Parent cognitions as predictors of child treatment response in attention-deficit/hyperactivity disorder

Black Mothers of Children With and Without ADHD: Relationships Among Maternal Psychopathology, Parenting Stress, and Parenting Cognitions

INTRODUCTION

Parents of children with attention-deficit/hyperactivity disorder (ADHD) endorse increased parenting stress and lower levels of parenting efficacy and satisfaction as compared to parents of children without ADHD. Additionally, maternal ADHD and depression differentiate children with and without ADHD, with children with ADHD being more likely to have a mother with psychopathology.

METHOD

With a focus on an understudied population, we investigated the extent to which maternal self-reported ADHD and depression were associated with self-reported parenting stress and parenting cognitions in 70 Black mothers of children with (maternal Mage = 35.52, SD = 6.49) and without ADHD (maternal Mage = 35.39, SD = 6.53) recruited from a metropolitan area in the southeastern United States.

RESULTS

Analyses indicated that Black mothers of children with ADHD reported higher levels of parenting stress, lower levels of parenting efficacy, and lower levels of parenting satisfaction. However, there were no significant differences between groups on measures of maternal ADHD or depression. Maternal depression significantly accounted for variability in both parenting satisfaction and parenting stress beyond child ADHD and maternal education. With maternal depression in the models, the association between maternal ADHD and parenting stress and parenting satisfaction lost significance.

DISCUSSION

Given the racial disparities in the treatment of ADHD, future research should focus on investigating the linkages between maternal depression, parenting stress, parenting satisfaction, and parenting behaviors in Black mothers in order to delineate whether there are cultural adaptations that may improve treatment utilization rates for child ADHD within this population.

Does attention deficit hyperactivity disorder worsen family functioning and parenting styles? A case control study

OBJECTIVE

A bidirectional relationship between family functioning and parenting styles and Attention Deficit and Hyperactivity Disorder (ADHD) is proposed. The aim of this study is to examine the effect of ADHD symptoms on parenting styles and the general functionality of the family as well as symptoms of depression and anxiety.

METHODS

73 children with ADHD (56%) and 56 controls (43%) (a total of 129 participants, 31% female, 69% male) with a mean age of 11.3 (7-17, n: 129) were included in the study, which was conducted in Gaziantep University Hospital Child Psychiatry Department in 2022. The participants completed psychometric scales.

RESULTS

Parents of children with ADHD showed higher positive parenting scores than the control group (p < 0.05). Inconsistent discipline scores were substantially higher in the ADHD combined subtype (14.38 ± 5.2) than in the attention deficit dominant group (17.59 ± 3.96) In addition, a strong correlation was found between familial functionality scores and ADHD severity in the ADHD attention deficit dominant subtype (r:0.601; p:0.027) and as ADHD severity increased, family functionality decreased.

CONCLUSIONS

This study shows that parents of children with ADHD have different parenting styles and ADHD affects the overall functionality of the family in the Turkish sample.

Parent attributions and attention deficit/hyperactivity disorder knowledge as predictors of specific help-seeking interests

Many children diagnosed with attention deficit/hyperactivity disorder (ADHD) do not receive appropriate services following diagnosis. Although information about ADHD is widely available and abundant, sometimes conflicting information may impede parent help-seeking. The present study examined parent knowledge of ADHD and attributions of child behavior as predictors of interest in formal and informal help seeking at the point of child evaluation for possible ADHD. Participants (89 caregivers of children ages 5-12) completed a measure of ADHD knowledge, rated attributions of child behavior in response to vignettes depicting ADHD symptoms, and indicated their interest in a range of formal and informal services that could be recommended following the child's evaluation. Parents reported strongest interest in academic services followed by medication, child focused therapy, and informal services (e.g., seeking information about ADHD). Family income, ADHD knowledge and attributions that child behavior will persist over time were associated with all types of help-seeking interest except academic services. Perceptions of child control over behavior predicted greater interest in medication. Findings suggest that increasing parent knowledge of ADHD and exploring parent goals and preferences for treatment may increase service utilization for children following assessment/diagnosis of ADHD.

Mental Health Literacy for Supporting Children: A Systematic Review of Teacher and Parent/Carer Knowledge and Recognition of Mental Health Problems in Childhood

The level of mental health literacy (MHL) in adults who work with or care for children is likely to influence the timeliness and adequacy of support that children receive for mental health problems. The aim of this study was to systematically review the literature on mental health literacy for supporting children (MHLSC, recognition/knowledge) among parents and teachers of school aged children (5 to 12 years old). A systematic search was conducted for quantitative studies published between 2000 and June 2021 using three databases (MEDLINE, PsycINFO and ERIC) and relevant citations reviewed in Scopus. To be included, studies needed to measure at least either 'mental health knowledge' or 'recognition'. Synthesis proceeded according to study design, adult population, child MHP, then MHL outcome. Study quality was assessed using AXIS. 3322 documents were screened, 39 studies met inclusion criteria. 49% of studies examined teachers' knowledge or recognition of ADHD; only five studies reported on parent samples. Synthesis found a nascent field that was disparate in definitions, methods and measures. Little research focussed on knowledge and recognition for internalizing problems, or on parents. Methods used for measuring knowledge/recognition (vignette vs screening) were associated with different outcomes and the quality of studies was most often low to moderate. Adults appear to have good recognition of childhood ADHD but their knowledge of internalizing disorders is less clear. Further research is required to develop standard definitions and validated measures so gaps in MHLSC can be better identified across populations who have a role in supporting children with their mental health.

Co-designed Mindful Parenting for Parents of Children with ADHD: A Pilot and Feasibility Study

This mixed-methods single arm pilot study examined the feasibility, acceptability, and preliminary outcomes of a co-designed mindful parenting intervention for parents of children with ADHD, Parents that Mind (PTM). The 5-week parent-only intervention comprised two face-to-face group retreats and 5 weeks home practice. Eighteen parents of children with ADHD participated in PTM, completing self-report questionnaires and semi-structured interviews. Indicating high acceptability, 100% of parents interviewed reported PTM was helpful and they would recommend PTM. High feasibility of parents attending one face-to-face retreat was observed, with all parents attending the first retreat, however intervention adherence was challenging, with 55% of parents attending the second retreat. Barriers to intervention adherence included: lack of time, work commitments, illness and exhaustion. Quantitative data indicate promising preliminary effects for parents and children. Addressing the barriers raised by parents in this pilot appear necessary, before examining efficacy in a blinded RCT.

