A waitlist-controlled trial of behavioral parent training for fathers of children with ADHD

Improving the efficacy and effectiveness of evidence-based psychosocial interventions for attention-deficit/hyperactivity disorder (ADHD) in children and adolescents

Attention-deficit/hyperactivity disorder (ADHD) is a prevalent, chronic, and impairing mental health disorder of childhood. Decades of empirical research has established a strong evidence-based intervention armamentarium for ADHD; however, limitations exist in regards to efficacy and effectiveness of these interventions. We provide an overview of select evidence-based interventions for children and adolescents, highlighting potential approaches to further improving the efficacy and effectiveness of these interventions. We conclude with broader recommendations for interventions, including considerations to moderators and under-explored intervention target areas as well as avenues to improve access and availability of evidence-based interventions through leveraging underutilized workforces and leveraging technology.

Mandated Parent Education: Applications, Impacts, and Future Directions

Mandated participation in parent education programs is a common practice across the United States for families who are undergoing divorce or who are involved in the child welfare or juvenile justice systems. Mandates to participate in parenting programs create substantial challenges for families, service providers, and service systems. Furthermore, the type and quality of the parenting services accessed vary widely, and their impacts need to be better understood. To address this need, an overview of the current state of the empirical literature on the impacts and outcomes of mandated parenting interventions for divorce and in child welfare and juvenile justice settings is provided, and suggestions to the field are offered to refine research related to mandated parenting programs. Given the challenges that mandated parenting programs pose, an alternative approach that views parenting through a public health lens is highlighted to build on the growing body of research on the impacts of population-wide applications of parenting support programs, and as a possible way to decrease the number of parents who are required to attend parenting programs. Opportunities to advance universal parenting support within a range of community settings, including primary care, early childhood education, and community mental health systems are offered. Gaps in knowledge regarding mechanisms of action of universal supports and impacts on the number of parents mandated to treatment are highlighted, and future directions for research in this area are suggested.

The Father's Part: A Pilot Evaluation of a Father-Centered Family Intervention Group in Child and Adolescent Psychiatry

Changes in parental roles have renewed the focus on a father's involvement in an offspring's psychological development. However, fathers are still under-represented in family research. There are only a few structured father-centered intervention programs in child and adolescent psychiatry. In a German population sample, a pilot father-centered family intervention program with n = 16 participants, conducted in person (n = 8) and online (n = 8), in a child and adolescent psychiatry inpatient/day clinic setting was evaluated by comparing paternal stress, PSE, and child-rated paternal competence in a pre-post design. Participating fathers showed significant decreases in child-related parenting stress (presence: p = 0.042, online: p = 0.047) and significant increases in PSE (p = 0.006/0.012). Parent-related stress and child-rated paternal competence were unaffected (p = 0.108/0.171; p = 0.167/0.101), while small-to-medium effect size measures pointed in the direction of our hypothesis (d = 0.48/0.36; d = 0.37/0.50). Participant satisfaction was higher in person than online (p = 0.008). As social and biological fathers have important influences on child and adolescent well-being and development, they should be included more frequently in prevention and intervention programs. Fathers seem to benefit from gender-specific intervention programs with regard to stress reduction, as well as experiencing competence- and PSE-increasing effects.

Effect of a sensory diet smartphone application on the symptoms of children with attention deficit hyperactivity disorder (ADHD): A feasibility study

Introduction

Sensory integration and sensory diet can improve the symptoms of children with attention deficit/hyperactivity disorder (ADHD). This feasibility study aimed to evaluate the effect of using a sensory diet smartphone application by mothers on the main symptoms of their children with ADHD, including hyperactivity, attention deficit, and impulsivity.

Methods

We conducted a need assessment study with the collaboration of 15 occupational therapists, developed an Android-based prototype, and evaluated it in terms of usability with the participation of 12 available mothers of children with ADHD. 12 other selected children were divided into control and experimental groups. At first, these children were evaluated using the hyperactivity subscale of the fourth version of the Pediatric Symptoms Questionnaire, and after two months of using the application by the mothers of the children in the experimental group, both groups were re-evaluated using the same questionnaire. We compared the mean score of this questionnaire before and after the mothers' use of the application.

Results

The application included 105 sensory diet exercises presented in animated format with accompanying text explanations. According to mothers' feedback, the usability of the application was rated at a high level with an average score of 8.35 out of 9. In the experimental group, attention deficit significantly improved compared to the pre-intervention stage (Mean ± SD = 13.67 ± 6.86 vs. 22 ± 6.13, P-value<0.0001) and compared to the control group after the intervention (P-value = 0.048). Additionally, after the intervention, the experimental group showed significant improvements in impulsivity (mean difference = -1.33) and hyperactivity (mean difference = -4.67) compared to the pre-intervention (P-value = 0.025 and 0.034, respectively). However, these improvements were not statistically significant when compared to the control group (P-value = 0.937 and 0.58, respectively).

Conclusion

The findings suggest that sensory diet smartphone applications have the potential to help alleviate symptoms related to attention deficit in children with ADHD.

