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Nonpharmacological Interventions for Preschoolers With ADHD: The Case for Specialized Parent Training

Sonuga-Barke, Edmund J. S. PhD; Thompson, Margaret MD; Abikoff, Howard PhD; Klein, Rachel MD; Brotman, Laurie Miller PhD

Section Editor(s): WOLRAICH, MARK L.

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Developmental Brain-Behaviour Unit, University of Southampton, UK (Drs Sonuga-Barke and Thompson); and the Child Study Center, New York University, NY (Drs Sonuga-Barke, Abikoff, Klein, and Brotman).

Corresponding author: Edmund J. S. Sonuga-Barke, PhD, Developmental Brain-Behaviour Unit, University of Southampton, University Rd, Southampton, SO17 1BJ, UK (e-mail: ejb3@soton.ac.uk).

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The past decade witnessed an increased use of stimulants for the treatment of attention-deficit/hyperactivity disorder (ADHD) in preschool children. However, the reluctance of parents of preschoolers to place their young children on stimulants (S. H. Kollins, 2004) coupled with the paucity of information regarding the long-term effects of stimulants in preschoolers makes the development and testing of nonpharmacological treatments for preschoolers with ADHD a major public health priority. This article addresses this issue. First, we highlight issues relating to the existence of ADHD in preschoolers as a clinically significant condition and the need for effective treatment. Second, we examine issues related to the use of pharmacological therapies in this age group in terms of efficacy, side effects, and acceptability. Third, we discuss existing nonpharmacological interventions for preschoolers and highlight the potential value of parent training in particular. Finally, we introduce one candidate intervention, the New Forest Parenting Package, and present initial evidence for its clinical value as well as data on potential barriers and limitations.

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) is a chronic condition, associated with impairments in multiple domains and long-term educational and vocational disadvantage, social exclusion, delinquency, and substance abuse (Swanson et al., 1998). The ADHD diagnosis is most commonly made when children reach middle childhood (around 7 years), but onset is typically during the preschool years. Recently, there has been an increase in the diagnosis of ADHD among preschool children (ie, younger than 5 years), as well as a 3-fold increase in prescriptions for psychopharmacological treatment in preschoolers (Zito et al., 2000). This trend has occurred despite uncertainties about efficacy, short- and long-term side effects, and general misgivings about treating very young children with psychotropic medications (Volkow & Insel 2003; Zito et al., 2000). This situation is likely due, in part, to the lack of efficacious nonpharmacological alternatives for use as frontline therapies for ADHD in general, and especially in the preschool period. This article addresses the current state of affairs regarding interventions for treating preschool ADHD by assessing the veracity of 4 basic propositions relating to preschool ADHD and its treatment. These propositions are that (i) preschool ADHD is a valid disorder that is associated with significant impairment and burden for the family; (ii) preschool ADHD is a risk factor for later serious psychopathology; (iii) pharmacotherapies commonly used with older children are regarded as unacceptable for young children by parents and clinicians; and (iv) initial evidence supports the efficacy of a nonpharmacological therapy, the New Forest Parenting Package (NFPP), as a candidate frontline treatment for preschool ADHD.

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ADHD among school-aged children has clinical and scientific utility (Sonuga-Barke et al., 2004). Symptoms of impulsivity, hyperactivity, and inattention cluster together, are associated with significant impairment, and can be distinguished from other conditions (Burns, Walsh, Owen, & Snell, 1997; Hinshaw, 2002; Sonuga-Barke, 1998; Tannock, 1998). A growing literature supports the validity of preschool ADHD as a disorder dimension by suggesting that the symptom structure, patterns of associated deficits, impairment, and neuropsychological characteristics are common to school-aged and preschool-aged children with ADHD (Sonuga-Barke, Dalen, & Ramington, 2003). This view is supported by factor analytic studies of large population-based samples of children (Fantuzzo et al., 2001; Pavuluri & Luk, 1998; Sonuga-Barke, Thompson, Stevenson, & Viney, 1997), and analyses of the internal consistency and clinical validity of preschool ADHD rating scales (Gadow & Nolan, 2002; Miller, Koplewicz, & Klein, 1997). There is evidence that subtypes of ADHD in preschoolers map on to their school-aged equivalents (Lahey et al., 1998). Patterns of comorbidity associated with preschool ADHD (particularly with conduct problems) parallel those observed in older children (Wilens et al., 2002). The clinical significance of preschool ADHD is demonstrated by its association with marked impairment across a number of domains. First, there is a consistent association with mild intellectual and language impairment, and poor preacademic skills (Gadow & Nolan, 2002; Shelton et al., 1998; Sonuga-Barke, Lamparelli, Stevenson, Thompson, & Henry, 1994). Second, preschool children with ADHD have more motor coordination problems and have more accidents than do their non-ADHD peers (Lahey et al., 1998). Third, young children with ADHD have deficits in social skills, especially in social cooperation (Merrell & Wolfe, 1998) and friendships (Lahey et al., 1998). They also experience problematic interactions with their parents and other relatives (Daley, Sonuga-Barke, & Thompson, 2003; DuPaul, McGoey, Eckert, & VanBrakle, 2001), which contribute to high levels of familial stress, which, in turn, exacerbate mental health problems among family members (DeWolfe, Byrne, & Bawden, 2000). Clinical diagnostic descriptors and thresholds may need to be refined in the future to take account of the context and demands of the preschool period (Brotman & Gouley, in press). However, existing data generally support the use of Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV) criteria for diagnosis in this age group (Ghuman, 2004; Lahey et al., 1994, 2004).