Parental Factors Associated with Child or Adolescent Medication Adherence: A Systematic Review

Medication adherence, especially among children and adolescents with psychiatric disorders, is often seen as a major treatment challenge. The purpose of this study is to systematically review studies addressing specific aspects of parental factors that are positively or negatively associated with medication adherence among children and adolescents with psychiatric disorders. A systematic literature search of English language publications, from inception through December 2021, was conducted from PubMed, Scopus, and MEDLINE databases. This review has complied with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines. A total of 23 studies (77,188 participants) met inclusion criteria. Nonadherence rates ranged between 8% to 69%. Parents' socioeconomic background, family living status and functioning, parents' perception and attitude towards the importance of medication taking in treating psychiatric disorders, and parents' mental health status are significant parental characteristics associated with medication adherence in children and adolescents with psychiatric disorders. In conclusion, by identifying specific parental characteristics related to the medication adherence of children and adolescents with psychiatric disorders, targeted interventions on parents could be developed to guide parents in improving their child's medication adherence.

Predictors and Moderators Two Treatments of Oppositional Defiant Disorder in Children

OBJECTIVE

The aim of this study was to examine predictors and moderators of behavioral improvement in children with Oppositional Defiant Disorder (ODD) following treatment with Parent Management Training (PMT) and Collaborative and Proactive Solutions (CPS). Initial problem severity, inconsistent discipline, parental attributions of child misbehavior, and child lagging cognitive skills were examined.

METHOD

One hundred and forty-five children aged between 7 and 14 (103 males, M = 8.88 years, ethnicity representative of the wider Australian population) were randomly assigned to PMT and CPS. Assessment was conducted at baseline, post-intervention, and at 6-month follow-up, using independently rated semi-structured diagnostic interviews and parent-ratings of ODD symptoms. Using an intent-to-treat sample in this secondary analysis (Murrihy et al., 2022), linear regressions and PROCESS (Hayes, 2017) were used to examine these predictors and possible moderators of treatment.

RESULTS

Higher pre-treatment levels of conduct problems, lagging skills, and inconsistent discipline predicted poorer behavioral outcomes following both treatments. The only characteristic that moderated treatment outcome was child-responsible attributions - mothers who were more likely to attribute their child's problematic behaviors to factors in the child had significantly poorer outcomes in PMT than CPS at 6-month follow-up.

CONCLUSIONS

CPS may be a more beneficial treatment than PMT for families who have been identified as having higher levels of child-responsible attributions before commencing treatment for ODD. While tentative, this provides promising insights as to how treatment outcomes for children with ODD may be improved.

Review of barriers and interventions to promote treatment engagement for pediatric attention deficit hyperactivity disorder care

Attention deficit hyperactivity disorder (ADHD) is a common and impairing behavioral health disorder, impacting over 5% of children worldwide. There are multiple evidence-based pharmacological and psychosocial treatments for ADHD, and greater service utilization is associated with improved acute and long-term outcomes. However, long-term outcomes are suboptimal as multimodal treatments are often not accessed and most care ends prematurely. This narrative review discusses barriers to engagement for children and adolescents with ADHD and their families as well as interventions to overcome these barriers. Families face a variety of structural and attitudinal barriers, ranging from cost and access to stigma and low self-efficacy to successfully implement change. There are multiple interventions that may enhance engagement with ADHD care including psychoeducation, integration of behavioral services in general medical settings, telehealth as well as specific adaptations to existing ADHD treatments, such as the use of motivational interviewing or shared decision making. Integration of behavioral health into general medical settings and telehealth have been found in controlled studies to increase access by reducing both structural and attitudinal barriers. Adding motivational interviewing, shared decision making and other engagement interventions to evidence-based ADHD treatments has been found to reduce attitudinal barriers that translates into improved participation and satisfaction while enhancing outcomes. However, little is known about how to promote extended engagement with ADHD services even though a chronic care model for ADHD is recommended.

Mind-Mindedness and Stress in Parents of Children with Developmental Disorders

Relations between mind-mindedness (assessed using the describe-your-child interview) and stress were investigated in parents of children with developmental disorders (ADHD, n = 51, ASD, n = 23, Down's Syndrome, n = 38, and 22q11.2 Deletion Syndrome, 22q11.2DS, n = 32) and typically-developing children (n = 89). Mind-mindedness did not differ across diagnostic groups, and mind-mindedness predicted parenting stress across groups. Parenting stress was lowest in the typically-developing and Down's Syndrome groups. Across all groups, mind-minded and positive descriptions predicted lower parenting stress, and negative descriptions predicted higher stress. In the developmental disorder groups, describing the children with reference to their disorder was negatively correlated with mind-mindedness. Results are discussed with regard to interventions for families where children have developmental disorders.

Transdiagnostic Associations Among Parental Causal Locus Attributions, Child Behavior and Psychosocial Treatment Outcomes: A Systematic Review

Parents' interpretations of the cause of their children's behavior, i.e., parental attributions, are linked to parenting behavior and child development. However, it is not yet known whether parental attributions are systematically associated with children's internalizing and externalizing symptoms and behavior or psychosocial treatment engagement and outcomes across diagnostic categories. This systematic review aimed to fill this knowledge gap using a transdiagnostic perspective to synthesize the literature on the associations between parent-causal and child-responsible attributions and children's internalizing and externalizing behavior, treatment engagement, and treatment outcomes for parents and children. A total of 67 studies were identified. Overall, biased child-responsible attributions were associated with elevated child internalizing and externalizing symptoms and behavior across diagnoses, while findings on the association between parent-causal attributions and child behavior were inconsistent. The link between parental attributions and treatment engagement was also mixed, varying across treatment type, child diagnosis, and focus of attributions. Regarding treatment outcomes, less biased parent-causal and child-responsible attributions were linked to post-treatment improvements in children's behaviors, while mixed findings were reported on post-treatment improvements in parental attributions. Findings are discussed with a focus on approaches to enhance the effectiveness of assessment and psychosocial treatment approaches across diagnostic categories with consideration of parental attributions.