Intervention and Implementation Characteristics to Enhance Father Engagement: A Systematic Review of Parenting Interventions

In recent years, the prevalence rates of children's mental health disorders have increased with current estimates identifying that as many as 15-20% of children meet criteria for a mental health disorder. Unfortunately, the same robust parenting interventions which have long targeted some of the most common and the most treatable child concerns (e.g., externalizing, disruptive behavior, and aggression) have also shown consistently low rates of father engagement. This persistent issue of engagement comes in the wake of an increasingly large body of literature which highlights the unique positive contributions fathers make to children and families when they are engaged in parenting interventions. As the role fathers play in families shifts to become more inclusive of childcare responsibilities and less narrowly defined by financial contributions, it becomes increasingly important to understand how best to engage fathers in interventions that aim to enhance parenting efficacy and family outcomes such as coparenting. The current review examined intervention (e.g., format and setting) and implementation characteristics (e.g., training and agency-level changes) associated with father engagement. Particular attention is paid to studies which described father-specific engagement strategies (e.g., inviting fathers directly, father-only groups, and adapting intervention to incorporate father preferences). A total of 26 articles met inclusion criteria after screening and full-text review. Results indicate that father engagement (i.e., initiating treatment) remains low with 58% of studies either not reporting father engagement or having engagement rates below 50%. More than two-thirds of studies did not include specific father engagement strategies. Those that did focused on changes to treatment format (e.g., including recreational activities), physical treatment setting (e.g., in-home and school), and reducing the number of sessions required for father participation as the most common father-specific engagement strategies. Some studies reported efforts to target racially and ethnically diverse fathers, but review results indicated most participants identified as Non-Hispanic White. Interventions were largely standard behavioral parent training programs (e.g., PCIT and PMT) with few exceptions (e.g., COACHES and cultural adaptations), and very few agencies or programs are systematically making adjustments (e.g., extended clinic hours and changes to treatment format) to engage fathers. Recommendations for future directions of research are discussed including the impact of differential motivation on initial father engagement in treatment, the importance of continuing to support diverse groups of fathers, and the potential for telehealth to address barriers to father engagement.

Experience and impact of the 1-2-3 magic parent programme for children with ADHD on the family unit from the mothers' perspectives: A narrative analysis

Parent programmes are often used in the clinical management of children with ADHD. Research into parent programmes has predominantly been concerned with their effectiveness and much less attention has been paid to the impact that they may be having on the family and the inter-relationships between family members. This study explores the perspectives and experiences of parents of children with ADHD, who participated in a parent programme, including its impact on the family unit. A purposive sample of six mothers of children with ADHD who completed a 1-2-3 Magic parent programme in Ireland was invited to take part in this qualitative study. Data were collected by means of individual in-depth, semi-structured interviews and a narrative inquiry approach further informed analysis of the interview data. Two major narrative constructions of experience: 'parent programme as positive' and 'parent programme as negative' were identified. Outcomes from this study illustrated some unintended consequences caused by the parent programme (i.e. sibling rivalry and conflict arising between family members). Mothers believed that the parent programme was a beneficial intervention, but it was not without its flaws and they felt it was helpful for their family when used in conjunction with other supports and mediations.

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.

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.

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.

COVID-19 and the Acceleration of Behavioral Parent Training Telehealth: Current Status and Future Directions

The SARS-COV-2 (COVID-19) pandemic and associated social distancing guidelines have accelerated the telehealth transition in mental health. For those providing Behavioral Parent Training (BPT), this transition has called for moving sessions that are traditionally clinic-based, active, and directive to engaging, supporting, and treating families of children with behavior disorders remotely in their homes. Whereas many difficulties accompany this transition, the lessons learned during the current public health crisis have the potential to transform BPT service delivery on a large scale in ways that address many of its long-standing limitations. We describe both challenges and opportunities and consider the possibilities inherent in a large scale BPT service delivery model capable of increasing the reach and impact of evidence-based treatment for all families.

A school-based parenting program for children with attention-deficit/hyperactivity disorder: Impact on paternal caregivers

Engaging male caregivers within school settings is a major need within the educational field. Paternal engagement may be particularly important for children with attention-deficit/hyperactivity disorder (ADHD). Children with ADHD have increased risk for a number of poor educational outcomes, which may be attenuated by the benefits of positive male caregiver involvement. The Coaching Our Acting Out Children: Heightening Essential Skills (COACHES) program has been illustrated to be an effective approach for engaging, retaining, and improving the parenting of male caregivers of children with ADHD in clinical settings. The present study reports on the efficacy of the COACHES in Schools program, an adaptation intended for deployment in elementary school settings. Sixty-one male caregivers were randomly assigned to COACHES in Schools or a waitlist control. Results indicated that male caregivers in COACHES in Schools used significantly more praise and less negative talk in a parent-child activity relative to male caregivers in the waitlist control at post-treatment and one-month follow-up. Distal outcomes related to child behavior at home and at school were not significantly different. Implications of the results for future studies and continued efforts to engage male caregivers within school settings are discussed.