Longitudinal studies of transition from preschool to school suggest that ADHD is relatively stable (Lavigne et al., 1998; Mathiesen & Sanson, 2000; Sonuga-Barke et al., 1997). In high-risk and clinical samples, persistence is particularly marked (Campbell, Pierce, March, Ewing, & Szumowski, 1994; Lavigne et al., 1998; Marakovitz & Campbell, 1998). The persistence of ADHD in 4–6-year-olds (N = 255) who met rigorous diagnostic and impairment criteria has been reported (Lahey et al., 2004). Over the ensuing 3 years, nearly all continued to meet full diagnostic criteria for ADHD and to display cross-situational impairment. As early as age 3, severity of ADHD is the most significant indicator of chronicity into middle childhood. ADHD severity in preschoolers also predicts the emergence of oppositional defiant disorder (ODD). The combination of ODD and ADHD predicts the persistence of both disorders into middle childhood (Campbell et al., 1994; DuPaul et al., 2001; Keenan & Wakschlag, 2000; Speltz, McClellan, DeKlyen, & Jones, 1999). This most likely reflects an interaction of a genetically based predisposition toward poor regulation of affect and impulses (Arseneault et al., 2003; Caspi, Henry, Mcgee, Moffitt, & Silva, 1995) and the social environment. Negative parenting (coercive, overstimulating, intrusive, and restrictive) expressed from the first year of life onwards is linked to both homotypic (continuation of ADHD) and heterotypic continuity (emergence of other problems; Jacobvitz & Sroufe, 1987; Morrell & Murray, 2003; Olson, Bates, & Bayles, 1990; Olson, Bates, Sandy, & Schilling, 2002). Such findings are typically interpreted as resulting from reciprocal parent-child effects: toddlers who are negative, poorly regulated, and challenging for parents elicit a negative response from parents. In turn, these negative responses maintain children's early defiant and impulsive behavior. This view is consistent with a growing literature that reports that the combination of child negativity and harsh parenting is associated with increases in externalizing behavior problems in young children (Bates, Dodge, Pettit, & Ridge, 1998; Belsky, 1999; Belsky, Hsieh, & Crnic, 1998; Brook, Tseng, & Cohen, 1996; DeKlyen, Speltz, & Greenberg, 1998; MacKinnon-Lewis, Starnes, Volling, & Johnson, 1997; O'Leary, Slep, & Reid, 1999; Rubin, Burgess, Dwyer, & Hastings, 2003; Smith, Calkins, Keane, Anastopoulos, & Shelton, 2004). This pattern suggests that positive and constructive parenting, in the face of challenging child behavior, has the potential to prevent negative child outcomes. This transactional model underscores the importance of socialization processes in either helping young children overcome their difficulties or exacerbating problems by fuelling anger, noncompliance, and poor impulse control (Bates et al., 1998; Belsky et al., 1998; Campbell, 2002; Kochanska, 1997). In summary, preschool ADHD causes significant impairment for the child and burden for the family. It represents an early manifestation of school-aged ADHD and a significant risk factor for the emergence of other impairing conditions. For these reasons, preschool ADHD represents an important intervention target.

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For school-aged children with ADHD, psychostimulant medication is the treatment of choice. Stimulants effectively control symptoms and reduce associated impairment in 75% to 80% of children (Daley, 2004). In the Multimodal Treatment of ADHD study (MTA), medication was superior in reducing ADHD symptoms when compared to an intensive psychosocial intervention and a community care control group (MTA Cooperative Group, 1999). A small number of studies have reported efficacy of psychostimulants in preschool ADHD; these have varied in design, quality, and size. Few published trials have included children younger than 4. Most placebo-controlled trials report beneficial effects in terms of symptom control as well as reductions in impairment. Barkley (1988) reported that stimulants improve the quality of interactions between preschoolers and their mothers. Monteiro-Musten, Firestone, Pisterman, Bennett, and Mercer (1997) found that stimulants increased preschoolers' attention, decreased impulsiveness, and improved adjustment but not compliance with parental requests. Byrne, Bawden, DeWolfe, and Beattie (1998) reported that stimulants improved behavior and significantly reduced errors of omission on visual and auditory vigilance tests. Short, Manos, Findling, and Schubel (2004) found a clinically significant reduction (≥1 SD) in ADHD symptoms in 82% (N = 28) of preschoolers treated with stimulants. Initial results from the large-scale multisite Preschool ADHD Treatment Study (PATS; Greenhill, 2004) indicate that methylphenidate is efficacious in reducing ADHD and ODD symptoms (Kollins, 2004). There are currently no data on the longer term benefits in preschool-aged children. While most recent studies suggest that methylphenidate is relatively well-tolerated by young children, some suggest that side effects might be more marked in preschoolers than in school-aged children (Firestone, Musten, Pisterman, Mercer, & Bennett, 1998). Furthermore, some researchers have argued that there is the potential for negative long-term effects on the developing brains of young children chronically medicated (Moll, Rothenberger, Ruther, & Huther, 2002).

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Acceptance by parents and clinicians

While the value of stimulant medication for the treatment of ADHD in school-aged children is well established, there is a substantial minority of parents and clinicians who have reservations about its use (Rushton, Fant, & Clark, 2004). Fifty-five percent of parents whose school-aged children take medication reported initial hesitation due to concerns over side effects and negative press reports (DosReis et al., 2003). In the NY/Montreal multimodal treatment study of 7–9-year-old children with ADHD, 25% of parents who inquired about the study indicated an unwillingness to consider medication treatment for their child. Moreover, an additional 12% who consented to participate did not because of antimedication attitudes (Klein, Abikoff, Hechtman, & Weiss, 2004). No systematic analysis has been published on parent and clinician attitudes toward the use of stimulants for ADHD in preschoolers. Clinical reports, however, suggest that the younger the child the greater the resistance. In the PATS study of methylphenidate, a substantial proportion of potential cases could not be included because of strong antimedication concerns. Reasons included unknown long-term effects of stimulant treatment in preschoolers, and a desire for nonpharmacological treatment.

