Components of Behavioral Parent Training for Children With Attention-Deficit/Hyperactivity Disorder: A Series of Replicated Single-Case Experiments.

Behavioral parent training (BPT) is an evidence-based treatment for children with attention-deficit/hyperactivity disorder (ADHD). Stimulus control techniques (antecedent-based techniques, e.g., clear rules, instructions) and contingency management techniques (consequent-based techniques, e.g., praise, ignore) are the most common ones that are being taught to parents in BPT. However, research into the additive effects of these techniques is scarce. In this replicated single-case experimental ABC phase design, including six children on stable medication for ADHD (8-11 years) and their parents, the added efficacy of consequent-based techniques on top of antecedent-based techniques was evaluated. After a baseline period (phase A), we randomized the commencement time of two sessions parent training in antecedent-based techniques and two sessions parent training in consequent-based techniques for each child. Children's behaviors were assessed by daily parent ratings of selected problem behaviors and an overall behavior rating. Although visual inspection showed that behavior improved for most children in both phases, randomization tests did not demonstrate the added efficacy of the consequent-based techniques on top of the antecedent-based techniques. Limitations of the study and recommendations for future single-case experiments in this population are discussed.

Review: Which components of behavioral parent and teacher training work for children with ADHD? - a metaregression analysis on child behavioral outcomes.

BACKGROUND: This metaregression analysis examined which behavioral techniques that are commonly used in behavioral parent and teacher training programs for children with attention-deficit/hyperactivity disorder (ADHD) were related to program effectiveness on children's behavioral outcomes. METHODS: We included 32 randomized controlled trials (N = 2594 children) investigating behavioral parent training, teacher training, or a combination, in children with ADHD under 18 years. Outcomes were symptom counts of total ADHD, inattention, and hyperactivity-impulsivity and behavioral problems. The dosage of techniques was extracted from the intervention manuals. Metaregression was used to assess which techniques and intervention characteristics (setting, delivery method, duration, and home-school collaboration) were associated with intervention effectiveness. RESULTS: Higher dosage of psycho-education for parents was associated with smaller effects on behavioral problems and, only in case of parent training, also with smaller effects on ADHD symptoms. Higher dosage of teaching parents/teachers to use negative consequences was associated with larger effects on behavioral problems. Individual training compared with group training was associated with larger effects on ADHD and hyperactivity-impulsivity symptoms. CONCLUSIONS: This study provides first insights into the specific techniques that are essential in behavioral parent and teacher training programs for children with ADHD. This knowledge can eventually be used to improve and tailor interventions.

The efficacy of a self-help parenting program for parents of children with externalizing behavior: a randomized controlled trial.

Parenting programs are effective for children with externalizing problems, but not always easily accessible for parents. In order to facilitate accessibility, we developed a self-help parenting program, consisting of a manual and online part. The efficacy of the program in reducing children's externalizing problems was compared to waitlist in a randomized controlled trial. In addition, two versions of the program were exploratively compared, one with and one without biweekly telephonic support. Candidate moderators (child and parent factors) and parental satisfaction were also examined. We randomly assigned 110 families to one of the following three conditions: the support condition, the no support condition, or the waitlist condition. Intervention duration was 15 weeks. Outcomes were collected at baseline (T0), 8 weeks (T1), 15 weeks (T2), and 28 weeks (T3) and included daily telephonic measurements of parent-rated externalizing behavior and the Intensity scale of the parent-rated Eyberg Child Behavior Inventory (ECBI). Main analyses compared outcomes at T2, using longitudinal regressions with T0 as fixed factor. Results showed that children improved significantly more on both outcomes in the intervention condition compared to waitlist, with small to medium effect sizes. Parental satisfaction was high. Neither differences in efficacy nor in parental satisfaction were found between the support and no support condition. No moderators were detected. The newly developed self-help parenting program is effective in reducing children's externalizing behavior problems and may help improve access to evidence-based care.

Which Techniques Work in Behavioral Parent Training for Children with ADHD? A Randomized Controlled Microtrial.

OBJECTIVE: Behavioral parent training (BPT) is an evidence-based intervention for children with attention-deficit/hyperactivity disorder (ADHD), but little is known about the effects of separate techniques parents learn in BPT. METHOD: In a three-armed randomized controlled microtrial including parents of 92 children (4-12 years) with ADHD, we examined the efficacy of two sessions parent training involving either stimulus control techniques (antecedent-based condition (AC)) or contingency management techniques (consequent-based condition (CC)), compared to a waitlist. Primary outcome was daily parent-rated problem behaviors, secondary outcomes were parent-rated symptoms of ADHD and oppositional defiant disorder (ODD), and mental health-care consumption. Measures were completed at baseline (T0), immediately after the training (T1), at two weeks (T2) and three months (T3) follow-up. We also explored whether child and parent characteristics moderated treatment effects. RESULTS: Compared to the waitlist, in the AC, daily rated problem behaviors improved at T1 (d= .56) and T2 (d= .65); in the CC, these behaviors only improved at T2 (d= .53). Daily rated problem behaviors within both conditions remained stable between T2 and T3. In the AC compared to the other conditions, inattention symptoms decreased at T1 and T2. For both active conditions compared to waitlist, hyperactivity-impulsivity symptoms decreased only at T2 and ODD symptoms did not decrease. No moderators were identified. Mental health-care consumption after training was low and did not differ between the active conditions. CONCLUSIONS: Brief training of parents in antecedent- or consequent-based techniques improves problem behaviors of children with ADHD. Antecedent-based techniques appear to be especially important to target inattention.