How to Improve Behavioral Parent and Teacher Training for Children with ADHD: Integrating Empirical Research on Learning and Motivation into Treatment

Attention deficit hyperactivity disorder [ADHD] is one of the most common psychiatric disorders of childhood with poor prognosis if not treated effectively. Recommended psychosocial evidence-based treatment for preschool and school-aged children is behavioral parent and teacher training [BPT]. The core elements of BPT are instrumental learning principles, i.e., reinforcement of adaptive and the ignoring or punishment of non-adaptive behaviors together with stimulus control techniques. BPT is moderately effective in reducing oppositional behavior and improving parenting practices; however, it does not reduce blinded ratings of ADHD symptoms. Also after training effects dissipate. This practitioner review proposes steps that can be taken to improve BPT outcomes for ADHD, based on purported causal processes underlying ADHD. The focus is on altered motivational processes (reward and punishment sensitivity), as they closely link to the instrumental processes used in BPT. Following a critical analysis of current behavioral treatments for ADHD, we selectively review motivational reinforcement-based theories of ADHD, including the empirical evidence for the behavioral predictions arising from these theories. This includes consideration of children's emotional reactions to expected and unexpected outcomes. Next we translate this evidence into potential ADHD-specific adjustments designed to enhance the immediate and long-term effectiveness of BPT programs in addressing the needs of children with ADHD. This includes the use of remediation strategies for proposed deficits in learning not commonly used in BPT programs and cautions regarding the use of punishment. Finally, we address how these recommendations can be effectively transferred to clinical practice.

Home-based parent training for school-aged children with attention-deficit/hyperactivity disorder and behavior problems with remaining impairing disruptive behaviors after routine treatment: a randomized controlled trial

The objective is to investigate the effectiveness of home-based behavioral parent training for school-aged children with attention-deficit/hyperactivity disorder (ADHD) and behavior problems with remaining impairing disruptive behaviors after routinely offered treatments in clinical practice. In a randomized controlled study including 73 referred children with ADHD and impairing disruptive symptoms after routine clinical pharmacotherapy and/or clinic-based parent training had been tried or, at least, offered, home-based behavioral parent training (n = 26) was compared to a waiting list (n = 23) and a care-as-usual home-based treatment (n = 24). It was unknown to families which of the home-based treatments that they received. Using mixed models for repeated measures, we examined the effectiveness on the primary outcome measure of children's severity of disruptive behaviors and on a number of secondary outcome measures [the degree to which parents experienced the disruptive behaviors as troublesome, ADHD symptoms, oppositional-defiant disorder (ODD) symptoms, and internalizing problems]. Compared to the waiting list, children receiving home-based parent training improved significantly more regarding severity of disruptive behaviors (ES = 0.75), ADHD symptoms (ES = 0.89), ODD symptoms (ES = 0.65), and internalizing problems (ES = 0.60). Compared to care-as-usual, home-based parent training was more effective in reducing disruptive behaviors (ES = 0.57), ADHD symptoms (ES = 0.89), and ODD symptoms (ES = 0.88). Significantly more reduction of children's internalizing problems was not found. In conclusion, children with ADHD and residual behavioral problems after routine treatment may benefit from home-based behavioral parent training.

A Randomized Controlled Trial Evaluating the Efficacy of a Psychoeducation Program for Families of Children and Adolescents With ADHD in the United Kingdom: Results After a 6-Month Follow-Up

Objective: Psychoeducation forms part of the current practice for ADHD; however, its efficacy is yet to be established. Method: Sixty-nine children/adolescents with ADHD were randomly assigned for their families to receive either a well-structured psychoeducation program (n = 35), or belong to a control group (treatment-as-usual, n = 34). Results: One-way analyses of variance showed a statistically significant Treatment × Time interaction, for ADHD total symptoms, inattention/cognition, and hyperactivity/impulsivity subdomains according to the parents, the first two with medium-large effect sizes. The effects of the intervention on the ADHD total and the inattention/cognition domain persisted after 6 months follow-up. No significant differences in teacher ratings were found; however, an improvement in clinical functioning as measured by clinicians was observed. Conclusion: This psychoeducation program has shown effectiveness in reducing ADHD symptoms when compared with treatment as usual. Psychoeducation needs to be considered as a valid and additional approach in ADHD.

An investigation of predictors of attendance for fathers in behavioral parent training programs for children with ADHD

Behavioral parent training programs are evidence-based treatment for children with attention-deficit/hyperactivity disorder (ADHD), yet attendance in such programs is variable. Relative to mothers of children with ADHD, far less is known about fathers and what predicts their attendance in treatment. The current study aimed to explore predictors of father (N = 171) attendance using data from four studies that tested the efficacy of behavioral parent training programs aimed specifically at fathers. A hierarchical regression was performed to test four potential predictors of attendance, including father race/ethnicity, father education level, child medication status, and father ratings of the child's oppositional defiant disorder symptoms. Father education level was determined to be a significant predictor of attendance, whereas father race/ethnicity, child medication status, and father ratings of the child's ODD behavior were not. The results suggest that future parent training interventions may need to be adapted to improve attendance from fathers of lower education levels.

