Research Paper on ADHD history, causes, treatment, prevention, cross cultural issues and christian worldview perspective on ADHD.

Prevention of ADHD related problems: a universal preschool program

Hanna Christiansen, Oliver Hirsch and Anika König Department of Clinical Child and Adolescent Psychology,

Philipps-University Marburg, Marburg, Germany Ricarda Steinmayr

Department of Educational Psychology, Technical University Dortmund, Dortmund, Germany, and

Bernd Roehrle Department of Clinical Psychology, Philipps-University Marburg,

Marburg, Germany

Abstract Purpose – 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

Health Education Vol. 115 No. 3/4, 2015

pp. 285-300 ©Emerald Group Publishing Limited

0965-4283 DOI 10.1108/HE-03-2014-0040

Received 31 March 2014 Revised 20 June 2014

18 July 2014 Accepted 23 July 2014

The current issue and full text archive of this journal is available on Emerald Insight at: www.emeraldinsight.com/0965-4283.htm

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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.,

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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).

We formulated the following hypotheses:

H1. The introduction of the new methods BM and AT in a preschool setting will change teacher’s self-efficacy, and this in turn will mediate children’s behavior.

H2. Children participating in BM-only and BM+AT will show less ADHD related symptoms after the intervention compared to children not participating in those interventions.

H3. Children in the BM+AT group will show greater training effects than children in the BM-only group.

H4. High risk children (Strengths and Difficulties Questionnaire (SDQ) and VBV scores above cut-off) will show a greater intervention benefit than low risk children.

H5. As found in previous studies on ADHD, age, gender, and SES will influence intervention success.

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Methods Subjects This was a quasi-experimental three group-design study on 413 German preschool children. A post-hoc power analysis with G-Power© established that with 413 participants, three groups at three measuring times, an ANOVA with repeated measures would detect a small effect size[1] of f¼ 0.1 with a power of 0.95 (1−β), F4,820¼ 3.28, α¼ 0.01. Ten preschools in Essen, Germany participated in the study with five of them being part of the experimental group (EG: n¼ 193) and five in the control group (CG: n¼ 220). In accordance with the criteria of the Declaration of Helsinki the study was approved by the local kindergarten institutions and verbal and written consent to study participation was obtained from all teachers, children, and parents of children. Mean age for all children was 4.31 years of age (0.89 SD), with 50 percent males (n¼ 207 of 413 children; see Table I for details). Preschools in the EG did not differ in any aspect from preschools in the CG (see baseline comparisons in the result section). Preschools in the CG reported that they did not want to participate as they did not have time to take part in the training sessions mandatory for the intervention. Preschools in the EGwere willing to randomize children to two different conditions. Thus the 193 children in the EG were randomized to either EG1 (n¼ 99) and received a preventive BM intervention (BM-only), or to EG2 (n¼ 94) and additionally received an attention-training with self-instruction elements (BM+AT; see Figure 1 for a flow-chart of the study with the allocation process). As children were randomly allocated to one of the two EG groups, children of both EG groups were in preschool classes taught by the same teachers. Depending on their EG-group affiliation status, children were handled differently by their teachers. Since the AT required a setting in a separate room, where children trained specific manualized attention techniques, it was ensured that the BM-only group did not receive any AT components. Interventions in EG1 and EG2 started after baseline measurement and lasted for six months.

Table I presents details on age, gender, parental educational attainment, race/ ethnicity, and SES at baseline.

EG1: BM-only EG2: BM+AT KG

Gender Male 44 (44.5%) 48 (51.1%) 115 (52.3%) Female 55 (55.5%) 46 (48.9%) 105 (47.7%) Total 99 94 220

Age Mean (SD) 4.25 (0.89) 4.37 (0.95) 4.32 (0.87) 3;0-3;11 22 19 46 4;0-4;11 38 33 69 5;0-5;11 31 30 92 6;0-6;11 8 12 13

Race/ethnicity White Caucasion 45% 33% 51.5% Turkish 14.7% 17.9% 18.9% African 12.8% 17.8% 4.7% Others 7.3% 6.3% 10.7% Missing 20.2% 25% 14.2% SES(range: 4-10) 5.58 (2.12) 5.41 (2.01) 6.09 (2.26)

