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Research project: The development of an integrated early detection and intervention model for Attention Deficit Hyperactive Disorder

Currently Active: 
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Enhancing child mental health is important in itself and provides a platform for well-being in later life. Attention Deficit/Hyperactivity Disorder (ADHD) is both a major cause of poor mental health during childhood and one of the biggest risk factors for underachievement, criminality and psychiatric illness in later life. If we can intervene early to treat ADHD then we can improve the quality of life for children and their families and reduce the long term burden associated with the condition. Here we develop PEDIA – The programme for Early Detection and Intervention Programme in ADHD. Its purpose is to identify, and treat pre-school ADHD children most at risk for a bad outcome and thus potentially the most difficult to treat.

There are five projects in the programme - the later projects build on the results of the earlier ones. In project 1 (P1) we develop a way of identifying the preschool children with ADHD most at risk for a poor outcome. This will be based on a prospective follow-up of individuals who were identified as having pre-school ADHD but are now entering late adolescence or early adult life. In P2 and P3 we explore the barriers to engaging and working with the most difficult to reach families using literature review and qualitative interviews with families and the professionals who work with them.

We will include families identified by Sure Start workers as being difficult to engage, children with speech and language problems and parents with mental health problems as well as other groups identified in P1 and P2. In P4 we will use this information to adapt an existing parenting intervention (i.e., New Forest Parenting Programme) on the basis of advice from experienced clinicians and parents so it can be used more effectively with high risk families and their children. The enhanced package will be evaluated in a large scale multi-centre controlled trial to see if it is more effective (and cost-effective) with children at high risk for poor outcomes than a generic package recommended by NICE. We are interested also in whether the benefits of the enhanced intervention extend across different settings and trial centres.

We will analyse whether the benefits of the treatment outweigh the additional cost of implementing it. If the programme is successful our hope is that it can be implemented nationally leading to substantial savings to the NHS and improvement in the well being of children and the quality of life experienced by their families.

Summary of Programme

Background

‘Every Child Matters’ (1) underscores the importance of child mental health as a key target of government health policy. Attention Deficit/Hyperactivity Disorder (ADHD) is estimated to affect between 3 to 5 percent of the school-aged population. It is a highly impairing condition that impacts on the child’s functioning at home and at school and is associated with poor outcome across a number of domains. Because of this it is associated with very significant costs to the NHS and burden to society more generally.

Aim

The goal of the proposed programme is to develop a Programme for Early Detection and Intervention for ADHD (PEDIA). PEDIA will be designed to identify and then target the children with pre-school ADHD who are at highest risk for poor outcomes and whose condition is associated with the highest burden. In order to achieve this, PEDIA will include an enhanced version of the New Forest Parenting Package (NFPP) which will include special components for children identified as being at most risk for high burden and difficult to reach and treat.

Projects

The programme will consist of five projects organised into 3 phases. In project 1 (P1) we will conduct a prospective longitudinal analysis of the late adolescent and early adult outcomes (including health economic costs) associated with preschool ADHD in a cohort for which pre-school data on ADHD and other factors was collected between 1989 and 1997. This data will be used to develop a preschool ADHD risk index (PARI) of poor outcome that can be used by us to identify children most in need of early treatment (see P3 and P5). P2 and P3 are both aimed at exploring the barriers to treatment engagement and treatment success in hard to reach and high risk families and their ADHD children. In P2 a series of systematic reviews of the literature on engaging socially excluded families and working with ADHD children with developmental delay and parents with mental health problems will be conducted. The results from P1 and P2 will inform P3. Here qualitative interviews will be conducted with; (i) the parents of pre-schoolers with ADHD who either come from socially excluded groups (e.g., Sure Start attendees), potential treatment non-responders (e.g., mothers with mental illness or children with speech and language delay) and any other groups specifically identified in an interim analysis in P1 as high burden; and (ii) the professionals who work with these groups. The interview schedule and question route, although initially based on the themes emerging from P2, will be adapted during the project as new themes emerge as early interviews are explored in more detail.

Key themes will be identified in the interviews and used to; (i) develop strategies for engaging socially disadvantaged and hard to reach and excluded families and (ii) to enhance the NFPP in ways that will address barriers to treatment and be tailored to the identified, needs of high risk children. In this way P4 and P5 will build on Projects 1 to 3 to develop, pilot, and then test the additional benefits of the enhanced version of the NFPP (e-NFPP). P4 will have four stages.

First expert therapists and clinical stake holders will work in groups to help develop e-NFPP on the basis of the findings from P2 and 3 and their own personal experiences. Second, focus groups of service users will be convened to explore the potential acceptability, feasibility and value of e-NFPP. Third, the provisional package will be piloted with samples of high risk families and their children to gain direct evidence of feasibility and potential value of the new therapeutic components. Fourth, e-NFPP will be finalised for P5 on the basis of this pilot process. P5 will be a four-centre randomised controlled trial to assess the effectiveness and cost effectiveness of e-NFPP relative to a generic group based parent training approach of the sort recommended as cost effective by NICE (Incredible Years).

The trial will use a parallel group design. Primary endpoint will be ADHD symptoms after treatment end. Secondary endpoints will include child comorbid mental health problems, functional impairment, maternal mental health at treatment end and all outcomes at 6 month follow-up. Recruitment strategies will ensure that the sample is enriched for high risk and potentially difficult to treat families. The extent to which outcomes in the two packages are moderated by risk status will be examined by including PARI scores as a moderator of outcome in statistical models. The generalisation of effects from home to school, across sites and over time will be examined. The extent to which improvements in children’s behaviour are driven by altered patterns of mother-child interaction will also be explored.

Project team

Professor Susan Latter

Professor Edmund Sonuga-Barke, School of Psychology (Chief Investigator)

Dr Margaret Thompson, Southampton City PCT

Dr David Turner,  University of Southampton


External:

Dr David Daley,  School of Psychology, University of Bangor

Dr David Coghill,  University of Dundee

Dr Joanne Barton, North Staffordshire, Combined Healthcare NHS Trust

Dr Wai Chen, Southampton City PCT

Dr Ros Tolcher,  Southampton City PCT

Project funder

NIHR Programme Grant for Applied Research

Related research groups

Health Work and Systems
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