New Forest, New Approaches: Providing the Evidence Base for Advances in the Psychological Treatment of Attention-Deficit/Hyperactivity Disorder
Submitting InstitutionUniversity of Southampton
Unit of AssessmentPsychology, Psychiatry and Neuroscience
Summary Impact TypeSocietal
Research Subject Area(s)
Medical and Health Sciences: Clinical Sciences, Public Health and Health Services
Psychology and Cognitive Sciences: Psychology
Summary of the impact
A research programme of randomised controlled trials undertaken at the
University of Southampton demonstrating the efficacy of the New Forest
Parenting Programme (NFPP) played a crucial role in: (i) influencing the
developers of clinical guidelines to recommend parent training in general
as a core part of the treatment of Attention-Deficit/Hyperactivity
Disorder (ADHD) and (ii) establishing the NFPP, in particular, as a widely
employed evidence-based treatment for ADHD, a condition estimated to
affect up to 400,000 children in the UK alone. As a direct result of the
trials, the programme, a novel therapeutic intervention that teaches
parents of preschool children with ADHD how to modify their children's
behaviour and improve their self-regulation, has been included in the
National Institute for Health and Clinical Excellence (NICE) and other
clinical guidelines and recommended internationally as an effective
alternative to medication, which often brings only short-term benefits and
is associated with a range of potentially debilitating side-effects.
The importance of treating ADHD: ADHD is estimated to affect
around 3% to 5% of children globally. The most frequently used treatment
for ADHD is medication, which targets the cognitive centres of the brain
with a stimulant. Although this is effective at controlling symptoms in
the short term, medication has limited lasting benefits and commonly (for
30% to 40% of children) leads to side-effects such as loss of sleep,
restricted growth and loss of appetite. Parents and clinicians are often
resistant to using stimulants to treat young children with ADHD.
Background to the NFPP: Initially developed in the clinical
setting in 1994, and revised and remodelled a number of times over the
following 20 years on the basis of clinical experience and research
findings, the NFPP is a novel non-pharmacological intervention for
preschool children with ADHD. It comprises an eight-to-12-week home-based
individualised programme specifically designed to teach parents of
preschool ADHD children how to modify their children's inattentive,
impulsive and challenging behaviour and to improve their self-regulation
through a series of easy-to-implement parenting techniques, including the
use of clear and short messages, eye contact and an authoritative tone to
improve communication. Parent led games to increase self-regulation
through parent-child interactions are a core part of the programme. The
NFPP is based on a combination of clinical insight and theoretical models
developed by Dr Margaret Thompson, Reader in Child Psychiatry, Edmund
Sonuga-Barke, Professor in Psychology, and Cathy Laver-Bradbury,
Consultant Nurse ADHD, at the Institute for Disorders of Impulse and
Attention (IDIA) at the University of Southampton's School of Psychology.
The efficacy of ADHD — from evidence to impact: This ICS relates
to the programme of research evaluating the NFPP carried out at the
University of Southampton involving a series of coordinated high quality
randomised controlled trials (RCT). The first RCT published in 2001
compared NFPP to both an active control arm involving general non-specific
support for parents and a no treatment control (Sonuga-Barke et al.,
2001). A wide range of child and parent mental health outcomes were
studied. Outcomes were measured both immediately after intervention and at
3 months follow up. This trial demonstrated that the NFPP can reduce
levels of ADHD and related problems to a statistically and clinically
significant degree. Some 53% of children who participated in the first
trial showed clinically significant improvements. These results challenged
the view that psychological treatments for ADHD are only adjunctive,
treating general behaviour problems rather than targeting the core ADHD
features of inattention, impulsivity and hyperactivity. Promisingly, the
effects on ADHD persisted for three months after treatment. In a recent,
already influential meta-analysis published in the American Journal of
Psychiatry (Sonuga-Barke et al., 2013) the NFPP was shown to have
the highest efficacy of all behavioural treatments for ADHD in terms of
core symptom reduction. Two other RCTs have been published (Sonuga-Barke
et al., 2004; Thompson et al., 2009). The first in 2004 was an
effectiveness trial which examined whether the NFPP could be delivered in
everyday practice. The results highlighted the importance of selecting
appropriately experienced and skilled therapists to deliver the programme.
The second, published in 2009, was an evaluation of the most recent
version of the NFPP which included an increased element of self-regulation
training and gave strikingly positive results.
This programme of RCTs has had impact on the treatment of preschool
children with ADHD in the UK and around the world because it has provided
high quality evidence for the efficacy of this treatment which has
been instrumental in changing clinical guidelines (e.g. NICE)
to highlight the value of parent training in general for the treatment of
ADHD (leading to a change in guidance) and more specifically has encouraged
clinicians to implement the NFPP as their package of choice.
This has led to the widespread cross-national implementation of the NFPP
as an evidence-based non-pharmacological treatment for ADHD.
As well as supporting the NFPP as an evidence-based treatment, findings
from these trials have informed the further improvement of the
intervention over the years. The NFPP has also been revised to reflect
findings from wider neuro-scientific research conducted in the
Developmental Brain- Behaviour Laboratory led by Professor Sonuga-Barke.
This has led to the NFPP seeking to improve children's cognitive abilities
in core areas of ADHD deficits, such as delay aversion and working memory
impairments, through the use of structured tasks. Sonuga-Barke &
Thompson have also been involved in large-scale trials of the revised NFPP
in the UK, the US and Europe.
References to the research
3.1 Sonuga-Barke EJS, Daley D, Thompson M et al. (2001). Parent-based
therapies for preschool attention deficit/hyperactivity disorder: a
randomised, controlled trial with a community sample. Journal of the
American Academy of Child & Adolescent Psychiatry, 40, 402-408. (271
citations in Google Scholar).
3.2 Sonuga-Barke EJS, Daley D, Thompson M (2002). Does Maternal AD/HD
reduce the effectiveness of parent training for pre-school children's
AD/HD? Journal of the American Academy of Child & Adolescent
Psychiatry, 41, 696-702. (143 citations in Google Scholar).
3.3 Sonuga-Barke EJS, Thompson M, Daley D, Laver-Bradbury C (2004).
Parent Training for Attention Deficit/Hyperactivity Disorder: Is it as
effective when delivered as routine rather than as specialist care?
British Journal of Clinical Psychology, 43, 449-457. (40 citations in
3.4 Thompson et al. (2009). A small-scale randomised controlled trial of
the revised New Forest Programme for Preschoolers with Attention Deficit
Hyperactivity Disorder. European Child & Adolescent Psychiatry, 18,
605-616. (28 citations in Google Scholar).
3.5 Sonuga-Barke E, Brandeis D, Cortese S, Daley D, Ferrin M, Holtmann M,
Stevenson J, Danckaerts M, van der Oord S, Döpfner M, Dittmann R, Simonoff
E, Zuddas A, Banaschewski T, Buitelaar J, Coghill D, Hollis C, Konofal E,
Lecendreux M, Wong I, and Sergeant J (2013). Non-pharmacological
interventions for Attention-Deficit/Hyperactivity Disorder: Systematic
review and meta-analyses of randomised controlled trials of dietary and
psychological treatments. American Journal of Psychiatry, 170, 275-289.
(20 citations in Google Scholar). The recent meta-analysis
highlighting the NFPP as the most effective parenting package available
3.6 Sonuga-Barke, EJS, Koerting, J, Smith, E, McCann, DC, Thompson, M
(2011).Early detection and intervention for
attention-deficit/hyperactivity disorder. Expert Review of
Neurotherapeutics, 11, 557-563. (12 citations in Google Scholar). A
paper describing the development of the NFPP.
Grants supporting the research
1) Initial efficacy RCT grant: 1994-97 — An evaluation of a
cognitive-behavioural intervention with pre-school children referred with
hyperactivity (Sonuga-Barke & Thompson) NHS R&D — £104k.
2) Effectiveness grant: 1997-99 and 2001-02 — The evaluation of programme
for the parents of hyperactive pre-school children. (Sonuga-Barke,
Thompson & Daley). Mental Health Foundation. £85k.
3) Trial of revised NFPP: 2005-07 — A parent training package for the
treatment of pre-school ADHD. (Sonuga-Barke & Thompson). HOPE. £100k.
Key output: Thompson MJJ, Laver-Bradbury C, 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 EJS (2009).
On-going large scale international evaluations
1) 2007-11 — Home based parent training for preschool ADHD (Abikoff,
Sonuga-Barke et al). NIMH — $2,042,289 (the analysis is still being
undertaken beyond 2011 but there is no cost extension);
2) 2010-14 — The development of an integrated early detection and
intervention model for Attention Deficit Hyperactive Disorder (PEDIA).
(Sonuga-Barke, Thompson et al., RP-PG-0108-10061); NIHR — £2,029,787;
3) 2012-16 — D'SNAPP trial in Denmark (TrygFonden (10 million Danish
Details of the impact
By providing some of the highest quality and strongest evidence for the
efficacy for any psycho-social intervention, the programme of clinical
trials into the efficacy of the NFPP conducted at Southampton, has (i)
made a major contribution to fundamentally changing guideline
recommendations in relation to ADHD clinical practice by
demonstrating the value of non-pharmacological interventions, and (ii) led
many practitioners more specifically to use the NFPP to improve the
lives of ADHD children and their families. The development of
the NFPP was a breakthrough in ADHD treatments transforming the ability of
parents in the UK and overseas to manage and modify the behaviour, and
improve the underlying self-regulation of children with ADHD, an illness
that affects one in 20 five-to- 15-year-olds — or around 400,000 children
in the UK. Participation in the NFPP enables a decrease in core ADHD
features without the use of medication and its unwanted side-effects.
Reducing children's levels of inattention, impulsivity and hyperactivity
has benefits for their educational attainment and social adjustment and
for their psychological development more generally. In addition to the
direct advantages for children with ADHD, reducing their disruptive
behaviour also benefits their families, teachers and associates. More
specifically, evidence from the first RCT suggests the NFPP can improve
mothers' mental health.
First, the programme has informed clinical guidelines for practitioners
treating children with ADHD, as well as leading to its widespread use in
the UK and abroad, directly benefiting children living with ADHD and their
families, increasing parental understanding of the disorder and
strengthening parent-child relationships. Although emphasis has been
placed on the treatment of children with early-onset ADHD, the NFPP is
being used clinically up to the age of 12 and parents can apply the
principles of the programme in caring for their children through their
teenage years. The 2001 NFPP trial was identified in the National
Institute for Health and Clinical Excellence's (NICE) 2008 guidance on
ADHD — guideline CG072 — as one of the few methodologically sophisticated
trials of parent training in the literature [5.1]. This
contributed towards NICE's subsequent recommendation that parent training
be made available as a frontline treatment for ADHD [5.1].
Professor Tim Kendall, chair of the ADHD guidelines committee has written
"Sonuga-Barke and colleagues' work was instrumental in leading to
the NICE guideline recommendations that the parents of all children
with ADHD, and those pre-school with these behaviours, should have
access to parent training/education programmes. Combined with similar
guidance for the provision of parent training for the parents of
children with conduct disorders, Sonuga-Barke' s work has also lead to
a major national implementation programme in which the number of such
parent training programmes has increased very substantially across
England and Wales" [5.8].
Following on from this, the NFPP was validated by the National Academy
for Parenting Practitioners, making it one of 10 Academy programmes
registered as an evidence-based treatment [5.2; 5.3]. The NFPP
forms the basis of an ADHD training website sponsored by the Welsh
Assembly that provides online training and support for general
practitioners, GPs with special interests, community paediatricians and
Child and Adolescent Mental Health Services staff [5.4; see also 5.5].
The NFPP was highly rated by the UK Department of Education [5.6].
The NFPP trials were also cited in the 2011 American Academy of
Paediatrics' revised guidelines for the treatment of ADHD, extending the
programme's reach to the United States [5.7].
The NFPP is now widely used across the UK and increasingly in Europe and
the US. 2,500 parents have purchased a NFPP self-help manual
published less than 2 years ago (Laver-Bradbury et al., 2010).
Thompson and Laver-Bradbury have coordinated a training programme in the
UK, Europe and the US. This has resulted in over 250 clinicians
being trained to use the techniques over the last 3 years
alone with courses run in Southampton, Portsmouth, London,
North Wales, Sheffield, Leicester, Bromley, Dundee, and Guernsey. These
meetings have been attended by practitioners from many parts of the UK and
Denmark, USA, Japan, Italy, Spain. Workshops have taken place at
international meetings in Turkey and Spain attended by staff from all over
Europe and South America. Based on the notion that each of these
clinicians used NFPP with 10 ADHD patients a year, we estimate
that at least 7,500 patients and their families have benefitted from
The perceived importance of the NFPP by public bodies is further
demonstrated by the funding of major trials by overseas governments. For
instance, a multi-centre NIHR trial in the UK is evaluating the efficacy
of a version of the NFPP adapted for treatment resistant families (i.e.,
PEDIA), while a trial in New York funded by the National Institute of
Mental Health (NIMH) at a cost of $2.3m, has compared the revised NFPP to
a generic intervention for conduct problems. The results of this trial
will be published in 2014. There is also a national study on-going in
Denmark with firm plans for studies in Japan, Hong Kong, Sweden and
Brazil. Discussions are currently underway regarding major initiatives in
Spain, Japan, Brazil, Hong Kong and the Middle East.
Sources to corroborate the impact
The following links corroborate the impact of the NFPP on national and
international health policy and practice.
5.1 NICE: http://www.nice.org.uk/CG072
5.2 National Academy of Parenting Practitioners (NAPP): https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/183457/DFE-RR186.pdf
5.3 Health Innovations Alliance: http://www.healthinnovationsalliance.org.uk/index.php/showcase/34-new-forest
5.4 Welsh Assembly: http://www.adhdtraining.co.uk/nonpharma.php
5.5 Evidence Based Nursing: http://ebn.bmj.com/content/4/4/109.full
5.6 UK Department of Education: http://education.gov.uk/commissioning-toolkit/Programme/Detail/41
5.7 American Academy of Pediatrics:
5.8 Personal communication from: Chair of the ADHD guidelines committee,
Director National Collaborating Centre for Mental Health (NCCMH), website