Parental Responses to Temper Outbursts in Children With ADHD: The Role of Psychological Factors

Objective: Children with ADHD frequently exhibit temper outbursts (TO). One related factor may be parental responses, such as harsh discipline and accommodation. This study tests the hypotheses that these responses will be associated with greater TO, and parental characteristics of higher anger and lower sense of competence, in children with ADHD. Method: Participants included 79 5- to 9-year-old children with ADHD (77.22% boys). Regressions were used to determine the association between parental psychological factors and responses to TO while covarying for TO frequency, severity, and duration. Results: Parental anger and sense of competence were not significantly related to any discipline responses after covarying for TO characteristics, although sense of competence predicted spanking at trend-level significance. Both parental anger and sense of competence significantly predicted accommodation over and above TO characteristics. Conclusion: Results underscore the importance of parental anger and sense of competency in predicting parental behavior, specifically parental accommodation.

Behavioral Parent Training for ADHD Reduces Situational Severity of Child Noncompliance and Related Parental Stress

Objective: Parents are more likely to seek treatment when a child's behaviors cause impairment and increase parental burden. Thus, it is important to document the effectiveness of behavioral parent training (BPT) on the pervasiveness and severity of children's behavior and related parental distress. Method: Data were obtained from 304 parents of school-aged children with attention-deficit hyperactivity disorder (ADHD) attending BPT groups in an outpatient setting. Results: After BPT, parents reported fewer and less severe problematic situations related to child noncompliance, particularly for chores, homework, mealtimes, and peer interactions. Parents also reported significantly reduced stress related to parenting a child with ADHD. Improvements in Nonfamilial Transactions and Task Performance were associated with reductions in degree of parental stress. Conclusion: BPT offered in a real-world clinical setting has meaningful impacts on the child behaviors that lead parents to seek treatment and reduces stress related to parenting a child with ADHD.

Personalizing Behavioral Parent Training Interventions to Improve Treatment Engagement and Outcomes for Culturally Diverse Families

Behavioral Parent Training (BPT) interventions are efficacious for young children with externalizing behavior problems. However, not all families benefit, and ethnic minority families in particular are less likely to enroll, engage, and improve in BPT. Versions of BPT interventions tailored for specific ethnic groups have been successful at improving engagement and outcomes for ethnic minorities; however, the specificity of these models presents challenges for broad dissemination. This article presents a personalization approach (PersIn) that utilizes cultural assessment results to tailor treatment protocols to the characteristics of individual families. We believe this approach has the potential to maximize cultural sensitivity while preserving generalizability to both minority and non-minority ethnic groups. We further propose that personalization on Parent Explanatory Model (PEM) parameters that have been found to vary across ethnic groups and to impact treatment engagement and/or outcomes is a promising approach to decreasing disparities in BPTs. We describe examples of evidence-supported PEMs that present good targets for personalization and provide examples from MY PCIT to illustrate how PersIn can be applied to Parent-Child Interaction Therapy (PCIT).

How Do Mothers' Parental Attributions Affect Child Outcomes from a Positive Parenting Intervention? A Mediation Study

Problematic parental attributions refer to negative causal explanations for child problem behaviour and are known to predict parenting intervention outcomes. This study examines alternative accounts of how mothers' problematic parental attributions, operationalised as negative pre-treatment and change resistant parental attributions during treatment, may affect child behaviour outcomes from a parenting intervention program. Putative mediators included parental feelings about the child and use of harsh discipline. Participants were 163 families with children aged from 3 to 16 referred to specialist clinics for the treatment of conduct problems. Measures were collected as part of pre-treatment, post-treatment, and 3-month follow-up assessments. Mothers' pre-treatment and change resistant parental attributions were associated with smaller improvements in parental feelings at the end of treatment which in turn were associated with greater use of harsh discipline. Greater use of harsh discipline was associated with greater conduct problems overall. Smaller improvements in parental feelings mediated the effects of pre-treatment and change resistant parental attributions on outcomes in mothers' use of harsh discipline and mediated the effects of change resistant parental attributions on outcomes in child conduct problems. Smaller improvements in parental feelings about the child may act as a mechanism that explains the impact of problematic parental attributions on treatment outcomes.

Effectiveness of the Stepping Stones Triple P group parenting program in reducing comorbid behavioral problems in children with autism

Children with autism spectrum disorders often exhibit comorbid behavioral problems. These problems have an impact on the severity of the core symptoms, the progression of the disorder as well as on the families’ quality of life. We evaluated the effectiveness of the Stepping Stones Triple P group parent training program as a supplementary intervention in the treatment of children with autism spectrum disorder. Therefore, we employed a single group repeated measures design and assessed child variables via parents’ and teachers’ judgments at four successive time points. The participants were parents of 24 children with autism spectrum disorder aged between 3.6 and 12 years. We found a significant reduction of comorbid behavioral problems in the children, primarily in the parents’ judgment at follow-up. Furthermore, a reduction of the autism spectrum disorder core symptoms emerged. The teachers’ judgment particularly revealed an improvement in children’s social relationships. Effect sizes were large ( ƞ2 ranging from 0.14 to 0.23). The findings demonstrate the effectiveness of the Stepping Stones Triple P as a supplementary intervention for reducing comorbid behavioral problems in the treatment of children with autism spectrum disorder. Higher parental self-efficacy and parental attributions, including parents’ ability to influence child problem behaviors, are discussed as important factors for the effectiveness of Stepping Stones Triple P.

Why is this Happening? A Brief Measure of Parental Attributions Assessing Parents' Intentionality, Permanence, and Dispositional Attributions of Their Child with Conduct Problems

We present and evaluate a new self-report measure of parental attributions developed for assessing child causal and dispositional attributions in parenting interventions. The Parent Attribution Measure (PAM) ascribes attributions along first-order dimensions of intentionality, permanence, likeability, and disposition, and a higher-order Total Scale. The psychometric analyses involved participants drawn from populations of clinical (n = 318) and community-based families (n = 214) who completed questionnaires assessing parental attributions, parenting behaviours, parental depression, parental feelings about the child, and child behavioural problems. Confirmatory factor analysis indicated that a 3-factor hierarchical structure provided a close fitting model. The model with intentionality, permanence, and disposition (consolidating likeability and disposition) dimensions as first-order factors grouped under a higher-order general factor was validated in independent samples and demonstrated sound psychometric properties. The PAM presents as a brief measure of parental attributions assessing parents' intentionality, permanence, and dispositional attributions of their child with conduct problems.

Parents' Spontaneous Attributions about their Problem Child: Associations with Parental Mental Health and Child Conduct Problems

Parents' attributions about their child's personality and behaviour are known to predict the quality of parent-child interactions and outcomes for the child, including those from parenting interventions. Nothing is known, however, about the quantity and quality of attributions parents use during free speech about their children referred for treatment of behavioural and emotional problems. We tested hypotheses about the types of attributions and associations among parental attributions, parental psychopathology and child conduct problems, using 504 five-minute speech samples (FMSS) coded using the Parent Attribution Speech Sample (PASS) coding system. Both mothers and fathers talked about their thoughts and feelings regarding their children with disruptive behaviour problems (N = 295; 74% male; 3-8 years old). The assessment of spontaneous parental attributions via the PASS coding system was shown to be valid and reliable. Mothers made more negative, dispositional attributions than fathers, however, parents of either gender made, on average, more positive than negative attributions about their children. Parents' natural attributions about these children with emotional and behavioural problems were rather independent from parents' own mental health, but were consistently related to child factors. Specifically, across parent gender and across all attribution dimensions, levels of callous-unemotional traits were associated with spontaneous parental attributions above and beyond other child and parent factors. Overall, the results show that parents' spontaneous speech about referred children contains important information about their causal attributions, and that these are associated with child temperament rather than specific referral symptoms.

Associations Between Patient-Reported Outcome Measures of Asthma Control and Psychosocial Symptoms

There is growing emphasis on using patient-reported outcome measures to enhance clinical practice. This study was a retrospective review of scores on the Childhood Asthma Control Test (C-ACT) and the Pediatric Symptom Checklist-17 (PSC-17) at a pediatric primary care center in Boston, Massachusetts. A total of 218 patients were selected at random using billing codes for well-child (WC) care and asthma, excluding complex medical conditions. Cutoff scores were used to identify uncontrolled asthma (C-ACT ⩽19) and clinically significant psychosocial symptoms (+PSC-17). Multiple logistic regression was used to measure associations between C-ACT ⩽19 and +PSC-17, adjusting for covariates. In multivariable analysis, C-ACT ⩽19 at WC visits was associated with +PSC-17 at WC visits (adjusted odds ratio = 3.2 [95% confidence interval = 1.3-8.6]). C-ACT ⩽19 at non-WC visits was also associated with +PSC-17 at WC visits (adjusted odds ratio = 3.1 [95% confidence interval = 1.2-8.9]). Patient-reported outcome measures of asthma control and psychosocial symptoms were positively correlated in this sample.

The role of parental attributions in predicting parenting intervention outcomes in the treatment of child conduct problems

BACKGROUND

Parent attributions about the causes of their children's behaviour problems are a known predictor of problematic parenting and ongoing child problems. However, their importance in parenting interventions remains unknown as research has not addressed whether parental attributions predict outcomes associated with parenting training. The current study examined whether problematic pre-treatment and change resistant parental attributions during treatment uniquely predict child behaviour outcomes.

METHOD

Participants were 250 families with children aged from 3 to 16 referred to specialist clinics for the treatment of conduct problems. Measures of family demographic information, parental attributions, and severity of child conduct problems were collected as part of pre-treatment, post-treatment, and 3-month follow-up assessments.

RESULTS

Linear regression showed that mothers' pre-treatment parental attributions uniquely predicted severity of conduct problems at the post-treatment and 3-month follow-up assessments. Fathers' pre-treatment parental attributions uniquely predicted severity of conduct problems at the 3-month follow-up assessment. Reductions in problematic pre-treatment parental attributions were recorded at post-treatment for both parents. However, smaller reductions or increases in mothers' problematic attributions uniquely predicted worse child behaviour outcomes, a result not replicated for fathers.

CONCLUSIONS

Findings that pre-treatment and change resistant parental attributions predict poorer child behaviour outcomes after controlling for other predictors and treatment effects recommend that parental attributions should be assessed prior to and after treatment and possibly included in treatment to maximise treatment gains for children with conduct problems.

The Pattern of Stability and Change in Parental Locus of Control Over 6 Years and Teacher Ratings of Child Behavior

A previous study from our group showed that parents' locus of control (LOC) obtained before the birth of their child was associated with the child's behavior at school in School Years 3 (ages 7-8) and 6 (ages 10-11). Here we examine whether a change in parental LOC over the first 6 years of the child's life was associated with differences in his or her behavior as rated by their teachers. As before, we use data from the Avon Longitudinal Study of Parents and Children (ALSPAC). A modified version of the adult Nowicki-Strickland internal-external LOC scale was completed by mothers and fathers in their own home during pregnancy and 6 years later. Externality was defined as a score greater than the median and internality as equal to, or less than, the median. Outcomes were the five individual subscales and the total difficulties of Goodman's Strengths and Difficulties Questionnaire (SDQ) completed by the children's class teachers at the end of School Years 3 and 6. As predicted, we found that parents who remained externally oriented, or became external, had children with more behavioral difficulties in primary school compared with parents who remained or became internal. Type of behavior difficulties varied somewhat with whether mothers or fathers remained or changed toward externality. These results support the possibility that changes in parental LOC are associated with children's personal and social adjustment. Consequently, programs to change parental LOC may be worth evaluating.

Improved Parent Cognitions Relate to Immediate and Follow-Up Treatment Outcomes for Children With ADHD-Predominantly Inattentive Presentation

We investigated treatment effects on parenting self-efficacy and parent cognitive errors, and whether these parent cognitions are related to short- and long-term outcomes in parenting behaviors in psychosocial treatment for youth with attention-deficit/hyperactivity disorder, predominantly inattentive presentation (ADHD-I). In a randomized controlled trial across two sites (University of California, San Francisco, and University of California, Berkeley), 199 children between the ages of 7 and 11 were randomized to the Child Life and Attention Skills (CLAS; n = 74) program, parent-focused treatment (PFT; n = 74), or treatment as usual (TAU; n = 51). Parents reported on self-efficacy, cognitive errors, positive parenting, and negative parenting prior to treatment, immediately after treatment, and in the next school year at follow-up. Compared to TAU, CLAS and PFT had higher posttreatment parenting self-efficacy, and CLAS alone had lower posttreatment parent cognitive errors. At follow-up, only CLAS had improved parent cognitive errors compared to TAU. No other between-group differences were found in parenting self-efficacy or cognitive errors. Improved parenting self-efficacy was associated with improved posttreatment negative parenting outcomes for PFT and CLAS, and improved parent cognitive errors were also related to improvements in positive and negative posttreatment parenting outcomes for CLAS. Posttreatment parenting self-efficacy mediated follow-up negative parenting outcomes for CLAS and posttreatment parent cognitive errors mediated improved follow-up positive and negative parenting outcomes for CLAS. PFT and CLAS led to enhanced parenting self-efficacy, and CLAS appears especially robust in improving parent cognitive errors both in the short and long term. Pathways provide support for the possibility of parent cognitions as mediators of treatment effects on parenting; clinical focus on such cognitions may be useful.

Parenting practices of Singaporean mothers of children with ADHD

Objectives:

We wanted to determine: (1) whether ADHD symptoms were more common in mothers of children with ADHD; (2) whether mothers of children with ADHD differed in their parenting strategies; and (3) whether there was a difference in care-giving arrangements for children with ADHD and without ADHD. This was done by comparing mothers of children with ADHD with mothers of children without ADHD in Singapore.

Methods:

Mothers of children with ADHD ( n=46) and mothers of children without ADHD ( n=45) completed the Conners’ Parent Rating Scale-Revised, the Conners’ Adult ADHD Rating Scale-Self Report and the Alabama Parenting Questionnaire.

Results:

Mothers of children with ADHD did not report higher levels of current ADHD symptoms compared with the control group. However, they did use less adaptive parenting strategies. There were also no differences in the reported behaviours of children cared for by a paid worker and those cared for by mothers.

Conclusions:

Data support the Singapore Clinical Guidelines recommendations for the promotion of parenting skills, and referral to parenting programmes for parents of children with ADHD. The promotion of parenting skills and referral to parenting programmes for mothers of children with ADHD might include the option of electronic forms of programme delivery. The model of using paid help in the home, which is commonplace in Singapore, does not seem to disadvantage children with ADHD.

Parental External Locus of Control in Pregnancy Is Associated with Subsequent Teacher Ratings of Negative Behavior in Primary School: Findings from a British Birth Cohort

The purpose of the present study was to examine whether parents' locus of control (LOC) obtained before the birth of their child predicts the child's behavior at school in School Years 3 (ages 7-8) and 6 (ages 10-11). A modified version of the adult Nowicki-Strickland internal-external locus of control scale was completed by mothers and fathers in their own home during pregnancy. Externality was defined as a score greater than the median and internality as equal to, or less than, the median. Outcomes were the five individual subscales and the total difficulties of Goodman's strengths and difficulties' questionnaire completed by the children's class teachers at the end of School Years 3 and 6. As predicted, it was found that the greater the presence of externality in the parents, the greater the increased risk of the child's adverse behavior as rated by teachers. The risk was generally greatest if both parents were external and lowest if both were internal. There was a consistent relationship at both Year 3 and Year 6 between maternal externality in pregnancy and children's emotional difficulties. However, for other behaviors, the pattern of associations varied depending on whether the mother or father was external, the type of adverse behavior, and the School Year in which children were assessed. Prenatal parental externality appears to be significantly associated with a variety of children's negative behaviors. Of note was the finding that fathers' as well as mothers' LOC was important in determining children's outcomes. Implications of the complexity of the results for the role parents may play in children's personality and adjustment are discussed.

Parent Education for Young Children With Autism and Disruptive Behavior: Response to Active Control Treatment

This study examines parent and child characteristics in young children with autism spectrum disorder and disruptive behavior who showed a positive response to a parent education program in a randomized clinical trial of parent training. Children with autism spectrum disorder (N = 180) were randomized to parent training (PT) or parent education program (PEP) for 6 months. Using the Clinical Global Impression-Improvement scale, masked independent evaluators rated positive response in 68.5% of children in PT compared to 39.6% in PEP. We compared baseline characteristics and change in parental stress, strain, competence, and mental health for participants who showed a positive response to PEP (PEP-R) to those who did not (PEP-NR). We also compared change in child and parent measures for PEP-R participants to those who showed a positive response to PT (PT-R). At baseline, PEP-R and PEP-NR participants did not differ on any demographic or clinical characteristics. Parents in PEP-R reported significant reductions on the Parenting Stress Index, Caregiver Strain Questionnaire, and Parent Health Questionnaire, and increases on the Parenting Sense of Competence scale. Improvements in child disruptive behavior and parental stress, strain, competence, and mental health for PEP-R participants were similar to PT-R participants. Vineland Daily Living Skills improved only for children in PT-R. PEP was an active control treatment with nearly 40% of participants showing a positive response. Change in child disruptive behavior and parental stress, strain, competence, and mental health were remarkably similar for participants independently rated with a positive response to PEP and PT.

Preschool children's response to behavioural parent training and parental predictors of outcome in routine clinical care

OBJECTIVE

To investigate the effectiveness of behavioral parent training (BPT) for preschool children with disruptive behaviours and to explore parental predictors of response.

METHODS

Parents of 68 preschool children, aged between 2.7 and 5.9 years, participated in BPT. We evaluated the changes in children's behaviour after BPT with a one group pretest-posttest design, using a waiting period for a double pretest. Outcome was based on parents' reports of the intensity and number of behaviour problems on the Eyberg Child Behavior Inventory. Predictor variables included parents' attention-deficit/hyperactivity disorder symptoms, antisocial behaviours, and alcohol use, and maternal parenting self-efficacy and disciplining.

RESULTS

Mother-reported child behaviour problems did not change in the waiting period but improved significantly after BPT (d = 0.63). High levels of alcohol use by fathers and low levels of maternal ineffective disciplining were each associated with somewhat worse outcome.

CONCLUSIONS

BPT under routine care conditions clearly improves disruptive behaviours in preschool children. Mothers who consider themselves as inadequate in disciplining and mothers whose partners do not consume high levels of alcohol report the largest improvements.

The Impact of Prenatal Parental Locus of Control on Children's Psychological Outcomes in Infancy and Early Childhood: A Prospective 5 Year Study

Locus of control is one of the most widely studied concepts in the history of personality psychology. In spite of its popularity and its associations with numerous relevant outcomes, the ability of locus of control to predict future behaviors involving parenting effectiveness has been under researched. The few parent locus of control children's outcome studies are characterized by cross-sectional methodologies that focus on mothers. The present study uses a prospective methodology to compare data on mothers' and fathers' locus of control with their child's behavior outcomes from a large scale research project, the Avon Longitudinal Study of Parents and Children (ALSPAC). Based on Rotter's Social Learning Theory published in 1954 and past empirical research, it was predicted and found that parent internality was associated with more positive child outcomes than parent externality. More specifically, when both parents were internal, their children had more positive outcomes in sleeping, eating, and tantrum behavior as compared to any other parent locus of control combination. However external parents had a less restrictive attitude which appeared to have a more beneficial effect on picky eating. Results confirmed how important parent locus of control is in the lives of children. Based on the findings, researchers are urged to develop interventions to change advice to parents and promote more internal locus of control among parents.

Preliminary Efficacy of a Behavioral Parent Training Program for Children With ADHD in Pakistan

OBJECTIVE

In an effort to address the lack of evidence-based interventions for ADHD in developing South Asian countries, we examined the preliminary efficacy of a behavioral parent training program in Pakistan.

METHOD

A quasi-experimental design was utilized. Eighty-five 4- to 12-year-old children with clinically significant ADHD symptoms participated: 55 were recruited from hospital clinics (active treatment group) and 30 were recruited from schools (waitlist control group). Parent and teacher ratings of ADHD, oppositional defiant disorder (ODD), and conduct disorder (CD) symptoms and impairment were collected.

RESULTS

Using intent-to-treat analyses, the treatment group showed significant pre-post improvement on parent-reported ODD symptoms and ADHD-related impairment. Teacher ratings showed no improvement.

CONCLUSION

This study provides preliminary evidence for the feasibility and effectiveness of behavioral parenting training for children with ADHD in Pakistan and represents a critical first step in identifying evidence-based treatments for Pakistani children with ADHD.

Occupational Therapy for Children with Attention Deficit Hyperactivity Disorder (ADHD), Part 1: A Delineation Model of Practice

An occupational therapy delineation model of practice is presented, which guides a multidimensional understanding of the psychopathology of attention deficit hyperactivity disorder (ADHD) and its management. Previous research has established that occupational therapists lack detailed training or theory in this field. The delineation model of practice is based on a literature review, clinical experience and a consensus study carried out with occupational therapists to determine their priorities for the evaluation of, and intervention with, children with ADHD.

Part 1 of this article presents the model and examines its implications for evaluation and intervention at the levels of child, task and environment. A family-centred assessment and treatment package, based on the delineation model, is described. Part 2 of this article will report the results of a multicentre study, which was designed to evaluate the effectiveness of this package.

Predicting Outcome in Parent-Child Interaction Therapy

This study explored predictors of treatment response and attrition in Parent-Child Interaction Therapy (PCIT). Participants were 99 families of 3- to 6-year-old children with disruptive behavior disorders. Multiple logistic regression was used to identify those pretreatment child, family, and accessibility factors that were predictive of success or attrition. For all study participants, waitlist group assignment and maternal age were the significant predictors of outcome. For treatment participants (study participants excluding those who dropped out after the initial evaluation but before treatment began), only maternal ratings of parenting stress and maternal inappropriate behavior during parent-child interactions were significant predictors of treatment outcome. These results suggest that for treatment studies of disruptive preschoolers, the benefits of using a waitlist control group may be outweighed by the disproportionate number of dropouts from this group. Once families begin PCIT, however, parent-related variables become salient in predicting treatment outcome.

Trajectories and Predictors of Response to the Challenging Horizons Program for Adolescents With ADHD

The Challenging Horizons After School Program is one of the only psychosocial interventions developed specifically for adolescents with attention-deficit/hyperactivity disorder (ADHD) that has demonstrated efficacy in multiple randomized controlled trials. To date, however, all research with the intervention has evaluated outcomes at the group level, and it is unclear whether all adolescents respond similarly, or if the intervention is particularly well suited for certain adolescents with ADHD. This type of information is needed to guide stakeholders in making informed choices as part of dissemination and implementation efforts. The purpose of this study was to evaluate trajectories of response to intervention for a large sample of middle-school age adolescents with ADHD (grades 6-8) who received the after-school intervention (N=112). An additional goal of the study was to evaluate potential predictors of response trajectories, focusing on determining what factors best distinguished between intervention responders and nonresponders. Latent trajectory analyses consistently revealed four or five distinct classes. Depending on the outcome, between 16% and 46% of participants made large improvements, moving into the normal range of functioning, and between 26% and 65% of participants made small or negligible improvements. Multivariate predictor analyses revealed that a strong counselor/adolescent working alliance rated from the adolescent perspective and lower levels of parenting stress and parent-adolescent conflict consistently predicted an increased likelihood of intervention response. Implications of these findings for disseminating the after school intervention and for further intervention development are discussed.

The Effectiveness and Tolerability of Central Nervous System Stimulants in School-Age Children with Attention-Deficit/Hyperactivity Disorder and Disruptive Mood Dysregulation Disorder Across Home and School

OBJECTIVE

This study examines the effectiveness and tolerability of stimulants in children with attention-deficit/hyperactivity disorder (ADHD) and disruptive mood dysregulation disorder (DMDD).

METHODS

To be eligible, participants had to meet Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision (DSM-IV) criteria for the combined subtype of ADHD and National Institute of Mental Health (NIMH) severe mood dysregulation criteria. The Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-V) DMDD criteria were retrospectively assessed after the study was completed. An open-label medication trial lasting up to 6 weeks was completed to optimize the central nervous system (CNS) stimulant dose. Measures of affective symptoms, ADHD symptoms and other disruptive behaviors, impairment, and structured side effect ratings were collected before and after the medication trial.

RESULTS

Optimization of stimulant medication was associated with a significant decline in depressive symptoms on the Childhood Depression Rating Score-Revised Scale (p<0.05, Cohen's d=0.61) and Mood Severity Index score (p<0.05, Cohen's d=0.55), but not in manic-like symptoms on the Young Mania Rating Scale. There was a significant reduction in ADHD (p<0.05, Cohen's d=0.95), oppositional defiant disorder (ODD) (p<0.05, Cohen's d=0.5), and conduct disorder (CD) symptoms (p<0.05, Cohen's d=0.65) as rated by parents. There was also a significant reduction in teacher-rated ADHD (p<0.05, Cohen's d=0.33) but not in ODD symptoms. Medications were well tolerated and there was no increase in side effect ratings seen with dose optimization. Significant improvement in functioning was reported by clinicians and parents (all p's<0.05), but youth still manifested appreciable impairment at end-point.

CONCLUSIONS

CNS simulants were well tolerated by children with ADHD comorbid with a diagnosis of DMDD. CNS stimulants were associated with clinically significant reductions in externalizing symptoms, along with smaller improvements in mood. However, most participants still exhibited significant impairment, suggesting that additional treatments may be needed to optimize functioning.

Parent-Child Automaticity: Links to Child Coping and Behavior and Engagement in Parent Training

This research investigated parent-child automaticity (i.e., automatic ways of thinking, feeling, and interacting) as it relates to child coping and behavior and caregiver engagement in a preventive parenting program, as well as program-related changes in automaticity. 610 caregivers (93% mothers) of children ages 3-6 years (52% boys; 49% African American) enrolled in the Parenting our Children to Excellence (PACE) program, and completed pre- and post- intervention assessments (N = 544 at post-intervention). Daycare providers also provided reports of school coping and behavior. Parent-child automaticity predicted parent and teacher- reported child social coping and aggressive behavior. Contrary to hypotheses, parents reporting elevated parent-child automaticity attended significantly more PACE sessions. A significant time x attendance interaction indicated decreased automaticity following the PACE program. Parent-child automaticity during the preschool years is an important correlate of child behavior and coping, and may be a motivating factor for parents to attend parent training programs.

Relationships between parenting self-efficacy and distress in parents who have school-aged children and have been treated with hematopoietic stem cell transplant or have no cancer history

OBJECTIVE

Studies demonstrate that parents with cancer experience distress and that parenting self-efficacy (PSE) is related to distress among parents without cancer. However, no study to date has examined the relationships between PSE and psychological distress among parents with cancer. This study sought to address this issue by comparing parents with cancer who had undergone hematopoietic stem cell transplantation (HSCT) to parents without cancer on measures of PSE and psychological distress.

METHODS

A sample of 57 patients diagnosed with cancer who had undergone HSCT and a control group of 57 parents with no history of cancer were recruited for participation in the study. Medical record reviews assessed clinical variables, and participants filled out self-report measures of demographics, PSE, general self-efficacy, and psychological distress.

RESULTS

As hypothesized, parents with cancer reported less PSE and more psychological distress than controls (all p-values ≤ 0.05). Furthermore, findings indicated that both PSE and general self-efficacy mediated the relationship between cancer status and psychological distress.

CONCLUSIONS

Findings expand understanding of the potential sources of distress among parents with cancer who have been treated with HSCT and who have school-aged children. They also suggest that interventions aimed at reducing distress in these individuals should seek to target both parenting and general self-efficacy.

Parenting skills and parent readiness for treatment are associated with child disruptive behavior and parent participation in treatment

OBJECTIVE

Parent management training programs for parents of children with disruptive behaviors are efficacious treatments; however, in order to maximize efficiency it is necessary to develop approaches to understand which parents are most likely to participate in treatment. Accordingly, the present study used a person-centered methodology to determine clinically relevant parenting profiles that capture the breadth of parents' readiness to engage in parenting treatment, and their self-reported parenting skills. Further, identified profiles were compared on the severity of children's behavior problems and used to predict participation in parent management training.

METHOD

One hundred and forty-three parents completed assessments at an urban children's mental health clinic. Parents were given measures to assess personal readiness to participate in parenting treatment, parenting skills, and child behavior. A subset of these parents participated in parent management training.

RESULTS

Three profiles emerged that differed in parents' treatment readiness and level of skills. Forty-one percent of parents were classified as "ready." They showed relatively higher rates of inconsistent discipline, but also somewhat higher levels of positive parenting. Thirty-nine percent of parents were classified as "less in need." These parents reported relatively less inconsistent discipline and poor supervision skills and greater positive parenting. Finally, approximately 20% of parents were classified as "almost ready." They showed high levels of inconsistent discipline and poor supervision skills, and low levels of positive parenting. Almost ready and ready parents reported the most problems with their children's behavior. Further, parents classified as less in need participated in the fewest treatment sessions.

CONCLUSIONS

Consideration of parent readiness and skills, in addition to symptom severity, may inform clinical decision making and screening procedures.

The association between parenting stress, parenting self-efficacy, and the clinical significance of child ADHD symptom change following behavior therapy

We examined parenting stress (PST) and self-efficacy (PSE) following participation in behavioral parent training (BPT) with regard to child treatment response. Forty-three families of children diagnosed with ADHD participated in a modified BPT program. Change in PST and PSE was evaluated using a single group, within-subjects design. Parenting outcomes based on child treatment response were evaluated based upon (1) magnitude and (2) clinical significance of change in child symptom impairment. Parents reported significant improvements in stress and self-efficacy. Parents of children who demonstrated clinically significant reduction in ADHD symptoms reported lower stress and higher self-efficacy than those of children with continued impairments. Magnitude of child impairment was not associated with parent outcomes. Clinical implications for these results include extending treatment duration to provide more time for symptom amelioration and parent-focused objectives to improve coping and stress management.