In summary, available data suggest that preschoolers with ADHD can be successfully treated with psychostimulant medication but the public's concerns over its use mean that many parents and clinicians will not use psychostimulants for preschool ADHD. Thus, although preschool ADHD is a serious condition that often persists into middle childhood and is a risk for other disorders, use of effective treatments is likely to be limited by concerns about stimulant medication in young children.

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In view of the above, the development of effective nonpharmacological therapies for treating preschool ADHD represents a major public health priority. The use of psychosocial approaches for the treatment of ADHD has a long history, and there are some data from controlled trials demonstrating their potential to reduce ADHD symptoms (Pelham, Wheeler, & Chronis, 1998). However, most trials report minimal effects on core symptoms (reviewed in Hinshaw, Klein, & Abikoff, 1998, 2002; McGoey, Eckert, & Dupaul, 2002). Consequently, psychosocial approaches are currently not recommended as stand-alone, frontline treatments for ADHD (American Academy of Child & Adolescent Psychiatry, 1997; American Academy of Pediatrics, 2000). Instead, they are considered as a component in a multimodal strategy that targets the broader range of behavioral and emotional problems that frequently accompany the disorder.

Two characteristics of current standard psychosocial approaches (SPAs) might explain their limited impact on ADHD. First, SPAs use techniques based upon generic theories of behavior management developed out of operant and social learning theory. In these models, parents and teachers are taught ways to manage the overt oppositional behavior associated with ADHD through the setting of rules and the effective management of contingencies (rewards and punishments) (Barkley et al., 2000). Although these types of interventions are highly effective in the treatment and prevention of conduct problems (Kazdin & Wassell, 2000; Wasserman & Miller, 1998), they do not target the putative dysfunctions underlying ADHD. Neither have they addressed the sociodevelopmental processes (mediated by the quality of parent-child interaction in creating so-called zones of proximal development and scaffolding the development of attentional skills) that play an important role in promoting psychological development in the relevant domains of attention, impulse control, and self-organization during early childhood (Crandell & Hobson, 1999; Puckering, Pickles, Skuse, & Heptinstall, 1995). Second, SPAs for the treatment of ADHD are often introduced relatively late, during middle childhood, after school entry, when the impact of ADHD has almost invariably become complicated and compounded by school failure and behavior problems and associated low self-esteem (Slomkowski, Klein, & Mannuzza, 1995), as well as a hardening of parental and teacher attitudes to children with ADHD. Consequently, ADHD may be intrinsically more difficult to treat using nonpharmacological means in middle childhood than it is in the preschool period.

A number of parenting programs have been shown to reduce conduct problems (not ADHD) in 2–5-year-old children (Parent-Child Interaction Therapy [Eyberg, Boggs, & Algina, 1995]; Incredible Years [Webster-Stratton, Reid, & Hammond, 2004]; Helping the Noncompliant Child [Forehand & McMahon, 1981]). Recently, it has been shown that SPAs are equally effective when used with 4–7-year-old children with conduct problems with or without attentional problems (Hartman, Stage, & Webster-Stratton, 2003). In nonclinical groups of preschoolers with behavior problems, parent training has resulted in significant reductions in oppositional behavior and improvements in parent-rated attention (Bor, Sanders, & Markie-Dadds, 2002; Strayhorn & Weidman, 1989). However, evaluation of changes in school behavior to assess generalization across settings was not done (Bor et al., 2002), or was not significant (Strayhorn & Weidman, 1989). Notably, these studies provide little evidence that SPAs represent an effective treatment for preschool ADHD per se. Barkley et al. (2000) evaluated a comprehensive group intervention format for parents from a community-derived sample of disruptive preschoolers with high levels of hyperactive, impulsive, and inattentive behavior. Parent training did not result in significant treatment effects. Problematically, attendance was limited; fewer than half the families attended at least 50% of sessions, and nearly a third did not attend any session at all. In randomized trials with clinical samples of children with ADHD, tailored combinations of parenting and family intervention for school-aged children (Hoath & Sanders, 2002) or parent training contingency management approaches that target noncompliance and disruptive behaviors in preschoolers with ADHD (Pisterman et al., 1989, 1992) have not reduced ADHD symptoms.

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The NFPP is a specialized ADHD psychosocial intervention that builds on the approaches used in preschool SPAs by combining behavior management techniques with a novel therapeutic component targeted directly at those parent-child processes thought to play a mediating role in the development of attentional and self-organizing skills. This model is based on the developmental literature relating to the important role played by constructive and reciprocal parent-child interactions during the preschool years in the psychological development of attention and impulse control. In particular, children of parents who engage in reciprocal, sensitive, and positive interactions, and effectively scaffold and motivate their child's attention and self-organization, display a developmental advantage over children of parents who do not (Connell & Prinz, 2002; Wacharasin, Barnard, & Spieker, 2003). Specifically, parents need to be supportive, aware of the child's developmental level, and set appropriate and challenging goals (Gauvain & Fagot, 1995). Key treatment goals in NFPP include (i) the reduction of parental negative reactions; (ii) the promotion of appropriate limit setting as a basis for authoritative parenting; (iii) an increase in both the quality and quantity of positive and constructive interaction between the parent and the child; and (iv) tailored motivation and scaffolding of attention and self-organizational competencies. Figure 1 presents a schematic description of the structure of the NFPP as it is currently formulated in terms of its goals and specific treatment targets and the week-by-week setting for training.

