APNA 29th Annual Conference Session 3033: October 30, 2015 PARENT - - PDF document

APNA 29th Annual Conference Session 3033: October 30, 2015 Ngili 1

PARENT’S SELF-HELP TRAINING FOR IMPROVED ATTENTION DEFICIT HYPERACTIVITY DISORDERS (ADHD) OUTCOMES

Pierre Ngili, DNP, RN, APN, PMHNP-BC

• R. Alexander Padilla, DNP, PMHNP-BC, RN

NO CONFLICT OF INTEREST

 The speakers have no conflicts of interest to disclose.

LEARNING OBJECTIVES

As a result of participating in this session, participants will be able to:

 Discuss the impact of ADHD  Discuss alternatives for the treatment modalities in the

management of children’ ADHD symptoms

 Appraise the effectiveness of parents psycho-education in the

management of children’s ADHD symptoms

 Enumerate advantages of using a remote parent training program

in the management of ADHD symptoms

APNA 29th Annual Conference Session 3033: October 30, 2015 Ngili 2

TYPE OF PRESENTATION

This presentation intends to address a gap in knowledge, skills, and practice

 The GAP. Parents should attend psychoeducation and training to

address ADHD symptoms but competing family and work priorities as well as lack of transportation may hinder adherence (Daley, O’Brien, 2013)

 Topic: Remote Parent Self-Help Program for the Management of

ADHD

ADHD DIAGNOSTIC CRITERIA

 A persistent pattern of inattention and/or hyperactivity-impulsivity  Several symptoms present before age 12  Six or more symptoms for each type present and interfering with

social, occupational or academic performance for at least six months

 symptoms distinguished from those of oppositional defiant disorder,

conduct disorders, learning disabilities or other mental disorders (American Psychiatric Association, 2013)

ADHD DEFINITION

ADHD is a neurodevelopmental disorder characterized by



A persistent pattern of inattention and/or hyperactivity-impulsivity



Interference with functioning or development” 2 Types: Inattentive/ Hyperactive/impulsive type



Inattentive

 failure to give attention to details, careless mistakes in school work  difficulty sustaining attention in tasks  distraction & failure to follow through instructions, difficulty organizing  avoidance & reluctance to engage in tasks that require mental effort,  losing things that are necessary to complete tasks, forgetfulness in

daily activities such as “doing chores or running errand (American

Psychiatric Association, 2013)

APNA 29th Annual Conference Session 3033: October 30, 2015 Ngili 3

ADHD DEFINITION (CONT’D)



Hyperactive and impulsive types characterized

 fidgeting or tapping hands  inappropriately leaving seats, running about or climbing,  inability to play or to engage in activity quietly, restlessness, or ‘on the

go’

 talkativeness, blurting out answers before the question has been asked  difficulty waiting a turn, interruption of or intrusion onto others

(American Psychiatric Association, 2013)

ADHD PREVALENCE



2 to 10% of children in the general population may have ADHD



More boys than girls affected at a rate of two to one (American Psychiatri Association, 2013)



Cause of ADHD still unknown (Waite, Vlam, Irrera-Newcomb & Babcock, 2013)



Neurobiological theories presume abnormalities in the central dopaminergic and noradrenergic systems due to one or a combination of



Genetic predispositions



exposure to toxins, infections and physical trauma (American Psychiatric Association, 2013) 

Other theories suspect psycho-social and environmental factors



abuse, neglect



violence and various forms of exposure to traumatic experiences (Block, Macdonald, & Piotrowski, 2014)

IMPACT OF ADHD

Due to children’ ADHD symptoms, parents



May feel helpless, become more punitive or distancing which in turn can exacerbate children’ maladaptive behaviors at home, in social settings and in the school environment (Kim & Yoo, 2013) Limited knowledge about ADHD



May cause parents to blame themselves for their children’s behaviors, to withdraw support and resign from caring for, or communicating with their children (Ghanizadeh, Yazdanshenas, Nasab, Firoozabadi & Farrashbandi, 2014) Children with ADHD



may perceive themselves as unwanted and may revert to rebellious and more maladaptive behaviors including poor school attendance and suboptimal academic performance (Voogd, 2014)

APNA 29th Annual Conference Session 3033: October 30, 2015 Ngili 4

IMPACT OF ADHD (CONT’D)



Concerns that ADHD is financially taxing.

