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Does the efficacy of parent–child training depend on maternal symptom improvement? Results from a randomized controlled trial on children and mothers both affected by attention-deficit/hyperactivity disorder (ADHD)

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Abstract

Multimodal treatment of children with ADHD often includes parent–child training (PCT). However, due to the high heritability, parents of children with ADHD are frequently also affected by the disorder, which is likely to constitute a significant barrier to successful treatment of the child. This secondary analysis of our randomized controlled multicentre AIMAC trial (ADHD in mothers and children) investigates whether children’s outcomes following parent–child training in combination with maternal ADHD treatment depend on maternal symptom improvement. In a first step focusing on treatment of maternal ADHD, 144 mothers of mother–child dyads were randomized to multimodal ADHD treatment (group psychotherapy plus methylphenidate) or clinical management (mainly supportive counselling). After 12 weeks (T2), a 12-week PCT program (T2–T3) for all mother–child dyads was added to treat children’s ADHD. Maternal symptomatology (CAARS-O:L; SCL-90-R) and children’s externalizing symptoms (ADHD-ODD Scale, SDQ) were repeatedly assessed (T1 = baseline, T2, T3). Effects of changes in maternal symptomatology (T1–T2) on the change in children’s symptom scores (T1–T3) were analysed using a general linear model, controlling for baseline scores, study centre, and maternal treatment group. 125 mother–child dyads were analysed. Mothers showed significant improvements in ADHD symptoms and overall psychopathology [CAARS-O:L ADHD index: mean − 3.54, SE 0.74 p < 0.0001; SCL-90-R Global Severity (GS): mean − 11.03, SE 3.90, p = 0.0056]. Although children’s externalizing symptoms improved significantly (ADHD-ODD Scale: mean − 4.46, SE 0.58, p < 0.0001), maternal improvement had no effect on children’s outcomes after Bonferroni–Holm correction for multiple testing. The findings do not support our hypothesis that children’s outcomes following PCT for ADHD depend on maternal symptom improvements.

Trial register CCT-ISRCTN73911400.

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Acknowledgements

The study is part of a multicentre research network on the psychotherapy of ADHD which was funded by the German Federal Ministry of Education and Research (BMBF; 01GV0605, 01GV0606). We thank Dr. Fischer (MEDICE Arzneimittel Puetter GmbH & Co. KG) for his advice concerning the preparation of the study protocol and case report forms and his assistance with severe adverse event management. Prof. Dr. F. Mattejat gave helpful, expert advice during the study planning. We thank Prof. J. Carpenter (London School of Hygiene & Tropical Medicine) for his advice on the conception and implementation of the last mean carried forward (LMCF) analyses. We are grateful for the independent supervision of psychosocial interventions carried out by staff members at the Department of Child and Adolescent Psychiatry and Psychotherapy at the Cologne University Hospital (parent–child training) and at the Institute for Psychology of Freiburg University in cooperation with colleagues in private practice (treatment of mothers). We also express our thanks to HOGREFE and BELTZ publishers for providing the treatment manuals at no cost. We gratefully thank all of the participating families and all of our partners for their cooperation. In memoriam Klaus Hennighausen, Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty and Medical Center—University of Freiburg.

Funding

BMBF 01GV0605, 01GV0606.

Author information

Authors and Affiliations

  1. Department of Child and Adolescent Psychiatry and Psychotherapy, Medical Faculty Mannheim, Central Institute of Mental Health, J5, University of Heidelberg, 68159, Mannheim, Germany

    Alexander Häge, Tobias Banaschewski, Katja Becker, Sarah Hohmann & Luise Poustka

  2. Department of Psychiatry and Psychotherapy, Medical Faculty Mannheim, Central Institute of Mental Health, University of Heidelberg, Mannheim, Germany

    Barbara Alm & Esther Sobanski

  3. Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Philipps-University Marburg, Marburg, Germany

    Katja Becker

  4. Department of Psychiatry and Psychotherapy, Campus Benjamin Franklin, Charité, Universitätsmedizin Berlin, Berlin, Germany

    Michael Colla

  5. Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Frankfurt University Hospital, Frankfurt am Main, Germany

    Christine Freitag

  6. Department of Child and Adolescent Psychiatry and Psychotherapy, Saarland University Hospital, Homburg, Germany

    Christine Freitag, Alexander von Gontard & Susann Hänig

  7. Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of Würzburg, Würzburg, Germany

    Julia Geissler, Timo D. Vloet, Andreas Warnke & Thomas Jans

  8. Clinical Trials Unit, Institute for Medical Biometry and Statistics, and Medical Faculty, Medical Center, University of Freiburg, Freiburg, Germany

    Erika Graf

  9. Department of Child and Adolescent Psychiatry and Psychotherapy, Medical Center, University of Freiburg, Freiburg, Germany

    Barbara Haack-Dees, Klaus Hennighausen & Katja Schneider-Momm

  10. Department of Psychiatry, Psychosomatics and Psychotherapy, University Hospital of Wuerzburg, Würzburg, Germany

    Christian Jacob

  11. Department of Psychiatry and Psychotherapy, Medius Hospital of Kirchheim, Kirchheim unter Teck, Germany

    Christian Jacob

  12. Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Campus Virchow-Klinikum, Charité, Universitätsmedizin Berlin, Berlin, Germany

    Charlotte Jaite & Viola Kappel

  13. Department of Biostatistics, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany

    Christine Jennen-Steinmetz

  14. Department of Psychiatry and Psychotherapy, Medical Center, University of Freiburg, Freiburg, Germany

    Swantje Matthies & Alexandra Philipsen

  15. Psychiatry and Psychotherapy, University Hospital, Karl-Jaspers-Klinik, School of Medicine and Health Sciences, Medical Campus, University of Oldenburg, Oldenburg, Germany

