Early Interventions in Children With Attention Deficit/Hyperactivity Disorder

Early Interventions in Children With Attention Deficit/Hyperactivity Disorder: Randomized Controlled Trial Comparing Methylphenidate Parental Training in Treating Preschool Children With Attention Deficit / Hyperactivity Disorder

Introduction: Attention deficit/hyperactivity disorder (ADHD) is one of the most prevalent mental disorders in children and is associated with important negative functional outcomes throughout development. The first signs and symptoms become apparent in preschool age. Therefore, early interventions in this population have the potential of limiting the disorder's negative impact and preventing future impairments in affected individuals. The first-choice medication for treating ADHD is methylphenidate, which has evidence of efficacy and safety in preschool children. However, non-evidence based worries and pressure from the media placed parent training as the first-line treatment for ADHD in clinical guidelines. Parent training is a behavioral intervention implemented with the parents, with weekly sessions for 8 weeks, adequate for treating ADHD dysfunctional symptoms and behaviors. However, the level of evidence for this intervention is reduced. Furthermore, the need of trained therapists in the public health system, added to the difficulties on adherence and comprehension from parents, limit its generalization and raise questions regarding its indications. Until now, no study has compared pharmacological treatment with methylphenidate to parent training in preschool children with ADHD regarding their clinical efficacy and cost-effectiveness. Moreover, no study has evaluated the impact of pharmacological intervention and psychotherapy on neurobiological mechanisms of ADHD, which is crucial for determining their impact on neurodevelopment.

Objectives: This is a double-blind randomized clinical trial that aims to evaluate the efficacy, tolerability, and acceptability of treatment with methylphenidate compared to parental training and placebo in preschool children with ADHD.

Methods: This study will be a randomized, double-blind, parallel-group, evaluating two active interventions and placebo control group. One hundred and fifty children aged 3 years and 11 months and 5 years and 11 months, diagnosed with ADHD, will be randomized to receive treatment with methylphenidate and information (50 children), parental training and treatment with placebo medication (50 children) or belong to active control group with educational information for parents and placebo treatment with no treatment (active control, 50 children). The treatment will last eight weeks, the neurobiological outcomes will be assessed before and after treatment and clinical outcomes will be assessed at weeks 0, 5 and 9. After the end of treatment, all participants will be invited to participate in a 3 years' annual follow-up. 50 children with typical development will also be evaluated in relation to neurobiological measures.

Implications: This study proposes an innovative and relevant analysis, which will enable the field to advance the knowledge of biological mechanisms related to ADHD and to treatment response. Also, the study will expand the evidence to guide early prevention strategies and early intervention.

Study Overview

• Status: Completed
• Conditions: Attention Deficit Disorder With Hyperactivity; Preschool Child
• Intervention / Treatment: Drug: Methylphenidate; Other: Psychoeducational groups for parents; Behavioral: Parental training; Drug: Placebo pill

Detailed Description

The recruitment of participants will be performed through social media divulgation, on our official website and through contact with preschools in the city of Sao Paulo. The participants that have been selected on the telephonic pre-screening are called for a diagnostic evaluation and an eligibility criteria verification performed by a child and adolescence psychiatrist and neuropsychologists. The psychiatric care and the outcomes evaluation sessions will be conducted by trained professionals, under the principal investigator's supervision.

The children will be randomized using the website randomization.com to one of the three groups: drug treatment with methylphenidate and educational information, parental training and placebo medication, or active control group with educational information and placebo medication. After the eight-week intervention, the participants can receive treatments not previously offered according to a clinical decision.

All selected participants for the clinical trial will be evaluated and accompanied by a child and adolescent psychiatrist before the study and bi-weekly until its completion. Furthermore, a blind evaluator will be responsible for the outcomes measures evaluation.

The clinical evaluator (child and adolescent psychiatrist) and the research assistant responsible for the questionnaires application will be blind towards the modality of treatment that the participant undergoes.