Table I. Gender, means and SD for age, race/ethnicity, parental educational attainment and SES for EG1, EG2, and CG at baseline (t0)

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In EG1/EG2 (n¼ 26), and CG (n¼ 18) a total of 44 female preschool teachers participated in the study. Teachers in the EG were trained in both manually based interventions[2] (BM-only, BM+AT) and trained both groups of children (EG1 and EG2). Thereby it was ensured that all teachers in the EG groups used BM in their daily interactions with the children and all teachers could deliver the AT in a special group setting. Thus, treated children but not teachers were allocated to one of the two EG groups. Hence training problems due to teachers’ absences (e.g. due to working plans, illness, etc.) could be avoided. Furthermore, trainer effects were avoided as all trained teachers were involved in both EG conditions.

Procedure In four two hour sessions teachers received psycho-education on ADHD, and were trained in BM techniques to enhance start behavior (i.e. following color based rules,

10 participating preschools

n = 413 children

n = 44 preschool teachers

5 preschools Experimental Group (EG)

n = 193 children

n = 26 preschool teachers

5 preschools Control Group (CG)

n = 220 children

n = 18 preschool teachers

Baseline (t0) assessment of

SDQ

VBV 3-6

Teacher self-efficacy

EG1: BM-only

n = 99 children EG2: BM+AT

n = 94 children

6 weeks after baseline (t1) assessment of

SDQ

VBV 3-6

Teacher self-efficacy

6 months after baseline (t2) assessment of

SDQ

VBV 3-6

Teacher self-efficacy

Randomization to EG1/EG2

Quasi-experimental allocation

Figure 1. Flow-chart study

design

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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 (Fábián, 2004; Koenig, 2007).

Teachers in the CG and EG filled out all questionnaires, described in the following section, at all three measurement points, i.e. before the intervention (baseline, t0), six weeks after baseline (t1), and six months after baseline (t2).

Measures SDQ. The SDQ is a brief behavioral screening questionnaire for three to 16 year olds. It is a measure of social, emotional and behavioral functioning. The SDQ is available in a parent as well as a teacher version and, additionally, in a self-report version for adolescents; for this study only the teacher version was used. Each item of the SDQ has the response options of 0 (not at all), 1 (a little, sometimes) or 2 (very much, all of the time). The five subscales assess prosocial behavior, hyperactivity, emotional, conduct, and peer problems. Furthermore, a total difficulties score can be obtained. The psychometric properties of the SDQ have been tested in several cultural contexts. Scores of 16 and above are indicative of elevated symptoms. The majority of studies have supported the five-factor structure and other psychometric properties of the SDQ in different populations (Goodman, 2001). Reliability, factorial, and concurrent validity of the German version are highly satisfactory (Becker et al., 2004; Klasen et al., 2000). Cronbach’s alpha in our study (only teacher ratings) ranged between 0.734 (peer problems) and 0.848 (hyperactivity).Test-retest-reliability between baseline and at t1 (six weeks after baseline) ranged between 0.58 (peer problems) and 0.81 (total score); for t2 (six months after baseline) between 0.51 (peer problems) and 0.73 (total score). Children in the EG1, EG2, and CG did not differ in any of the SDQ-ratings at baseline (see Table II for details).

Behavior rating for preschool children, subscale attention deficit/hyperactivity vs play duration (VBV 3-6). The Behavior Rating for preschool children (VBV 3-6) assesses the frequency of daily, situation specific behaviors over a period of the last four weeks (Döpfner et al., 1993). The subscale attention deficit/hyperactivity vs play duration consists of 18 items to be scored on a six-point Likert scale from 0 (not at all) to

EG1 (n¼ 99) EG2 (n¼ 94) CG (n¼ 220) SDQ Emotional 1.98 (2.18) 1.76 (1.94) 1.72 (2.13) Conduct 1.57 (2.00) 1.89 (2.10) 1.63 (1.95) Hyperactivity 3.21 (2.60) 3.72 (2.99) 3.88 (2.87) Peer problems 1.83 (2.04) 1.97 (2.33) 2.21 (2.14) Pro-social 6.42 (2.57) 6.17 (2.65) 6.29 (2.81) Total 8.60 (5.84) 9.34 (6.17) 9.45 (6.33) VBV 3-6 19.59 (14.97) 23.49 (16.67) 23.93 (15.56)

