Parent ADHD and Evidence-Based Treatment for Their Children: Review and Directions for Future Research

One fourth to one half of parents of children with attention-deficit/hyperactivity disorder (ADHD) have ADHD themselves, complicating delivery of evidence-based child behavioral and pharmacological treatments. In this article, we review the literature examining the relation between parent ADHD and outcomes following behavioral and pharmacological treatments for children with ADHD. We also review research that has incorporated treatment of parent ADHD (either alone or in combination with child treatment) with the goal of improving parenting and child outcomes. Finally, we offer recommendations for future research on the relation between parent ADHD and evidence-based treatment outcomes for their children, with the purpose of advancing the science and informing clinical care of these families.     

The role of treatment acceptability in the initiation of treatment for ADHD

Approximately 50% of families of children with ADHD fail to pursue, or adhere to, recommended treatments. The present study examines parent ratings of the acceptability of pharmacological and behavioral treatments for ADHD and the relationships between these ratings and subsequent pursuit of treatment. Fifty-five families whose children received an evaluation for ADHD completed questionnaires and were contacted 3 to 4 months later to assess their pursuit of treatment. Consistent with previous research, parents rated behavior therapy as more acceptable than medication. Parent ratings of medication acceptability significantly predict pursuit of pharmacological treatment, whereas ratings of the acceptability of behavior therapy do not predict pursuit of this treatment. Preliminary analyses found that Caucasian parents' ratings of medication are significantly higher than those of non-Caucasian parents. Furthermore, Caucasian families were more likely to pursue a recommendation for pharmacological treatment than non-Caucasian families. The clinical and research implications of these results are considered.     

Enhancements to the Behavioral Parent Training Paradigm for Families of Children with ADHD: Review and Future Directions

Behavioral parent training (BPT) is one of the empirically supported psychosocial treatments for ADHD. Over many years and in many studies, BPT has been documented to improve both child ADHD behavior and maladaptive parenting behavior. In some studies, BPT has also been found to result in benefits in additional domains, such as parenting stress and child classroom behavior. However, the BPT literature on children selected as having ADHD lags behind research conducted on BPT for children selected as having oppositional defiant and conduct disorders (ODD and CD, respectively) with regard to examination of factors that may limit treatment attainment, compliance, and outcomes, such as single parenthood, parental psychopathology, and child comorbidity. Because of the high degree of comorbidity between ADHD and ODD/CD, it is difficult to separate the two BPT literatures. The parameters of BPT (e.g.. format and setting), parent factors, and child factors that may contribute to treatment outcomes for families of children with ADHD are reviewed here and recommendations for future BPT research in the area of ADHD are made.     

Assessing Stress in Families of Children with ADHD: Preliminary Development of the Disruptive Behavior Stress Inventory (DBSI)

This paper describes the initial development of the Disruptive Behavior Stress Inventory (DBSI). This 40-item measure, which provides indices of the number of stressors experienced during the past 6 months and the rated stressfulness of these events, is designed to assess behavior-related family stress experienced by families of children with attention-deficit/hyperactivity disorder (ADHD). Findings provide strong support for the internal consistency of the DBSI and suggest adequate test-retest reliability. Support for the validity of the measure is suggested by findings that DBSI stress indices differentiate between parents of children with ADHD and those with no history of this disorder. Additional support is provided by findings that scores on the DBSI also differentiate between parents of children with ADHD, combined type and parents of children with ADHD, inattentive type. It is suggested that this measure may provide useful clinical information regarding stress levels in families of children with ADHD and that it may be of potential value as an ADHD treatment outcome measure.     

Putting families in the center: family perspectives on decision making and ADHD and implications for ADHD care

Objective: To examine components of family-centered care in families' stories about treatment decision making for their child with ADHD. Method: Twenty-eight families participated in qualitative interviews that addressed families' perspectives on (a) the treatment decision-making process, (b) the cause and impact of their child's symptoms, and (c) treatment goals and preferences. Results: The majority of families preferred to be primary or shared decision makers regarding treatment decisions. Families' perspectives on the cause of the child's symptoms varied and often were not consistent with a biomedical framework. Families described multiple areas of impairment on child, family relationships, and family functioning. Perspectives toward evidence-based treatments were mixed, with families also expressing interest in and pursuing interventions not delineated in current treatment guidelines. Conclusion: These findings reinforce the importance of eliciting families' perspectives and involving these important stakeholders in shared decision making as critical components of family-centered care for children with ADHD.     