Paternal influences on treatment outcome of behavioral parent training in children with attention-deficit/hyperactivity disorder

This study aims to explore the influence of paternal variables on outcome of behavioral parent training (BPT) in children with attention-deficit/hyperactivity disorder (ADHD). 83 referred, school-aged children with ADHD were randomly assigned to BPT plus ongoing routine clinical care (RCC) or RCC alone. Treatment outcome was based on parent-reported ADHD symptoms and behavioral problems. Moderator variables included paternal ADHD symptoms, depressive symptoms, and parenting self-efficacy. We conducted repeated measures analyses of variance (ANOVA) for all variables, and then analyzed the direction of interaction effects by repeated measures ANOVA in high and low scoring subgroups. Paternal ADHD symptoms and parenting self-efficacy played a moderating role in decreasing behavioral problems, but not in decreasing ADHD symptoms. Paternal depressive symptoms did not moderate either treatment outcome. BPT is most beneficial in reducing children's behavioral problems when their fathers have high levels of ADHD symptoms or high-parenting self-efficacy.

Healthy body, healthy mind?: the effectiveness of physical activity to treat ADHD in children

Data from animal studies provide convincing evidence that physical exercise enhances brain development and neurobehavioral functioning in areas believed to be impaired in children with attention-deficit/hyperactivity disorder (ADHD). To a lesser but still compelling extent, results from studies in typically developing children and adults indicate beneficial effects of exercise on many of the neurocognitive functions that have been shown to be impaired in children with ADHD. Together, these data provide a strong rationale for why a program of structured physical exercise might serve as an effective intervention for children with ADHD.

Child impairment and parenting self-efficacy in relation to mothers' views of ADHD treatments

OBJECTIVE

This study assessed the relations of child impairment and parenting self-efficacy with parental views of the acceptability and effectiveness of behavioral, medication, and combined treatments for child ADHD. Child impairment and parenting self-efficacy were also assessed in relation to the effectiveness views of specific behavioral treatment strategies.

METHOD

Ninety-five mothers of children with ADHD completed questionnaires assessing child impairment, parenting self-efficacy, perceptions of the overall acceptability and effectiveness of ADHD treatments, and views of the effectiveness of specific behavioral treatment strategies.

RESULTS

Hierarchical linear modeling using child impairment and parenting self-efficacy as predictors of treatment views suggests that mothers viewed combined treatments as most acceptable and effective when their child was more impaired, and mothers with higher parenting self-efficacy rated behavioral treatment strategies as more effective.

CONCLUSION

Child impairment and parenting self-efficacy are related to perceptions of the acceptability and/or effectiveness of ADHD treatments.

Psychometric qualities of the Short Form of the Self-efficacy for Parenting Tasks Index-Toddler Scale

Parental self-efficacy (PSE; parental self-perceived competence in parenting) is known to have considerable impact on parenting quality. Although PSE is particularly under pressure during the turbulent period of toddlerhood, most studies so far have focused on PSE in parents of older children. The current study presents the psychometric qualities of the Short Form of the Self-Efficacy for Parenting Tasks Index-Toddler Scale (SEPTI-TS). Parents from a normal (n = 282) and clinical sample (n = 27) of children filled in the SEPTI-TS, and other questionnaires concerning PSE, general self-evaluation, and psychological problems. Factor analysis resulted in a 26-item instrument, representing four domains of PSE with a strong factor structure and high reliability: nurturance, discipline, play, and routine. For this new Short Form of the SEPTI-TS, good face, discriminative, concurrent, and divergent validity were found. Cut-offs for normal PSE were provided. The Short Form SEPTI-TS enables identifying problematic PSE in specific domains of parenting during toddlerhood.

Does pharmacological treatment of ADHD in adults enhance parenting performance? Results of a double-blind randomized trial

OBJECTIVE

This study examines the effects of parental lisdexamfetamine (LDX) treatment on parent-child interactions.

METHODS

Participants were 30 parents (27% were male) and their children aged 5-12 years, both diagnosed with DSM-IV attention-deficit/hyperactivity disorder (ADHD). Optimal LDX dose (30, 50, or 70 mg/day) was determined for parents during a 3-week open-label titration, followed by a within-subjects trial of the acute impact of LDX and placebo on observable parent-child interactions. Two laboratory-based, parent-child interactions simulating typical family tasks (e.g., homework, joint play) were conducted within 2 weeks, once with the adult on a blinded optimal dose of LDX and once on placebo (phase I). Parents were then randomly assigned to continue blinded treatment with LDX or placebo for another month followed by a third interaction task (phase II) to assess the ongoing effects of LDX on parent-child interactions. The primary outcome was the change in rate of parenting behaviors coded during the parent-child interaction tasks. Secondary outcomes included observed rates of children's inappropriate behaviors during the laboratory tasks and changes in parental ADHD symptom severity (ADHD-Rating Scale).

RESULTS

Twenty parents (67%) completed the trial. In phase I, medication was associated with a significant reduction in negative talk by parents (p = 0.0066, d = -0.47). There was a Medication × Task interaction (p = 0.0235) with a reduction in children's negative behaviors in the homework phase only (p = 0.0154, d = -0.58). In phase II, LDX was associated with significant increases in praise by parents (d = 0.81) and reductions in parental commands (d = -0.88) and children's inappropriate behaviors (d = -0.84) (all p-values < 0.05). While not reaching statistical significance, LDX was also associated with large reductions in parental verbalizations (d = -0.82), moderate increases in parental responsiveness (d = 0.55), and large reductions in the ratio of commands to verbalizations during the non-homework task (d = -1.05) (all p-values < 0.10). Significant reductions in parental ADHD symptoms vs. placebo were observed (p < 0.005). Loss of appetite, dry mouth, headaches, and delayed sleep onset were the most common adverse events.

CONCLUSIONS

Improvements in parent-child interactions emerged over time with LDX treatment of parental ADHD. Results suggest that pharmacological treatment of parental ADHD may improve outcomes in parents and their children.