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We have compared the efficacy of a version of this package when delivered as an 8-week home-based intervention. Seventy-eight 3-year-old children identified from a general population of more than 3000 children who met modified criteria for ADHD entered the study. These children were randomly assigned to 1 of 3 conditions: parent training (n = 30), an active parent counselling and support control condition (n = 28) or a wait-list control (n = 20). Both treatments were delivered over 8 weeks with weekly 1-hour sessions in the family home. Treatment was delivered by skilled specialist nurse-therapists. They had extensive experience of working with families of young children with ADHD. Parent training focused on the management of ADHD symptoms and the promotion of improved attention and self-regulation. The control condition excluded any focus on management or parenting skills, and consisted of nonspecific support. Treatment integrity as rated by independent observers was very high (96% correct designation of treatment sessions). Measures were obtained at baseline, immediately posttreatment, and at 15 weeks follow-up. Objective measures were conducted in the homes by a researcher blind to treatment condition. Based on an intention to treat design, analyses of covariances indicated a main effect of treatment on ADHD symptoms and maternal well-being (Fs > 10.30; P < .001). The NFPP was superior to the wait-list control (Fs > 17.00; P < .001) and active attention control condition (Fs > 8.40; P < .01) on both indices. The effect sizes for NFPP impact on ADHD against wait-list control were 0.87 (parent reports) and 0.43 for direct observations of attention. Fifty-three percent of children receiving the NFPP showed normalized behavior after treatment as compared to 25% of those in the wait-list control group (P < .05).

Following the positive results obtained in the first study, the next investigation tested whether similar positive results were obtainable with the NFPP when delivered by nonspecialist nurses given brief training (Sonuga-Barke, Thompson, Daley, & Laver-Bradbury, in press). Using a protocol identical to that previously used, 69 children out of 3409 screened participated, with 59 randomized to parent training and 10 to a wait-list control group. Program content of parent training was identical to that used in the first trial, but program delivery and training of interventionists differed. In this trial, the program was delivered by 16 nonspecialist nurses randomly selected from a large pool. Training consisted of a 2½ day in-service course. Unlike the first trial, there was no significant improvement in ADHD symptoms with the NFPP. A qualitative analysis suggested that children treated by nurses with experience working with preschoolers with ADHD had better outcomes. However, the study was not powered to assess therapist effects. Also, the small n in the control group may have limited power.

Secondary analysis of data from the 2 trials was undertaken to identify parent and child characteristics that might predict effectiveness of the NFPP (Sonuga-Barke, Daley, & Thompson, 2002). On the basis of the clinical observation that adults with ADHD often experience difficulties in parenting, we focused on the status of parental symptoms of ADHD as a potential barrier to treatment (Weiss, Hechtman, & Weiss, 2000). It has been suggested that parental inconsistency and reactivity (perhaps driven by impulsiveness) and organizational and planning difficulties (perhaps driven by inattention) result in an inconsistent and disorganized parenting style, exacerbating children's problems (Sonuga-Barke, Daley, Thompson, Laver-Bradbury, & Weeks, 2001) and presenting a significant barrier to effective management of a child with ADHD (Evans, Vallano, & Pelham, 1994). Mothers' scores on the adult AD/HD Rating Scale (AARS; Barkley & Murphy, 1998) in the 2 trials were trichotomized. A comparison of NFPP efficacy across these 3 groups showed that while children in the low maternal ADHD group displayed a marked and statistically significant reduction of ADHD symptoms following the NFPP, those in the high ADHD group showed little or no change (parental ADHD Group by Time interaction term: F4,160 = 3.13; P < .05). These effects remained even when other parent and child factors, such as maternal health, parenting satisfaction, and efficacy, and baseline levels of child behavior problems (other than ADHD) were controlled. Additional support for the influence of maternal ADHD on parent intervention outcomes comes from a recent study indicating that parent training is relatively less effective in children with ADHD with parents with elevated ADHD scale scores (Harvey et al., 2003).

In summary, when delivered by experienced and specialist therapists, the NFPP leads to clinically significant reductions in ADHD symptoms and improvements in maternal well-being. The effects on ADHD were clinically meaningful and in the range of those shown with stimulants in preschoolers. These effects were maintained at 15 weeks follow-up. This study provides the best evidence to date of the potential of parent-based interventions to reduce ADHD symptoms in preschool children with an ADHD equivalent. Parental ADHD symptoms appear to be a significant barrier to the implementation of the package.

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Preschool ADHD presents a major target for clinical intervention. Although pharmacological interventions are potentially efficacious, there is controversy around their use in young children. Effective nonpharmacological interventions are required to provide alternative treatment options for parents and clinicians. The NFPP, which integrates cognitive-behavioral parent management training with parenting skills based on the developmental literature related to attention and regulation, represents one candidate specialist parenting intervention. Initial trial evidence supports the efficacy of the NFPP. Further studies are required to (1) replicate findings, particularly with preschoolers systematically diagnosed with ADHD according to DSM-IV criteria; (2) demonstrate maintenance over time; and (3) show generalization to school and peer group settings.

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American Academy of Child & Adolescent Psychiatry. (1997). Practice parameters for the assessment and treatment of children, adolescents, and adults with attention-deficit/hyperactivity disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 36, 85S–121S.