 Using existing data on health care and mental-health care utilization,

medication utilization, education costs, juvenile delinquency costs, and work-loss costs, the estimated annual cost of ADHD to society stands at approximately $14,500 per child ($42.5 billion total).

 Estimated incremental education costs are approximated to be $3,400

per ADHD child annually (Robb, et al. 2011) Number of children diagnosed with ADHD in 2011 would have grown by 40% (Vestal, 2014)



Recent increase in diagnosis not paralleled with increase in treatment (CDC, 2014).

RECOMMENDED TREATMENT

• Medication still mainstay treatment for ADHD
• Combination of pharmacology and psycho-education believed to bear

superior outcomes

• Psychosocial and multimodal interventions for extended family, parents

and children recommended in addressing complex symptomatology of ADHD and in shaping the child’s behavior (Fields & Hale, 2011

• Unfortunately, many parents/guardians not able to afford treatment.
• Evidence-based project undertaken to tackle disparities in the treatment of

ADHD by providing affordable self-help training to parents/guardians of ADHD-diagnosed children/adolescents (Daley, O’Brien, 2013).

RECOMMENDED TREATMENT (CONT’D)

 ADHD symptoms largely affect the child’ social support systems



children with ADHD are more prone to disruptive behaviors and to peer and family rejections



Constant exposure of the family to maladaptive ADHD behaviors is a source of potential emotional exhaustion and family stressful relationships (American Psychiatric Association, 2013)  Focus treatment modalities on the family and view the child’s

symptoms from an integrated system (Kim, & Yoo, 2013; Daley& O’Brien, 2013).

APNA 29th Annual Conference Session 3033: October 30, 2015 Ngili 5

ADHD AND EFFECTIVE PARENTING



Children with ADHD need proactive care to help develop adaptive skills and to prevent reoccurring problems caused by child’s maladaptive behaviors (Malek, Mashhadi, Soltanifar, Moharreri & Ghamanabad, 2014).



Effective parenting



requires that parents communicate and negotiate clearly with their children



Nurtures achievable age-appropriate behaviors



Ensures that the children understand parents’ expectations and the house rules.



Praises good behaviors and provides explicit clarity for the consequences of unacceptable behaviors (Laver- Bradbury, Thompson, Weeks, Daley, & Sonuga-Barke, 2010)



Respects the child and promotes learning that helps the child acquire and exercise control of his or her behavior. 

Effective parenting is also characterized by interactive relationship that appreciates positive points and makes the child feel good about her/himself (Laver-Bradbury, Thompson, Weeks, Daley & Sonuga-Barke, 2010).

ADHD AND EFFECTIVE PARENTING (CONT’D)

In Effective Parenting



Parents understand and accept the child’s condition.



Parents recognize that a child with ADHD needs more support, guidance and parental acceptance



Parents reassure children and help them develop self-control behavioral skills (Laver-Bradbury, Thompson, Weeks, Daley & Sonuga-Barke, 2010).

Effective Parenting



Improves parent-child communication, makes children feel more accepted, affects pattern of interactions in the family and globally improves family relationships (Kim & Yoo, 2013).

ADHD AND EFFECTIVE PARENTING (CONT’D)

Effective Parenting

 Promotes the child’s social skills  Improve child’s attention and concentration through play, attention

training play, tone of voice, and importantly, discussing emotions.

 It entails improving the child’s communication, expanding language

through play, distraction techniques, quiet time, or even timed timeout

 Also teaches managing the child’s ADHD symptoms outside of the

house through self- monitoring, rewards, mutual respect, instructions repetition (Laver-Bradbury, Thompson, Weeks, Daley & Sonuga-Barke, 2010).

APNA 29th Annual Conference Session 3033: October 30, 2015 Ngili 6

ADHD AND EFFECTIVE PARENTING (CONT’D)

 Effective parenting

 Recognizes that the parents are human too  Reminds the parents to rehearse and practice learned skills of

life experience and parenting educational opportunities

 Calls for parents’ intuition to take care of self, to seek help when

needed, and to learn and lay ahead strategies to use during difficult times (Laver-Bradbury, Thompson, Weeks, Daley & Sonuga-Barke, 2010).