Are parental changes related to improvements in preschool children's disruptive behaviours?

OBJECTIVE

To investigate whether changes in parenting after behavioural parent training in routine clinical care are associated with improvements in preschool children's disruptive behaviours.

METHOD

We evaluated changes after parent training in maternal and paternal self-reports of parental discipline practices parenting sense of competence, and parents' ratings of child disruptive behaviours in parents of 63 children, with a one group pretest-posttest design. We also compared parenting parameters in this clinical sample with a nonclinical sample (n = 121).

RESULTS

Mothers' self-reports of parental discipline practices and parenting sense of competence significantly improved after behavioural parent training. Less over-reactivity in both mothers and fathers was associated with fewer disruptive behaviours in children. After parent training, mothers' ratings of their discipline techniques did not differ anymore from those in the nonclinical sample.

CONCLUSION

Positive changes in parental discipline practices, particularly less over-reactive parental behaviours, were related to a decrease of disruptive child behaviours.

Exploring Parent Beliefs and Behavior: The Contribution of ADHD Symptomology Within Mothers and Fathers

OBJECTIVE

To use a multi-method approach to examine the association of parental ADHD and gender with observed and self-reported parenting beliefs and behaviors.

METHOD

Seventy-nine mother-father dyads completed measures of child behavior and impairment, parenting beliefs and behaviors, and self- and partner ratings of ADHD symptoms and functional impairment. Forty-five parents also completed structured parent-child interactions.

RESULTS

A hierarchical linear model suggests impairment in functional domains may be associated with negative emotions about parenting and less effective parenting strategies. For fathers, greater severity of partner-reported symptoms of ADHD may be associated with greater frequency of negative talk during parent-child interactions.

CONCLUSION

Findings suggest that higher levels of parental ADHD symptoms and functional impairment may be associated with reported beliefs and behaviors related to parenting. Differences emerged among mothers' and fathers' use of parenting strategies when self- and other-report of ADHD symptoms and impairment were assessed.

The impact of SafeCare® Dads to Kids program on father maltreatment risk and involvement: Outcomes and lessons learned from an efficacy trial

Child Maltreatment (CM) is a public health problem, and experts recommend parent training programs as a prevention method. Few programs target fathers, even though male caregivers are involved as perpetrators in approximately 45% of substantiated CM cases. This study examines the efficacy of an adapted version of SafeCare (Dad2K) with marginalized fathers. Participants include a convenience sample of fathers with children ages 2-5 years. Fathers (n=99) were randomized to an 1) intervention group (SafeCare Dad2K) or to a 2) comparison group (receiving parenting information in the mail). Quantitative data were collected at baseline, post-intervention (7-weeks post-baseline), and 3-months post-intervention. Qualitative data (semi-structured interviews) were collected from 11 intervention father completers following the second quantitative data collection timepoint. Multi-level modeling results indicated no statistically significant time-by-treatment findings for father involvement (b=0.03, 95% confidence interval [CI]: -0.03, 0.08, p=0.38), total corporal punishment (b=-0.03, 95% CI: -0.47, 0.41, p=0.89), or neglect (b=-0.13, 95% CI: -1.93, 1.68, p=0.89). Qualitative findings indicated that Dad2K completers exhibited positive knowledge and behavioral change related to parenting. Study limitations, lessons learned from this formative work, and recommendations for future research are discussed.

Practitioner Review: Current best practice in the use of parent training and other behavioural interventions in the treatment of children and adolescents with attention deficit hyperactivity disorder

BACKGROUND

Behavioural interventions are recommended for use with children and young people with attention deficit hyperactivity disorder (ADHD); however, specific guidance for their implementation based on the best available evidence is currently lacking.

METHODS

This review used an explicit question and answer format to address issues of clinical concern, based on expert interpretation of the evidence with precedence given to meta-analyses of randomised controlled trials.

RESULTS

On the basis of current evidence that takes into account whether outcomes are blinded, behavioural intervention cannot be supported as a front-line treatment for core ADHD symptoms. There is, however, evidence from measures that are probably blinded that these interventions benefit parenting practices and improve conduct problems which commonly co-occur with ADHD, and are often the main reason for referral. Initial positive results have also been found in relation to parental knowledge, children's emotional, social and academic functioning - although most studies have not used blinded outcomes. Generic and specialised ADHD parent training approaches - delivered either individually or in groups - have reported beneficial effects. High-quality training, supervision of therapists and practice with the child, may improve outcomes but further evidence is required. Evidence for who benefits the most from behavioural interventions is scant. There is no evidence to limit behavioural treatments to parents with parenting difficulties or children with conduct problems. There are positive effects of additive school-based intervention for the inattentive subtype. Targeting parental depression may enhance the effects of behavioural interventions.

