Early onset of behavioral disorders is predictive of long term adverse outcomes. There are some indicated and selective early prevention programs for attention deficit/hyperactivity disorder (ADHD), one of the most common behavioral disorders in childhood and adolescence. The purpose of this paper is to present a universal preschool program for preventing the development of ADHD related symptoms for children aged three to six. Design/methodology/approach – A total of 413 preschool children (experimental group (EG)¼ 193; control group (CG)¼ 220), and their teachers participated in the study. Children in the EG were randomized to two conditions: universal intervention (behavior modification (BM)¼ 99) vs additional ADHD specific elements (BM+attention training; BM+AT¼ 94) to evaluate effects of a universal intervention vs additional ADHD specific elements. The universal intervention trained general behavior modification (BM) techniques to enhance start behavior (i.e. following color based rules, positive participation in activities, enhancement of skills related to attentional function), and to extinguish stop behavior (i.e. hyperactive behavior such as uncontrolled running around, disturbing others, quarreling, etc.). These techniques were based on published intervention programs (Phelan and Schonour, 2004). The AT consisted of thirteen teacher led 45 minute based sessions in a small group format with an introductory play activity, 15 minutes picture based AT tasks (task analysis, action planning, action, reappraisal), a social interaction game, and a game to enhance perception of visual, auditory, olfactory, haptic, and gustatory senses. To determine effects, the Strength and Difficulties Questionnaire (SDQ) and the Behavior Rating for Preschoolers (VBV) were used. A high risk group with high scores on those measures was analyzed separately. Findings – Children in all three groups did not differ significantly at baseline in all relevant variables (ADHD symptoms measured with the SDQ and VBV, socio-economic status (SES), gender, age: MANCOVA: F10,796¼ 1.732, p¼ 0.07) and none of the children had a diagnosis of ADHD. After training participation, children in the EG showed significantly less ADHD related problem behavior compared to children in the CG (F8,1,506¼ 2.717, p¼ 0.006); this was especially so for the high risk group (F4,754¼ 2.60, p¼ 0.035). Multi-level analyses revealed significant influences of age, gender, and SES on post-training symptom ratings (SDQ: t-statistic¼ 3.03, p¼ 0.003; VBV 3-6: t-statistic¼ 4.151, po0.001). Research limitations/implications – This is a quasi-experimental study, since due to time restriction half the preschools did not want to participate in the experimental study. Thus, participating children were not randomly assigned to the experimental and control conditions, though children were randomly assigned to two different treatments within the intervention group (EG1/EG2). Due to the design of the study and to ensure high participation rates, only preschool teachers rated children’s behavior, though the predictive value of teacher ADHD symptoms exceeds parental ones. Finally, inclusion of parent training elements would most probably enhance effects. Practical implications – General BM techniques are easily taught and seem to positively influence children’s ADHD related symptoms while not harming children without such symptoms. Since studies showed that after a bogus instruction teacher expected children to exhibit ADHD symptoms and rated them as more disturbed (Rosenthal effect), a universal approach is less stigmatizing and possibly more effective, especially when interventions start early in life before symptoms result in full diagnoses. Social implications – This study established positive universal effects, and moderate to large effects for the subgroup of high risk children with ADHD related symptoms. General behavior management in preschools might thus be a possible strategy for preventive interventions of ADHD related symptoms. Originality/value – The is one of the first studies on a preventive ADHD preschool program. General BM techniques of this study were easily taught and implemented, and showed positive effects. Since selective and indicated interventions depend on high program fidelity, are harder to implement, and related to higher costs, general BM techniques as introduced in this study, might be an option for universal prevention strategies for ADHD related symptoms in preschool settings. Keywords Behaviour, Universal, ADHD, Health promoting schools, Prevention, Child health, Behavioural change, Child psychology, Community-based prevention, Behaviour modification, Preschool Paper type Research paper
Introduction Attention deficit/hyperactivity disorder (ADHD) is one of the most common behavioral disorders in childhood and adolescence. It is characterized by the symptom clusters of hyperactivity, inattention, and impulsivity with cross-situational impairment (e.g. at home and at school/preschool). It develops in early childhood, and frequently leads to social, academic, and occupational impairments (Wilens and Spencer, 2010). Pooled world-wide prevalence rates for ADHD reach 5.29 percent (Polanczyk et al., 2007), with boys being more frequently affected than girls, younger children being more often diagnosed with ADHD (Evans et al., 2010), and low socio economic status (SES) predicting higher rates of the disorder (Huss et al., 2008). ADHD not only often persists from preschool years into the school years and adolescence, but also into adulthood and is associated with severe long-term impairment (Daley et al., 2009; Wilens and Spencer, 2010).
