Evidence

Sonuga-Barke, E. J. S., Daley, D., Thompson, M., Laver-Bradbury, C. & Weeks, A. (2001). Parent-based therapies for preschool attention-deficit/hyperactivity disorder: A randomized, controlled trial with a community sample. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 402-408.

Three-year-old children at high risk of ADHD as measured by being above cut off on both a parent rated preschool ADHD questionnaire and a clinical interview D (n = 78) were randomly assigned to either a parent training (PT = 30), a parent counselling and support (PC&S N= 28), or a waiting-list control group (N = 20). The PT group received NFPP. The PC&S group received nondirective support and counselling. Measures of child symptoms and parental well-being were taken before and after intervention and at 15 weeks follow-up. ADHD symptoms were reduced, and mothers’ sense of well-being was increased by NFPP relative to both other groups, although counselling was also better than no treatment  Fifty-three percent of children in the NFPP group displayed clinically significant improvement. NFPP was a valuable treatment for preschool ADHD. Constructive training in parenting strategies is an important element in the success of parent-based interventions.

Sonuga-Barke, E. J. S., Thompson, M., Daley, D. & Laver-Bradbury, C. (2004). Parent training for pre-school Attention Deficit/Hyperactivity Disorder: is it effective as part of routine primary care? British Journal of Clinical Psychology, 449 – 457

The effectiveness of NFPP when delivered as part of specialist tier-two services for preschool ADHD children was demonstrated by Sonuga-barke et al (2001). This study aimed to assess the effectiveness NFPP when delivered as part of routine primary care by non-specialist nurses delivering NFPP as part of their everyday case load. A sample of 89 3-year-old children at risk of ADHD took part in a controlled trial of NFPP delivered by health visitors Children were allocated randomly to NFPP (N= 59) and waiting list control (WLC = 30). Compared to more specialised nurses, health visitors struggled to make time to attend supervision or treat enough families during the study to become confident in the delivery of NFPP. Results showed that NFPP did not reduce AD/HD symptoms. Maternal well-being decreased in both PT and WLC groups. Conclusion while NFPP is an effective intervention for preschool AD/HD when delivered in specialised settings, these benefits do not appear to generalize when NFPP was delivered as part of routine primary care by non-specialist nurses and with less access to supervision.

Thompson, M.J.J., Laver-Bradbury, C.L., Ayres, M., Le Poidevin, E., Mead, S., Dodds, C., Psychogiou, L., Bitsakou, P., Daley, D., Weeks, A., Miller-Brotman, L., Abikoff, H., Thompson, P. & Sonuga-Barke, E.J.S (2009). A small-scale randomized controlled trial of the revised New Forest Parenting Package for preschool children with Attention Deficit Hyperactivity Disorder. European Child and Adolescent Psychiatry, 18, 605-616 

The revised new forest parenting programme (NFPP) is an 8-week psychological intervention designed to treat ADHD in preschool children by targeting, amongst other things, both underlying impairments in self-regulation and the quality of mother–child interactions. Forty-one children were randomized to either the revised NFPP or treatment as usual conditions. Outcomes were ADHD and ODD symptoms measured using questionnaires and direct observation, mothers’ mental health and the quality of mother–child interactions. Effects of the revised NFPP on ADHD symptoms were large (effect size >1) and significant and effects persisted for 9 weeks post-intervention. Effects on ODD symptoms were less marked. There were no improvements in maternal mental health or parenting behaviour during mother–child interaction although there was a reduction in mothers’ negative comments and an increase in their positive comments during a 5-minute speech sample. The small-scale trial, although limited in power and generalizability, provides support for the efficacy of the revised NFPP. The findings need to be replicated in a larger more diverse sample.

Daley, D., & O’Brien, M. (2013). A small-scale randomized controlled trial of the self-help version of the New Forest Parent Training Programme for children with ADHD symptoms. European child & adolescent psychiatry, 22(9), 543-552.

