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，包括给照顾者和儿童造成严重的情绪困扰，被日托或早期教育机构开除，对照顾者的时间要求，事故倾向和其他安全问题(2，3)。然而，对于有注意力和行为问题的学龄前儿童，几乎没有循证的早期干预措施，这一点至关重要，因为它们被强烈建议作为学龄前儿童ADHD的一线治疗(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，针对EF(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，英孚技能被幼儿园教师确定为学校成功的首要先决条件(5)。EF缺陷独立地导致ADHD较差的结果(6-8岁)，并与学业缺陷(9-11岁)和社会功能缺陷(12-14岁)直接相关。鉴于EF和大脑发育在学龄前几年发展迅速(15岁)，学龄前儿童可能会从针对EF技能的早期干预中受益最大。我们已经为学龄前儿童开发了一种有前景的干预措施，即高管注意力和元认知培训(ETAM)，并进行了一项小型的初步开放试验，证明了该干预措施的初步可接受性。我们还发现，父母、临床医生和教师在EF(16)客观测量中的中等效应大小和中等到大的效应大小降低了注意力不集中和行为症状的评级。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，还是由于父母的关注和/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。我们将开发一个注意力控制(AC)对照组，并通过对60名ADHD高危儿童进行一项试验性随机对照试验，评估以下方面的可行性：识别、招募和保留ADHD高危学龄前儿童、随机选择、EF和功能结果的测量，以及AC和ETAM的交付方案。探索性目标包括评估ETAM组的儿童是否比AC组的儿童在目标(训练的)结果(即EF的测量)和未训练的结果(即ADHD症状、学习准备情况、社交能力)方面显示出进步。我们还将评估是否保持了成果，并调查潜在的主持人/调解人。鉴于EF与儿童发展的许多方面--包括学习技能、社交能力和精神病风险--的关系，在幼儿中促进EF的研究是一个科学优先事项。 公共卫生相关性：包括注意力缺陷/多动障碍(ADHD)在内的破坏性行为是一个主要的公共卫生问题，包括给照顾者和儿童造成严重的情绪困扰、被日托机构或早期教育机构开除、对照顾者时间的要求、事故倾向和其他安全问题。旨在减少负面结果和提高能力的有效早期干预可能会减少症状或推迟症状的出现，并缓冲长期损害。为高危学龄前儿童开发可行的、成本效益高的、父母可以接受的、在改善注意力、记忆力和自我控制方面有效的非药物治疗是至关重要的，并可作为兴奋剂治疗的替代方案。

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. PUBLIC HEALTH RELEVANCE: Disruptive behaviors, including Attention-Deficit/Hyperactivity Disorder (ADHD), 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. Effective early intervention designed to reduce negative outcomes and increase capacities may decrease symptoms or delay their onset and buffer long-term impairment. Developing non-pharmacological treatments for at-risk preschoolers that are feasible, cost-effective, acceptable to parents, and effective in improving attention, memory, self control, are essential, and could serve as an alternative to treatment with stimulant medication.