The Outcome of an ADHD Parenting Group Training Programme (APEG) In the Peterborough Neurodevelopmental Service (NDs)

The Outcome of an ADHD Parenting Group Training Programme (APEG) In the Peterborough Neurodevelopmental Service (NDs) Hani Ayyash1*, Michael O Ogundele2, Ruth Wisbey1, Emma Weisblatt1, Lorraine Cuff1 and Venkat Reddy1 1Cambridgeshire and Peterborough NHS Foundation Trust, University of Cambridge Health Partnersn England 2Community Paediatrics Dept, Glenwood Health Centre, NHS Fife, Glenrothes, Scotland


INTRODUCTION
ADHD is the most common neurodevelopmental disorder in children and adolescents with prevalence ranging between 5% and 12% in developed countries [1]. ADHD is de ined by a persistent (> 6 months), age-inappropriate and impairing pattern of inattention and/or hyperactivity/impulsivity. Three main presentations of ADHD as de ined by the recently published Diagnostic and Statistical Manual of Mental Disorders, ifth edition (DSM-5) by the American Psychiatric Association [2] are "predominantly inattentive"; "predominantly hyperactive/impulsive"; and "combined". Hyperkinetic Disorder (HKD), de ined in the International Classi ication of Diseases, 10 th Edition [3], is a narrower diagnostic category, requiring both symptoms of inattention and hyperactivity/impulsivity overlapping with the "combined presentation" of ADHD as per  ADHD is thought to be caused by a complex interplay of genetic and environmental factors. There is evidence from published literature that alterations in any single neurotransmitter system are unlikely to explain the complexity of ADHD; rather, the disorder has been linked to dysfunctions in several systems, including the dopaminergic, adrenergic, serotoninergic and cholinergic pathways [4].
ADHD is often comorbid with other psychiatric conditions, such as oppositional de iant disorder/conduct disorder, speci ic learning disorders, mood and anxiety disorders, and sleep disturbances [5]. Impairing symptoms of ADHD persist in adulthood in up to 65% of cases [6], with a pooled prevalence of adulthood ADHD calculated at 2.5% [7].
Because of both core symptoms and comorbid disorders, ADHD imposes an enormous burden on society in terms of psychological dysfunction, adverse vocational outcomes, stress on families, and societal inancial costs. In particular, children with ADHD might experience one or more of the following: underachievement at school, problems with family, peer and adult relationships, problems with inding and keeping a job, alcohol and substance abuse and criminal behaviour. Behavioural symptoms in children with neurodevelopmental disorders have been found to be the primary source of parenting stress [8].
There is ample evidence that carefully structured enhanced behavioural parenting programmes are useful in the management of ADHD [1,9]. The National Institute for Health and Care Excellence (NICE) in the UK, recommended that parent training /education programmes should be offered as irst-line therapy for children with moderate levels of impairment from ADHD. Medication is offered as irst-line treatment in children with severe ADHD, along with a comprehensive treatment plans that includes psychological, behavioural and educational advice. Behavioural interventions might include family therapy focusing on strategies for the family as a whole, and individual therapy focusing on changing behaviours [1].
Previous studies have con irmed the effectiveness of behavior modi ication for children ADHD [10]. Recent meta-analyses by the European ADHD Guidelines Group [11,12] have challenged the effectiveness of parent training for ADHD core symptoms, although they clearly show that parent training is useful to decrease ADHD-related impairment and improve parenting skills. Parenting a child with ADHD can lead to increased stress especially when social support is lacking [13,14]. A more recent systematic review of 12 meta-analyses of non-pharmacological psychosocial treatments for ADHD has found considerable diversity across the meta-analyses in terms of the inclusion/exclusion criteria, types of psychosocial treatments reviewed, methodological characteristics, and magnitude of reported effect sizes, making it dif icult to aggregate indings across meta-analyses or to investigate moderators of outcome. The published effect sizes varied across various outcomes assessed [15].
The Peterborough Neurodevelopmental Service (NDS) is an integrated multidisciplinary service for school age children and young people with known or suspected neurodevelopmental dif iculties. It provides a range of services to children and families including consultation, assessment, diagnosis, interventions, monitoring, review and training. The ADHD Parenting Group (APEG) is a programme designed for support and training of families who have children with ADHD, which follows a Parent Advisor Model, building on the existing knowledge and experience of parents. Experienced trainers follow the core parent programme in 6 sessions focusing on understanding different aspects of ADHD behavior and sensory needs (Appendix 1). The intervention is aimed at improving parents' knowledge of ADHD, building their skills in effective parenting, stress management and problem-solving, as well as providing social support.
This study aimed to identify the outcome of an ADHD group parenting training programme offered by the Peterborough Neurodevelopmental Service (NDS) in improving the knowledge and skills of carers.