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.

Social skills group training in children with autism spectrum disorder: a randomized controlled trial.

In 122 high-functioning children with autism spectrum disorder (ASD; 9-13 years; 19 girls), we investigated the effectiveness of a 15-session social skills group training (SST) with and without parent and teacher involvement (PTI) in a randomized controlled trial with three conditions: SST (n = 47), SST-PTI (n = 51), and care-as-usual (CAU, n = 24). Hierarchical linear modeling was used for immediate and 6-month follow-up analyses. Measures were administered before randomization (blind), post-treatment and at follow-up (not blind). Trial registration: Dutch Trial Register; http://www.trialregister.nl ; NTR2405. At post-treatment, children in both SSTs had improved significantly more than CAU on the primary outcome, Vineland Socialization (SST: Cohen's d = 0.39; 95% CI - 2.23 to 3.11 and SST-PTI: d = 0.43; 95% CI - 2.19 to 3.15) and on the secondary outcome parent-SSRS "Cooperation" (SST: d = 0.43; 95% CI - 0.23 to 1.15 and SST-PTI: d = 0.45; 95% CI - 0.21 to 1.17), with no difference between post-treatment and follow-up. Additionally, children in SST-PTI improved significantly more on the teacher-SSRS than in CAU ["Cooperation" d =0.42 (95% CI - 0.33 to 1.13); "Assertion" d =0.34 (95% CI - 0.39 to 1.11); "Self-Control" d =0.61 (95% CI - 0.08 to 1.34)] and in SST ["Cooperation" d =0.34 (95% CI - 0.37 to 1.05); "Self-Control" d =0.59 (95% CI - 0.13 to 1.32)]. The current study corroborates earlier findings in smaller samples and wider age ranges, with small but statistically significant effects of SST for high-functioning pre-adolescent children with ASD. Parental and teacher involvement intensified treatment, yet did not yield an additional effect relative to SST for children only, as reported by parents. 6 months after training, no further improvement or decline was found.

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.

Methylphenidate Has Superior Efficacy Over Parent-Child Interaction Therapy for Preschool Children with Disruptive Behaviors.

OBJECTIVE: To compare the effectiveness between parent-child interaction therapy (PCIT) and methylphenidate in preschool children with attention-deficit/hyperactivity disorder (ADHD) symptoms and disruptive behaviors who had remaining significant behavior problems after previous behavioral parent training. METHODS: We included 35 preschool children, ranging in age between 3.4 and 6.0 years. Participants were randomized to PCIT (n = 18) or methylphenidate (n = 17). Outcome measures were maternal ratings of the intensity and number of behavior problems and severity of ADHD symptoms. Changes from pretreatment to directly posttreatment were compared between groups using two-way mixed analysis of variance. We also made comparisons of both treatments to a nonrandomized care as usual (CAU) group (n = 17) regarding intensity and number of behavior problems. All children who started one of the treatments were included in the analyses. RESULTS: Mothers reported a significantly more decreased intensity of behavior problems after methylphenidate (pre-post effect size d = 1.50) compared with PCIT (d = 0.64). ADHD symptoms reduced significantly over time only after methylphenidate treatment (d = 0.48) and not after PCIT. Changes over time of children in the CAU treatment were nonsignificant. CONCLUSIONS: Although methylphenidate was more effective than PCIT, both interventions may be effective in the treatment of preschool children with disruptive behaviors. Our findings are preliminary as our sample size was small and the use of methylphenidate in preschool children lacks profound safety data as reflected by its off-label status. More empirical support is needed from studies with larger sample sizes.

Predictors of discrepancies between fathers and mothers in rating behaviors of preschool children with and without ADHD.

To examine child factors and parental characteristics as predictors of discrepancies between parents' ratings of externalizing and internalizing behavior problems in a sample of preschool children with ADHD and behavior problems and in a nonclinical sample. We investigated correspondence and discrepancies between parents' ratings on the externalizing and internalizing behavior problems broadband scales of the Child Behavior Checklist version for preschool children (CBCL/1.5-5). Parents of 152 preschool children, with ADHD and behavior problems (n = 72) and nonclinical children (n = 80), aged between 28 and 72 months (M = 47.26, SD = 12.7), completed the CBCL/1.5-5. Candidate predictors of discrepancy included the child's age and sex, and parents' levels of parenting stress, depressive mood, attention-deficit and disruptive behavior. Hierarchical multiple regression analyses were conducted. Correspondence between parents, both for ratings on internalizing and externalizing behavior problems, was high (r = .63-.77). In the clinical sample, mothers rated the severity of externalizing behavior problems significantly higher than did fathers (p = < .001). Discrepancy between fathers and mothers on externalizing behavior problems was not predicted by child factors or interparental differences in psychopathology, but it was predicted by interparental differences in parenting stress (R 2 = .25, p < .001). This effect was significantly larger in the nonclinical sample (ΔR 2 = .06, p < .001). When parents disagree on the severity level of preschool children's externalizing behavior problems, the clinician should take into consideration that differences in parenting stress might be involved.