The precise cause of ADHD is still unknown, with both genetic and environmental factors contributing to the disorder, and neuro-psychological and -biological alterations that are moderated by different factors (e.g. parenting style, expressed emotions), influencing the course of the disorder (Daley et al., 2009; Sonuga-Barke and Halperin, 2010; Taylor et al., 1996). In their review, Sonuga-Barke and Halperin (2010) attempted to identify potential targets for early interventions for children with ADHD. They hypothesized that targeting underlying causal pathways could reduce the likelihood of disorder emergence, limit its persistence, and cut its associated long-term burden (Sonuga-Barke and Halperin, 2010). Especially early interventions are assumed to be effective, since psychopathology is most likely not fully developed. Indeed, existing preschool programs for children with ADHD target working memory, attention, and self-regulation, as well as parenting. Such programs have shown promising short- and long-term effects (Daley et al., 2009; Sonuga-Barke and Halperin, 2010; Thompson et al., 2009). Targeting the parent-child-relationship to enhance positive interactions and dyadic synchrony significantly contributes to effects (Healy et al., 2010; Jones et al., 2007, 2008; Tamm et al., 2005; Thompson et al., 2009; Wolff Metternich et al., 2002), and possibly to the increase of parental warmth which in turn might be preventive for the development of comorbid disorders (Christiansen et al., 2010; Taylor et al., 1996). The majority of those preschool programs are designed for parents and children, but the study by Wolff Metternich et al. (2002) additionally included teachers, as do most programs for school aged children with ADHD (Döpfner et al., 2007; Barkely, 1994). Schools and preschools are ideal for universal prevention, since they reach large groups and also subjects with only slight symptoms that might not qualify for selective or indicated approaches. Thus, with respect to the potentially important elements for early interventions as identified by Sonuga-Barke and Halperin (2010), preschool programs might be effective prior to symptom onset. They could alter developmental processes related to ADHD, expand into children’s real life settings, and could generalize to later school-settings where ADHD symptoms typically start to be more problematic.
To date there is no universal preschool based prevention program targeting possible ADHD symptoms at school. Based on the studies described above, we developed a universal preschool program combining a specific intervention (attention training (AT) program) with universal behavior modification (BM) elements for children aged three to six. The program comprises units for preschool teachers (teacher training with BM techniques; universal approach) and for children (basic AT and self-regulation; selective approach). To control for further possible moderators, teacher’s self-efficacy was assessed. Though there are very few studies on self-efficacy in preschool teachers with mixed results (Baker et al., 2010; Kallestad and Olweus, 2003), high teacher self-efficacy is thought to positively influence student behavior (Soodak and Podell, 1998). Positive effects could be obtained for student learning and academic achievement (Ashton, 1984). The implementation of new teaching methods resulted in higher teacher self-efficacy (Stein and Wang, 1988), with younger students profiting more than older ones from this feature (Anderson et al., 1988). Since teachers were not familiar with the BM and basic AT techniques which were planned to be implemented in the preschool setting before training, we assumed that the training would contribute to teacher’s self-efficacy and in turn enhance prevention effects. There is a trend in prevention research to test for such possible moderators, as well as for the known moderators described above such as age, gender, and SES (eds O’Connell et al., 2009).