Preparing Families for Evidence-Based Treatment of ADHD: Development of Bootcamp for ADHD

Objective: Many families of children with attention-deficit/hyperactive disorder (ADHD) do not initiate evidence-based treatments (EBTs), placing these children at risk for poor outcomes. Bootcamp for ADHD (BC-ADHD) is a novel, four-session, group intervention designed to prepare parents as informed consumers to engage in multimodal EBTs for ADHD. This paper describes the theory of change and the development of BC-ADHD, outlines its components, and provides an initial proof of concept of the program. Method: Participants were 11 families of children with ADHD (ages 5–11; 55% male; 91% non-Hispanic; 55% White, 27% Black, 18% more than one race) who were the initial participants receiving BC-ADHD during a small-scale, randomized controlled trial. Parent-report outcome measures assessed parental empowerment, treatment preferences, affiliate stigma, intention to pursue treatment, and treatment initiation at baseline, posttreatment, and 6-week follow-up. Results: Parent engagement was high, as indicated by an 86% session attendance rate and high ratings of program satisfaction. Parents reported an increase in empowerment to access systems of care. Ratings of acceptability for behavior therapy increased at posttreatment and follow-up with minimal or no concerns about feasibility. The acceptability of medication was high at each assessment, although parents expressed increased concerns about stigma and adverse effects of medication at posttreatment and follow-up. Nonetheless, there was a marked increase in parental intention to use medication at posttreatment and follow-up. Accounting for ceiling effects, parents reported substantial increases in intention to use medication, behavioral parent training (BPT), and school services. Changes in treatment initiation were in the expected direction. Conclusions: BC-ADHD has the potential to promote family empowerment in seeking services and increase their intent to initiate EBTs, as well as actual initiation of these treatments.     

Family factors associated with attention deficit hyperactivity disorder and emotional disorders in children

Few well-controlled studies have identified psychosocial profiles of families of boys with ADHD and boys with emotional disorders compared with normal controls. However, the clinical and theoretical literature pinpoints four domains in which distinctive profiles would be expected to occur. In this study, twenty-two mothers and thirteen fathers of twenty-two boys with ADHD; twenty mothers and fifteen fathers of twenty boys with a mood or anxiety disorder; and twenty-six mothers and sixteen fathers of twenty-seven normal controls were compared on: (1) stress, support and quality of life; (2) current family functioning; (3) parenting style and satisfaction in the family of origin and current family; and (4) current and past parental functioning. The two clinical groups showed higher levels of stress and lower levels of both social support and quality of life than did normal controls. Both clinical groups showed deficits in current family functioning, but contrary to expectations the ADHD and emotional disorder group did not show distinctly different profiles. Parents of ADHD children reported higher levels of authoritarian parenting styles, and parents from both clinical groups reported less parenting satisfaction than did normal controls in both their current families and their families of origin. Parents of children with ADHD and emotional disorders reported greater parenting satisfaction in their families of origin than in their current families. This discrepancy was greatest for parents of ADHD children. Parents of children with ADHD and emotional disorders reported greater psychological health problems and more childhood ADHD symptomatology than did normal controls. Parents of children with ADHD and emotional disorders have significant psychosocial difficulties in family and personal functioning. Family intervention is highly appropriate for families with children who are referred for help with both types of difficulties.     

Parent-Child Interaction Therapy for ADHD: A Conceptual Overview and Critical Literature Review

ABSTRACT

Attention-Deficit/Hyperactivity Disorder (ADHD), a chronic disorder beginning in childhood, is identifiable and diagnostically valid during the preschool years. Compared to school-aged children, preschoolers have not received as much attention in the literature. Parent-Child Interaction Therapy (PCIT) is an empirically-supported parent training program for young children with disruptive behaviors that may also be effective in treating ADHD. The purpose of the current article was to explore the theoretical rationale for utilizing PCIT with this population and to conduct a literature review of published PCIT treatment outcome studies that measured ADHD symptoms. The literature demonstrates that children with ADHD have been included in PCIT research and evidence suggests that PCIT may be effective for young children with ADHD. However, future research is needed to specifically examine the effects of PCIT on ADHD.     

Psychosocial Treatments for Children with Attention Deficit/Hyperactivity Disorder

This article reviews studies examining the efficacy of behavioral interventions for the treatment of attention-deficit/hyperactivity disorder (ADHD). A specific emphasis is placed on evidence-based interventions that include parent training, classroom, academic, and peer interventions. Results indicate that school-aged children respond to behavioral interventions when they are appropriately implemented both at home and in the classroom setting. Combined treatments (behavioral management and stimulant medication) represent the gold standard in ADHD treatment and are often recommended as the first-line treatment option due to the many problems faced by children with ADHD. Diversity issues, although an important consideration in the treatment of ADHD, continue to remain an understudied area. Recommendations for future research are made pertaining to treatment sequencing with regard to behavior management as well as for subgroups of ADHD children who may respond best to specific treatments.     

ADHD and delinquency--a developmental perspective

Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent psychiatric disorders of childhood and adolescence. Until now, it has been unclear whether ADHD by itself constitutes a risk factor for later delinquency or does so only in combination with other disruptive symptoms. This article seeks to give a comprehensive account of the literature to shed light on the developmental pathway from childhood ADHD to adult criminality. Comorbid ADHD and conduct disorder (CD) are significantly related to a range of biological and environmental risk factors such as neurocognitive impairment, high parental psychopathology, poor social functioning, and other comorbid mental disorders, particularly substance abuse, that are described in this review. In addition, the results of treatment studies are presented, with a special focus on the results of the Multimodal Treatment Study of Children with ADHD (MTA). Although treatment programs, including medication and psychosocial treatment, can be very effective in improving the functioning of children with ADHD in the social and academic domains in the short term, there is no conclusive evidence that such treatments lower the risk for developing delinquency in adulthood.     

Story Comprehension in Children with ADHD

A wealth of research is available examining children's story comprehension. However, little attention has been directed toward understanding the story comprehension of children with attention deficit hyperactivity disorder (ADHD). The present paper attempts to integrate the developmental literature on children's story comprehension with the little that is known about the story comprehension processes of children with ADHD. This review is guided by a network model of story representation that emphasizes the structure of causal and enabling relations between story events. Examination of the available studies indicates that children with ADHD lag behind their peers in their understanding of causal relations, and that their attentional problems may contribute to difficulties in understanding factual information in the preschool years and causally related information in the elementary years. Some evidence also is presented suggesting that children with ADHD are less effective in taking advantage of story structure features in guiding their recall of story events. Suggestions for future research are offered that would elaborate our knowledge of the developmental progression in the processing of complex information by children with ADHD.     

Family Processes and Treatment Outcome in the MTA: Negative/Ineffective Parenting Practices in Relation to Multimodal Treatment

To elucidate processes underlying therapeutic change in a large-scale randomized clinical trial, we examined whether alterations in self-reported parenting practices were associated with the effects of behavioral, medication, or combination treatments on teacher-reported outcomes (disruptive behavior, social skills, internalizing symptoms) in children with attention-deficit hyperactivity disorder (ADHD). Participants were 579 children with Combined-type ADHD, aged 7–9.9 years, in the Multimodal Treatment Study of Children with ADHD (MTA). We uncovered 2 second-order factors of parenting practices, entitled Positive Involvement and Negative/Ineffective Discipline. Although Positive Involvement was not associated with amelioration of the school-based outcome measures, reductions in Negative/Ineffective Discipline mediated improvement in children's social skills at school. For families showing the greatest reductions in Negative/Ineffective Discipline, effects of combined medication plus behavioral treatment were pronounced in relation to regular community care. Furthermore, only in combination treatment (and not in behavioral treatment alone) was decreased Negative/Ineffective Discipline associated with reduction in children's disruptive behavior at school. Here, children in families receiving combination treatment who showed the greatest reductions in Negative/Ineffective Discipline had teacher-reported disruptive behavior that was essentially normalized. Overall, the success of combination treatment for important school-related outcomes appears related to reductions in negative and ineffective parenting practices at home; we discuss problems in interpreting the temporal sequencing of such process-outcome linkages and the means by which multimodal treatment may be mediated by psychosocial processes related to parenting.     

Sex differences in school-aged children with pervasive attention deficit hyperactivity disorder

This study investigated 54 children (37 boys and 17 girls) with cross-situational attention deficit hyperactivity disorder (ADHD) to determine whether there are sex differences in the expression of either the primary or secondary symptomatology of ADHD. Results indicated that the male and female ADHD groups were strikingly similar on all measures of primary (impulsivity, inattention, and overactivity) and secondary (learning problems, externalizing symptoms, internalizing symptoms, peer relationship difficulties, and self-perceptions) symptomatology included in this study. The lack of significant sex differences conflicts with prior reports in the literature, and these conflicting results are discussed in terms of differences in inclusion criteria. Implications for understanding the long-term outcome of ADHD in girls are also discussed.     

Online Story Comprehension among Children with ADHD: Which Core Deficits are Involved?

Children with ADHD have difficulty understanding causal connections and goal plans within stories. This study examined mediators of group differences in story narrations between children ages 7-9 with and without ADHD, including as potential mediators both the core deficits of ADHD (i.e., inattention, disinhibition, planning/working memory) as well measures of phonological processing and verbal skills. Forty-nine children with ADHD and 67 non-referred children narrated a wordless book and completed tasks assessing the core deficits of ADHD, phonological processing, and verbal skills. Results revealed that, although no shorter than those of non-referred children, the narratives of children with ADHD contained fewer elements relating to the story's causal structure and goal plan. Deficits in sustained attention accounted for the most variance in these differences. Results have implications for understanding and ameliorating the academic problems experienced by children with ADHD.     

Validity of the parenting scale for parents of children with attention-deficit/hyperactivity disorder

The present study examined the validity of the parenting scale for parents of elementary school-aged children with attention-deficit/hyperactivity disorder (ADHD). Parents from 109 families with children who had been diagnosed with ADHD (106 mothers and 93 fathers) and from 70 families with non-problem children (69 mothers and 59 fathers) completed the parenting scale and reported on their children's behavior problems. Factor analyses revealed two interpretable factors for both mothers and fathers, corresponding to the overreactivity and laxness factors identified in previous studies of the parenting scale. Overreactivity and laxness scores were significantly higher for mothers and fathers of ADHD children than of non-ADHD children; this effect appeared to be accounted for by comorbid aggression and conduct problems among ADHD children. Results support the validity of the parenting scale for use with parents of ADHD children.     

Children With Conduct Problems and Co-occurring ADHD: Behavioral Improvements Following Parent Management Training

To scale up evidence-based treatment of conduct problems, parent management training, Oregon model (PMTO) has been disseminated throughout Norway. This study examined whether Attention Deficit Hyperactivity Disorder (ADHD) predicted the outcomes of PMTO. Of 253 children and families, 97 were reported to have an ADHD diagnosis. Although different at intake, the groups with and without ADHD had close to an equal change in behavioral status following treatment. Maternal depression and family income predicted the combined group's behavior following PMTO. The study indicates that reductions in conduct problems following PMTO are of the same magnitude in children with or without ADHD. However, some characteristics may differentially predict outcomes for children with combined problems.     

Parental involvement in children's learning: Comparing parents of children with and without Attention-Deficit/Hyperactivity Disorder (ADHD)

The present study examined involvement in children's learning among parents of 101 children between 8 and 12 years of age (53 parents of children with ADHD, 48 parents of children without ADHD). Compared to parents of children without ADHD, parents of children with ADHD reported lower self-efficacy in their ability to help their children, felt less welcome and supported by their children's schools and teachers, and perceived less time and energy for involvement in their children's academic lives. Mothers of children with and without ADHD reported similar types and levels of involvement behaviors in the home. Fathers of children with ADHD reported being more disengaged from their children's learning and using more coercive and punitive interactions regarding their children's achievement compared to fathers of children without ADHD. These findings underscore the difficulties in parent-supported learning practices and home-school collaboration initiatives faced by parents of children with ADHD and educators alike. Implications for school psychology practice are discussed.     

The Relation Between Maternal ADHD Symptoms &; Improvement in Child Behavior Following Brief Behavioral Parent Training is Mediated by Change in Negative Parenting

This study examined the extent to which maternal attention-deficit/hyperactivity disorder (ADHD) symptoms predict improvement in child behavior following brief behavioral parent training. Change in parenting was examined as a potential mediator of the negative relationship between maternal ADHD symptoms and improvement in child behavior. Seventy mothers of 6–10 year old children with ADHD underwent a comprehensive assessment of adult ADHD prior to participating in an abbreviated parent training program. Before and after treatment, parenting was assessed via maternal reports and observations and child disruptive behavior was measured via maternal report. Controlling for pre-treatment levels, maternal ADHD symptomatology predicted post-treatment child disruptive behavior problems. The relation between maternal ADHD symptomatology and improvement in child behavior was mediated by change in observed maternal negative parenting. This study replicated findings linking maternal ADHD symptoms with attenuated child improvement following parent training, and is the first to demonstrate that negative parenting at least partially explains this relationship. Innovative approaches combining evidence-based treatment for adult ADHD with parent training may therefore be necessary for families in which both the mother and child have ADHD. Larger-scale studies using a full evidence-based parent training program are needed to replicate these findings.     

Upgrading the science and technology of assessment and diagnosis: laboratory and clinic-based assessment of children with ADHD

Reviews the usefulness of clinic-based and laboratory-based instruments and paradigms for diagnosing attention deficit hyperactivity disorder (ADHD) and monitoring treatment effects. Extant literature examining the performance of normal children and those with ADHD on an extensive range of neurocognitive tests, tasks, and experimental paradigms indicates that particular types of instruments may be more reliable than others with respect to detecting between-group differences. We review task parameters that may distinguish the more reliable from less reliable instruments. The value of clinic-based and laboratory-based instruments for monitoring treatment response in children with ADHD is questionable when evaluated in the context of ecologically relevant variables such as classroom behavior and academic functioning. We present a general conceptual model to highlight conceptual issues relevant to designing clinic-based and laboratory-based instruments for the purposes of diagnosing and monitoring treatment effects in children with ADHD. Application of the model to currently conceptualized core variables indicates that attention and impulsivity-hyperactivity may represent correlative rather than core features of the disorder. We discuss implications of these findings for designing the next generation of clinic-based and laboratory-based instruments.