Pharmacotherapy for parents with attention-deficit hyperactivity disorder (ADHD): impact on maternal ADHD and parenting

Study of white matter integrity in fathers of children with attention deficit hyperactivity disorder

Background

Attention deficit hyperactivity disorder (ADHD) is an early-onset neurodevelopmental disorder that can extend into adulthood with multiple reported neuroimaging abnormalities. The focus of this research was to assess white matter impairments in ADHD children’s fathers with and without potential adult ADHD to see if these differences are connected with the persistence of ADHD into adulthood.

Results

The occurrence rate of the potential adult ADHD diagnosis among fathers of children with ADHD was 60%. There were statistically significant differences between fathers with ADHD and the non-ADHD population, due to the fact that the mean FA of the left superior corona radiata and the right posterior corona radiata were lower in the ADHD group than in the non-ADHD group, while the FA of the ADHD group was significantly greater than that of the non-ADHD group in terms of the left and right anterior thalamic radiations, the right superior longitudinal fasciculus and the left anterior corona radiata.

Conclusions

We observed an increased prevalence of ADHD in fathers of children diagnosed with ADHD. Fathers with potential adult ADHD have a variety of white matter abnormalities that reflect the neurobiological basis of ADHD, even in sub-threshold cases. This may provide insight into the neuroanatomical locations associated with the maintenance of ADHD throughout adulthood.

Impact of Parental Impulsivity on Attention Deficit Hyperactivity Disorder and Oppositional Defiant Disorder: Do Mothers' Attitudes Predict Symptom Severity in Children?

ABSTRACT

Attention deficit hyperactivity disorder (ADHD) is a chronic neurodevelopmental disorder that occurs early in school-aged children, and it is highly comorbid with oppositional defiant disorder (ODD). Parents of children with ADHD frequently show mental problems related to impulsivity. The aim of this study was to examine the relationship between impulsivity of the mothers and the symptom patterns and severity of children. A total of 85 children between the ages of 6 and 12 and their mothers participated. Conners' Parent and Teacher Scales, Structured Clinical Interview for DSM-IV Personality Disorders, and ıowa gambling task were applied. We found a positive correlation between the impulsivity of the mothers and the total symptom severity of ADHD and ODD in children. During the treatment process of ADHD, the evaluation of impulsivity in mothers of children with ODD comorbidity and treatment of impulsivity in the mother would be beneficial. In future studies, examining the effects after treatment of impulsivity may contribute to the literature.

Efficacy and Safety of PRC-063, Extended-Release Multilayer Methylphenidate in Adults with ADHD Including 6-Month Open-Label Extension

Objective: To evaluate the efficacy and safety of a 16-hr multilayer-release methylphenidate (PRC-063) in a community-based adult ADHD population. Method: In a double-blind study, 375 participants were randomized to one of four fixed doses of PRC-063 or placebo. The primary outcome was the ADHD-Rating Scale-5 (RS). The first 50% of double-blind completers were invited to participate in a 6-month dose-optimized open-label study to assess response and safety. Results: In total, 333 participants completed the double-blind trial; 184 entered the open-label study. PRC-063 produced greater symptom reduction in ADHD-RS-5 total score from baseline compared with placebo in the double-blind study (least-square [LS] mean = -4.7 [-7.7, -1.6], p = .003). The most frequent adverse events were headache, insomnia, and decreased appetite. No significant sleep quality impact was observed (p = .123). Significant improvements in ADHD-RS-5 scores from baseline continued through the open-label study (p < .0001), coincident with dose optimization. Conclusion: PRC-063 was well tolerated and significantly improved ADHD symptomatology in adults.

A Randomized Clinical Trial of an Integrative Group Therapy for Children With Severe Mood Dysregulation

OBJECTIVE

Nonepisodic irritability is a common and impairing problem, leading to the development of the diagnoses severe mood dysregulation (SMD) and disruptive mood dysregulation disorder (DMDD). No psychosocial therapies have been formally evaluated for either, with medication being the most common treatment. This study examined the feasibility and efficacy of a joint parent-child intervention for SMD.