The efficacy of a self-help parent training programme for children with attention deficit hyperactivity disorder (ADHD) was evaluated. The New Forest Parenting Programme Self-help (NFPP-SH) is a 6-week self-help book designed to support parents of children with ADHD. Forty-three children were randomised to either NFPP-SH or a waiting list control group. Outcomes were child ADHD symptoms measured using questionnaires and direct observation, self-reported parental mental health, parenting competence, and the quality of parent–child interaction. Measures of child symptoms and parental outcomes were assessed before and after the six-week intervention. Results showed that ADHD symptoms were reduced, and parental competence was increased by NFPP-SH. Forty-five percent of intervention children showed clinically significant reductions in ADHD symptoms. NFPP-SH did not lead to improvements in parental mental health or parent–child interaction. Findings provide support for the efficacy of NFPP-SH for a clinical sample of children with ADHD symptoms. Self-help may provide a potentially cost-effective method of increasing access to evidence-based interventions for children with ADHD.

Abikoff, H. B., Thompson, M., Laver‐Bradbury, C., Long, N., Forehand, R. L., Miller Brotman, L., Klein, R.G., Reiss, P & Sonuga‐Barke, E. (2015). Parent training for preschool ADHD: a randomized controlled trial of specialized and generic programs. Journal of Child Psychology and Psychiatry, 56(6), 618-631.

The ‘New Forest Parenting Package’ (NFPP), an 8-week home-based intervention for parents of pre-schoolers with attention-deficit/hyperactivity disorder (ADHD), fosters constructive parenting to target ADHD-related dysfunctions in attention and impulse control. Although NFPP has improved parent and laboratory measures of ADHD in community samples of children with ADHD-like problems, its efficacy in a clinical sample, and relative to an active treatment comparator, is unknown. The aims of this study were to evaluate the short- and long-term efficacy and generalization effects of NFPP compared to an established clinic-based parenting intervention for treating noncompliant behaviour [‘Helping the Noncompliant Child’ (HNC)] in young children with ADHD.

A randomized controlled trial was conducted with a total of 164 3–4-year-old children 73.8% male, meeting DSM-IV ADHD diagnostic criteria were randomized to NFPP (N = 67), HNC (N = 63), or wait-list control (WL, N = 34). All participants were assessed at post-treatment. NFPP and HNC participants were assessed at follow-up in the next school year. Primary outcomes were ADHD ratings made by teachers blind to and uninvolved in treatment, and by parents. Secondary ADHD outcomes included clinician assessments, and laboratory measures of on-task behaviour and delay of gratification (delay tolerance). Other outcomes included parent and teacher ratings of oppositional behaviour, and parenting measures. (Results showed that in both treatment groups, children's ADHD and ODD behaviours, as well as aspects of parenting, were rated improved by parents at the end of treatment compared to control. Most of these gains in behaviour and in some parenting practices were sustained at follow-up. However, these parent-reported improvements were not corroborated by teacher ratings or objective observations. NFPP was also not significantly better than HNC.

Sonuga-Barke, E. J., Barton, J., Daley, D., Hutchings, J., Maishman, T., Raftery, J.,Stanton, L., Laver-bradbury, C., Chorozogul, M., Coghilll, D., Little, L. & Thompson, M. J. (2018). A comparison of the clinical effectiveness and cost of specialised individually delivered parent training for preschool attention-deficit/hyperactivity disorder and a generic, group-based programme: a multi-centre, randomised controlled trial of the New Forest Parenting Programme versus Incredible Years. European child & adolescent psychiatry, 27(6), 797-809.