CONCLUSIONS

Parent training is an important part of the multimodal treatment of children with ADHD, which improves parenting, reduces levels of oppositional and noncompliant behaviours and may improve other aspects of functioning. However, blinded evidence does not support it as a specific treatment for core ADHD symptoms. More research is required to understand how to optimise treatment effectiveness either in general or for individual patients and explore potential barriers to treatment uptake and engagement. In terms of selecting which intervention formats to use, it seems important to acknowledge and respond to parental treatment preferences.

Fathers' Perceptions of Change Following Parenting Intervention: Randomized Controlled Trial of Triple P for Parents of Children With Asthma or Eczema

Objective

To test whether families' participation in an evidence-based parenting program can improve health-related outcomes reported by fathers of 2- to 10-year-old children with asthma and/or eczema.

Methods

A 2 (Triple P-Positive Parenting Program vs. care as usual) by 3 (baseline, postintervention, 6-month follow-up) design was used, with random group assignment. Of 107 families, 51.4% (N = 55) had a father participate alongside the child's mother, who was the primary intervention target. Fathers completed questionnaires assessing illness-related child behavior problems; self-efficacy with illness management and illness-related child behavior problems; and health-related quality of life.

Results

Secondary intent-to-treat analyses indicated improved child behavior and self-efficacy for managing eczema, but not asthma. Health-related quality of life improved for children, but not parents/families. There were no other significant intervention effects.

Conclusions

Intervention outcomes were positive for eczema but not asthma, and did not depend on the extent of father participation in the intervention.

Initial Findings from a Feasibility Trial Examining the SafeCare Dad to Kids Program with Marginalized Fathers

Few studies have explored the direct impact of behavioral parent training programs on child maltreatment behaviors among marginalized, at-risk fathers. This feasibility study examined SafeCare® Dad to Kids (Dad2K), an augmented version of the evidence-based child maltreatment prevention program SafeCare, to determine the acceptability and initial efficacy of the program for improving father parenting skills and reducing maltreatment risk. Ninety-nine fathers were enrolled in the study and randomized to the SafeCare Dad2K Intervention (n=51) or comparison (n=48). Intervention fathers participated in 6 home visiting sessions and comparison fathers received parenting materials via mail. All fathers participating in the study completed a baseline and 8-week assessment (post-intervention) of maltreatment behaviors. In addition, intervention fathers completed feasibility and parenting skill measures. A significant main effect emerged indicating decreases for both groups in psychologically aggressive behaviors. No significant group by time findings emerged for child maltreatment behaviors. Father intervention completers endorsed high satisfaction ratings for the program and demonstrated significant improvements in targeted father-child interaction skills. Based on the high rates of acceptability and initial improvement in positive parenting skills, findings demonstrate the feasibility for involving at-risk fathers in behavioral parent training programs targeting child maltreatment prevention.

Exploration of Factors Predictive of At-risk Fathers' Participation in a Pilot Study of an Augmented Evidence-Based Parent Training Program: A Mixed Methods Approach

There has been burgeoning parenting intervention research specifically addressing fathers in recent decades. Corresponding research examining their participation and engagement in evidence-based parent training programs, which have almost exclusively targeted mothers, is just emerging. The current study used mixed methods to examine factors that influenced completion of an augmented version of an evidence-based child maltreatment prevention program developed for male caregivers called SafeCare Dad to Kids (Dad2K) in a pilot study. The current sample comprised 50 male caregivers (Mage = 29.42 years, SD = 8.18) of a child between the ages of 2 and 5 years. Fathers participated in a baseline assessment and were considered program completers (n = 27) if they participated in the program's six home visiting sessions. A subsample of completers (n = 11) was recruited to participate in qualitative interviews that provided in-depth information about fathers' experiences in Dad2K. Logistic regression indicated that, in the context of other demographic predictors, fathers with an education beyond high school were over 5 times more likely to complete Dad2K program compared to fathers with a high school education or less. Qualitative analyses revealed that interviewed father completers were motivated to enroll and participate in a fathering program because of an interest to learn and obtain skills to make them a better parent. Fathers with a high school education or less may require additional engagement strategies to help proactively encourage their enrollment and completion of parent training programs.

Engaging Fathers in Effective Parenting for Preschool Children Using Shared Book Reading: A Randomized Controlled Trial

Engaging fathers and improving their parenting and, in turn, outcomes for their children in preventive/promotion-focused parenting interventions has been a notable, but understudied, challenge in the field. This study evaluated the effects of a novel intervention, Fathers Supporting Success in Preschoolers: A Community Parent Education Program, which focuses on integrating behavioral parent training with shared book reading (i.e., Dialogic Reading) using key conceptual models (i.e., common elements, deployment model, task shifting) to engage and improve father (i.e., male guardians) and child outcomes. One hundred twenty-six low-income, Spanish-speaking fathers and their children were recruited across three Head Start centers in urban communities and were randomized to the intervention or to a waitlist control condition. Outcomes were obtained before and immediately postintervention and included observed and father-reported parenting and child behaviors, standardized assessments of language, and father self-reported parental stress and depressive symptoms. Attendance data were also collected as a proxy measure of engagement to the intervention. Parenting behaviors (observed and father-reported), child behaviors (father-reported), and language development of the children in the intervention group improved significantly relative to those in the waitlist control condition. Effect sizes (ESs) were in the small to large range across outcomes. Fathers can be engaged in parenting interventions, resulting in improved parent and child outcomes. Greater attention must be given to methods for maximizing parenting within a family and toward developing effective, engaging, and sustainable intervention models for fathers.

Enhancing Father Engagement and Interparental Teamwork in an Evidence-Based Parenting Intervention: A Randomized-Controlled Trial of Outcomes and Processes

This study examined the outcomes and process in a positive parenting program adapted to enhance father engagement and teamwork. A randomized control trial of the Group Triple P Program with additional father-relevant content was conducted with 42 families of children with conduct problems aged between 3 to 8years. Families were allocated to either the intervention or waitlist condition. Assessments of child behavior, self- and partner-reported parenting, and the interparental relationship were conducted at T1 (pre), T2 (post), and T3 (6-month follow-up). Observations were used to examine fathers' and mothers' unique and shared contributions to group process during participation in parenting group sessions. Following program completion (T2) intervention group fathers and mothers reported significantly fewer child behavior problems, dysfunctional parenting practices, and interparental conflict about child-rearing than waitlist parents. Intervention group mothers also reported increased parenting confidence and rated their partners as showing significantly fewer dysfunctional parenting practices. Intervention effects were maintained at 6-month follow-up. Observational data showed that fathers and mothers made similar contributions during the group sessions. The most frequent types of contributions were asking questions and sharing information with other parents about implementing parenting strategies. The key differences between parents were fathers' more frequent use of humor and mothers' more frequent sharing of personal stories and reporting co-parenting cooperation. The levels of session attendance and program satisfaction were high for both fathers and mothers. Findings highlight the potential benefits of efforts to engage both fathers and mothers for program adherence, satisfaction, and effectiveness.

Mindfulness training as an adjunct to evidence-based treatment for ADHD within families

OBJECTIVE

Individuals with ADHD face significant neurodevelopmental hurdles with inattention and/or hyperactive/impulsive behavior through their life span. Mindfulness training may be one self-regulatory method for strengthening attentional processes (orienting, alerting, and executive attention). This review's goals are to (a) argue for the use of mindfulness training as an adjunct to evidence-based treatment for ADHD and (b) call for improving psychosocial intervention for ADHD within families by integrating mindfulness training with behavioral parent training.

METHOD

EBSCOhost was utilized to search 29 psychology-related research databases through Athabasca University.

RESULTS

Mindfulness training should be incorporated into current treatment guidelines as a psychosocial option for families with ADHD.

CONCLUSION

Preliminary findings suggest significant improvements in attentional processes, and prominent mindfulness-based approaches have been successfully adapted for ADHD.

Co-occurrence of attention-deficit hyperactivity disorder symptoms with other psychopathology in young adults: parenting style as a moderator

The extent to which parenting styles can influence secondary psychiatric symptoms among young adults with ADHD symptoms is unknown. This issue was investigated in a sample of 2284 incoming college students (male, 50.6%), who completed standardized questionnaires about adult ADHD symptoms, other DSM-IV symptoms, and their parents' parenting styles before their ages of 16. Among them, 2.8% and 22.8% were classified as having ADHD symptoms and sub-threshold ADHD symptoms, respectively. Logistic regression was used to compare the comorbid rates of psychiatric symptoms among the ADHD, sub-threshold ADHD and non-ADHD groups while multiple linear regressions were used to examine the moderating role of gender and parenting styles over the associations between ADHD and other psychiatric symptoms. Both ADHD groups were significantly more likely than other incoming students to have other DSM-IV symptoms. Parental care was negatively associated and parental overprotection/control positively associated with these psychiatric symptoms. Furthermore, significant interactions were found of parenting style with both threshold and sub-threshold ADHD in predicting wide-ranging comorbid symptoms. Specifically, the associations of ADHD with some externalizing symptoms were inversely related to level of paternal care, while associations of ADHD and sub-threshold ADHD with wide-ranging comorbid symptoms were positively related to level of maternal and paternal overprotection/control. These results suggest that parenting styles may modify the effects of ADHD on the risk of a wide range of temporally secondary DSM-IV symptoms among incoming college students, although other causal dynamics might be at work that need to be investigated in longitudinal studies.

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.

Engaging African American Fathers in Behavioral Parent Training: To Adapt or Not Adapt

The Positive Parenting Program, Triple P, is an evidence-based parenting program with strong empirical support that increases parenting skills and decreases child behavior problems. Few studies on Triple P include fathers or African American fathers. This study was undertaken to determine if adaptation to Triple P level 4 is necessary to ensure fit with urban African American fathers. Qualitative focus groups and interviews were conducted with African American fathers. Some received a brief overview of the program before giving feedback (series A) and others received the entire intervention (series B). Inductive thematic analysis was used to analyze transcripts and codebooks were developed through an iterative process. Series B fathers had fewer negative perceptions and a more detailed perspective. Limited exposure to an intervention may cause participants to provide inaccurate data on intervention acceptability. The fathers' initial perceptions of interventions, regardless of accuracy, will affect recruitment and engagement and must be addressed. One strategy is to tailor program examples and language to reflect the experiences of African American fathers.