SOME HELPFUL PROGRAMS FOR PARENTS



Many programs aimed at training parents to observe and to appreciate their children’s difficulties dealing with ADHD symptoms



Most of these programs help parents develop or apply effective strategies to manage their Children’s ADHD symptoms



Some of these programs are

 CHADD (CHADD, 2015) 

THE FAMILY-SCHOOL SUCCESS (FSS) (Power, 2012)

 COPE(Lakes, Vargas, Riggs, Schmidt, Baird, 2011)  SIX STEP PARENT SELF HELP (Daley and O'Brien, 2013)

PROJECT JUSTIFICATION



Youth at the program receiving invaluable skills and information to help manage symptoms of their respective diagnosis



However, the youth’s gain of skills often contradicted the parents/guardians’ perceptions



Continued complaint of parents/guardian helplessness in the face of unmanageable youth’s behaviors



Counselors at school and at ADS often reported sustained improvement or youth’s potentials to improve



Parent’s continued expression of willingness to attend during intake and psychiatric evaluations



However only less than 10% of parents were regularly attending sessions to integrate skills that the youth were getting from the Center.

APNA 29th Annual Conference Session 3033: October 30, 2015 Ngili 7

SIX STEPS PARENT SELF HELP

Six-step Parenting Program is

 Consultative and a teaching tool  A version of the New Forest Parent Training Program (NFPP)  Remotely administered over six weeks  Especially relevant to occupied parents, with competing priorities,

those without transportation or those who may have other adherence problems (Daley & O’Brien, 2013)

 Based on earlier evidence-based research which applied the Six-

step Parenting Program (Daley, O’Brien, 2013)

 Intended to help parents develop ADHD awareness and to quip

them with practical parenting skills to manage ADHD symptoms

SIX STEPS PARENT SELF-HELP (CONT’D)



Six steps

1.

Making eye contact, recruiting child’s attention, improving listening, noticing the good, speaking with respect

2.

Scaffolding, setting boundaries, consistency, giving clear messages

3.

Helping the child’s attention and concentration through play, attention training play, tone of voice, discussing emotions

4.

Improving child’s communication, expanding language through play, distraction techniques, quiet time, and timeout

5.

Managing the child’s ADHD outside of the house through self- monitoring, rewards, mutual respect, and instruction repetition

6.

Review of the skills learned in previous steps, taking care of oneself, coping during difficult times and seeking help when needed.

APN AND PARENT SELF-HELP

 Psychoeducation needed but APN constrained by time  APNs reviewed and evaluated the problem  Majority of the youth enrolled in the program had been diagnosed

with ADHD

 Only small number of parents found to be actively and

consistently involved.

 Potential participants identified through chart review of phone

calls and in-person interview

 8 guardian/parents qualified and enrolled

APNA 29th Annual Conference Session 3033: October 30, 2015 Ngili 8

SUMMARY OF STEPS



Parents and staff expressed concerns regarding parents’ difficulties attending psycho-educational programs to help manage ADHD symptoms



Remote ADHD psycho-education considered better option for parental engagement in the management of their children’ ADHD



Induction Session and pre-test



6-week parents Self-help training using the manual and practicing at home



Weekly phone monitoring, education, support and coaching by APNs.



Closing session and posttest



Outcome evaluation and dissemination.

SNAP-IV ADHD QUESTIONNAIRE



The 18 item version of the SNAP-IV ADHD questionnaire pre/posttest.

 SNAP-IV is a psychometric scale originally conceived by Swanson,

Nolan & Pelham as a tool to assess ADHD symptoms

 Based on the criterion of the diagnostic and statistical manual

(DSM) (Bussing et al., 2008)

 Can be used by either parents or teachers to record symptoms of

ADHD

 Of the 18 items, the first nine relate to inattention and the next nine

items relate to hyperactivity

OUTCOMES



Eight parents/guardians enrolled & completed all the steps of the project.



Posttest SNAP-IV score improvement by an average of 12.4%



Perception of improvement in children’s ADHD symptoms for 75% of participants



Overall improvement in scores on 16 of the 18 variables of the SNAP-IV



Agency leadership recommendation for a possible integration of the six- step parent training program into standard treatment modalities.