    Alexandra Philipsen

  16. Department of Child and Adolescent Psychiatry, Medical University of Göttingen, Göttingen, Germany

    Luise Poustka

  17. Faculty of Medicine, Institute for Forensic Psychology and Psychiatry, Saarland University, Saarbrücken, Germany

    Wolfgang Retz & Michael Rösler

  18. Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany

    Wolfgang Retz

  19. Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, University Medical Center Mainz, Mainz, Germany

    Esther Sobanski

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  1. Alexander Häge
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  2. Barbara Alm
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  3. Tobias Banaschewski
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  4. Katja Becker
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  5. Michael Colla
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  6. Christine Freitag
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  7. Julia Geissler
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  8. Alexander von Gontard
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  9. Erika Graf
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  10. Barbara Haack-Dees
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  11. Susann Hänig
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  12. Klaus Hennighausen
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  13. Sarah Hohmann
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  14. Christian Jacob
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  15. Charlotte Jaite
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  16. Christine Jennen-Steinmetz
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  17. Viola Kappel
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  18. Swantje Matthies
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  19. Alexandra Philipsen
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  20. Luise Poustka
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  21. Wolfgang Retz
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  22. Michael Rösler
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  23. Katja Schneider-Momm
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  24. Esther Sobanski
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  25. Timo D. Vloet
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  26. Andreas Warnke
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  27. Thomas Jans
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Corresponding author

Correspondence to Alexander Häge.

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Conflict of interest

A. Häge received speakers’ fees, was on advisory boards, or has been involved in clinical trials by Shire, Janssen-Cilag, Otsuka, Lundbeck, and Servier. B. Alm was involved in Phase-III studies for Medice, Eli Lilly, and Novartis; was on Eli Lilly’s advisory board; and received speakers’ honoraria from Medice. T. Banaschewski served in an advisory or consultancy role for Actelion, Hexal Pharma, Lilly, Medice, Novartis, and Shire. He received conference support or speaker’s fee by Medice, Novartis, and Shire. He is/has been involved in clinical trials conducted by Shire & Viforpharma. He received royalities from Hogrefe, Kohlhammer, CIP Medien, Oxford University Press. The present work is unrelated to the above grants and relationships. K. Becker was on the Advisory Board of Eli Lilly/Germany, was member of the Scientific Committee of Shire, and received speakers’ honorary (independent lecture content) by Shire. No research/clinical trials sponsored by pharmaceutical industry within the last 5 years. M. Colla was on advisory boards, received speakers’ honoraria, and participated in Phase-III studies for Shire, Eli Lilly, and Novartis within the last 3 years. C. Freitag received speakers’ honoraria (independent lecture content) from Eli Lilly, Novartis, and Shire during the last 3 years and was an independent clinical consultant for Desitin in 2010. A. von Gontard was invited by Eli Lilly to the present two lectures. S. Hohmann received speakers’ honoraria from Jansen Cilag in 2012. C. Jacob received speakers’ honoraria from Novartis and Medice and is a member of the adult ADHD Advisory Board of the latter company. S. Matthies received speakers’ fees from Janssen-Cilag and was involved in clinical trials conducted by Janssen-Cilag and Lilly as a study physician in the years 2007–2009. A. Philipsen was on advisory boards, presented lectures, was involved in Phase-III studies, and received travel grants from Eli Lilly, Janssen-Cilag, Medice, Novartis, and Shire within the last 3 years; she is the author of books and articles on psychotherapy published by Elsevier, Hogrefe, Schattauer, Kohlhammer, and Karger; she is involved in clinical trials funded by the German Federal Ministry of Education and Research. L. Poustka received speakers’ honoraria from Eli Lilly and Shire during the last 3 years. W. Retz received speakers’ honoraria from and is on Medice, Novartis, and Shire advisory boards; he is involved in clinical trials for the German Ministry of Education and Research (BMBF), Novartis, Medice, and Vifor. M. Rösler is a member of the Medice, Janssen, and Shire speakers’ bureaus, is a member of Lilly, Shire, Medice, and Janssen advisory boards, and performed clinical trials for Medice and Lilly. E. Sobanski was on advisory boards, was involved in Phase-III studies or investigator-initiated trials, and presented lectures for Medice, Shire, Eli Lilly, and Novartis within the last 3 years. A. Warnke received speakers’ fees from Janssen-Cilag, Medice, Novartis, and Lilly and was involved in clinical trials conducted by Lilly, Novartis, Medice, and Shire; no fees or research funding have been awarded in the last 2 years. All other authors declared no conflicting interests (E. Graf, J. Geissler, B. Haack-Dees, S. Hänig, K. Hennighausen, C. Jaite, T. Jans, T. D. Vloet, C. Jennen-Steinmetz, V. Kappel, and K. Schneider-Momm).

Ethical standards statement

The study received appropriate ethics committee approval from the leading Ethics Committee (Faculty of Medicine, Würzburg University, 120/06) and the local ethics committees and was authorized by the competent German authorities. The study was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. All participants gave their informed consent and assent prior to their inclusion in the study. The study is registered in Current Controlled Trials (ISRCTN73911400).

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Häge, A., Alm, B., Banaschewski, T. et al. Does the efficacy of parent–child training depend on maternal symptom improvement? Results from a randomized controlled trial on children and mothers both affected by attention-deficit/hyperactivity disorder (ADHD). Eur Child Adolesc Psychiatry 27, 1011–1021 (2018). https://doi.org/10.1007/s00787-018-1109-0

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