Parent training to improve health behaviors in children with ADHD

Attention Research Update, David Rabiner, Ph.D.
Parent training to improve health behaviors in children with ADHD

While the adverse impact of ADHD on children’s academic, behavioral, and social functioning is widely known, there is less awareness that ADHD is also associated with suboptimal health behaviors such as reduced physical activity, sleep difficulties, and elevated screen time. For example, it is recommended that school-aged children participate in at least 1 hour per day of moderate to vigorous physical activity, get at least 8 hours of sleep, and spend less than 2 hours per day on recreational screen time use. On average, however, only about one-third of children with ADHD meet these recommendations and the majority of youth with ADHD sleep less, get less daily activity, and spend more time on devices than their peers. Evidence-based ADHD treatments – medication management and behavior therapy – focus on core ADHD symptoms and associated behavior problems, and the degree to which they impact important health behaviors is unknown. This is problematic as developing research suggests that positive health behaviors like increased physical activity may diminish core ADHD symptoms and long-term health for individuals with ADHD.A study published online in the Journal of Attention Disorders [Schoenfelder et al., (2023) Parent behavior management training for child ADHD enhanced to address health beahviors: Comparison on telemedicine “telegroup” versus in-person delivery. Journal of Attention Disorders] evaluated the impact of a parent behavior management program on important health behaviors in school-age children with ADHD and whether that impact varied based on whether the program was provided in-person or online. Participants were 56 5-10 year-old children and their caregivers who received an 8-week behavior management training program called LEAP (Lifestyle Enhancement for ADHD Program) that enhances traditional behavioral parent training with adaptations that focus on physical activity (PA), sleep, and screen time use. For example, beyond topics typically covered in behavioral parent training, e.g., strategies to promote positive behavior, the effective use of consequences, limit setting), LEAP group leaders discussed how to set PA goals with their children and how to effectively use incentives to promote increased PA. Other session content focused on educating parents about media use and ADHD and reducing both child and parent media use. The link between sleep and ADHD was also discussed as were strategies to increase the quantity and quality of children’s sleep. The program was delivered to groups of up to 8 families on a weekly basis for 8 weeks; each session was about 90 minutes. Prior to the advent of Covid, thirty-three families had received the program in-person. During Covid, the remaining 23 families received the program via Zoom.

Physical activity – The amount of daily physical activity that children engaged in was measured using a Garmin wrist activity tracker. Contrary to predictions, there was no significant increase in physical activity following the intervention relative to baseline; this was true for the in-person and online delivery groups.

Sleep – A majority of parents reported significant sleep disturbances in their child at baseline. After the intervention, sleep difficulties had declined significantly for children in the in-person group.

Screen time – Based on parent reports, weekly recreational screen time declined significantly for the in-person but not for the online delivery group. In part, this may have reflected the impact of Covid on screen time, given the relative lack of competing alternatives during this time.

ADHD symptoms – Significant declines in teacher ratings of both inattentive and hyperactive/impulsive symptoms were found for both groups.Acceptability – The majority of parents in both groups reported that they were satisfied with the intervention and found many of the skills taught to be helpful. Both groups reported that the most helpful skill they learned was setting up a consistent sleep routine. Attendance was over 90% in both groups.

Summary and implications
The encouraging results from this study were that core ADHD symptoms were reduced in both groups and that delivering the program via Zoom is feasible and was associated with good levels of parent satisfaction.The impact of the intervention on health behaviors, however, were mixed. There was no evidence of increased physical activity in either group, despite that being an important focus of LEAP. And, positive impacts on sleep and screen time were only found in families who received the intervention in person. Thus, while online delivery may be acceptable to families, this is preliminary evidence that this delivery method may be less effective. Of course, the very different circumstances in many families during Covid makes it impossible to know whether it was differences in circumstances vs. the online delivery method that may have reduced the program’s effects. Results from this study should be considered preliminary in that the sample was small and there was no control group. I think the value of the study is its attention to important health behaviors that are typically not considered in ADHD interventions. In this regard, it is noteworthy that parents felt that learning to set a consistent bed time routine for their child was the most helpful skill they learned. This is a helpful reminder that while reducing ADHD symptoms and behavior problems is a critical focus of ADHD treatment, attending to behaviors that have important implications for long term health outcomes is also important and should be incorporated into ADHD care. 
Copyright © 2023 by David Rabiner

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