Client-centred coaching in the paediatric health professions: a critical scoping review

PURPOSE

Coaching is mainstream in business and is expanding into paediatric health care. With the focus on evidence-informed health practice, it is imperative to identify the key active components of interventions. Coaching is by definition a complex intervention with numerous components. The purpose of this critical review is to determine how coaching is currently defined, its prevalence in paediatric health care services and the frequency of the active components of coaching and to consider the findings of research to date.

METHOD

A critical review of the literature was conducted. Inclusion/exclusion criteria were based on the International Coach Federation, which stipulates that coaching is a collaborative process that involves client-centred goal setting, facilitation, self-discovery and capacity building. Seventeen studies were selected for thorough review.

RESULTS

Throughout the literature, there was inconsistency in how coaching was defined. Studies included various components, but overall the literature lacked cohesion.

CONCLUSION

To advance the field, a list of components that foster client engagement was developed along with a comprehensive definition of coaching involving affective, behavioural and cognitive components and a path of research necessary to evaluate this complex intervention. Implications for Rehabilitation A comprehensive approach to coaching involves consideration of multiple components. A coaching approach can enhance engagement in rehabilitation interventions. The operationalization of holistic ABC coaching that encapsulates the important components, which are affective, behavioural and cognitive in nature.

Summer Treatment Programs for Youth with Attention-deficit/hyperactivity Disorder

Children with attention-deficit/hyperactivity disorder (ADHD) require intensive treatments to remediate functional impairments and promote the development of adaptive skills. The summer treatment program (STP) is an exemplar of intensive treatment of ADHD. STP intervention components include a reward and response-cost point system, time-out, use of antecedent control (clear commands, establishment of rules and routines), and liberal praise and rewards for appropriate behavior. Parents also participate in parent management training programming to learn how to implement similar procedures within the home setting. There is strong evidence supporting the efficacy of the STP as an intervention for ADHD.

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.

Evaluation of a psychoeducation programme for parents of children and adolescents with ADHD: immediate and long-term effects using a blind randomized controlled trial

Recent guidelines for the diagnosis and treatment of attention deficit hyperactivity disorder (ADHD) have claimed the possible benefits of psychoeducational techniques in the comprehensive management of ADHD. To evaluate the efficacy of a psychoeducation programme for parents of children and adolescents with ADHD in a clinical setting using a blind randomized trial. 81 children/adolescents with ADHD were randomly assigned for their families to receive either a well-structured psychoeducation programme (intervention group, n = 44), or a parent counselling and support intervention (control group, n = 37). Measures of child ADHD symptoms, psychopathology, quality of life and family stress were taken before and after intervention and after a year follow-up. Parents and evaluators were unaware of the condition received. Compared to the support control group, the psychoeducation group showed ADHD Index and cognitive/inattention levels significantly reduced after the intervention ended (Mann-Whitney U = 3.34; p = 0.001; Mann-Whitney U = 3.47; p = 0.001). An improvement in the pro-social domain was also observed after 1 year follow-up (Mann-Whitney U = -2.37; p = 0.018), and clinical global impression found a statistically significant effect for severity over the time. Differences were initially found for the impact of the disorder in the family in different domains, including emotional and social functioning; these differences were no longer significant after alpha correction. No significant differences in quality of life or family stress were found in comparison with the control group. This psychoeducation programme is a valuable treatment for parents/carers of children/adolescents with ADHD, which needs to be considered when evaluating different non-pharmacological treatment options. Psychoeducation and other kind of non-pharmacological approaches need to be regarded not as a substitute, but as a complementary treatment to medications; these approaches might help other very crucial aspects of ADHD including social and familiar outcomes.

Behavioral interventions in attention-deficit/hyperactivity disorder: a meta-analysis of randomized controlled trials across multiple outcome domains

OBJECTIVE

Behavioral interventions are recommended as attention-deficit/hyperactivity disorder (ADHD) treatments. However, a recent meta-analysis found no effects on core ADHD symptoms when raters were probably blind to treatment allocation. The present analysis is extended to a broader range of child and parent outcomes.

METHOD

A systematic search in PubMed, Ovid, Web of Knowledge, ERIC, and CINAHAL databases (up to February 5, 2013) identified published randomized controlled trials measuring a range of patient and parent outcomes for children and adolescents diagnosed with ADHD (or who met validated cutoffs on rating scales).