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.

Dopamine transporter gene moderates response to behavioral parent training in children with ADHD: a pilot study.

There is great variability in the degree to which children with attention deficit/hyperactivity disorder (ADHD) improve through behavioral treatments. This study investigates the influence of the dopamine transporter gene (SCL6A3/DAT1) on outcome of behavioral parent training (BPT). Study subjects were a subsample (n = 50, for whom DAT1 genotypes were available) of a randomized controlled BPT effectiveness study (N = 94) comparing BPT plus ongoing routine clinical care (RCC) versus RCC alone in referred children (4-12 years old) with ADHD. Treatment outcome was based on parent-reported ADHD symptoms and behavioral problems. Presence of 2 versus no or 1 DAT1 10-repeat allele served as moderator variable. Time × Treatment × Genotype effect was analyzed with repeated-measures analysis of variance, controlling for baseline medication status. Results indicate that DAT1 moderated treatment response (p = .009). In children with no or 1 DAT1 10-repeat allele, superior treatment effects of BPT + RCC compared with RCC alone were present (p = .005), which was not the case in children with 2 DAT1 10-repeat alleles (p = .57). Our findings suggest that genetic differences in DAT1 in children with ADHD influence their susceptibility to a behavioral intervention directed at shaping their environment through their parents. The role of the dopamine system in motivation and learning and in the aberrant sensitivity to reinforcement in children with ADHD may explain this moderating effect, given that the management of contingencies is typically addressed in BPT.

Behavioral parent training as an adjunct to routine care in children with attention-deficit/hyperactivity disorder: moderators of treatment response.

OBJECTIVE: To investigate predictors and moderators of outcome of behavioral parent training (BPT) as adjunct to ongoing routine clinical care (RCC), versus RCC alone. METHODS: We randomly assigned 94 referred children (4-12 years) with attention-deficit/hyperactivity disorder (ADHD) to BPT plus RCC or RCC alone. Outcome was based on parent-reported behavioral problems and ADHD symptoms. Predictor/moderator variables included children's IQ, age, and comorbidity profile, and maternal ADHD, depression, and parenting self-efficacy. RESULTS: Superior BPT treatment effects on behavioral problems and ADHD symptoms were present in children with no or single-type comorbidity-anxiety/depression or oppositional defiant disorder (ODD)/conduct disorder (CD)-and when mothers had high parenting self-efficacy, but absent in children with broad comorbidity (anxiety/depression and ODD/CD) and when mothers had low parenting self-efficacy. In older children ADHD symptoms tended to decrease more through BPT than in younger children. CONCLUSIONS: Adjunctive BPT is most useful when mothers have high parenting self-efficacy and in children with no or single-type comorbidity.

Effectiveness of behavioral parent training for children with ADHD in routine clinical practice: a randomized controlled study.

OBJECTIVE: To investigate the effectiveness of behavioral parent training (BPT) as adjunct to routine clinical care (RCC). METHOD: After a first phase of RCC, 94 children with attention-deficit/hyperactivity disorder (ADHD) ages 4-12, all referred to a Dutch outpatient mental health clinic, were randomly assigned to 5 months of BPT plus concurrent RCC (n = 47) or to 5 months of RCC (n = 47) alone. BPT consisted of 12 sessions in group format; RCC included family support and pharmacotherapy when appropriate. Exclusionary criteria were minimized, and children with and without medication could participate. Parent-reported behavioral problems, ADHD symptoms, internalizing problems, and parenting stress were assessed before and after treatment. Follow-up assessment of the BPT + RCC group was completed 25 weeks post-BPT intervention. Repeated-measures analyses of variance were carried out on an intention-to-treat basis. RESULTS: Both groups showed improvements over time on all measures. BPT + RCC was superior to RCC alone in reducing behavioral (p = .017) and internalizing (p = .042) problems. No outcome differences were found in ADHD symptoms (p = .161) and parenting stress (p = .643). These results were equal for children with and without medication. Children allocated to RCC alone received more polypharmaceutical treatment. CONCLUSIONS: Adjunctive BPT enhances the effectiveness of routine treatment of children with ADHD, particularly in decreasing behavioral and internalizing problems, but not in reducing ADHD symptoms or parenting stress. Furthermore, adjunctive BPT may limit the prescription of polypharmaceutical treatment.