The objective of this study was to compare the efficacy and cost of specialised individually delivered NFPP for preschool children with attention-deficit/hyperactivity disorder (ADHD) against generic group-based Incredible Years and treatment as usual (TAU). This was a multi-centre three-arm, parallel group randomised controlled trial conducted in National Health Service Trusts. The participants included in this study were preschool children (33–54 months) fulfilling ADHD research diagnostic criteria. New Forest Parenting Programme (NFPP) in this study was enhanced for hard to engage and difficult to treat families to a 12-week individual, home-delivered ADHD PT programme and compared against  Incredible Years (IY) infant and toddler, a 12-week group-based, PT programme initially designed for children with behaviour problems. Primary outcome—Parent ratings of child’s ADHD symptoms (Swanson, Nolan & Pelham Questionnaire—SNAP-IV). Secondary outcomes—teacher ratings (SNAP-IV) and direct observations of ADHD symptoms and parent/teacher ratings of conduct problems. NFPP, IY and TAU outcomes were measured at baseline (T1) and post treatment (T2). NFPP and IY outcomes only were measured 6 months post treatment (T3). Intervention and other costs were estimated using standardized approaches. NFPP and IY did not differ on parent-rated SNAP-IV, ADHD combined symptoms or any other measure. Small but non-significant, benefits of NFPP over TAU were seen for parent-rated SNAP-IV, ADHD combined symptoms. NFPP significantly reduced parent-rated conduct problems compared to TAU across scales. No significant benefits of IY over TAU were seen for parent-rated SNAP, ADHD symptoms or parent-rated conduct problems. The cost per family of providing NFPP in the trial was significantly lower than IY (£1591 versus £2103). Although, there were no differences between NFPP and IY with regards clinical effectiveness, individually delivered NFPP cost less. However, this difference may be reduced when implemented in routine clinical practice. Clinical decisions should consider parental preferences between delivery approaches.

Lange, A. M., Daley, D., Frydenberg, M., Houmann, T., Kristensen, L. J., Rask, C., Sonuga-barke E.J., Sondergard-baden, S., Udupi, A. & Thomsen, P. H. (2018). Parent training for preschool ADHD in routine, specialist care: a randomized controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry, 57(8), 593-602.

Parent training is recommended for attention-deficit/hyperactivity disorder (ADHD) in preschool children. Evidence-based interventions are important, but only if they produce better outcomes than usual care. This was a randomized controlled trial conducted in routine specialist ADHD clinics within Danish Child and Adolescent Mental Health Services. Children (N = 164, 3–7 years old) newly diagnosed with ADHD received a well-established parent training program (New Forest Parenting Programme; n = 88) or intensive treatment as usual (n = 76). The primary outcome was parent ratings of child ADHD symptoms. Secondary outcomes included teacher ratings and direct observations of ADHD symptoms. Outcomes were measured at baseline, after treatment, and at follow-up (36 weeks later). Representativeness of participants in the trial was evaluated against the total national cohort of children (N = 1,378, 3–7 years old) diagnosed with ADHD during the same period using the Danish Civil Registration System. Results showed that after treatment, NFPP was superior to treatment as usual on reduction of parent-rated ADHD symptoms and family strain and enhancement of parenting self-efficacy. Effects persisted to 36 weeks after treatment. There were no effects on teacher ratings or direct observations of ADHD. The clinical sample did not differ from the rest of  the national cohort of young children with ADHD who received a diagnosis during the time of the study. Evidence-based NFPP has value as an intervention for ADHD in routine clinical settings.

Shimabukuro, S., Daley, D., Thompson, M., Laver-Bradbury, C., Lovern, K., & Tripp, G. (2020). Supporting Japanese Mothers of Children at Risk for Attention Deficit Hyperactivity Disorder (ADHD): A Small-Scale Randomized Control Trial of Well Parent Japan. Journal of Child and Family Studies, 29(6), 1604-1616.

