of doing it for a few months, and then the child will learn a different way, and the parents will not have to recruit the child’s attention at one point? Do you see what I mean? Is it a… Dr David Daley Yeah. Dr Blandine French …long-term thing, the strategies will have to be like this for all their parenting time, or is there a time when you can phase them out and maybe parent in a similar way that you would do your non-neurodiverse children? Dr David Daley So, that’s a great question, and it’s something that parents that I work with are always really worried about. They’re saying, “Am I going to have to still do this when he’s 30 years of age?” And the answer is no, but in terms of the strategies that are taught in behavioural interventions, the parents do have to use them a lot, and in a very structured way, for quite a long time. And they should do because they work, they help the child, but they also make the process of parenting that child so much more easy and so much more manageable. So, there’s lots of reasons why parents should carry on using them, even if it is extra effort, and even if it means they have to do lots of things that parents of children who don’t have ADHD don’t have to do. Over time, the child does gain some of these skills themselves, but the rate at which they gain them varies hugely from child to child. So, an example is strategies that help a child to calm down. So, when the child is quite young, we would be encouraging parents to anticipate when the child was becoming upset, to intervene early, before the child actually got upset, and to help the child to calm down. Over time, because parents do that, the child begins to recognise the early warning signs that they themselves are getting upset, and they begin to gain the skills to calm themselves down. And so, by parents working really hard on that strategy for maybe 18 months or two years, what they actually help their child to gain is self-regulation. And that’s what we’re really aiming for in the longer term here. We’re aiming for children with ADHD to gain self-regulatory skills so that they’re able to stay calm, they’re able to pay attention, they’re able to tolerate waiting, in no matter what situation they find themselves in the future. Dr Blandine French So, does it mean that, you know, by learning the strategies, then it impacts the symptoms of ADHD, such as attention, like you mentioned – so, does it mean that there would be a point where my child will stop experiencing inattention symptoms? If I put all these strategies in place, in the long-term, he will have no more – he or she will have no more inattention? Is that how it works? Dr David Daley Oh, I wish that’s how it worked. Sadly, no. So, what we’re talking about here is management. So, these children will grow up into adolescents and adults who will still experience the core symptoms of ADHD. What we are providing in behavioural interventions are ways in which parents can use strategies to modify their child’s environment to reduce the expression of ADHD symptoms, so to manage the core symptoms, and over time, help their children gain the skills so that they can manage the symptoms. The symptoms are probably always going to be there, but if we can help individuals gain regulatory skills, then although the symptoms are there, the impact of those symptoms is going to be reduced or go away. So, the sym – but you’ll always be inattentive, but you’ll find ways of managing your inattention so that it doesn’t impact on your ability to learn at school or your ability to stay focused in a work meeting or hold your job or lear – earn an income. So, that’s really what we’re focusing on, it’s about managing the symptoms. The symptoms are always going to be there. And in some ways, that’s a good things, because although lots of ADHD symptoms cause lots of problems for individuals with ADHD, sometimes there are also benefits to having those symptoms, and so, we wouldn’t necessarily want all of them to go away. I’ve often thought about how I would behave if I worked on the Stock Exchange. I’m a very cautious person, I don’t make decisions quickly, and if I was – if I worked on the Stock Exchange, I think by the time I decided whether I was going to buy or sell, the Stock Exchange would probably have closed. Whereas if I had ADHD, I’d be able to make rapid decisions, and I’d probably – my job would be very well suited to working on the Stock Exchange, because I would make really quick decisions, and I’d be able to sell quickly, and, hopefully, you would make more money than you lost and have a successful career. Whereas I’d be a disastrous person working on the Stock Exchange. I literally wouldn’t want to know what to do, but I’d want to spend all the time evaluating the pros and cons. And so, there are advantages to disadvantages to ADHD symptoms, as well, and so the focus is on managing them, rather than hoping that they will disappear. Dr Blandine French Thank you. So, you mentioned that, obviously, getting this parenting intervention as earlier as possible, you know, the earlier the parents come the better, is there any evidence that there’s an age where the parenting interventions stop working? Maybe, for example, in adolescence, when a child reach, you know, 14/15, is it still okay to implement similar intervention? And if not, what would a parent do if they start noticing ADHD symptoms are really – what would a parent do if they think that their 16 or 17-year-old has a – child has ADHD, if those interventions are not suitable? Dr David Daley Okay, so there’s lots of really interesting questions in there. So, first of all, we do know that when we look at the