Table II. Means and SD for SDQ and VBV 3-6 ratings for children in EG1, EG2, and CG at baseline

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5 (frequently/always). Children scoring high on this scale are hyperactive, easily distracted, have a short attention span, and do not listen to details. Items are summed up for a total score and stanine (mean¼ 5, SD¼ 2) scores are available for children aged three to seven; scores of ⩾7 are indicative for elevated ADHD symptoms. The documented internal consistency is highly satisfactory with a Cronbach’s α of 0.93 (Renner et al., 2004); this value was also reached in our study (α¼ 0.937). Test-retest reliability in our study ranged between 0.76 (baseline – t1) and 0.69 (baseline – t2). Children in the EG1, EG2, and CG did not differ on VBV 3-6 ratings at baseline (see Table II for details).

Teacher self-efficacy and ADHD knowledge. Self-efficacy of preschool teachers was assessed with the ten item self-efficacy scale by Schwarzer and Schmitz (1999), that is rated on a four-point Likert scale. Items address the four categories job performance, career opportunities, social interaction, and stress levels. Internal consistency is satisfactory with Cronbach’s α ranging between 0.76 and 0.82 (Schwarzer and Schmitz, 1999). Cronbach’s α in our study was 0.829, and six months test-retest-reliability (baseline – t2) was rtt¼ 0.73.

Knowledge of ADHD symptoms was measured by means of different case studies on the three ADHD core symptoms (inattention, hyperactivity, impulsivity) at baseline and six months after the intervention (t2). Further, knowledge on externalizing/ internalizing symptoms, positive behavior attributions, action strategies, intervention techniques, implicit and explicit BM strategies were also assessed with case studies at both measuring points. Teachers were asked to identify problematic and ADHD related behavior and to describe strategies for coping with such behaviors. Those statements were then rated by two blinded and independent raters to assess inter-rater reliability. Disagreement between raters was resolved with a third independent party. Cohen’s κ was satisfactory with 0.73, and intra-class-correlations ranged from 0.902 (action strategy), over 0.885 (externalizing symptoms), 0.846 (internalizing symptoms), 0.811 (explicit BM strategies), 0.789 (action strategy), 0.788 (implicit BM strategies) to 0.774 (positive behavior attributions).

SES. The SES was assessed with the Brandenburg social index (SI) that is based on parents’ education and employment. This SI is used for analyzing health and social inequalities (Böhm et al., 2007). The SI is assessed by means of two variables: education (three-levels: less than ten years education/ten years education/more than ten years education) and employment (two-levels: employed/unemployed). According to this, three social groups are established: high (9-10 points), middle (7-8 points), and low (4-6 points) SES. The SI is frequently used in different communities in Germany, and also for identifying groups in need for social compensation funds (Böhm et al., 2007). Table I shows means and standard deviations for SES values for the three different groups at baseline.

Statistical analyses. All raw data were stored at the Philipps University Marburg, Germany, Department of Clinical Child and Adolescent Psychology. Data reduction and analyses were carried out using the statistical package SPSS 18.0.

First, a MANCOVA controlling for age, gender, and SES was calculated for baseline SDQ and VBV 3-6 ratings. Second, an ANOVA compared teacher self-efficacy at baseline and a MANOVA with repeated measures established changes in teacher’s self-efficacy over time and between groups. Third, a MANCOVA with repeated measures controlling for age, gender, SES, and teacher-self-efficacy compared SDQ and VBV 3-6 ratings over time for the three different groups. Fourth, a MANOVA with

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repeated measures compared high-risk vs low-risk children in the CG and EG1/2. A multi-level analysis with SDQ and VBV 3-6 as dependent and group, gender, age, and SES as independent variables controlling the obtained results for clustering effects at pre-school level was calculated.