Guidelines recommend parent training in the multi-modal treatment of attention deficit hyperactivity disorder (ADHD). The availability of such interventions in Japan is limited. This study evaluated the effects of Well Parent Japan WPJ, a hybrid intervention including a group based Japanese language adaptation of the New Forest Parenting Programme for ADHD (NFPP) augmented with strategies to improve parent’s psychological wellbeing and enhance confidence in their ability to implement change. Mothers of children aged 6–12 at risk of ADHD were randomly assigned to WPJ (n = 28) or a waitlist control condition (n = 24). Measures were completed at baseline and again 14 weeks later. Parenting stress was the primary outcome. Other outcomes included maternal depression, parenting self-efficacy, reported, and observed parenting behaviour, and maternal ratings of child ADHD, oppositional defiant disorder (ODD) symptoms, and internalizing problems. Parents who received WPJ reported significantly less parenting stress, higher parenting self-esteem and used more effective parenting strategies compared with controls, including a reduction in observed negative parenting, post intervention. Parents who received WPJ also reported lower levels of child aggression and internalizing problems post intervention and toward reduced symptoms of inattention. Well Parent Japan is an effective psychosocial intervention for parents of children with ADHD in Japan. The group format and the session content was well tolerated. This is the first randomized control trial (RCT) of a psychosocial intervention targeting ADHD in Japan.

Daley, D., Tarver, J., & Sayal, K. (2021). Efficacy of a self‐help parenting intervention for parents of children with attention deficit hyperactivity disorder in adjunct to usual treatment—Small‐scale randomized controlled trial. Child: Care, Health and Development, 47(2), 269-280.

Multimodal intervention incorporating psychosocial intervention and medication is recommended for school-aged children with attention deficit hyperactivity disorder (ADHD). This randomized controlled trial (RCT) investigated the adjunctive benefit of the self-help version of the New Forest Parenting Programme (NFPP-SH) when offered in addition to treatment as usual (TAU) compared with TAU alone. Fifty-two children, receiving medication for ADHD as part of their usual care, were randomized to receive NFPP-SH + TAU or TAU alone. Results showed that when used in adjunct to TAU, NFPP-SH may have beneficial effects for parenting efficacy, child social performance in school and negative comments made by parents during a recorded speech sample. However, the self-help intervention did not have any additional effect on child behaviour. This study provides further support for NFPP-SH as a potentially low-intensity and cost-effective alternative to therapist-led parenting interventions. The findings require replication in larger samples before any firm conclusions about adjunctive efficacy

Shimabukuro, S., Daley, D., Thompson, M., Laver‐Bradbury, C., Nakanishi, E., & Tripp, G. (2017). Supporting Japanese mothers of children with ADHD: cultural adaptation of the New Forest Parent Training Programme. Japanese Psychological Research, 59(1), 35-48.

International practice guidelines recommend medication and behavioural intervention as evidenced-based treatments for attention deficit hyperactivity disorder (ADHD). Currently in Japan, the availability of non-pharmacological interventions for ADHD is limited. We report the results of a pilot and a proof-of-concept study for a new behavioural intervention for Japanese mothers of children with ADHD. The pilot study delivered a standard six-session behavioural intervention and two parent-support sessions. Participants approved the group format and requested additional support to change parenting practices and behavioural strategies targeting ADHD symptoms. For the proof-of-concept study, the intervention was revised to include five sessions of pre-intervention support followed by six sessions of the New Forest Parent Training Programme (NFPP), an evidence-based intervention for ADHD. The revised intervention, Well Parent Japan, was associated with reductions in the mothers’ reports of children's ADHD symptoms and aggression, more effective parenting practices, and reduced parenting stress. The pilot and proof-of-concept studies indicate that it is possible to successfully modify Western behavioural interventions for Japanese mothers and to justify a randomized controlled trial evaluation of the NFPP-Japan, which should report in 2022.

Thompson, M. J., Au, A., Laver‐Bradbury, C., Lange, A. M., Tripp, G., Shimabukuro, S. Zhang, S., Shuai, L., Thompson, C.E., Daley, D. & Sonuga‐Barke, E. J. (2017). Adapting an attention‐deficit hyperactivity disorder parent training intervention to different cultural contexts: The experience of implementing the New Forest Parenting Programme in China, Denmark, Hong Kong, Japan, and the United Kingdom. PsyCh journal, 6(1), 83-97.