evidence base for how effective intervention – behavioural interventions for ADHD are in general, so not looking at any one specific intervention, but when we look across the evidence base for all interventions, there’s very clear evidence that age matters, and the younger the child, the more effective the intervention is. And that makes sense, because what we’re trying to do is provide parents with strategies to modify the child’s environment. And when your child is very young, you know, under the age of seven or eight, then parents pretty much control everything. They decide what the child wears and what the child eats and who they play with, and what school they go to. So, we’re really working with somebody who already has a lot of control over the child’s environment, and so, by training those parents, where they’re able to apply those skills. And because young children spent a lot of time with the parents, because it’s not safe for them to be out on their own, there’s lots of opportunity for the parents to modify the environment. When children get above the age of 11 or 12, and particularly here in the UK, that important transition from primary school to secondary school, they become a lot more independent. They usually, if they haven’t got a phone already, they have a phone at that point. They often get a, you know, a key to the front door. They’re allowed to go to school on their own, go on the bus or the train or walk or cycle, so they become more much independent. And at that point, the parent now has a lot less influence in the child’s environment. And in adolescence what becomes more important is the peer group. So, the peer group are what influence and dominate the child, whereas, previously, it was the parent and the Teacher. And therefore, behavioural interventions for ADHD are a lot less likely to be effective once the child gets into secondary school, because we’re, basically, working with – we’re targeting the wrong person. We’re training the parents, but the parents see the child a lot less and the child is a lot less responsive to the demands of the parent, because it’s the peer group that they’re influenced by. If you don’t realise your child has ADHD until adolescence, then there are very few interventions, unfortunately, out there that are evidence-based. There’s, basically, no psychological intervention that’s going to target core ADHD symptoms in adolescence, but there is some evidence for interventions that might target some of the consequences of having ADHD in adolescence. So, cognitive behavioural therapy, for instance, there is some evidence for CBT, but it’s – CBT isn’t addressing ADHD. CBT is addressing the thoughts and feelings that those adolescents have as a consequence of having ADHD, but nevertheless, that’s also very important. So, CBT won’t make you less impulsive or make you pay attention more, but it might reduce the risk of developing anxiety or depression as a consequence of having ADHD. Dr Blandine French Thank you. So, families with younger children, then, what kind of interventions are available? You mentioned parenting interventions, but, you know, what are they called and how do I access them? You know, as a mother, how would I go about receiving this support? You know, is it online, is it face-to-face, do I need to go through my healthcare professional? How does it work? Dr David Daley Well, it’s quite – unfortunately, it’s quite messy. So, there are lots of interventions that are available. Not all of the interventions that are available are evidence-based, unfortunately. That doesn’t mean they don’t work. It just means that nobody’s taken the time to do a research study to check whether they work or not, so we just don’t know. But of the evidence-based interventions that are available here in the UK and internationally, there are five or six. So, there is Incredible Years, Triple P, Parent Management Training, Helping the Noncompliant Child, 1-2-3 Magic, and New Forest Parenting Programme. So, there are lots of evidence-based interventions. The evidence base for them varies hugely. There’s actually very little evidence for 1-2-3 Magic for ADHD. There’s more evidence for IY and Triple P, and actually, New Forest Parenting Programme, which is a British based intervention, has the strongest evidence overall. Dr Blandine French And can I access them as a parent easily, you know, can I do a course online? Can I just search for these, and then I’ll be able to start this programme? Dr David Daley So, again, here in the UK, provision of support for parents of children with ADHD is patchy, so it does depend on what is available in your local area. So, most clinical services in the UK would offer one of these interventions. They don’t always offer them pre-diagnostically and post-diagnostically. So, in some areas, like I’m based in Nottingham, so in Nottingham, we have a variety of behavioural interventions for ADHD, and they are available pre-diagnostically and post-diagnostically. So, you can actually contact your GP and get a referral into a parenting group or individual one-to-one support before your child even has a diagnosis. So, having a concern that your child might have – might be at risk of ADHD, and a healthcare professionally saying, “Yes, they certainly look like they have some difficulties,” would be enough in order to get you access to some support. That support is offered in a number of ways. It can be one-to-one individual support, it can be a group, or it can be guided self-help, either face-to-face or online. So, lots of different things are offered here in Nottingham. In other parts of the country, the offer is less extensive, and in some areas, you have to seek an assessment and a diagnosis for the child before you can access psychological support. In other areas of the country getting access to behavioural interventions is a prerequisite for seeking a diagnosis. So, actually you can’t go forward to get an assessment and seek a diagnosis until after you’ve been on a parenting group. I think the rationale there is that – misguidedly, is that if everything improves just because you give the parents some parenting support, that it means the child doesn’t have ADHD. I’ve never quite worked out why it is that some services require that, but it varies hugely. And so, unfortunately, I’d love to be able to give a clear, easy message to any parent who might be watching this, but essentially, if your child is under the age of five, contact your Health Visitor here in the UK. If your child’s over the age of five, go and have a chat with your GP. Dr Blandine French Thank you, and my final question is around medication. So, are parenting interventions alone enough, or – you know, if I follow a parenting programme, does it mean I will – my child will not need any ADHD medication, or do they need to be given together, or is it one or the other, if I do the parenting programme, then I shouldn’t give my child medication? Dr David Daley Okay, so that’s a great question. It does depend slightly on the age of the child. So, you may remember previously that I said that behavioural interventions are more effective the earlier you start, and the evidence base for how good these interventions are goes down as low as three years of age. So, there have been loads of trials done here in the UK with three-year-old children who are at risk of ADHD. For medication, children are usually six years or above before they get offered medication. And the reason for that is just that there are very few trials that have trialled medication below the age of six. There have been a number in the United States, but those trials that have looked in medication in pre-school children have generally found that the medication works less effectively than in school age children, and usually has much higher levels of side effects. So, for a whole range of reasons, at least here in the UK, most Clinicians don’t want to try medication until the child is a little bit older. So, if we identify children at risk of ADHD in the pre-school period, then absolutely, it should be behavioural interventions as a first-line treatment, because the child is too young for anything else. Above the age of six, it really should be a combination, because often, when parents come looking for an assessment and a diagnosis for ADHD, they’re at a point of crisis. It may be that the school have said they can no longer handle this child and maybe the child’s at risk of being expelled, or the parents have reached the point where they can no longer manage or cope, usually because other things have also maybe happened at home at the same time. So, the parents might have – be having marital difficulties, or there may have been a bereavement. Other things have happened in the family that have eroded the parents’ ability to cope. So, parents are at a point of crisis, and at a point of crisis, we know that stimulant medication works really well for children over the age of six, and it can have an effect within 30 minutes. So, it can be, kind of, quite transformative on some of the core symptoms of ADHD. So, when you’re at a point of crisis, my recommendation would be, if you can access medication and it’s going to help immediately, then take that, while also working on a more long-term solution, like behavioural interventions, that do work, but we have to recognise they take a little bit of time before you start to see the benefits. And, also, I think we need to remember, and be empathic towards the parents of children with ADHD, because when they – when your child receives a diagnosis of ADHD, most parents are already exhausted. They’ve been parenting this child for a long time. They’ve not been quite sure why is it that parenting this particular child is so difficult. They’re not quite sure why everybody blames them and tells them they’re terrible parents. So, there are lots of reasons why these parents are also quite vulnerable. And behavioural interventions are effective and they do help, and I thoroughly recommend them, but they are a lot of effort. And so, if you can use medication initially to make everything – to make the child’s behaviour a little bit better, it reduces some stress in the family, and it gives the parent that little bit of breathing space in order to be able to find the resilience and the time and the effort to start working hard on acquiring behavioural strategies, as well. I like to think of it like hammer and heat. So, if you want to change the shape of a piece of metal, then you can take a hammer and you can pretty much heat it – you can pretty much take a hammer and you can hit it all day long, and it’s not really going to change its shape much. Or you can heat it up, but until you heat it up so much so that it turns to liquid, it’s also not going to change its shape. But if you heat that bit of metal up a little bit, and then you start hitting it with a hammer, then it’s quite easy to change its shape. And so, I think of medication as the heat. We give children stimulant medication and it heats them up, and then behavioural intervention is the hammer, and it helps the parent shape – change the child’s shape, so that they’re a better fit for what society expects of them, and the demands that are put on them in places like schools. Dr Blandine French Thank you very much, David.