Results The MANCOVA controlling for age, gender, and SES for SDQ and VBV 3-6 ratings revealed no significant differences between groups of children (EG1/EG2/CG) at baseline: F10,796¼ 1.732, p¼ 0.07. Neither were there significant differences between teacher’s self-efficacy ratings at baseline (ANOVA: F1,35¼ 2.73, p¼ 0.105), nor over time (MANOVA with repeated measures: F1,35¼ 0.034, p¼ 0.854). Thus, groups at baseline did not differ significantly in primary outcome measures, and contrary to our expectations teacher’s self-efficacy in EG1/2 did not change after training and over time. Hence, the requirement for the mediation hypothesis, that teacher self-efficacy will change over time and mediate student outcome over time, was not fulfilled. Accordingly, this hypothesis needs to be rejected and will not be explored further.

Changes in children’s problem scores (SDQ and VBV 3-6) The MANCOVAwith repeated measures controlling for age, gender, SES, and teacher’s self-efficacy on SDQ and VBV 3-6 ratings over time resulted in a significant small main effect of time (F4,374¼ 4.652, p¼ 0.001, η2¼ 0.047), a significant small main effect of group (F4,754¼ 4.21, p¼ 0.002, η2¼ 0.022), and a significant interaction time× group (F81,506¼ 2.717, p¼ 0.006, η2¼ 0.014). Details for SDQ and VBV means and standard deviations over time can be seen in Table III. Contrary to our expectation, children in the BM+AT group did not show significant reductions in ADHD related symptoms, but children in the BM-only group did, as can be seen in Figure 2.

High risk vs low risk children In both EG1 and EG2, 36 children scored equal to or higher than stanine 7 (mean¼ 5, SD¼ 1) on the VBV 3-6 and equal to or higher than 16 on the SDQ (VBV/SDQ cut-off scores for high risk), whereas 115 children in EG1/EG2 scored lower on those ratings (low risk) at baseline. In the CG 41 children scored equal to or higher than stanine 7 on the VBV 3-6 and equal to or higher than 16 on the SDQ, whereas 174 children scored lower on those ratings. To compare training effects for the three groups with high and low risk, a MANOVAwith repeated measures compared SDQ and VBV 3-6 ratings over time. There was a significant main effect of time (F4,397¼ 14.44, po0.001, η2¼ 0.127),

Time EG1 EG2 CG

SDQ Baseline 8.96 (0.62) 9.97 (0.74) 9.21 (0.43) t1 8.60 (0.62) 9.94 (0.74) 8.22 (0.42) t2 7.33 (0.66) 9.77 (0.80) 8.21 (0.46)

VBV Baseline 20.08 (1.53) 25.61 (1.84) 23.65 (1.05) t1 17.27 (1.41) 20.91 (1.69) 21.63 (0.97) t2 16.19 (1.38) 19.60 (1.65) 20.47 (0.95)

Table III. Means and SE for SDQ and VBV ratings over time for EG1, EG2, and CG

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a significant interaction time× risk (F4,397¼ 5.61, po0.001, η2¼ 0.054), a significant interaction time× group (F8,796¼ 2.59, p¼ 0.008, η2¼ 0.025), and the interaction time× risk× group approached significance (F8,796¼ 1.81, p¼ 0.07, η2¼ 0.018). Thus, symptoms significantly reduced over time, and this reduction is also significantly associated with risk status. The interaction of interest, that children with high risk status in the different groups show larger improvements only approached significance. Since risk status is dichotomous, post-hoc comparisons could not be calculated. Table IV shows the SDQ and VBV ratings over time for the different groups (high vs low risk for the EG1, EG2, CG). Univariate analyses revealed that the three-way interaction (time× risk× group) is due to changes in the SDQ (F¼ 2.49, p¼ 0.042) and not to VBV changes (F¼ 0.166, p¼ 0.95).

A sub-analysis with high vs low risk children in the EG1/EG2 only showed more pronounced effects (MANOVA time× group: F4,754¼ 2.60, p¼ 0.035, η2¼ 0.014), again with high risk children showing significant symptom reductions compared to low risk ones, in both SDQ (univariate results: F2¼ 4.28, p¼ 0.014, η2¼ 0.022) and VBV ratings (univariate results: F2¼ 13.56, po0.001, η2¼ 0.067). Within-effect sizes were moderate to large for the high risk group and small for the low risk one. Between group effect sizes are large for all three time points, with high risk children scoring higher on VBV and SDQ ratings, but differences reduce over time; see also Figure 3.

A subsequent repeated measure ANOVA comparing differences in children at risk between baseline and t2 revealed a significant difference between groups (F2,218¼ 3.53, p¼ 0.03). Children in EG1 showed a significant symptom reduction compared to children in the CG (mean difference¼ 0.091, p¼ 0.03), whereas there was no significant difference in symptom reduction between children in EG1/EG2 (mean difference¼−0.033, p¼ W0.99), and EG2/CG (mean difference¼ 0.057, p¼ 0.38).

VBV EG1

VBV EG2

VBV CG

SDQ EG1

SDQ EG2

SDQ CG

Figure 2. Changes in VBV 3-6 and SDQ ratings for EG1 (BM-only), EG2 (BM+AT) and CG

over time

SDQ VBV Risk Group t0 t1 t2 t0 t1 t2

High CG 18.49 (4.43) 13.97 (5.82) 14.26 (6.73) 7.97 (0.99) 7.00 (1.36) 6.45 (1.55) EG1 16.08 (6.33) 16.41 (6.88) 13.5 (8.67) 7.94 (0.96) 7.05 (1.47) 6.45 (1.99) EG2 18.16 (5.11) 15.94 (7.43) 15.47 (8.69) 8.22 (0.94) 7.27 (1.77) 6.79 (1.99)

Low CG 7.18 (4.53) 6.77 (5.17) 6.49 (5.39) 4.93 (1.85) 4.78 (1.81) 4.53 (1.85) EG1 7.04 (4.36) 6.76 (4.71) 6.16 (5.11) 4.24 (1.65) 4.02 (1.77) 3.89 (1.89) EG2 7.42 (4.16) 7.86 (4.77) 7.46 (5.21) 4.72 (1.83) 4.58 (1.68) 4.40 (1.52)

MANOVA time× risk× group

p¼ 0.042 p¼ 0.95

Table IV. Means and SD for

SDQ and VBV ratings over time for EG1, EG2, CG and high- and low-risk

groups

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Multi-level analysis A multi-level analysis controlled for clustering at preschool level, since intra-class coefficients ranged from 0.03 to 0.18 for SDQ and VBV 3-6 ratings in the total sample for the three measurement points. According to this analysis, groups did not differ significantly in teacher self-efficacy ratings at all time points and in SDQ ratings at baseline (F1,13¼ 0.81, p¼ 0.38), and t1 (F1,28¼ 1.35, p¼ 0.25). Significant differences were obtained for SDQ ratings at t2 (F1,112¼ 6.26, p¼ 0.014), and VBV 3-6 ratings (baseline: F1,51¼ 7.18, p¼ 0.01; t1: F1,52¼ 9.28, p¼ 0.004; t2: F1,95¼ 5.44, p¼ 0.02). Group, gender, age, and SES also significantly influenced ratings, with children in the CG scoring higher on SDQ/VBV 3-6 ratings over time (SDQ: t-statistic¼ 3.03, p¼ 0.003; VBV 3-6: t-statistic¼ 4.151, po0.001), children from low SES backgrounds receiving higher problem ratings (SDQ: t-statistic¼−6.63, po0.001; VBV 3-6: t-statistic¼−6.02, po0.001), and girls (SDQ: t-statistic¼−7.38, po0.001; VBV3-6: t-statistic¼−8.32, po0.001), and older children scoring lower on both SDQ and VBV 3-6 ratings (SDQ: t-statistic¼−6.73, po0.001; VBV: t-statistic¼−12.95, po0.001).