All of the study's evaluation protocol and monitoring is done on the platform Research Electronic Data Capture - REDCap, a software developed by Vanderbilt University - Tennessee, which is hosted in The Clinics Hospital of the University of São Paulo Medical School server. REDCap presents three main functions: a) electronic data collection; b) data management; c) study flow management. This data bank complies with the international policies of data's privacy and security on health area. In addition to the collection and storage structure, validation, auditing and data exporting tools of the system itself are also used.

The efficacy analysis will be made from treatment intention (data from all randomized patients will be included in the analysis). The outcomes (clinical measures of efficacy and tolerability) will be analyzed through mixed effects analyses, with individual models for each outcome. This model assumes that missing data occurs at random and avoids potential biases associated with the analysis only of the individuals who completed the observations or using the strategy to carry the last observation made. The model will include fixed effects for treatment (three levels), time (0, 5 and 9 weeks), time-treatment interaction and randomization effect for the participants. Effect sizes will be calculated by subtracting of the modification of each of the outcomes between the patients in the active groups versus active group control, and between both active treatments, divided by the standard deviation of the entire sample.

• Study Type: Interventional
• Enrollment (Actual): 153
• Phase: Phase 4

Contacts and Locations

Study Locations

• Brazil
  • Sao Paulo, Brazil, 01060-970
    • Instituto de Psiquiatria do Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 3 years to 5 years (Child)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Attention deficit hyperactivity disorder DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) diagnosis
• Score above 32 on the Swanson, Nolan, and Pelham-IV scale
• Child is registered in a school or day care center
• Children without the use of stimulants or any psychotropic in the last 30 days

Exclusion Criteria:

• Intelligence quotient <70
• The presence of clinical condition or history of neurological disorder or head trauma with conscience loss
• The presence of affective and psychotic disorders, as well as autism spectrum disorders.
• The absence of a legal representative with the capacity to understand the study objectives and the instructions related to its participation.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Quadruple

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Methylphenidate-psychoeducational group; Methylphenidate treatment with a initial dosage of 0,3 mg/kg per day (weekly dosage adjustments) and weekly psychoeducational groups for parents during 8 weeks.	Drug: Methylphenidate; Methylphenidate treatment with a initial dosage of 0,3 mg/kg per day (weekly dosage adjustments).; Other: Psychoeducational groups for parents; Weekly psychoeducational groups conducted by educators.
Experimental: Parental training-placebo pill; Weekly parental training conducted by behavioral psychologists and placebo pill during 8 weeks.	Behavioral: Parental training; Weekly parental training conducted by behavioral psychologists.; Drug: Placebo pill; Placebo pill during 8 weeks.
Placebo Comparator: Psychoeducational group-placebo pill; Weekly psychoeducational groups for parents and placebo pill during 8 weeks.	Other: Psychoeducational groups for parents; Weekly psychoeducational groups conducted by educators.; Drug: Placebo pill; Placebo pill during 8 weeks.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in attention deficit and hyperactivity symptoms	The child will be assessed with the Swanson, Nolan and Pelham (SNAP) scale.	Baseline, after 8 weeks (post intervention) and follow-up 1, 2 and 3 years after the end of the intervention
Change in symptom severity	The child will be assessed by a blinded rater with the Clinical Global Impressions Scale (CGI).	Baseline, after 8 weeks (post intervention) and follow-up 1, 2 and 3 years after the end of the intervention
Change in social and psychiatric functioning	The child will be assessed with the Children's Global Assessment Scale (CGAS).	Baseline, after 8 weeks (post intervention) and follow-up 1, 2 and 3 years after the end of the intervention

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in executive functions	The child will be assessed with the Continuous Performance Test (CPT).	Baseline, after 8 weeks (post intervention) and follow-up 1, 2 and 3 years after the end of the intervention
Adverse effects of the treatment	The caregiver will be assessed by an adverse effects scale.	Along 8 weeks.
Evaluate ADHD symptoms that may influence treatment response and adherence	The caregiver will be assessed by Adult ADHD Self-Report Scale (ASRS).	Baseline, after 8 weeks (post intervention) and follow-up 1, 2 and 3 years after the end of the intervention
Evaluate Depression symptoms that may influence treatment response and adherence	The caregiver will be assessed with Beck Depression Inventory (BDI-II)	Baseline, after 8 weeks (post intervention) and follow-up 1, 2 and 3 years after the end of the intervention
Changes in irritability symptoms	The child will be assessed with the Affective Reactivity Index (ARI) scale.	Baseline and after 8 weeks (post intervention) and follow-up 1, 2 and 3 years after the end of the intervention
Changes in disruptive behavior symptoms	The child will be assessed with the Multidimensional Assessment Profile of Disruptive Behavior (MAP-DB)	Baseline, after 8 weeks (post intervention) and follow-up 1, 2 and 3 years after the end of the intervention