METHOD
Parents of children who had received a diagnosis of ADHD within the Neurodevelopmental Service in Peterborough are invited to attend the APEG course. As part of the APEG programme, each parent attending the course was given a questionnaire asking them to rate their knowledge and understanding of 5 different aspects of ADHD in their children: 1) Understanding of local ADHD services; 2) Understanding diagnosis of ADHD; 3) Understanding ADHD medications; 4) Understanding sensory integration and its relevance to a child with ADHD; 5) Understanding of behaviour strategies to manage ADHD (Appendix 2).
The parents and carers rated their con idence in each area on a 6 point scale ranging from 0 (not at all) to 5 (very much). Parents rated the 5 items before starting the course, and following the completion of the 6 core sessions. The parents also had an opportunity to make additional comments in free text. The mean pre-course and a post-course con idence levels for each of ive different aspects of ADHD diagnosis and management were compared. Paired Student's t-test was also used to compare the change in mean score between the pre-and post-course responses for each of the ive aspects. The responses were also split into "insuf icient understanding" (ratings 0-3) and "suf icient understanding" (ratings 4-5) and analysis of the categorical data undertaken using chi-square to compare categories before and after the APEG intervention.

RESULTS
Peterborough is a city in the Eastern Region of England that has a high level of social deprivation and has also seen a large increase in its population in the last few years. Peterborough City Council Statistics for 2012 recorded a population of 186,400 with the number of children under 5 at 14,700 and 5 to 19 years at 34,600, with 3,300 live births per year. The rates of childhood poverty which is up to35% are signi icantly higher than the rest of the UK where the average is 21.4%.
All children aged between 6 years and 18 years in Peterbrough city are referred to the NDS for concerns about behavior or developmental. They are assessed by a multi-disciplinary team including Paediatricians, Psychiatrists, Psychologist and Developmental Neuropsychiatrists using a number of different screening tools. We receive on average twelve referrals to the NDS every month, out which an average of 5 children are diagnosed with ADHD. Most of the patients have a range of co-mordities, most commonly Autism (ASD), oppositional de iant disorder (ODD), learning dif iculties, Anxiety and Conduct disorder. Each parents of every newly diagnosed patients are offered the invitation to attend the group parenting programme. From our own longstanding experience and from unpublished data, the socio-economic and educational background of parents attending the APEG are not signi icantly different from the parents who have not previously attended. While some parents are keen to attend the APEG within a few months of their children being diagnosed with ADHD, others tend to take a more relaxed attitude, and attend when they are able to arrange a convenient time.
A total of 27 parents taking part in three different 6-session training courses completed the 53 pre-and post-course questionnaires between Jan 2013 and Nov 2014. The total number of ratings for 0 (not at all), 1 (just little), 2 (just enough) and 3 (a bit more) was signi icantly decreased after the course (22 vs 198) while there was corresponding signi icantly increased scoring of 4 (more than little) and 5 (very much so) (243 vs 68) ( Table 1). This difference was highly statistically signi icant (chi square 239, df 1, p value <0.01). There was statistically signi icant improvement in the selfreported knowledge among the participating care-givers for each of the ive aspects assessed when the mean pre-and post-course responses were compared (Table 2). These remain highly signi icant even allowing for multiple testing, as all p values were less than 0.0001.
Many parents also made several favourable comments about the training programme and most of them would recommend it to other parents

DISCUSSION
The results of this study support the notion that evidence-based group Parent training programmes are effective in improving the carers' knowledge and skills in managing their children's ADHD symptoms. A recent review of the literature suggests that Parent training is the most appropriate intervention for preschoolers and for school-age children with mild to moderate impairments from ADHD [16]. The results presented here are similar to those found in a recent study analysing the effectiveness of a post-diagnosis training group for parents of children with ADHD in South Durham of UK [17].
Parent training groups are based on social learning theory and have been found to be effective in reducing oppositional behaviour in children with ADHD and improve parental con idence through empowerment to break coercive behavioural cycles [1,18]. Effective training programmes help to increase the parents' knowledge about ADHD and improve their con idence in its management. It also helps to improve adherence to further treatment and provides an opportunity for social support through interaction with active interaction with other parents [19]. The effect of parental psychoeducation on persistence of medication use is however inconsistent [20].
The results of this study should be interpreted with caution because of the inherent limitations. The parents attending the training programme were selected on the basis of voluntary response to invitation to all parents of children newly diagnosed with ADHD. The rate of response was relatively high (on average 75%), and they may represent a self-selected group of more motivated parents than those who have not accepted the invitation. We did not attempt to evaluate the parents for any symptoms of ADHD in themselves. Parents at risk for ADHD have been shown to have dif iculty maintaining effects multimodal family interventions for themselves and their children [21] which might potentially impact on long-term effects of the group. The study did not set out to be a controlled trial but was an open study of perceived effectiveness The questionnaire used for this study was designed primarily for the evaluation of this training group and has not been validated in any previous large-scale study, although it follows the accepted form of an ordinal 6 point scale. This study has not evaluated the long-term effect of the training programme and further studies are needed to determine if the ef icacy of the training persist over a longer-term period. Effects of parental psychoeducation on several domains have been found to persist till at least a year after the intervention [22]. Further work could include analysing concordance of responses between members of the same child's family attending the group, and analysing any correlations between child characteristics (age, comorbidity) and the effectiveness of the group.

CONCLUSION
Provision of a psychosocial intervention group programme for parents of ADHD children through the APEG parenting training proved to be effective in signi icantly improving the level of knowledge and understanding of parents regarding several aspects of ADHD diagnosis, symptom identi ication and behaviour control. Group as opposed to 1:1 interventions have clear health economic bene its and in addition the interaction with other parents is often much appreciated and found bene icial. For parents unable to use group interventions for whatever reason (such as psychiatric illness or life-limiting illness) the sessions can be provided in a 1:1 format.