Executive Function/Metacognitive Training for At-Risk Preschoolers

描述（由申请人提供）：破坏性行为障碍，特别是注意力缺陷/多动障碍（ADHD），是学龄前儿童最常见的诊断之一(1)。破坏性行为是一个主要的公共卫生问题，包括对照顾者和儿童造成严重的情绪困扰，从日托或早期教育环境中驱逐，对照顾者时间的要求，事故易发性和其他安全问题（2,3）。然而，对于有注意力和行为问题的学龄前儿童，很少有基于证据的早期干预措施存在，这是至关重要的，因为它们被强烈建议作为学龄前ADHD儿童的一线治疗方法(4)。由于执行功能（EF）一直被认为是破坏性行为障碍发展的一个假定因素，因此针对儿童早期执行功能（如抑制、工作记忆）、注意力和元认知的干预可能会影响学龄前儿童破坏性行为障碍的发展。事实上，幼儿园教师认为EF技能是学校成功的首要先决条件(5)。EF缺陷是ADHD患者预后较差的独立因素（6-8），并且与学业缺陷（9-11）和社会功能缺陷（12-14）直接相关。考虑到EF和大脑发育在学龄前迅速发展（15），学龄前儿童可能从针对EF技能的早期干预中获益最多。我们为学龄前儿童开发了一种很有前景的干预措施，即注意力和元认知执行训练（ETAM），并进行了一项小规模的初步公开试验，证明了该干预措施的初步可接受性。我们还发现，EF的客观测量有显著的中等效应（16），家长、临床医生和教师对注意力不集中和行为症状的评分有中等到较大的影响。需要一项随机对照试验来调查这些对执行功能、注意力和行为的积极影响是由于ETAM还是由于父母注意的影响和/或安慰剂效应。与R34机制的参数一致，我们建议评估未来RCT设计的可行性。我们将建立一个注意控制（AC）对照组，并通过对60名有ADHD风险的儿童进行试点RCT，评估以下方面的可行性：识别、招募和保留有ADHD风险的学龄前儿童、随机选择、EF和功能结果的测量以及AC和ETAM的实施方案。探索性目的包括评估ETAM组的儿童与AC组的儿童相比，是否在目标（训练）结果（即EF测量）和未训练结果（即ADHD症状、学业准备、社交能力）方面表现出收益。我们还将评估收益是否能保持，并调查潜在的调节者/调解者。考虑到EF与儿童发展的许多方面的关系——包括学术技能、社会能力和精神病理风险——促进幼儿EF的研究是一个科学的优先事项。

DESCRIPTION (provided by applicant): Disruptive behavior disorders, particularly Attention-Deficit/Hyperactivity Disorder (ADHD), constitute one of the most common diagnoses in preschool children (1). Disruptive behaviors are a major public health problem including causing significant emotional distress for caregivers and children, expulsion from daycare or early education settings, demands on caregiver's time, accident proneness and other safety concerns (2, 3). However, few evidence-based early interventions exist for preschoolers with attention and behavior problems, which is critical because they are strongly suggested as the first line of treatment for preschoolers with ADHD (4). Because executive functioning (EF) has been consistently been proposed as a putative factor in the development of disruptive behavior disorders an intervention targeting EF (e.g., inhibition, working memory), attention, and metacognition during early childhood could likely affect the development of disruptive behavior disorders in preschoolers. Indeed, EF skills are identified by kindergarten teachers as primary prerequisites for school success (5). EF deficits independently contribute to poorer outcomes in ADHD (6-8), and have been linked directly to academic (9-11) and social functioning deficits (12-14). Given that EF and brain development are rapidly developing during the preschool years (15), preschoolers may benefit most from an early intervention targeting EF skills. We have developed a promising intervention, Executive Training of Attention and Metacognition (ETAM), for preschoolers, and have conducted a small preliminary open trial demonstrating the initial acceptability of the intervention. We also found significant moderate effect sizes on objective measures of EF (16) and moderate to large effect size reductions in ratings of inattention and behavioral symptoms by parents, clinicians, and teachers. An RCT is needed to investigate if these positive effects on executive functioning, attention, and behavior are due to ETAM or to the effect of parental attention and/or a placebo effect. Consistent with the parameters of the R34 mechanism we propose to assess the feasibility of a design for a future RCT. We will develop an attention control (AC) comparison group and assess the feasibility of: identifying, enrolling and retaining preschoolers at-risk for ADHD, randomization choices, the measurement of EF and functional outcomes, and delivery protocol for both AC and ETAM by conducting a pilot RCT with 60 children at-risk for ADHD. Exploratory aims include assessing whether children in the ETAM group show gains compared to those in AC on targeted (trained) outcomes (i.e., measures of EF) and untrained outcomes (i.e., ADHD symptoms, academic readiness, social competence). We will also assess whether gains are maintained as well as investigate potential moderators/mediators. Given the relation of EF to a number of aspects of child development-including academic skills, social competence, and risk for psychopathology-research promoting EF in young children is a scientific priority.