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Changes in Midbrain, black substance, red nucleus, median raphe, third ventricle, thalamus, anterior horn of lateral ventricles, caudate nucleus and lentiform nucleus	The child will be assessed by a transcranial ultrasound.	Baseline and after 8 weeks (post intervention).
Changes in Expressed Emotion	The caregiver will be assessed with Five Minute Speech Sample (FMSS)	Baseline and after 8 weeks (post intervention).
Changes in oscillatory neural connectivity	The child will complete a battery of cognitive tasks (resting-state, Go/Nogo, emotion recognition) during electrophysiological (EEG) recording. Changes in oscillatory neural networks engaged by each task will be investigated pre- to post-intervention.	Baseline and after 8 weeks (post-intervention)
Changes in parenting behavior	Parenting behavior will be assessed by structured observation and coding performed according to the Coding System Behavior (MacMahon & Forehand, 2003).	Baseline and after 8 weeks (post intervention)
Changes in parenting practices	Parenting practices will be assessed with the Parenting Scale (PS).	Baseline and after 8 weeks (post intervention)
Changes in parenting practices	Parenting practices will be assessed with the Parenting Practices Scale (PPS).	Baseline and after 8 weeks (post intervention)
Changes in parenting sense of competence	Parenting sense of competence will be assessed with the Parenting Sense of Competence Scale (PSOC).	Baseline and after 8 weeks (post intervention)

Collaborators and Investigators

• Sponsor: University of Sao Paulo
• Collaborators: Conselho Nacional de Desenvolvimento Científico e Tecnológico
• Investigators: Principal Investigator: Guilherme V Polanczyk, University of Sao Paulo Medical School

Publications and helpful links

General Publications

• Sugaya LS, Salum GA, de Sousa Gurgel W, de Morais EM, Del Prette G, Pilatti CD, Dalmaso BB, Leibenluft E, Rohde LA, Polanczyk GV. Efficacy and safety of methylphenidate and behavioural parent training for children aged 3-5 years with attention-deficit hyperactivity disorder: a randomised, double-blind, placebo-controlled, and sham behavioural parent training-controlled trial. Lancet Child Adolesc Health. 2022 Dec;6(12):845-856. doi: 10.1016/S2352-4642(22)00279-6. Epub 2022 Oct 26.

Study record dates

Study Major Dates

• Study Start: June 1, 2016
• Primary Completion (Actual): December 1, 2019
• Study Completion (Actual): June 30, 2020

Study Registration Dates

• First Submitted: June 9, 2016
• First Submitted That Met QC Criteria: June 20, 2016
• First Posted (Estimate): June 21, 2016

Study Record Updates

• Last Update Posted (Actual): August 18, 2020
• Last Update Submitted That Met QC Criteria: August 14, 2020
• Last Verified: August 1, 2020

More Information

Terms related to this study

• Keywords: Parental training; Preschool age; Attention Deficit/Hyperactivity Disorder (ADHD)
• Additional Relevant MeSH Terms: Mental Disorders; Pathologic Processes; Nervous System Diseases; Neurologic Manifestations; Dyskinesias; Attention Deficit and Disruptive Behavior Disorders; Neurodevelopmental Disorders; Disease; Attention Deficit Disorder with Hyperactivity; Hyperkinesis; Physiological Effects of Drugs; Neurotransmitter Agents; Molecular Mechanisms of Pharmacological Action; Neurotransmitter Uptake Inhibitors; Membrane Transport Modulators; Dopamine Agents; Dopamine Uptake Inhibitors; Central Nervous System Stimulants; Methylphenidate
• Other Study ID Numbers: 466859/2014-7

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO