Parental influence on children with attention-deficit/hyperactivity disorder: II. Results of a pilot intervention training parents as friendship coaches for children

Targeting Peer Contagion Dynamics in Children with ADHD: Effects from a Two-Site Randomized Controlled Trial

OBJECTIVE

Parental Friendship Coaching (PFC) teaches parents to coach their children in friendship skills. This paper examines whether PFC fosters positive peer contagion processes (i.e. dyadic mutuality) and reduces negative peer contagion processes (i.e. coercive joining) within the friendships of children with attention-deficit/hyperactivity disorder (ADHD).

METHOD

Participants were 134 families of children with ADHD and peer problems (age 6-11 years; 69% male; 72% white) at two Canadian sites, randomized to PFC or CARE (an active comparison intervention). Children were observed in the lab at baseline, post-treatment, and at 8-month follow-up during cooperation and competition tasks with a real-life friend. Amount and reciprocity of dyadic mutuality indicators (i.e. positive affect and positive behaviors) and coercive joining indicators (i.e. aggressive, controlling, and rule-breaking behaviors) between friends were coded.

RESULTS

Across treatment conditions, children showed an increase in the amount of dyadic mutuality during cooperation and a decrease in the amount of coercive joining during competition over time. Relative to CARE, PFC induced a reduced amount of coercive joining behaviors during cooperation at post-treatment and follow-up. However, PFC led to decreases in the reciprocity of positive affect during cooperation at post-treatment and to increases in the reciprocity of coercive joining during competition at follow-up relative to CARE. Moderation analyses suggest PFC was associated with better outcomes for children with externalizing comorbidity, and for those with a stable or a best friend.

CONCLUSIONS

Findings highlight the importance of transactional processes, contextual differences, externalizing comorbidities, and friendship status when assessing the efficacy of PFC.

Friendship interventions for children with neurodevelopmental needs: A systematic review and meta-analysis

RATIONALE

Children with neurodevelopmental disorders such as attention-deficit hyperactivity disorder (ADHD), autism, developmental language disorder (DLD), intellectual disability (ID), and social (pragmatic) communication disorder (SPCD) experience difficulties with social functioning due to differences in their social, emotional and cognitive skills. Previous systematic reviews have focussed on specific aspects of social functioning rather than broader peer functioning and friendships.

OBJECTIVE

To systematically review and methodologically appraise the quality and effectiveness of existing intervention studies that measured friendship outcomes for children with ADHD, autism, DLD, ID, and SPCD.

METHOD

Following PRISMA guidelines, we searched five electronic databases: CINAHL, Embase, Eric, PsycINFO, and PubMed. Two independent researchers screened all abstracts and disagreements were discussed with a third researcher to reach consensus. The methodological quality of studies was assessed using the Cochrane Risk of Bias Tool for Randomised Trials.

RESULTS

Twelve studies involving 15 interventions were included. Studies included 683 children with a neurodevelopmental disorder and 190 typically-developing children and diagnosed with either autism or ADHD. Within-group meta-analysis showed that the pooled intervention effects for friendship across all interventions were small to moderate (z = 2.761, p = 0.006, g = 0.485). The pooled intervention effect between intervention and comparison groups was not significant (z = 1.206, p = 0.400, g = 0.215).

CONCLUSION

Findings provide evidence that some individual interventions are effective in improving social functioning and fostering more meaningful friendships between children with neurodevelopmental disorders and their peers. Effective interventions involved educators, targeted child characteristics known to moderate peer functioning, actively involved peers, and incorporated techniques to facilitate positive peer perceptions and strategies to support peers. Future research should evaluate the effectiveness of friendship interventions for children with DLD, ID and SPCD, more comprehensively assess peer functioning, include child self-report measures of friendship, and longitudinally evaluate downstream effects on friendship.

Understanding Problematic Social Media Use in Adolescents with Attention-Deficit/Hyperactivity Disorder (ADHD): A Narrative Review and Clinical Recommendations

Attention-Deficit/Hyperactivity Disorder (ADHD) is consistently associated with a host of social problems, such as victimization and difficulties in maintaining close friendships. These problems are not limited to offline relations but also manifest in the online social world, as previous research shows that ADHD is associated with problematic use of social media. Given the ubiquitous nature of social media, the goal of the current review is to understand why adolescents with ADHD demonstrate more problematic social media use than their typically developing peers. To this end, we provide a narrative review on the evidence for the link between ADHD and social media use, and consequently present an integrative framework, which encompasses neurobiological mechanisms (i.e., imbalance theory of brain development and dual pathway model of ADHD) and social mechanisms, including influences from peers and parents. We conclude that empirical work shows most consistent evidence for the link between problematic social media use and ADHD (symptoms), while intensity of social media use is also associated with several other behaviors and outcomes. Finally, we hypothesize how existing interventions for ADHD may work on the identified mechanisms and provide at-hand clinical recommendations for therapists working with adolescents with ADHD who exhibit problematic social media use.

Meta-analysis: Which Components of Parent Training Work for Children With Attention-Deficit/Hyperactivity Disorder?

OBJECTIVE

Behavioral parent training is an evidence-based intervention for children with attention-deficit/hyperactivity disorder (ADHD), but it is unknown which of its components are most effective. This meta-regression analysis investigated which specific behavioral techniques that parents learn in parent training are associated with effects on parental outcomes.

METHOD

A search was performed for randomized controlled trials on parent training for children with ADHD, with positive parenting, negative parenting, parenting sense of competence, parent-child relationship quality, and parental mental health as outcome measures. After screening 23,026 publications, 29 studies contributing 138 effect sizes were included (N = 2,345). For each study, the dosage of 39 behavioral techniques was derived from intervention manuals, and meta-regression determined which techniques were related to outcomes.

RESULTS

Parent training had robust small- to medium-sized positive effects on all parental outcomes relative to control conditions, both for unblinded and probably blinded measures. A higher dosage of techniques focusing on the manipulation of antecedents of behavior was associated with better outcomes on parenting sense of competence and parental mental health, and a higher dosage of techniques focusing on reinforcement of desired behaviors was related to larger decreases in negative parenting. Higher dosages of psychoeducation were negatively related to parental outcomes.

CONCLUSION

Although techniques were not investigated in isolation, the results suggested that manipulation of antecedents of behavior and reinforcement techniques are key components of parent training for children with ADHD in relation to parental outcomes. These exploratory findings may help to strengthen and tailor parent training interventions for children with ADHD.

An Individual Participant Data Meta-analysis: Behavioral Treatments for Children and Adolescents With Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

Behavioral interventions are well established treatments for children with attention-deficit/hyperactivity disorder (ADHD). However, insight into moderators of treatment outcome is limited.

METHOD

We conducted an individual participant data meta-analysis (IPDMA), including data of randomized controlled behavioral intervention trials for individuals with ADHD <18 years of age. Outcomes were symptoms of ADHD, oppositional defiant disorder (ODD), and conduct disorder (CD) and impairment. Moderators investigated were symptoms and impairment severity, medication use, age, IQ, sex, socioeconomic status, and single parenthood.

RESULTS

For raters most proximal to treatment, small- to medium-sized effects of behavioral interventions were found for symptoms of ADHD, inattention, hyperactivity/impulsivity (HI), ODD and CD, and impairment. Blinded outcomes were available only for small preschool subsamples and limited measures. CD symptoms and/or diagnosis moderated outcome on ADHD, HI, ODD, and CD symptoms. Single parenthood moderated ODD outcome, and ADHD severity moderated impairment outcome. Higher baseline CD or ADHD symptoms, a CD diagnosis, and single parenthood were related to worsening of symptoms in the untreated but not in the treated group, indicating a protective rather than an ameliorative effect of behavioral interventions for these children.

CONCLUSION

Behavioral treatments are effective for reducing ADHD symptoms, behavioral problems, and impairment as reported by raters most proximal to treatment. Those who have severe CD or ADHD symptoms, a CD diagnosis, or are single parents should be prioritized for treatment, as they may evidence worsening of symptoms in the absence of intervention.

Psychoeducation Intervention Effectiveness to Improve Social Skills in Young People with ADHD: A Meta-Analysis

OBJECTIVE

Attention Deficit Hyperactivity Disorder (ADHD) can be associated with limited understanding of the condition and poor social skills. Some evidence favors a psychoeducational approach, but little is known about the effectiveness of psychoeducation.

METHODS

Systematic review and meta-analysis of studies assessing psychoeducational interventions that aim to improve social skills of young people with ADHD.

RESULTS

Ten studies, including 943 participants, reported across 13 papers met the inclusion criteria. Although effect sizes were small, findings suggest the included interventions significantly improved social skills in young people with ADHD.

CONCLUSIONS

Results show promise for psychoeducational behavioral interventions . However, the recommendations that can be developed from existing evidence are somewhat limited by the low quality of studies. Further rigorous trials are needed. In addition, future research should consider the long-term outcomes for these interventions, they should be iteratively co-designed and research should consider the context they intend to be delivered in.

School-Based Interventions for Elementary School Students with Attention-Deficit/Hyperactivity Disorder

Children with attention-deficit/hyperactivity disorder experience significant academic, social, and behavioral impairments in elementary school settings. Although psychopharmacologic treatments can improve symptomatic behaviors, these rarely are sufficient for enhancing school performance. Thus, medication should be supplemented by one or more school interventions, including behavioral strategies, academic interventions, behavioral peer interventions, organizational skills training, and self-regulation strategies. Although all of these school interventions have been found effective, classroom behavioral strategies, organizational skills training, and self-regulation strategies have the strongest empirical support. Clinicians should collaborate with school mental health professionals to encourage implementation of effective school interventions across school years.

Family-based treatments for attention-deficit/hyperactivity disorder: A review of family functioning outcomes in randomized controlled trials from 2010 to 2019

This review details advances in randomized controlled trials of family-based treatments for attention-deficit/hyperactivity disorder (ADHD) conducted in the United States from 2010 to 2019, and the impact of these treatments on the domain of family functioning. Twenty-two studies were included in the review and three types of family treatments, integrated parent-child treatments, parent-directed treatments, and youth treatments with adjunctive parent involvement, were identified for children and adolescents. Studies point to considerable advancements in consideration of understudied and diverse populations, and results of the review show all three types of family interventions for ADHD should be considered well-established interventions addressing family functioning. Practical guidelines are offered, and future directions for research are discussed.

Social participation to support good mental health in neurodisability

BACKGROUND

Young people with neurodisability experience lower levels of mental wellbeing and are at increased risk of mental illness compared with their non-disabled peers. Social participation is recognized as a protective factor against mental illness and a potential pathway to support better mental wellbeing in neurodisability.

METHOD

This co-design study involved young people, parents and clinicians. First, possible interventions were identified through a rapid systematic evidence review. Any study designs were considered, which included people with a neurodisability aged 0-18 years, which evaluated a therapy intervention with social participation and mental health outcomes. Titles and abstracts were screened by two reviewers, from the included studies data were extracted and then presented using written summaries. Second, the summaries were discussed and prioritized in stakeholder groups with young people, parents and clinicians. Groups were audio recorded and framework analysis was used to identify and specify intervention elements and their delivery.

RESULTS

The evidence review identified 13,870 records, from which 43 were included. These records were published 1994-2017 and reported studies with 4-249 participants aged 16 months-18 years with a range of neurodisabilities. Five intervention approaches (social skills training, arts, sports, technology and play) were identified from the review. Two themes emerged from the stakeholder groups: intervention in the real world, feeling judged and feeling safe. The groups prioritized an intervention in real-world social leisure contexts (i.e. existing clubs and groups) using nine key intervention elements (e.g. feedback and positive verbal reinforcement) delivered by club leaders trained by healthcare professionals using five intervention procedures (e.g. a manual and video training).

CONCLUSION

This study has identified core elements of social participation interventions that may improve mental health outcomes in young people with neurodisability, which should now be tested.

Effects of the Parental Friendship Coaching Intervention on Parental Emotion Socialization of Children with ADHD

Parental emotion-related socialization behaviors shape children's socioemotional functioning and appear important for children with attention-deficit/hyperactivity disorder (ADHD). The Parental Friendship Coaching (PFC) intervention teaches parents to coach their children with ADHD in friendship skills, which includes managing emotions. We examined whether PFC, relative to psychoeducation and social support (Coping with ADHD through Relationships and Education; CARE), improved parental emotion-related socialization behaviors, child affect with a friend, and child social behaviors related to emotional difficulties. Participants were 172 families of children with ADHD (ages 6-11, 30% female), randomized to PFC or CARE. At baseline, children and their real-life friends interacted and their affect was coded. Parents coached their child in friendship skills before and after the child-friend interaction, and parents' praise, warmth, criticism, and discussion of emotion-related friendship strategies were coded. Parents and teachers reported children's withdrawn/depressed and aggressive behaviors. Results suggested that PFC (relative to CARE) led to parents providing more emotion strategies and praise at post-treatment and follow-up, and more warmth at follow-up, and to children showing less withdrawn/depressed behavior at follow-up. For bidirectional relationships from baseline to post-treatment, more parental warmth was associated with less child withdrawn/depressed behavior, and more parental criticism with more child aggression. More child withdrawn/depressed behavior and positive affect at post-treatment were associated with more parental criticism at follow-up. After corrections for multiple comparisons, only PFC effects on praise and emotion strategies at post-treatment, and praise and withdrawn/depressed behavior at follow-up, maintained. Implications are discussed for supporting socioemotional functioning in children with ADHD.

Does helping mothers in multigenerational ADHD also help children in the long run? 2-year follow-up from baseline of the AIMAC randomized controlled multicentre trial

ADHD often affects multiple generations in a family. Previous studies suggested that children with ADHD benefit less from therapy if parents are also affected, since ADHD symptoms interfere with treatment implementation. This two-group randomised controlled trial examined whether targeting maternal ADHD boosts the efficacy of parent-child training (PCT) for the child's ADHD. Here, we report follow-up results 2 years from baseline. Mothers of 144 mother-child dyads (ADHD according to DSM-IV) were examined for eligibility (T1) and randomised to 12 weeks of intensive multimodal treatment comprising pharmacotherapy and DBT-based cognitive behavioural group psychotherapy (TG, n = 77) or clinical management comprising non-specific counselling (CG, n = 67) for Step 1 (concluded by T2). Subsequently, all dyads participated in 12 weekly PCT sessions for Step 2 (concluded by T3). In Step 3, participants received maintenance treatments for 6 months (concluded by T4). At 24 months after baseline (T5), we performed follow-up assessments. The primary endpoint was child ADHD/ODD score (observer blind rating). Outcomes at T5 were evaluated using ANCOVA. Assessments from 101 children and 95 mothers were available at T5. Adjusted means (m) of ADHD/ODD symptoms (range 0-26) in children did not differ between TG and CG (mean difference = 1.0; 95% CI 1.2-3.1). The maternal advantage of TG over CG on the CAARS-O:L ADHD index (range 0-36) disappeared at T5 (mean difference = 0.2; 95% CI - 2.3 to 2.6). Sensitivity analyses controlling for medication and significant predictors of follow-up participation showed unchanged outcomes. Within-group outcomes remained improved from baseline. At the 24-month follow-up, TG and CG converged. The superiority of intensive treatment regarding maternal symptoms disappeared. In general, cross-generational treatment seems to be effective in the long term. (BMBF grant 01GV0605; registration ISRCTN73911400).

ADHD in Adolescents: Commentary on the Special Issue of Ripple Effects in Self-Perceptions and Social Relationships

Adolescence is a developmental period that affords both risk as well as enormous opportunity. Ripple effects can extend far and wide and speak to the nuance and complexity in understanding and treating ADHD during the adolescent period. The studies in this special issue provide novel and important insights into the lives of adolescents with ADHD, and they collectively point to important areas for both research and clinical attention. Further, each of the studies underscore the importance of soliciting the perspective of adolescents with ADHD. In this commentary, I consider the value of self-report when working with adolescents with ADHD, the possibility of a self-perception bias in youth with ADHD, challenges in assessing social functioning in adolescence, and implications for school-based assessments and interventions. For treatment specifically, I raise the possibility of a modular intervention approach for adolescents with ADHD and shared decision making that solicits and incorporates the adolescent perspective. The voices of adolescents with ADHD may be crucial for understanding how to lower risk, promote resilience, reduce stigma, and improve our assessments and interventions.

Evidence Base Update for Measures of Social Skills and Social Competence in Clinical Samples of Youth

Social skills and social competence are key transdiagnostic processes in developmental psychopathology and are the focus of an array of clinical interventions. In this Evidence Base Update, we evaluated the psychometric properties of measures of social skills and social competence used with clinical samples of children and adolescents. A systematic literature search yielded eight widely used measures of social skills and one measure of social competence. Applying the criteria identified by Youngstrom et al. (2017), we found that, with some exceptions, these measures had adequate to excellent norms, internal consistency, and test-retest reliability. There was at least adequate evidence of construct validity and treatment sensitivity in clinical samples for nearly all measures assessed. Many of the scales included items assessing constructs other than social skills and competence (e.g., emotion regulation). Development of updated tools to assess youth's effectiveness in key interpersonal situations, including those occurring online, may yield clinical dividends.

Behavioral Treatment for the Social-Emotional Difficulties of Preadolescent and Adolescent Girls with ADHD

Girls with attention-deficit/hyperactivity disorder (ADHD) are at high risk for peer difficulties that often persist into adolescence and adulthood and portend risk for additional difficulties, such as depression, anxiety, and borderline personality disorder. However, very little research has examined interventions that address the widespread peer difficulties of girls with ADHD. This paper describes two open trials of behavior therapy aimed at addressing their social-emotional difficulties. The first trial includes 33 preadolescent girls (ages 7-11) with ADHD enrolled in an eight-week treatment and the second trial includes 22 adolescent girls (ages 12-16) with ADHD enrolled in a 12-week treatment. Measures of treatment feasibility and acceptability and measures of social functioning and psychopathology were collected in both trials. High levels of treatment feasibility and acceptability were reported in both the preadolescent and adolescent trial. In addition, improvements were reported in areas of social functioning and reductions in psychopathology, although the magnitude and specific areas of improvement differed somewhat in the preadolescent versus adolescent group. These preliminary findings provide a first step towards addressing the widespread social-emotional difficulties of girls with ADHD and offer insight into continuing efforts to address their treatment needs.

Evaluation of a multi-component and multi-agent intervention to improve classroom social relationships among early elementary school-age children

We present the preliminary evaluation of a comprehensive, multi-component and multi-agent 2-year classroom intervention to enhance children's relationships with their peers and teachers among early elementary school students in Spain. The intervention contained universal components directed to the whole class plus targeted components for children with peer problems. Using a quasi-experimental design, 229 children (in 10 classrooms) formed a comparison group whose teachers engaged in their typical practices, followed the next year by 214 children (in 9 classrooms) who received the intervention. Children completed a sociometric procedure, and reported their self-perceptions of peer functioning and their relationship quality with teachers at the beginning of 1st grade (pretest) and the end of 2nd grade (posttest; 93% retention). After statistical control of pretest functioning, by posttest those in the intervention group received fewer negative sociometric nominations, perceived themselves to receive fewer negative sociometric nominations and to have greater overall peer acceptance, and reported their teachers to have greater warmth and organization, compared to children in the comparison group. However, intervention group children also received fewer positive sociometric nominations (as well as perceived themselves to receive fewer positive nominations) than comparison group children. Target children, selected for being disliked by peers, received accentuated benefits from the intervention on the outcome variables of fewer negative nominations received and greater teacher warmth. Implications for practice are discussed.

Considering equifinality in treatment planning for social impairment: Divergent paths in neurodevelopmental disorders

Youth with autism spectrum disorder (ASD) present with deficits in both social cognition and executive functioning (EF), which contribute to social impairment. Autistic youth are also frequently diagnosed with comorbid attention-deficit/hyperactivity disorder (ADHD), a disorder that, like ASD, includes impaired EF and social functioning. The comorbidity of ASD and ADHD may result in compounded social impairment, but prior research has not sufficiently evaluated the extent to which this comorbidity profile responds to evidence-based intervention targeting social deficits. It is conceivable that dually targeting EF and social cognition impairment will be more impactful than direct social skills training alone. The authors present an integrative model for intervention programming that examines pathways to social impairment in order to more effectively improve social skills and thereby impact both proximal (e.g., emotion expression, current peer relationships) and more distal outcomes (e.g., depression, self-esteem) in youth with ASD and other neurodevelopmental disorders.

Social functioning in youth with attention-deficit/hyperactivity disorder and autism spectrum disorder: transdiagnostic commonalities and differences

Attention-Deficit/Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD) are both neurodevelopmental disorders originating in childhood with high associated impairments and public health significance. There has been growing recognition of the frequent co-occurrence, and potential interrelatedness, between ADHD and ASD without intellectual disability. In fact, the most recent (5th) edition of the DSM is the first to allow ADHD and ASD to be diagnosed in the same individual. The study of transdiagnostic features in ADHD and ASD is important for understanding, and treating, these commonly co-occurring disorders. Social impairment is central to the description and prognosis of both disorders, and many youth with some combination of ADHD and ASD present to clinics for social skills training interventions. However, the aspects of social functioning that are impaired may have both shared and distinct features between the two disorders, relating to some overlapping and some diverse etiologies of social problems in ADHD compared to ASD. These findings have implications for interventions to address social problems in youth with these conditions. We conclude with a discussion about areas for future research and novel intervention targets in youth with ADHD, ASD, and their comorbidity.

Sequenced neurocognitive and behavioral parent training for the treatment of ADHD in school-age children

The present study examines the potential of sequencing a neurocognitive intervention with behavioral parent training (BPT) to improve executive functions (EFs), psychiatric symptoms, and multiple indices of functional impairment in school-age children aged 7 to 11 years who have been diagnosed with attention-deficit/hyperactivity disorder (ADHD). Specifically, in a randomized controlled trial design, 85 children were assigned to either Cogmed Working Memory Training (CWMT) followed by an empirically supported, manualized BPT intervention, or to a placebo version of CWMT followed by the same BPT intervention. Working memory maintenance (i.e., attention control/short-term memory), working memory processing and manipulation, ADHD and oppositional defiant disorder (ODD) symptoms, impairment in parent-child dynamics, familial impairment, and overall functional compromise were evaluated as outcomes. The results suggest specific effects of the combined CWMT and BPT program on verbal and nonverbal working memory storage and nonverbal working memory processing and manipulation but no incremental benefits in regard to ADHD symptoms, ODD symptoms, and functional outcomes. The present findings do not support the hypothesis regarding the complementary and augmentative benefits of sequenced neurocognitive and BPT interventions for the treatment of ADHD. These results, the study's limitations, and future directions for research are further discussed.

Social Problems in ADHD: Is it a Skills Acquisition or Performance Problem?

Recent models suggest that social skills training's inefficacy for children with ADHD may be due to target misspecification, such that their social problems reflect inconsistent performance rather than knowledge/skill gaps. No study to date, however, has disentangled social skills acquisition from performance deficits in children with ADHD. Children ages 8-12 with ADHD (n=47) and without ADHD (n=23) were assessed using the well-validated social behavioral analysis framework to quantify cross-informant social skills acquisition deficits, performance deficits, and strengths. Results provided support for the construct and predictive validities of this Social Skills Improvement System (SSIS) alternate scoring method, including expected magnitude and valence relations with BASC-2 social skills and ADHD symptoms based on both parent and teacher report. Acquisition deficits were relatively rare and idiosyncratic for both the ADHD and Non-ADHD groups, whereas children with ADHD demonstrated cross-informant social performance deficits (d=0.82-0.99) on several specific behaviors involving attention to peer directives, emotion regulation, and social reciprocity. Relative to themselves, children with ADHD were perceived by parents and teachers as exhibiting more social strengths than social acquisition deficits; however, they demonstrated significantly fewer social strengths than the Non-ADHD group (d = -0.71 to -0.89). These findings are consistent with recent conceptualizations suggesting that social problems in ADHD primarily reflect inconsistent performance rather than a lack of social knowledge/skills. Implications for refining social skills interventions for ADHD are discussed.

Peer Inclusion in Interventions for Children with ADHD: A Systematic Review and Meta-Analysis

Objective

To assess the effectiveness of peer inclusion in interventions to improve the social functioning of children with ADHD.

Methods

We searched four electronic databases for randomized controlled trials and controlled quasi-experimental studies that investigated peer inclusion interventions alone or combined with pharmacological treatment. Data were collected from the included studies and methodologically assessed. Meta-analyses were conducted using a random-effects model.

Results

Seventeen studies met eligibility criteria. Studies investigated interventions consisting of peer involvement and peer proximity; no study included peer mediation. Most included studies had an unclear or high risk of bias regarding inadequate reporting of randomization, blinding, and control for confounders. Meta-analyses indicated improvements in pre-post measures of social functioning for participants in peer-inclusive treatment groups. Peer inclusion was advantageous compared to treatment as usual. The benefits of peer inclusion over other therapies or medication only could not be determined. Using parents as raters for outcome measurement significantly mediated the intervention effect.

Conclusions

The evidence to support or contest the efficacy of peer inclusion interventions for children with ADHD is lacking. Future studies need to reduce risks of bias, use appropriate sample sizes, and provide detailed results to investigate the efficacy of peer inclusion interventions for children with ADHD.

Neurocognitive and behavioral predictors of social problems in ADHD: A Bayesian framework

OBJECTIVE

Social problems are a key area of functional impairment for children with attention deficit hyperactivity disorder (ADHD), and converging evidence points to executive dysfunction as a potential mechanism underlying ADHD-related social dysfunction. The evidence is mixed, however, with regard to which neurocognitive abilities account for these relations.

METHOD

A well-characterized group of 117 children ages 8-13 (M = 10.45, SD = 1.53; 43 girls; 69.5% Caucasian/Non-Hispanic) with ADHD (n = 77) and without ADHD (n = 40) were administered multiple, counterbalanced tests of neurocognitive functioning and assessed for social skills via multi-informant reports.

RESULTS

Bayesian linear regressions revealed strong support for working memory and cross-informant interfering behaviors (inattention, hyperactivity/impulsivity) as predictors of parent- and teacher-reported social problems. Working memory was also implicated in social skills acquisition deficits, performance deficits, and strengths based on parent and/or teacher report; inattention and/or hyperactivity showed strong correspondence with cross-informant social problems in all models. There was no evidence for, and in most models strong evidence against, effects of inhibitory control and processing speed. The ADHD group was impaired relative to the non-ADHD group on social skills (d = 0.82-0.88), visuospatial working memory (d = 0.89), and phonological working memory (d = 0.58). In contrast, the Bayesian ANOVAs indicated that the ADHD and non-ADHD groups were equivalent on processing speed, IQ, age, gender, and socioeconomic status (SES). There was no support for or against group differences in inhibition.

CONCLUSIONS

These findings confirm that ADHD is associated with impaired social performance, and implicate working memory and core ADHD symptoms in the acquisition and performance of socially skilled behavior. (PsycINFO Database Record

The Effects of Behavioral Parent Training With Adjunctive Social Skills Training for a Preadolescent Girl With ADHD and Borderline Personality Features

Girls with attention deficit hyperactivity disorder (ADHD) are at high risk of a range of social–emotional difficulties, including peer rejection, suicide attempts, and borderline personality disorder (BPD), which are associated with serious, long-term impairment and have not emerged as clearly in samples of boys with ADHD. BPD is a particularly concerning long-term outcome of ADHD in girls, given the high risk for suicidality and long-lasting relationship difficulties. Very little research has focused on treatment for the interpersonal impairments of girls with ADHD, or on addressing risk for developing BPD. This case study describes the use of behavioral parent training (BPT) with adjunctive social skills training (SST) to address the social–emotional difficulties of a 9-year-old girl, “Violet,” who was diagnosed with ADHD Combined Presentation and was being treated with medication for anxiety. Violet presented with many social difficulties, including low self-esteem, emotional dysregulation, and unstable relationships, which were conceptualized as borderline personality features (BPF). Treatment was associated with improvements in parent functioning, including reductions in caregiver strain and inconsistent discipline, as well as improvements in child functioning, including reductions in ADHD symptoms, a range of impairments, and BPF. This case study illustrates the benefit of a brief psychosocial intervention in reducing multiple indices of interpersonal impairment, including BPF, for a girl with ADHD.

Using task performance to inform treatment planning for youth with ADHD: A systematic review

The role that neuropsychological task performance plays in the assessment of Attention-Deficit/Hyperactivity Disorder (ADHD) is currently ambiguous, and findings are mixed regarding whether tasks have validity for diagnosing the disorder. Irrespective of their validity for diagnosing ADHD, neuropsychological tasks could provide valuable information to mental health professionals if they can inform recommendations for treatment targets and modalities. Therefore, this review sought to synthesize the available evidence related to the use of neuropsychological task performance as a tool for informing treatment planning for youth with ADHD. Reviewed studies focused on examinations of associations between task performance and academic, social, and health outcomes, as well as response to treatment. Twenty-five relevant studies using samples of youth diagnosed with ADHD in clinical, community, and school settings were identified. Review of the evidence suggests that task performance may be useful in identifying individuals with ADHD at risk for academic impairment. However, the evidence is less compelling for identifying youth at risk for impaired social functioning or poor health outcomes. The review also found that task performance is likely useful for predicting response to treatment with methylphenidate. Across studies, evidence indicated that interpreting task performance in an integrated manner, such as a factor score or mean score, was more consistently useful for predicting outcomes of interest than interpreting performance from a single task. Implications for the use of tasks in ADHD assessments are discussed, and future directions are outlined for further examining the clinical utility of task performance.

Social Skills Training and ADHD-What Works?

PURPOSE OF REVIEW

Many children and adolescents with attention-deficit/hyperactivity disorder (ADHD) have difficulties in their social skills and peer relationships. Because social problems exacerbate later maladjustment in ADHD populations, it is important to address this serious impairment. Although social skills training (SST) is a common intervention approach, evidence to date suggests that SST has limited efficacy, at least when provided in traditional, clinic-based settings. The current review summarizes recent advances to traditional SST approaches that may potentially enhance their efficacy.

RECENT FINDINGS

We identify two promising directions in which SST may be modified to make it more efficacious for ADHD populations. The first direction involves providing increased reinforcement and reminders of appropriate social behavior at the point of performance to youth with ADHD (e.g., in vivo, in real life peer situations as opposed to in the clinic). We note the importance of ensuring that youth with ADHD are receptive to such reminders. The second direction involves encouraging peers to be more socially accepting and inclusive of youth with ADHD. This avenue has been understudied in the literature to date. SST for children and adolescents with ADHD may be enhanced by providing more in vivo reminders and feedback at the point of performance and by making efforts to alter peers' impressions about youth with ADHD.

Custom-fit Parenting: How Low- and Well-Accepted Young Adolescents Benefit from Peer-related Parenting

OBJECTIVE

The present study investigated whether longitudinal associations between peer-related parenting behaviors (facilitation of peer interactions, social coaching about peer problems) and peer adjustment were moderated by young adolescents' peer status.

DESIGN

Participants included 123 young adolescents (M age = 12.03 years; 50% boys; 58.5% European American) at Time 1. At Time1 (summer before the middle school transition), parents reported on their facilitation of peer interaction opportunities and coaching strategies to a hypothetical peer exclusion situation; teachers reported on youth peer acceptance. At Times 1 and 2 (spring after the middle school transition), youth reported on peer adjustment (friendship quality, loneliness, peer victimization).

RESULTS

Peer acceptance (pre-middle school transition) moderated prospective associations between peer-related parenting and peer adjustment, yielding two patterns of associations. Parental facilitation predicted better friendship quality and lower levels of loneliness over time among youth with high peer acceptance, but not among youth with low peer acceptance. In contrast, parental social coaching predicted better friendship quality among youth with low peer acceptance, but lower friendship quality among youth with high peer acceptance.

CONCLUSIONS

Not all forms of positive peer-related parenting are equally beneficial for all youth. Well-accepted youth may have the social opportunities to take advantage of parental facilitation, whereas low-accepted youth may have greater social needs and benefit from support in the form of social coaching. Implications of these findings are discussed in relation to the literatures on peer-related parenting and peer adjustment.

Physical Activity of Mexican-Heritage Youth During the Summer and School-Year: The Role of Parenting Strategies

Mexican-heritage youth living along the U.S.-Mexico border have higher rates of obesity than non-Hispanic Whites. Parenting strategies may influence youth physical activity (PA) and sedentary behaviors (SB) mitigating these obesity rates; however, parenting strategies have not been well examined in Hispanic cultures. Therefore, we examined relationships between parenting strategies and PA and SB of Mexican-heritage youth. Mother-child dyads (n = 121 dyads) were surveyed during the summer and school-year. Quantile regression estimated relationships between parenting strategies, and PA and SB. Summer. Reinforcement was negatively associated with moderate-to-vigorous PA (MVPA) among more active youth (β = -364.4); limit setting was negatively associated with SB among less sedentary youth (β = -23.3); and use of discipline was negatively associated with sedentary screen time in youth reporting less screen use (β = -3.2). School-year. Males reported more MVPA (773.9 min/week) than females (738.7 min/week). Reinforcement was positively associated with weekly MVPA among more active youth (β = 173.6), fewer sedentary minutes/week among all youth, and fewer sedentary screen time minutes among less sedentary youth (β = -6.4). Parenting strategies are related with PA and SB. Investigators should focus on identifying modifiable parenting strategies to address the various needs presented during summertime and school-year for Mexican-heritage youth.

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.

Differential impact of a multimodal versus pharmacological therapy on the core symptoms of attention deficit/hyperactivity disorder in childhood

The aim of this study was to analyze the relative and differential efficacy of a combined versus medical treatment to reduce the symptoms of ADHD children in the school and family environment. A total of 100 subjects participated: 20 children with ADHD, their 40 parents and their 40 teachers. Half of the subjects were assigned to the drug group and half to the combined (drug plus psychosocial, psychoeducational intervention with teachers and mothers/fathers).

RESULTS

The group analyses indicated that both treatments were effective, without significant differences between them. Individualized clinical analyses indicated that higher percentages of improvement and normalization were obtained in the children in the combined group than in the drug only group. Our findings point to the desirability of implementing long-lasting multimodal, multicontextual interventions for ADHD in childhood.

A Randomised Controlled Trial of a Play-Based Intervention to Improve the Social Play Skills of Children with Attention Deficit Hyperactivity Disorder (ADHD)

There is a need for effective interventions to address the social difficulties of children with ADHD. This randomised controlled trial examined the effectiveness of a play-based intervention for improving the social play skills of children with ADHD in peer-to-peer interactions. Children with ADHD (5 to 11 years) were randomised to an intervention-first (n = 15) or waitlist control-first group (n = 14). Participants allocated to the control-first group received the intervention after a 10-week wait period. Children invited a typically-developing playmate and parents of children with ADHD participated. The intervention involved: six clinic play-sessions, weekly home-modules and a one-month home follow up. The Test of Playfulness (ToP) was scored by a blinded rater. Parent reported treatment adherence was used to assess treatment fidelity. Between group statistics were used to compare the change of the intervention-first (10-week intervention period) and control-first (10-week wait period) groups. Once all children had received the intervention, repeated measures ANOVA, post hoc Least Significance Difference tests and Cohen’s-d were used to measure effect. Changes in ToP social items were analysed using Friedman’s ANOVA. Linear regression analyses were used to identify variables that predicted change. The control-first group did not change during the wait period. The change in the intervention-first group was significantly greater than the change in the control-first group (during the wait period). When the data from the two groups were combined, the mean ToP scores of the children with ADHD (n = 29) improved significantly following the intervention, with a large effect from pre to post intervention and from pre intervention to follow up. Children maintained treatment gains at follow up. All ToP social items improved significantly following the intervention. The findings support the use of play involving parent and peer mediated components to enhance the social play skills of children with ADHD.

Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12614000973617

Child outcomes of a pilot parent-delivered intervention for improving the social play skills of children with ADHD and their playmates

OBJECTIVE

This pilot study examined the effectiveness of a parent-delivered intervention for improving: the social play skills of children with attention deficit hyperactivity disorder (ADHD) and their typically developing playmates and the empathy of children with ADHD.

METHODS

Participants were children with ADHD and their typically developing playmates (n = 9/group). The intervention was primarily parent-implemented and involved: parent-training, weekly home-modules, three clinic play-sessions, therapist-parent phone consultations and a one-month follow-up. The Test of Playfulness (ToP) was the primary outcome measure. Cohen's-d and paired sample t-test calculations were used to measure effect.

RESULTS

Social play outcomes of children with ADHD improved significantly from: pre- to post-test (t = 3.2; p = 0.02; d = 1.0) and post-test to follow-up intervention (t = 2.7; p = 0.02; d = 1.1). Playmate's improved significantly from pre- to post-intervention (t = 3.9; p = 0.03; d = 1.2). Children with ADHD improved significantly on 4/7 ToP empathy items (t = 2.31-3.16; p = 0.02).

CONCLUSION

The intervention successfully improved the social play skills of children with ADHD and their playmates.

Heterogeneity in ADHD: Neurocognitive predictors of peer, family, and academic functioning

Childhood attention-deficit/hyperactivity disorder (ADHD) is associated with impairments in peer, family, and academic functioning. Although impairment is required for diagnosis, children with ADHD vary significantly in the areas in which they demonstrate clinically significant impairment. However, relatively little is known about the mechanisms and processes underlying these individual differences. The current study examined neurocognitive predictors of heterogeneity in peer, family, and academic functioning in a well-defined sample of 44 children with ADHD aged 8-13 years (M = 10.31, SD = 1.42; 31 boys, 13 girls; 81% Caucasian). Reliable change analysis indicated that 98% of the sample demonstrated objectively-defined impairment on at least one assessed outcome measure; 65% were impaired in two or all three areas of functioning. ADHD children with quantifiable deficits in academic success and family functioning performed worse on tests of working memory (d = 0.68 to 1.09), whereas children with impaired parent-reported social functioning demonstrated slower processing speed (d = 0.53). Dimensional analyses identified additional predictors of peer, family, and academic functioning. Working memory abilities were associated with individual differences in all three functional domains, processing speed predicted social functioning, and inhibitory control predicted family functioning. These results add to a growing literature implicating neurocognitive abilities not only in explaining behavioral differences between ADHD and non-ADHD groups, but also in the substantial heterogeneity in ecologically-valid functional outcomes associated with the disorder.

Developmental trajectories of aggression, prosocial behavior, and social-cognitive problem solving in emerging adolescents with clinically elevated attention-deficit/hyperactivity disorder symptoms

Middle school is a critical yet understudied period of social behavioral risks and opportunities that may be particularly difficult for emerging adolescents with attention-deficit/hyperactivity disorder (ADHD) given their childhood social difficulties. Relatively few ADHD studies have examined social behavior and social-cognitive problem solving beyond the elementary years, or examined aspects of positive (prosocial) behavior. The current study examined how middle school students with clinically elevated ADHD symptoms differ from their non-ADHD peers on baseline (6th grade) and age-related changes in prosocial and aggressive behavior, and the extent to which social-cognitive problem solving strategies mediate these relations. Emerging adolescents with (n = 178) and without (n = 3,806) clinically elevated, teacher-reported ADHD-combined symptoms were compared longitudinally across 6th through 8th grades using parallel process latent growth curve modeling, accounting for student demographic characteristics, oppositional-defiant disorder (ODD) symptoms, deviant peer association, school climate, and parental monitoring. Sixth graders with elevated ADHD symptoms engaged in somewhat fewer prosocial behaviors (d = -0.44) and more aggressive behavior (d = 0.20) relative to their peers. These small social behavioral deficits decreased but were not normalized across the middle school years. Contrary to hypotheses, social-cognitive problem solving was not impaired in the ADHD group after accounting for co-occurring ODD symptoms and did not mediate the association between ADHD and social behavior during the middle school years. ADHD and social-cognitive problem solving contributed independently to social behavior, both in 6th grade and across the middle school years; the influence of social-cognitive problem solving on social behavior was highly similar for the ADHD and non-ADHD groups.

Friendship Characteristics of Children With ADHD

OBJECTIVE

This study explored the friendship characteristics of 8 to 12 year old children with and without Attention-Deficit/Hyperactivity Disorder (ADHD). Friendship characteristics included number of nominated and corroborated friends, duration of friendships, amount of contact with friends, and the proportion of friends with learning and behavioral problems.

METHOD

The sample comprised 92 children, 50 with a diagnosis of ADHD and 42 comparison children.

RESULT

While children with ADHD did not differ from comparison children in the number of friends they nominated, parents and teachers of children with ADHD were less likely to corroborate that these friendships existed. The friendships of children with ADHD were also shorter in duration. While children with ADHD were indistinguishable from comparison children with regards to the amount of telephone contact with friends, they spent less time with friends outside of school than comparison children. Children with ADHD had a higher proportion of friends with learning and behavior problems.

CONCLUSION

While children with ADHD differ from comparison children in the above friendship characteristics, it is promising that they still fall within the average range for the number of corroborated friendships and they demonstrate adequate stability in their friendships.

Improved quality of life among adolescents with attention-deficit/hyperactivity disorder is mediated by protective factors: a cross sectional survey

BACKGROUND

The aim of this study was to assess the role of protective factors as mediators and/or moderators of the relationship between coexisting emotional and conduct problems and quality of life (QoL) among adolescents with attention-deficit/hyperactivity disorder (ADHD).

METHODS

The sample consisted of 194 adolescents with ADHD. Participants completed measures of individual competencies, family cohesion and social support, and QoL. Coexisting emotional and conduct problems were assessed using the Strength and Difficulties Questionnaire.

RESULTS

Individual competencies and social support mediated the association between emotional and conduct problems and QoL. Family cohesion was associated with both emotional and conduct problems. No moderating effects of protective factors and coexisting problems were found.

CONCLUSIONS

The assessment of individual competencies, social resources, and family cohesion may identify potential treatment goals for adolescents with ADHD and coexisting problems, and may contribute to improvements in QoL.

Psychosocial interventions in attention-deficit/hyperactivity disorder: update

Attention-deficit/hyperactivity disorder (ADHD) is the most common reason for referral to child and adolescent psychiatry clinics. Although stimulant medications represent an evidence-based approach to managing ADHD, psychosocial interventions for child/adolescent ADHD target functional impairments as the intervention goal, and rely heavily on behavioral therapy techniques and operant conditioning principles. Evidence-based psychosocial interventions for managing pediatric ADHD include behavioral parent training, school-based interventions relying on behavioral modification, teaching skills, and operant conditioning principles, and intensive summer treatment programs. The use of conjoint psychosocial treatments with ADHD medications may enable lower doses of each form of treatment.

ADHD, Multimodal Treatment, and Longitudinal Outcome: Evidence, Paradox, and Challenge

Given major increases in the diagnosis of attention-deficit hyperactivity disorder (ADHD) and in rates of medication for this condition, we carefully examine evidence for effects of single versus multimodal (i.e., combined medication and psychosocial/behavioral) interventions for ADHD. Our primary data source is the Multimodal Treatment Study of Children with ADHD (MTA), a 14-month, randomized clinical trial in which intensive behavioral, medication, and multimodal treatment arms were contrasted with one another and with community intervention (treatment-as-usual), regarding outcome domains of ADHD symptoms, comorbidities, and core functional impairments. Although initial reports emphasized the superiority of well-monitored medication for symptomatic improvement, reanalyses and reappraisals have highlighted (a) the superiority of combination treatment for composite outcomes and for domains of functional impairment (e.g., academic achievement, social skills, parenting practices); (b) the importance of considering moderator and mediator processes underlying differential patterns of outcome, including comorbid subgroups and improvements in family discipline style during the intervention period; (c) the emergence of side effects (e.g., mild growth suppression) in youth treated with long-term medication; and (d) the diminution of medication's initial superiority once the randomly assigned treatment phase turned into naturalistic follow-up. The key paradox is that whereas ADHD clearly responds to medication and behavioral treatment in the short term, evidence for long-term effectiveness remains elusive. We close with discussion of future directions and a call for greater understanding of relevant developmental processes in the attempt to promote optimal, generalized, and lasting treatments for this important and impairing neurodevelopmental disorder.

Beyond symptom control for attention-deficit hyperactivity disorder (ADHD): what can parents do to improve outcomes?

Attention-deficit hyperactivity disorder (ADHD) and its associated behavioural manifestations develop and progress as the result of complex gene-environment interactions. Parents exert a substantial influence and play a major role in their child's social environment. Despite this, recent evidence has suggested that adapting the child's environment via parenting interventions has minimal effects on child ADHD symptoms when analysing data from informants who are probably blind to treatment allocation. However, adverse parenting and family environments may act as a source of environmental risk for a number of child outcomes beyond ADHD symptoms. This is a narrative review that critically discusses whether parenting interventions are beneficial for alternative functioning outcomes in ADHD including neuropsychological, academic and social functioning and disruptive behaviour and how parenting and familial environments may be associated with these outcomes. In addition, the review explores how parental depression and parenting efficacy impact on capacity for optimal parenting and whether parenting interventions benefit parents too. A review of the evidence suggests that with modification, parenting interventions are beneficial for a number of outcomes other than ADHD symptom reduction. Improving the parent-child relationship may have indirect benefits for disruptive behaviour. Furthermore, parenting behaviours may directly benefit child neuropsychological, academic and social functioning. Parenting interventions can have therapeutic benefits for parents as well as children, which is important as parent and child well-being is likely to have a transactional relationship. Evaluation of the clinical success of parenting interventions should focus on a wider range of outcomes in order to aid understanding of the multifaceted benefits that they may be able to offer. Parenting interventions should not be seen as a redundant adjunct to medication in multi-modal treatment approaches for ADHD; they have the potential to target outcomes that, at present, medication seems less able to improve.

Improving outcomes for youth with ADHD: a conceptual framework for combined neurocognitive and skill-based treatment approaches

Attention-deficit/hyperactivity disorder (ADHD) is a prevalent and chronic mental health condition that often results in substantial impairments throughout life. Although evidence-based pharmacological and psychosocial treatments exist for ADHD, effects of these treatments are acute, do not typically generalize into non-treated settings, rarely sustain over time, and insufficiently affect key areas of functional impairment (i.e., family, social, and academic functioning) and executive functioning. The limitations of current evidence-based treatments may be due to the inability of these treatments to address underlying neurocognitive deficits that are related to the symptoms of ADHD and associated areas of functional impairment. Although efforts have been made to directly target the underlying neurocognitive deficits of ADHD, extant neurocognitive interventions have shown limited efficacy, possibly due to misspecification of training targets and inadequate potency. We argue herein that despite these limitations, next-generation neurocognitive training programs that more precisely and potently target neurocognitive deficits may lead to optimal outcomes when used in combination with specific skill-based psychosocial treatments for ADHD. We discuss the rationale for such a combined treatment approach, prominent examples of this combined treatment approach for other mental health disorders, and potential combined treatment approaches for pediatric ADHD. Finally, we conclude with directions for future research necessary to develop a combined neurocognitive + skill-based treatment for youth with ADHD.

Evaluation of a Pilot Parent-Delivered Play-Based Intervention for Children With Attention Deficit Hyperactivity Disorder

OBJECTIVE. This study evaluated a parent-delivered intervention aiming to address the social difficulties of children with attention deficit hyperactivity disorder (ADHD). The intervention was evaluated from three perspectives: effectiveness, feasibility, and appropriateness.

METHOD. This one-group pretest–posttest study included 5 children with ADHD and their parents, who had previously participated in a therapist-delivered play-based intervention. The 7-wk parent-delivered intervention involved home modules (including a DVD, manual, and play dates with a typically developing playmate) and three therapist-led clinic-based play sessions. The Test of Playfulness was used as a pre- and postintervention and follow-up measure. Parents were interviewed 1 mo following the intervention, and data were analyzed for recurring themes.

RESULTS. Children’s social play outcomes improved significantly from pretest to 1-mo follow-up (Z = 2.02, p = .04, d = 1.0). Three themes emerged: the clinic play environment as a sanctuary, parental barriers to intervention delivery, and tools for repeating learned lessons.

CONCLUSION. The parent-delivered intervention demonstrated preliminary evidence for feasibility and effectiveness. Further research is warranted regarding appropriateness.

Social skills training

Children with attention-deficit/hyperactivity disorder (ADHD) have prominent social impairment, which is commonly manifested in unskilled behaviors in social situations and difficulties in being accepted and befriended by peers. This social impairment often remains after administration of medication and behavioral contingency management treatments that address the core symptoms of ADHD. This article reviews traditional social skills training (SST) approaches to remediating social impairment, and presents the evidence for their efficacy and significant limitations to their efficacy. The article introduces potential reasons why the efficacy of traditional SST may be limited, and concludes with some promising alternative SST approaches.

Behavior Management for School Aged Children with ADHD

Behavior management treatments are the most commonly used nonpharmacologic approaches for treating attention-deficit/hyperactivity disorder (ADHD) and associated impairments. This review focuses on behavioral parent training interventions for school-age children in the home setting and adjunctive treatments developed to extend effects across settings. Empirical support includes numerous randomized clinical trials, systematic reviews, and meta-analyses showing positive effects of these interventions on child compliance, ADHD symptoms and impairments, parent-child interactions, parenting and parenting stress. These studies support categorization of behavior management treatment as a well-established, evidence-based treatment of ADHD. Factors for consideration in clinical decision making and directions for research are provided.