METHOD

A total of 68 participants aged 7 to 12 years with attention-deficit/hyperactivity disorder (ADHD) and SMD were randomly assigned to the 11-week therapy or community-based psychosocial treatment. All participants were first stabilized on psychostimulant medication by study physicians. Of the participants, 56 still manifested impairing SMD symptoms and entered the therapy phase. Masked evaluators assessed participants at baseline, midpoint, and endpoint, with therapy participants reassessed 6 weeks later.

RESULTS

All but 2 therapy participants attended the majority of sessions (n = 29), with families reporting high levels of satisfaction. The primary outcome of change in mood symptoms using the Mood Severity Index (MSI) did not reach significance except in the subset attending the majority of sessions (effect size = 0.53). Therapy was associated with significantly greater improvement in parent-rated irritability (effect size = 0.63). Treatment effects for irritability but not MSI diminished after therapy stopped. Little impact on ADHD symptoms was seen. Results may not be generalizable to youth with SMD and comorbidities different from those seen in this sample of children with ADHD, and are limited by the lack of a gold standard for measuring change in SMD symptoms.

CONCLUSION

While failing to significantly improve mood symptoms versus community treatment, the integrative therapy was found to be a feasible and efficacious treatment for irritability in participants with SMD and ADHD.

CLINICAL TRIAL REGISTRATION INFORMATION

Group-Based Behavioral Therapy Combined With Stimulant Medication for Treating Children With Attention Deficit Hyperactivity Disorder and Impaired Mood; http://clinicaltrials.gov/; NCT00632619.

Self-Rated ADHD Symptoms Among Biological Mothers or Fathers of Children with Confirmed ADHD in a French Population

Parents of children with ADHD are more likely to present the disorder, which can affect quality of life and parenting strategies. Few studies have examined parental ADHD to date, none in France. Prevalence of self-rated ADHD symptoms in adulthood and childhood was estimated among 60 biological mothers or fathers of children with confirmed ADHD in France. Cutoffs were total score ≥46 on the Wender Utah Rating Scale and ≥4 on the Adult ADHD Self-Report Scale Screener. Results indicated possible child and adult ADHD in 12.5% of mothers and 10.0% of fathers. As these percentages exceed reported prevalence rates for the French population, a greater effort must be made to diagnose the disorder in parents.

Personalized Treatment of Mothers With ADHD and Their Young At-Risk Children: A SMART Pilot

Young children of mothers with adult attention-deficit/hyperactivity disorder (ADHD) are at risk for ADHD by virtue of genetics and environmental factors. Moreover, parent ADHD is associated with maladaptive parenting and poor child behavioral treatment response. Thus, a combined approach consisting of behavioral parent training (BPT) and maternal stimulant medication (MSM) may be needed to effectively treat ADHD within families. However, providing combined BPT+MSM initially to all families may be unnecessarily burdensome because not all families likely need combined treatment. The purpose of this study is to examine how to combine, sequence, and personalize treatment for these multiplex families in order to yield benefits to both the parent and child, thereby impacting the course of child ADHD and disruptive behavior symptoms. This article presents our rationale for, design of, and preliminary experiences (based on 26 participants) with an ongoing pilot Sequential Multiple Assessment Randomized Trial (SMART) designed to answer questions regarding the feasibility and acceptability of study protocols and interventions. This article also describes how the subsequent full-scale SMART might change based on what is learned in the SMART pilot and illustrates how the full-scale SMART could be used to inform clinical decision making about how to combine, sequence, and personalize treatment for complex children and families in which a parent has ADHD.

Does intensive multimodal treatment for maternal ADHD improve the efficacy of parent training for children with ADHD? A randomized controlled multicenter trial

BACKGROUND

This is the first randomized controlled multicenter trial to evaluate the effect of two treatments of maternal attention-deficit hyperactivity disorder (ADHD) on response to parent-child training targeting children's external psychopathology.

METHODS

Mother-child dyads (n = 144; ADHD according to DSM-IV; children: 73.5% males, mean age 9.4 years) from five specialized university outpatient units in Germany were centrally randomized to multimodal maternal ADHD treatment [group psychotherapy plus open methylphenidate medication; treatment group (TG): n = 77] or to clinical management [supportive counseling without psychotherapy or psychopharmacotherapy; control group (CG): n = 67]. After 12 weeks, the maternal ADHD treatment was supplemented by individual parent-child training for all dyads. The primary outcome was a change in the children's externalizing symptom scores (investigator blinded to the treatment assignment) from baseline to the end of the parent-child training 6 months later. Maintenance therapy continued for another 6 months. An intention-to-treat analysis was performed within a linear regression model, controlling for baseline and center after multiple imputations of missing values.

RESULTS

Exactly, 206 dyads were assessed for eligibility, 144 were randomized, and 143 were analyzed (TG: n = 77; CG: n = 66). After 6 months, no significant between-group differences were found in change scores for children's externalizing symptoms (adjusted mean TG-mean CG=1.1, 95% confidence interval -0.5-2.7; p = .1854), although maternal psychopathology improved more in the TG. Children's externalizing symptom scores improved from a mean of 14.8 at baseline to 11.4 (TG) and 10.3 (CG) after 6 months and to 10.8 (TG) and 10.1 (CG) after 1 year. No severe harms related to study treatments were found, but adverse events were more frequent in TG mothers than in CG mothers.

CONCLUSIONS

The response in children's externalizing psychopathology did not differ between maternal treatment groups. However, multimodal treatment was associated with more improvement in maternal ADHD. Child and maternal treatment gains were stable (CCT-ISRCTN73911400).

Commentary: Does helping mothers with ADHD in multiplex families help children? Reflections on Jans et al. (2015)

Reflecting on the accompanying article by Jans et al., we draw the following thoughts. Future research on multiplex ADHD families is needed to elucidate mechanisms, timing, and a sequencing of interventions, preferably in treatment naïve participants. Furthermore, in addition to symptom measures, it is likely that multi-informant measures of functional impairments such as parenting and parent-child observations may help elucidate the complex mechanisms linking maternal and child ADHD, and eventually lead to more targeted, efficient, and feasible prevention and intervention strategies.

The Role of Parental ADHD in Sustaining the Effects of a Family-School Intervention for ADHD

This study investigated the extent to which parental Attention-Deficit/Hyperactivity Disorder (ADHD) symptoms impact child and parent outcomes following a multimodal family-school intervention, the Family School Success (FSS) program, when compared to an active-control condition (CARE). Participants were 139 children with ADHD (67% male; 91% non-Hispanic; 77% Caucasian; Grades 2-6) and their primary caretaker (91% female; ages 26-59) who participated in a randomized clinical trial evaluating the efficacy of FSS. Associations were examined between parent-reported ADHD symptoms at baseline and intervention outcomes reported by parents and teachers after treatment and at a 3-month follow-up, including child homework and classroom impairments, child ADHD and oppositional defiant disorder symptoms, parenting behaviors, and parent-teacher relationship quality. Across both treatment conditions, parental ADHD was not associated with parent or child outcomes at postassessment. However, differences emerged between the two treatment groups at follow-up for parents with ADHD, particularly when an empirically supported symptom cutoff was used to identify parents at risk for having ADHD. In FSS, but not in CARE, parental ADHD was associated with declines in treatment gains in the quality of the parent-teacher relationship and the child's homework performance. Parents at risk for ADHD had difficulty maintaining treatment effects for themselves and their child in the FSS intervention but not in CARE. The supportive and educational components central to the CARE intervention may be helpful in promoting the sustainability of psychosocial interventions for children with ADHD who have parents with elevated ADHD symptoms.

Delivering evidence-based treatments for child attention-deficit/hyperactivity disorder (ADHD) in the context of parental ADHD

Behavioral parent training (BPT) and stimulant medications are efficacious treatments for child attention-deficit/hyperactivity disorder (ADHD); however, there is some evidence to suggest that parental ADHD may reduce the efficacy of both treatment modalities. This review paper summarizes the literature related to the evidence-based behavioral and pharmacological treatment of child ADHD in the context of parental ADHD. We also review the literature on the effects of treating parents' ADHD symptoms on parenting and child behavior outcomes. Although the literature is small and inconsistent, studies suggest that medicating parents' ADHD symptoms may or may not be sufficient in demonstrating desired improvements in parenting and child behavioral outcomes. Therefore, interventions targeting both parent and child ADHD, when both are present, are likely needed to improve parent-child interactions and family functioning. Ongoing studies using a multimodal approach are discussed.

Parenting teens with attention-deficit/hyperactivity disorder: challenges and opportunities

Attention-deficit/hyperactivity disorder (ADHD) presents in childhood with inattention, hyperactivity, and impulsivity and is associated with functional impairments. These children tend to display a variety of disruptive behaviors, which may worsen in adolescence. Teens with ADHD may show high levels of defiance, posing significant challenges for parents. Early efforts to understand parenting in the context of teen ADHD reveal high levels of parental stress and reactivity in response to the teen's ADHD symptoms. Subsequent research recognized that some of these parents have ADHD or other psychopathology that may contribute to maladaptive parenting. However, some parents adjust and demonstrate optimism and resilience in the face of their teens' ADHD. Recent research has identified parental factors (eg, emotional intelligence) and interventions (eg, mindfulness training) that may improve parenting/teen relationships and the developmental outcomes of teens. This article explores parenting teens with ADHD with a focus on these novel interventions.

Paternal ADHD symptoms and child conduct problems: is father involvement always beneficial?

BACKGROUND

Maternal psychopathology robustly predicts poor developmental and treatment outcomes for children with attention-deficit/hyperactivity disorder (ADHD). Despite the high heritability of ADHD, few studies have examined associations between paternal ADHD symptoms and child adjustment, and none have also considered degree of paternal involvement in childrearing. Identification of modifiable risk factors for child conduct problems is particularly important in this population given the serious adverse outcomes resulting from this comorbidity.

METHODS

This cross-sectional study examined the extent to which paternal involvement in childrearing moderated the association between paternal ADHD symptoms and child conduct problems among 37 children with ADHD and their biological fathers.

RESULTS

Neither paternal ADHD symptoms nor involvement was independently associated with child conduct problems. However, the interaction between paternal ADHD symptoms and involvement was significant, such that paternal ADHD symptoms were positively associated with child conduct problems only when fathers were highly involved in childrearing.

CONCLUSIONS

The presence of adult ADHD symptoms may determine whether father involvement in childrearing has a positive or detrimental influence on comorbid child conduct problems.

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.

Are parental autism spectrum disorder and/or attention-deficit/Hyperactivity disorder symptoms related to parenting styles in families with ASD (+ADHD) affected children?

An understudied and sensitive topic nowadays is that even subthreshold symptoms of autism spectrum disorder (ASD) and attention-deficit/Hyperactivity disorder (ADHD) in parents may relate to their parenting styles. The aim of this study was to explore the influence of (the combined) effect of child diagnosis (ASD or ASD + ADHD affected/unaffected children) and parental ASD and/or ADHD on parenting styles. Ninety-six families were recruited with one child with a clinical ASD (+ADHD) diagnosis, and one unaffected sibling. Parental ASD and ADHD symptoms were assessed using self-report. The Parenting Styles Dimensions Questionnaire (PSDQ) self- and spouse-report were used to measure the authoritative, authoritarian, and permissive parenting styles. Fathers and mothers scored significantly higher than the norm data of the PSDQ on the permissive style regarding affected children, and lower on the authoritative and authoritarian parenting style for affected and unaffected children. Self- and spouse-report correlated modestly too strongly. Higher levels of paternal (not maternal) ADHD symptoms were suboptimally related to the three parenting styles. Further, two parent-child pathology interaction effects were found, indicating that fathers with high ADHD symptoms and mothers with high ASD symptoms reported to use a more permissive parenting style only towards their unaffected child. The results highlight the negative effects of paternal ADHD symptoms on parenting styles within families with ASD (+ADHD) affected offspring and the higher permissiveness towards unaffected offspring specifically when paternal ADHD and/or maternal ASD symptoms are high. Parenting training in these families may be beneficial for the well-being of all family members.