Discussion Children in the intervention groups showed significant and positive changes over time compared to children in the CG, though effects were overall small. However, since universal programs target all children with and without any clinical impairment, only small effects may be expected (Durlak and Wells, 1997; Heinrichs et al., 2006; Lipsey and Wilson, 1993). Contrary to our expectation, children in the EG2 (BM+AT) did not show larger symptom reductions, but children in the BM alone condition (BM-only) did. Other studies have shown that general and easily implemented BM techniques are more effective for changing problem behavior in a preschool setting than specialized interventions targeting specific problem areas (Baker et al., 2010). According to the teachers, the introduction of the AT spurred problem behavior during the activities. It might be that even though play activities were included, the AT was too long with 45 minutes in a small group setting. Preschool children are not used to the more structured school-setting that this format requires (Arnold and Doctoroff, 2003; Bramlett et al., 2000; Heinrichs et al., 2006). General BM techniques that the preschool teachers can use throughout their daily interactions with the children might be more powerful, since they are easy to integrate in their routine education repertoire (Baker et al., 2010). Further, attention problems are not as prominent in the preschool years, self-regulation is highly age

VBV High Risk

d = 0.81

d = 0.18

d = 0.39

d = 0.07

Notes: In the figure, within effect-sizes (change within the high risk and low risk group) over time are reported. Between group (high vs low risk) effect-sizes (Cohen’s d ) are as follows: VBV t0 = 2.55, t1 = 1.57, t2 = 1.41; SDQ t0 = 2.01, t1 = 1.46, t2 = 1.05

SDQ High Risk

SDQ Low Risk VBV Low Risk

Figure 3. Change in problem score for high risk vs low risk children in EG1, and EG2

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dependent (Shiels and Hawk, 2010) and corresponding programs have more often been developed for older children (Guderjahn et al., 2013) though other studies also reported positive effects for the promotion of self-regulation in three to five year olds (Somech and Elizur, 2012).

The analysis on high risk vs low risk children revealed that 23 percent were within the clinical range of both the VBV 3-6 and the SDQ-total scales at baseline (based on the defined cut-off scores). These children showed greater symptom reductions over time than children with low risks. With prevalence rates of about 5 percent for ADHD (Huss et al., 2008; Polanczyk et al., 2007), a proportion of 23 percent of children at high risk seems unlikely. But we did not have parental behavior ratings that are required for ADHD assessment, and younger children are also more likely to be diagnosed with ADHD than older children (Elder, 2010; Evans et al., 2010). This most likely explains this high number of children categorized as at high risk. But, independent of the actual prevalence rate of ADHD in this sample (and according to parent and teacher information, none of the children had a formal diagnosis), the risk analysis showed that symptoms reduce over time. There was a trend toward children in the EG group showing greater symptom reductions that was confirmed in the sub-analyses on children in EG1/EG2 only. This demonstrated that children at high risk profited more from the intervention than low-risk children, confirming prior research (Hautmann et al., 2010; Heinrichs et al., 2006). Since the introduced BM techniques are easily taught, it would be a useful universally preventive strategy to include such elements in the general training of preschool teachers. Specific services on the other hand are often harder to reach, especially for disadvantaged families, and often appointed at inconvenient times, producing higher thresholds for participation (Daley et al., 2009). Further, studies have shown that adverse effects that result in higher ratings of problem behaviors are related to labeling children with ADHD at a young age (Sayal et al., 2010). Thus un-stigmatizing, universal approaches might avoid such effects, while being beneficial to children at risk.

Contrary to our expectation, teacher’s self-efficacy ratings did not improve after the intervention. The scale by Schwarzer and Schmitz (1999) ranges from 1 (low) to 4 (high). Mean ratings in all three groups were above three at baseline, thus indicating high levels of self-efficacy from the beginning that were not further enhanced during the training. Thus, failing to show significant effects for this variable could be due to a ceiling-effect.

Finally, as expected, the multi-level analysis established that older children and girls showed significantly less, and children from low SES backgrounds more problem behavior, confirming prior research (Elder, 2010; Evans et al., 2010; Huffman et al., 2001; Huss et al., 2008; Webster-Stratton et al., 2008; West et al., 2001). Those studies also established that ADHD is linked to low SES (Huffman et al., 2001; Huss et al., 2008; Webster-Stratton et al., 2008; West et al., 2001), and interventions like the current one presented might be an option for low threshold interventions in communities/ preschools with families from low SES backgrounds, since specialized services are often not accessed by those families and are associated with high drop-out rates (Thompson et al., 2009).

Limitations 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). Future studies should try to randomize groups from

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the beginning to rule out possible confounding influences that might have been contributing to the significant improvement for children in the EG group compared to control children, especially since up to 18 percent of the variance explained was due to clustering at preschool level.

The improvement over time might also be due to maturation processes, since within six months in the life of a three year old numerous developmental processes take place. A long-term follow-up would be ideal to control such natural maturation processes, and additional assessments in elementary school could control for positive effects on later school behavior and whether diagnoses of ADHD could in fact be prevented (Evans et al., 2010; Heinrichs et al., 2006), as the present study does not show actual preventive effects. In the present study we only investigated symptoms related to ADHD, and not the diagnosis per se.

An important issue is, that due to the design of the study and to ensure high participation rates, preschool teacher were not blinded to child allocation. Further only preschool teachers rated children’s behavior. However, the predictive validity of teacher ratings for ADHD symptoms has proved to be higher than parental ratings in some studies (Drechsler et al., 2014), though parental ratings would have improved the assessment of current problem behavior, since diagnostic ADHD criteria require ratings from two different sources. But since this was a universal prevention program, the target were not children with ADHD, but all children, and the aim was to reduce ADHD related problem behaviors in general in the preschool setting, and not to reduce incidence rates of ADHD diagnoses. The problem remains that preschool teachers rated their own intervention success. Even though they seem to have differentially rated children’s behavior, as can be reasoned from the analysis on high vs low risk children, and used the trained strategies as the fidelity ratings show, this should be improved in future studies with independent measurements accompanied by observational or neuropsychological measures.

Also the fact, that children of both EG groups were in preschool classes taught by the same teachers might have presented a problem. To meet this limitation, we tried to ensure program fidelity by regular supervision (AK) and used small case studies for which intervention strategies were asked to be selected by the teachers to further assess whether teacher’s used the strategies taught. We found significant time× group interactions in favor of teacher knowledge in both EG groups for inattention (F¼ 4.38, p¼ 0.03, η2¼ 0.03), hyperactivity (F¼ 4.05, p¼ 0.04, η2¼ 0.027), and impulsivity (F¼ 4.06, p¼ 0.04, η2¼ 0.03). Still, this does not fully compensate the limitation that implementation was not fully assessed.

Finally, inclusion of parent training elements would most probably enhance effects. Especially parent programs targeting specific problem domains in real life settings have shown promising effects (Sonuga-Barke and Halperin, 2010; Thompson et al., 2009), though nothing is known about long term outcomes of such programs (Sonuga-Barke and Halperin, 2010).

Conclusion The 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. This should be explored further.

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Notes 1. According to the literature small to moderate effects as defined by Cohen (Borenstein, 2009)

can be expected for primary universal interventions (Lipsey and Wilson, 1993; Durlak and Wells, 1997).

2. A German version of both manuals can be obtained from the first author of the study.

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About the authors Hanna Christiansen, PhD, is a Professor for Clinical Child and Adolescent Psychology. Her main research focus is on attention-deficit/hyperactivity disorder, prevention and therapy of psychological disorders of childhood and adolescence, and early interventions, as well as diagnostics and neuropsychology. Professor Hanna Christiansen is the corresponding author and can be contacted at: [email protected]

Dr Oliver Hirsch, PhD, is a Clinical Psychologist and a Neuropsychologist. His research interests are attention-deficit/hyperactivity disorder, neuropsychology, shared decision making and public health.

Anika König, MSc, is a Clinical Psychologist and a Business Studies Graduate. In her master thesis she addressed the prevention of attention-deficit/hyperactivity disorder. By now she works as a humane resource manager for a utility company.

Ricarda Steinmayr, PhD, is a Professor for Educational Psychology. Her main research interests are determinants of scholastic achievement, gender differences, motivation, and educational diagnostics.

Bernd Roehrle, PhD, is a Professor Emeritus for Clinical Psychology and Psychotherapy. His main research fields are mental health promotion, social networks, and community psychology.

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