RESULTS

Thirty-two of 2,057 nonduplicate screened records were analyzed. For assessments made by individuals closest to the treatment setting (usually unblinded), there were significant improvements in parenting quality (standardized mean difference [SMD] for positive parenting 0.68; SMD for negative parenting 0.57), parenting self-concept (SMD 0.37), and child ADHD (SMD 0.35), conduct problems (SMD 0.26), social skills (SMD 0.47), and academic performance (SMD 0.28). With probably blinded assessments, significant effects persisted for parenting (SMD for positive parenting 0.63; SMD for negative parenting 0.43) and conduct problems (SMD 0.31).

CONCLUSION

In contrast to the lack of blinded evidence of ADHD symptom decrease, behavioral interventions have positive effects on a range of other outcomes when used with patients with ADHD. There is blinded evidence that they improve parenting and decrease childhood conduct problems. These effects also may feed through into a more positive parenting self-concept but not improved parent mental well-being.

The Triple P-Positive Parenting Program: a systematic review and meta-analysis of a multi-level system of parenting support

This systematic review and meta-analysis examined the effects of the multilevel Triple P-Positive Parenting Program system on a broad range of child, parent and family outcomes. Multiple search strategies identified 116 eligible studies conducted over a 33-year period, with 101 studies comprising 16,099 families analyzed quantitatively. Moderator analyses were conducted using structural equation modeling. Risk of bias within and across studies was assessed. Significant short-term effects were found for: children's social, emotional and behavioral outcomes (d=0.473); parenting practices (d=0.578); parenting satisfaction and efficacy (d=0.519); parental adjustment (d=0.340); parental relationship (d=0.225) and child observational data (d=0.501). Significant effects were found for all outcomes at long-term including parent observational data (d=0.249). Moderator analyses found that study approach, study power, Triple P level, and severity of initial child problems produced significant effects in multiple moderator models when controlling for other significant moderators. Several putative moderators did not have significant effects after controlling for other significant moderators. The positive results for each level of the Triple P system provide empirical support for a blending of universal and targeted parenting interventions to promote child, parent and family wellbeing.

Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder

The purpose of this research was to update the Pelham and Fabiano ( 2008 ) review of evidence-based practices for children and adolescents with attention-deficit/hyperactivity disorder. We completed a systematic review of the literature published between 2007 and 2013 to establish levels of evidence for psychosocial treatments for these youth. Our review included the identification of relevant articles using criteria established by the Society of Clinical Child and Adolescent Psychology (see Southam-Gerow & Prinstein, in press ) using keyword searches and a review of tables of contents. We extend the conceptualization of treatment research by differentiating training interventions from behavior management and by reviewing the growing literature on training interventions. Consistent with the results of the previous review we conclude that behavioral parent training, behavioral classroom management, and behavioral peer interventions are well-established treatments. In addition, organization training met the criteria for a well-established treatment. Combined training programs met criteria for Level 2 (Probably Efficacious), neurofeedback training met criteria for Level 3 (Possibly Efficacious), and cognitive training met criteria for Level 4 (Experimental Treatments). The distinction between behavior management and training interventions provides a method for considering meaningful differences in the methods and possible mechanisms of action for treatments for these youth. Characteristics of treatments, participants, and measures, as well as the variability in methods for classifying levels of evidence for treatments, are reviewed in relation to their potential effect on outcomes and conclusions about treatments. Implications of these findings for future science and practice are discussed.

Recruiting Fathers to Parenting Programs: Advice from Dads and Fatherhood Program Providers

The benefits of high-quality father-child relationships for fathers and children alike are well documented. While evidence suggests parenting programs can improve the quality of father-child relationships, few fathers participate in such programs. This qualitative study aims to fill the gap in knowledge on best practices for recruiting urban African American fathers, a group of fathers with unique parenting challenges, to parenting programs. Focus groups were conducted with 29 fathers to gain their perspectives on recruitment strategies. Semi-structured interviews were also conducted with a nationwide sample of 19 fatherhood program providers to learn about their most successful recruitment strategies. Recruitment strategies based on emergent themes from the focus groups and interviews are presented here. Themes included using word-of-mouth recruitment, increasing advertising, targeting advertising specifically to urban African American fathers, providing transportation and incentives, recruiting through the courts, collaborating with other community agencies, and offering parenting programming along with other programming valued by fathers such as employment assistance. Implications for developing strategies for recruiting urban African American fathers to parenting programs are discussed.

Father's role in parent training for children with developmental delay

The current pilot study was a quasi-experimental examination of the impact of father involvement in parent training among 44 families with a young child who presented with elevated externalizing behavior problems and developmental delay. All families were offered to receive Parent-Child Interaction Therapy (PCIT), an evidence-based parent-training intervention, at a hospital-based outpatient clinic. Single-mother families were significantly more likely to drop out of treatment than two-parent families. Of the families that completed treatment, children from families in which a father participated in treatment had lower levels of parent-reported externalizing behavior problems than children from single-mother families and children from two-parent families in which the father did not participate in treatment. Additionally, children from father-involved families were significantly more compliant during a cleanup task than children from single-mother families following treatment. The current study is consistent with the limited research examining father involvement in parent training and extends the findings to children with developmental delay. These findings highlight the importance of involving fathers in parent training, particularly when working with children with developmental delay.