The New Forest Parenting Programme (NFPP) is a parenting program developed for parents who have a child with attention-deficit hyperactivity disorder (ADHD). It is a manualized program that is delivered in a parent's home over 8 weeks, or in a group format, or through a self-help manual(NFPP-SH). Three randomized controlled trials have been carried out in the United Kingdom. The NFPP group has adapted the program according to feedback from parents and therapists, and for use with different populations, both within the United Kingdom and internationally. The first international trial took place in New York, United States. Trials in Denmark, Hong Kong, and Japan followed. More recently, a trial of the self-help manual has been carried out in mainland China. This paper will outline the adaptions that were needed to be able to deliver the program in different countries with their own expectations of parenting, culture, and language. Training had to be differently focused; manuals and handouts had to be revised, translated and back-translated; and supervision had to be delivered at a distance to maintain the fidelity of the program. The international group will outline their experience of running trials in their own countries with the NFPP in a face-to-face format (Denmark), a group format (Hong Kong and Japan), and a self-help format (mainland China).

Larsen, L. B., Daley, D., Lange, A. M., Sonuga-Barke, E., Thomsen, P. H., & Rask, C. U. (2020). Effect of parent training on health-related quality of life in preschool children with attention-deficit/hyperactivity disorder: A secondary analysis of data from a randomized controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry.

School-age children with attention-deficit/hyperactivity disorder (ADHD) have reduced health-related quality of life (HRQoL), but it is unclear whether this is also true for preschool children. It is unknown whether parent training (PT) improves HRQoL. This study compared HRQoL in preschool children with ADHD with age-matched children from the general population; examined whether PT improves HRQoL; and tested if treatment-related changes in HRQoL were mediated by improvements in ADHD, parent efficacy, and family stress. Parents of 164 children aged 3–7 years with an ADHD diagnosis participated in a randomized controlled trial comparing the New Forest Parenting Programme and treatment as usual. Measures of HRQoL, ADHD, parent efficacy, and family stress were completed at baseline, posttreatment, and 36-week follow-up. Results showed that pre-schoolers with ADHD had lower HRQoL than the reference groups. The New Forest Parenting Programme, but not treatment as usual, was associated with improvement in psychosocial HRQoL at posttreatment and at 36-week follow-up. Parent efficacy and family stress scores at posttreatment significantly mediated improvements in HRQoL at 36-week follow-up; ADHD scores at posttreatment did not. This study concluded that ADHD negatively impacts HRQoL in early childhood. NFPP for ADHD has the potential to improve HRQoL independently of its effects on ADHD symptoms.

Tarver, J., Daley, D., & Sayal, K. (2021). A self‐help version of the New Forest Parenting Programme for parents of children with attention deficit hyperactivity disorder: a qualitative study of parent views and acceptability. Child and Adolescent Mental Health. https://doi.org/10.1111/camh.12476

Although parent interventions are recommended as a frontline treatment approach for children with attention deficit hyperactivity disorder (ADHD), several practical and situational barriers can impact accessibility and availability. Self-help parent interventions offer a potential alternative to therapist-led interventions when barriers prevent access to face-to-face treatment. This qualitative study aims to explore participant views and acceptability of self-help parent interventions. Semi-structured interviews were conducted with parents/carers of 12 children (age 6–10 years) with ADHD who received the self-help version of the New Forest Parenting Programme (NFPP-SH) as part of a randomised controlled trial. Thematic analysis (as proposed by Braun and Clarke) was used to analyse the data. Overall, participants had favourable views of the self-help intervention but also experienced some barriers to treatment adherence. Six key themes were identified in parent interviews related to parental desire to learn more; acquisition of new skills; the flexibility of the intervention; self-help intervention vs. traditional therapist-led formats; barriers to engagement in the home environment; and need for earlier access to help.NFPP-SH was an acceptable intervention for parents. However, some parents may need additional support to overcome barriers associated with completing an intervention at home. Implications for healthcare providers and researchers developing self-help parent interventions for ADHD and child behaviour are discussed.