American Academy of Pediatrics. (2000). Clinical practice guidelines: Diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics, 105, 1158–1170.

Arseneault, L., Moffitt. T. E., Caspi, A., Taylor, A., Rijsdijk, F. V., Jaffee, S. R., et al. (2003). Strong genetic effects on cross-situational antisocial behaviour among 5-year-old children according to mothers, teachers, examiner-observers, and twins' self-reports. Journal of Child Psychology and Psychiatry and Allied Disciplines, 44, 832–848.

Barkley, R. A. (1988). The effects of methylphenidate on the interactions of preschool ADHD children with their mothers. Journal of the American Academy of Child & Adolescent Psychiatry, 27, 336–341.

Barkley, R. A., & Murphy, K. R. (1998). Attention-deficit hyperactivity disorder: A clinical workbook (2nd ed.). New York: Guilford Press.

Barkley, R. A., Shelton, T. L., Crosswait, C., Moorehouse, M., Fletcher, K., Barrett, S., et al. (2000). Multi-method psycho-educational intervention for preschool children with disruptive behavior: Preliminary results at post-treatment. Journal of Child Psychology and Psychiatry and Allied Disciplines, 41, 319–332.

Bates, J. E., Dodge, K. A., Pettit, G. S., & Ridge, B. (1998). Interaction of temperamental resistance to control and restrictive parenting in the development of externalizing behavior. Developmental Psychology, 34, 982–995.

Belsky, J. (1999). Quantity of nonmaternal care and boys' problem behavior/adjustment at ages 3 and 5: Exploring the mediating role of parenting. Psychiatry-Interpersonal and Biological Processes, 62, 1–20.

Belsky, J., Hsieh, K. H., & Crnic, K. (1998). Mothering, fathering, and infant negativity as antecedents of boys' externalizing problems and inhibition at age 3 years: Differential susceptibility to rearing experience? Development and Psychopathology, 10, 301–319.

Brotman, L., & Gouley, K. (in press). Clinical assessment of preschoolers—Special issues. In K. McBurnett, L. Pfiffner, R. Schacher, G. Elliot, & J. Nigg (Eds.), Attention deficit hyperactivity disorder. New York: Marcel Dekker.

Bor, W., Sanders, M. R., & Markie-Dadds, C. (2002). The effects of the Triple P-Positive Parenting Program on preschool children with co-occurring disruptive behavior and attentional/hyperactive difficulties. Journal of Abnormal Child Psychology, 30, 571–587.

Brook, J. S., Tseng, L. J., & Cohen, P. (1996). Toddler adjustment: Impact of parents' drug use, personality, and parent–child relations. Journal of Genetic Psychology, 157, 281–295.

Burns, G. L., Walsh, J. A., Owen, S. M., & Snell, J. (1997). Internal validity of attention deficit hyperactivity disorder, oppositional defiant disorder, and overt conduct disorder symptoms in young children: Implications from teacher ratings for a dimensional approach to symptom validity. Journal of Clinical Child Psychology, 26, 266–275.

Byrne, J. M., Bawden, H. N., DeWolfe, N. A., & Beattie, T. L. (1998). Clinical assessment of psychopharmacological treatment of preschoolers with ADHD. Journal of Clinical and Experimental Neuropsychology, 20, 613–627.

Campbell, S. B. (2002). Behavior problems in preschool children: Clinical and developmental issues (2nd ed.) New York: Guilford Press.

Campbell, S. B., Pierce, E. W., March, C. L., Ewing, L. J., & Szumowski, E. K. (1994). Hard-to-manage preschool boys: Symptomatic behavior across contexts and time. Child Development, 65, 836–851.

Caspi, A., Henry, B., Mcgee, R. O., Moffitt, T. E., & Silva, P. A. (1995). Temperamental origins of child and adolescent behavior problems: From age 3 to age 15. Child Development, 66, 55–68.

Connell, C. M., & Prinz, R. J. (2002). The impact of childcare and parent–child interactions on school readiness and social skills development for low-income African American children. Journal of School Psychology, 40, 177–193.

Crandell, L. E., & Hobson, R. P. (1999). Individual differences in young children's IQ: A social-developmental perspective. Journal of Child Psychology and Psychiatry and Allied Disciplines, 40, 455–464.

Daley, D., Sonuga-Barke, E. J. S., & Thompson, M. (2003). Assessing expressed emotion in mothers of preschool AD/HD children: Psychometric properties of a modified speech sample. British Journal of Clinical Psychology, 42, 53–67.

Daley, K. C. (2004). Update on attention-deficit/ hyperactivity disorder. Current Opinion in Pediatrics, 16, 217–226.

DeKlyen, M., Speltz, M. L., & Greenberg, M. T. (1998). Fathering and early onset conduct problems: Positive and negative parenting, father–son attachment, and the marital context. Clinical Child and Family Psychology Review, 1, 3–21.

DeWolfe, N. A., Byrne, J. M., & Bawden, H. N. (2000). ADHD in preschool children: Parent-rated psychosocial correlates. Developmental Medicine and Child Neurology, 42, 825–830.

DosReis, S., Zito, J. M., Safer, D. J., Soeken, K. L., Mitchell, J. W., Jr., & Ellwood, L. C. (2003). Parental perceptions and satisfaction with stimulant medication for attention-deficit hyperactivity disorder. Journal of Developmental & Behavioral Pediatrics, 24, 155–162.

DuPaul, G. J., McGoey, K. E., Eckert, T. L., & VanBrakle, J. (2001). Preschool children with attention-deficit/hyperactivity disorder: Impairments in behavioral, social, and school functioning. Journal of the American Academy of Child & Adolescent Psychiatry, 40, 508–515.

Evans, S. W., Vallano, G., & Pelham, W. (1994). Treatment of parenting behavior with a psychostimulant: A case-study of an adult with attention-deficit hyperactivity disorder. Journal of Child and Adolescent Psychopharmacology, 4, 63–69.

Eyberg, S. M., Boggs, S. R., & Algina, J. (1995). Parent–child interaction therapy: A psychosocial model for the treatment of young children with conduct problem behavior and their families. Psychopharmacology Bulletin, 31, 83–91.

Fantuzzo, J., Grim, S., Mordell, M., McDermott, P., Miller, L., & Coolahan, K. (2001). A multivariate analysis of the revised Conners' Teacher Rating Scale with low-income, urban preschool children. Journal of Abnormal Child Psychology, 29, 141–152.

Firestone, P., Musten, L. M., Pisterman, S., Mercer, J., & Bennett, S. (1998). Short-term side effects of stimulant medication are increased in preschool children with attention-deficit/hyperactivity disorder: A double-blind placebo-controlled study. Journal of Child and Adolescent Psychopharmacology, 8(1), 13–25.

Forehand, R. L., & McMahon, R. J. (1981). Helping the noncompliant child: A clinician's guide to parent training. New York: The Guilford Press.

Gadow, K. D., & Nolan, E. E. (2002). Differences between preschool children with ODD, ADHD, and ODD plus ADHD symptoms. Journal of Child Psychology and Psychiatry and Allied Disciplines, 43, 191–201.

Gauvain, M., & Fagot, B. (1995). Child temperament as a mediator of mother toddler problem-solving. Social Development, 4, 257–276.

Ghuman, J. K., for the PATS Study Group. (2004, June). Diagnosing ADHD in preschool children. Paper presented at the annual meeting of the New Clinical Drug Evaluation Unit (NCDEU), Phoenix, AZ.

Greenhill, L. L. (2004, August). Advances in ADHD: Preschool diagnosis and management. Paper presented at the annual meeting of the American Academy of Child and Adolescent Psychiatry, Berlin, Germany.

Hartman, R. R., Stage, S. A., & Webster-Stratton, C. (2003). A growth curve analysis of parent training outcomes: Examining the influence of child risk factors (inattention, impulsivity, and hyperactivity problems), parental and family risk factors. Journal of Child Psychology and Psychiatry and Allied Disciplines, 44, 388–398.

Harvey, E., Danforth, J. S., Eberhardt McKee, T., Ulaszek, W. R., & Friedman, J. L. (2003). Parenting of children with attention-deficit hyperactivity disorder (ADHD): The role of parental ADHD symptomatology. Journal of Attention Disorders, 7, 31–42.

Hinshaw, S. P. (2002). Process, mechanism, and explanation related to externalizing behavior in developmental psychopathology. Journal of Abnormal Child Psychology, 30, 431–446.

Hinshaw, S. P., Klein, R. G., & Abikoff, H. (1998). Childhood attention-deficit hyperactivity disorder: Nonpharmacologic and combination approaches. In P. E. Nathan & J. M. Gorman (Eds.), A guide to treatments that work (pp. 27–41). New York: Oxford University Press.

Hinshaw, S. P., Klein, R. G., & Abikoff, H. (2002). Childhood attention-deficit hyperactivity disorder: Nonpharmacologic treatments and their combination with medication. In P. E. Nathan & J. M. Gorman (Eds.), A guide to treatments that work (pp. 1–23). New York: Oxford University Press.

Hoath, F. E., & Sanders, M. R. (2002). A feasibility study of enhanced group Triple P-Positive Parenting Program for parents of children with attention-deficit/hyperactivity disorder. Behaviour Change, 19, 191–206.

Jacobvitz, D., & Sroufe, L. A. (1987). The early caregiver–child relationship and attention-deficit disorder with hyperactivity in kindergarten: A prospective-study. Child Development, 58, 1496–1504.

Kazdin, A. E., & Wassell, G. (2000). Therapeutic changes in children, parents, and families resulting from treatment of children with conduct problems. Journal of the American Academy of Child & Adolescent Psychiatry, 39, 414–420

Keenan, K., & Wakschlag, L. S. (2000). More than the terrible twos: The nature and severity of behavior problems in clinic-referred preschool children. Journal of Abnormal Child Psychology, 28, 33–46.

Klein, R. G., Abikoff, H., Hechtman, L., & Weiss, G. (2004). Design and rationale of controlled study of long-term methylphenidate and multimodal psychosocial treatment in children with ADHD. Journal of the American Academy of Child & Adolescent Psychiatry, 43, 792–801.

Kochanska, G. (1997). Mutually responsive orientation between mothers and their young children: Implications for early socialization. Child Development, 68, 94–112.

Kollins, S. H., for the PATS Study Group. (2004, June). Preschool ADHD Treatment Study (PATS). Paper presented at the annual meeting of the New Clinical Drug Evaluation Unit (NCDEU), Phoenix, AZ.

Lahey, B. B., Applegate, B., McBurnett, K., Biederman, J., Greenhill, L., Hynd, G. W., et al. (1994). DSM-IV field trials for attention-deficit hyperactivity disorder in children and adolescents. American Journal of Psychiatry, 151, 1673–1685.

Lahey, B. B., Pelham, W. E., Loney, J., Kipp, H., Erhardt, A., Lee, S. S., et al. (2004). Three year predictive validity of DSM-IV attention-deficit/hyperactivity disorder in children diagnosed at 4–6 years of age. American Journal of Psychiatry, 161, 2014–2020.

Lahey, B. B., Pelham, W. E., Stein, M. A., Loney, J., Trapani, C., Nugent, K., et al. (1998). Validity of DSM-IV attention-deficit/hyperactivity disorder for younger children. Journal of the American Academy of Child & Adolescent Psychiatry, 37, 695–702.

Lavigne, J. V., Arend, R., Rosenbaum, D., Binns, H. J., Christoffel, K. K., & Gibbons, R. D. (1998). Psychiatric disorders with onset in the preschool years: I. Stability of diagnoses. Journal of the American Academy of Child & Adolescent Psychiatry, 37, 1246–1254.

MacKinnon-Lewis, C., Starnes, R., Volling, B., & Johnson, S. (1997). Perceptions of parenting as predictors of boys' sibling and peer relations. Developmental Psychology, 33, 1024–1031.

Marakovitz, S. E., & Campbell, S. B. (1998). Inattention, impulsivity, and hyperactivity from preschool to school age: Performance of hard-to-manage boys on laboratory measures. Journal of Child Psychology and Psychiatry and Allied Disciplines, 39, 841–851.

Mathiesen, K. S., & Sanson, A. (2000). Dimensions of early childhood behavior problems: Stability and predictors of change from 18 to 30 months. Journal of Abnormal Child Psychology, 28, 15–31.

McGoey, K. E., Eckert, T. L., & Dupaul, G. J. (2002). Early intervention for preschool-age children with ADHD: A literature review. Journal of Emotional and Behavioral Disorders, 10, 14–28.

Merrell, K. W., & Wolfe, T. M. (1998). The relationship of teacher-rated social skills deficits and ADHD characteristics among kindergarten-age children. Psychology in the Schools, 35, 101–109.

Miller, L. S., Koplewicz, H. S., & Klein, R. G. (1997). Teacher ratings of hyperactivity, inattention, and conduct problems in preschoolers. Journal of Abnormal Child Psychology, 25, 113–119.

Moll, G. H., Rothenberger, A., Ruther, E., & Huther, G. (2002). Developmental psychopharmacology in child and adolescent psychiatry: Results of experimental animal studies with fluoextine and methylphenidate in rats. Psychopharmakother, 9(1), 19–24.

Monteiro-Musten, L., Firestone, P., Pisterman, S., Bennett, S., & Mercer, J. (1997). Effects of methylphenidate on preschool children with ADHD: Cognitive and behavioral functions. Journal of the American Academy of Child & Adolescent Psychiatry, 36, 1407–1415.

Morrell, J., & Murray, L. (2003). Parenting and the development of conduct disorder and hyperactive symptoms in childhood: A prospective longitudinal study from 2 months to 8 years. Journal of Child Psychology and Psychiatry and Allied Disciplines, 44, 489–508.

MTA Cooperative Group. (1999). A 14-month randomized clinical trial of treatment strategies for attention deficit/hyperactivity disorder. Archives of General Psychiatry, 56, 1073–1086.

O'Leary, S. G., Slep, A. M. S., & Reid, M. J. (1999). A longitudinal study of mothers' overreactive discipline and toddlers' externalizing behavior. Journal of Abnormal Child Psychology, 27, 331–341.

Olson, S. L., Bates, J. E., & Bayles, K. (1990). Early antecedents of childhood impulsivity: The role of parent–child interaction, cognitive competence, and temperament. Journal of Abnormal Child Psychology, 18, 317–334.

Olson, S. L., Bates, J. E., Sandy, J. M., & Schilling, E. M. (2002). Early developmental precursors of impulsive and inattentive behavior: From infancy to middle childhood. Journal of Child Psychology and Psychiatry and Allied Disciplines, 43, 435–447.

Pavuluri, M. N., & Luk, S. L. (1998). Recognition and classification of psychopathology in preschool children. Australian and New Zealand Journal of Psychiatry, 32, 642–649.

Pelham, W. E., Wheeler, T., & Chronis, A. (1998). Empirically supported psychosocial treatments for attention deficit hyperactivity disorder. Journal of Clinical Child Psychology, 27, 190–205.

Pisterman, S., Firestone, P., McGrath, P., Goodman, J. T., Webster, I., Mallory, R., et al. (1992). The role of parent training in treatment of preschoolers with ADDH. American Journal of Orthopsychiatry, 62, 397–408.

Pisterman, S., McGrath, P., Firestone, P., Goodman, J. T., Webster. I., & Mallory, R. (1989). Outcome of parent-mediated treatment of preschoolers with attention deficit disorder with hyperactivity. Journal of Consulting and Clinical Psychology, 57, 628–635.

Puckering, C., Pickles, A., Skuse, D., & Heptinstall, E. (1995). Mother–child interaction and the cognitive and behavioural development of four-year-old children with poor growth. Journal of Child Psychology and Psychiatry and Allied Disciplines, 36, 573–595.

Rubin, K. H., Burgess, K. B., Dwyer, K. M., & Hastings, P. D. (2003). Predicting preschoolers' externalizing behaviors from toddler temperament, conflict, and maternal negativity. Developmental Psychology, 39, 164–176.

Rushton, J. L., Fant, K. E., & Clark, S. J. (2004). Use of practice guidelines in the primary care of children with attention-deficit/hyperactivity disorder. Pediatrics, 114, E23–E28.

Shelton, T. L., Barkley, R. A., Crosswait, C., Moorehouse, M., Fletcher, K., Barrett, S., et al. (1998). Psychiatric and psychological morbidity as a function of adaptive disability in preschool children with aggressive and hyperactive-impulsive-inattentive behavior. Journal of Abnormal Child Psychology, 26, 475–494.

Short, E. J., Manos, M. J., Findling, R. L., & Schubel, E. A. (2004). A prospective study of stimulant response in preschool children: Insights from ROC analyses. Journal of the American Academy of Child & Adolescent Psychiatry, 43, 251–259.

Slomkowski, C., Klein, R. G., & Mannuzza, S. (1995). Is self-esteem an important outcome in hyperactive children? Journal of Abnormal Child Psychology, 23(3), 303–315.

Smith, C. L., Calkins, S. D., Keane, S. P., Anastopoulos, A. D., & Shelton, T. L. (2004). Predicting stability and change in toddler behavior problems: Contributions of maternal behavior and child gender. Developmental Psychology, 40, 29–42.

Sonuga-Barke, E. J. S. (1998). Categorical models of childhood disorder: A conceptual and empirical analysis. Journal of Child Psychology and Psychiatry, 39, 115–133.

Sonuga-Barke, E. J. S., Thompson, M., Daley, D., & Laver-Bradbury, C. (2004). Parent training for pre-school attention-deficit/hyperactivity disorder: Is it effective when delivered as routine rather than as specialist care? British Journal of Clinical Psychology, 43, 449–457.

Sonuga-Barke, E. J. S., Dalen, L., & Remington, B. (2003). Do executive deficits and delay aversion make independent contributions to preschool attention-deficit/hyperactivity disorder symptoms? Journal of the American Academy of Child & Adolescent Psychiatry, 42, 1335–1342.

Sonuga-Barke, E. J. S., Daley, D., & Thompson, M. (2002). Does maternal ADHD reduce the effectiveness of parent training for preschool children's ADHD? Journal of the American Academy of Child & Adolescent Psychiatry, 41, 696–702.

Sonuga-Barke, E. J. S., Daley, D., Thompson, M., Laver-Bradbury, C., & Weeks, A. (2001). Parent-based therapies for preschool attention-deficit/hyperactivity disorder: A randomized, controlled trial with a community sample. Journal of the American Academy of Child & Adolescent Psychiatry, 40, 402–408.

Sonuga-Barke, E. J. S., Lamparelli, M., Stevenson, J., Thompson, M., & Henry, A. (1994). Behaviour problems and pre-school intellectual attainment: The associations of hyperactivity and conduct problems. Journal of Child Psychology and Psychiatry and Allied Disciplines, 35, 949–960.

Sonuga-Barke, E. J. S., Thompson, M., Stevenson, J., & Viney, D. (1997). Patterns of behavior problems among pre-school children. Psychology Medicine, 27, 909–918.

Speltz, M. L., McClellan, J., DeKlyen, M., & Jones, K. (1999). Preschool boys with oppositional defiant disorder: Clinical presentation and diagnostic change. Journal of the American Academy of Child & Adolescent Psychiatry, 38, 838–845.

Strayhorn, J. M., & Weidman, C. S. (1989). Reduction of attention deficit and internalizing symptoms in preschoolers through parent–child interaction training. Journal of the American Academy of Child & Adolescent Psychiatry, 28, 888–896.

Swanson, J. M., Sergeant, J. A., Taylor, E., Sonuga-Barke, E. J. S., Jensen, P. S., & Cantwell, D. P. (1998). Attention-deficit hyperactivity disorder and hyperkinetic disorder. Lancet, 351, 429–433.

Tannock, R. (1998). Attention-deficit hyperactivity disorder: Advances in cognitive, neurobiological, and genetic research. Journal of Child Psychology and Psychiatry and Allied Disciplines, 39, 65–99.

Volkow, N. D., & Insel, T. R. (2003). What are the long-term effects of methylphenidate treatment? Biological Psychiatry, 54, 1307–1309.

Wacharasin, C., Barnard, K. E., & Spieker, S. J. (2003). Factors affecting toddler cognitive development in low-income families: Implications for practitioners. Infants & Young Children, 16, 175–181.

Wasserman, G. A., & Miller, L. S. (1998). The prevention of serious and violent juvenile offending. In R. Loeber & D. P. Farrington (Eds.), Serious & violent juvenile offenders: Risk factors and successful interventions (pp. 197–247). Thousand Oaks, CA: Sage Publications, Inc.

Webster-Stratton, C., Reid, M. J., & Hammond, M. (2004). Treating children with early-onset conduct problems: Intervention outcomes for parent, child, and teacher training. Journal of Clinical Child and Adolescent Psychology, 33, 105–124.

Weiss, M., Hechtman, L., & Weiss, G. (2000). ADHD in parents. Journal of the American Academy of Child & Adolescent Psychiatry, 39, 1059–1061.

Wilens, T. E., Biederman, J., Brown, S., Tanguay, S., Monuteaux, M. C., Blake, C., et al. (2002). Psychiatric comorbidity and functioning in clinically referred preschool children and school-age youths with ADHD. Journal of the American Academy of Child & Adolescent Psychiatry, 41, 262–268.

Zito, J. M., Safer, D. J., DosReis, S., Gardner, J. F., Boles, M., & Lynch, F. (2000). Trends in the prescribing of psychotropic medications to preschoolers. JAMA, 283, 1025–1030.

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attention-deficit/hyperactivity disorder; behavior modification; preschoolers; psychosocial treatments

©2006Lippincott Williams & Wilkins, Inc.


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