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)
- 416 Downloads
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.
KeywordsMaternal ADHD Parent–child training Treatment response
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.
BMBF 01GV0605, 01GV0606.
Compliance with ethical standards
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).
- 8.Chronis-Tuscano A, O’Brien KA, Johnston C, Jones HA, Clarke TL, Raggi VL, Rooney ME, Diaz Y, Pian J, Seymour KE (2011) The relation between maternal ADHD symptoms & improvement in child behavior following brief behavioral parent training is mediated by change in negative parenting. J Abnorm Child Psychol 39(7):1047–1057. https://doi.org/10.1007/s10802-011-9518-2 CrossRefPubMedPubMedCentralGoogle Scholar
- 10.Chronis-Tuscano A, Seymour KE, Stein MA, Jones HA, Jiles CD, Rooney ME, Conlon CJ, Efron LA, Wagner SA, Pian J, Robb AS (2008) Efficacy of osmotic-release oral system (OROS) methylphenidate for mothers with attention-deficit/hyperactivity disorder (ADHD): preliminary report of effects on ADHD symptoms and parenting. J Clin Psychiatry 69(12):1938–1947. https://doi.org/10.4088/JCP.v69n1213 CrossRefPubMedGoogle Scholar
- 11.Chronis-Tuscano A, Rooney M, Seymour KE, Lavin HJ, Pian J, Robb A, Efron L, Conlon C, Stein MA (2010) Effects of maternal stimulant medication on observed parenting in mother–child dyads with attention-deficit/hyperactivity disorder. J Clin Child Adolesc Psychol 39(4):581–587. https://doi.org/10.1080/15374416.2010.486326 CrossRefPubMedGoogle Scholar
- 12.Babinski DE, Waxmonsky JG, Pelham WE Jr (2014) Treating parents with attention-deficit/hyperactivity disorder: the effects of behavioral parent training and acute stimulant medication treatment on parent–child interactions. J Abnorm Child Psychol 42(7):1129–1140. https://doi.org/10.1007/s10802-014-9864-y CrossRefPubMedGoogle Scholar
- 13.Waxmonsky JG, Waschbusch DA, Babinski DE, Humphrey HH, Alfonso A, Crum KI, Bernstein M, Slavec J, Augustus JN, Pelham WE (2014) Does pharmacological treatment of ADHD in adults enhance parenting performance? Results of a double-blind randomized trial. CNS Drugs 28(7):665–677. https://doi.org/10.1007/s40263-014-0165-3 CrossRefPubMedGoogle Scholar
- 16.Thompson MJ, Laver-Bradbury C, Ayres M, Le Poidevin E, Mead S, Dodds C, Psychogiou L, Bitsakou P, Daley D, Weeks A, Brotman LM, Abikoff H, Thompson P, Sonuga-Barke EJ (2009) A small-scale randomized controlled trial of the revised new forest parenting programme for preschoolers with attention deficit hyperactivity disorder. Eur Child Adolesc Psychiatry 18(10):605–616. https://doi.org/10.1007/s00787-009-0020-0 CrossRefPubMedGoogle Scholar
- 18.Jans T, Jacob C, Warnke A, Zwanzger U, Gross-Lesch S, Matthies S, Borel P, Hennighausen K, Haack-Dees B, Rosler M, Retz W, von Gontard A, Hanig S, Sobanski E, Alm B, Poustka L, Hohmann S, Colla M, Gentschow L, Jaite C, Kappel V, Becker K, Holtmann M, Freitag C, Graf E, Ihorst G, Philipsen A (2015) Does intensive multimodal treatment for maternal ADHD improve the efficacy of parent training for children with ADHD? A randomized controlled multicenter trial. J Child Psychol Psychiatry 56(12):1298–1313. https://doi.org/10.1111/jcpp.12443 CrossRefPubMedGoogle Scholar
- 20.Hesslinger B, Philipsen A, Richter H (2004) Psychotherapie der ADHS im Erwachsenenalter: Ein Arbeitsbuch. Hogrefe, GoettingenGoogle Scholar
- 21.Döpfner M, Schürmann S, Frölich J, Gehrmann K (2013) Therapieprogramm für Kinder mit hyperkinetischem und oppositionellem Problemverhalten THOP: Mit Online-Materialien. Beltz, WeinheimGoogle Scholar
- 24.Klasen H, Woerner W, Wolke D, Meyer R, Overmeyer S, Kaschnitz W, Rothenberger A, Goodman R (2000) Comparing the German versions of the strengths and difficulties questionnaire (SDQ-Deu) and the child behavior checklist. Eur Child Adolesc Psychiatry 9(4):271–276. https://doi.org/10.1007/s007870070030 CrossRefPubMedGoogle Scholar
- 26.Conners CK, Erhardt D, Sparrow EP (1999) Conner’s adult ADHD rating scales: CAARS. In: Technical manual, MHSGoogle Scholar
- 27.Franke GH (2002) Symptom-Checkliste von Derogatis (SCL-90-R). Beltz, WeinheimGoogle Scholar
- 28.Jans T, Philipsen A, Graf E, Ihorst G, Gerlach M, Warnke A (2009) Does the treatment of maternal attention deficit and hyperactivity disorder (ADHD) enhance the efficacy of a behavioural parent training for the treatment of their children’s ADHD? Study protocol of a randomized controlled multicentre trail. Atten Defic Hyperact Disord 1(1):33–45. https://doi.org/10.1007/s12402-009-0004-4 CrossRefPubMedGoogle Scholar
- 29.Jans T, Graf E, Jacob C, Zwanzger U, Gross-Lesch S, Matthies S, Perlov E, Hennighausen K, Jung M, Rosler M, Schulte-Altedorneburg M, von Gontard A, Hanig S, Sobanski E, Alm B, Poustka L, Bliznak L, Colla M, Gentschow L, Burghardt R, Salbach-Andrae H, Becker K, Holtmann M, Freitag C, Warnke A, Philipsen A (2013) A randomized controlled multicentre trial on the treatment for ADHD in mothers and children: enrolment and basic characteristics of the study sample. Atten Defic Hyperact Disord 5(1):29–40. https://doi.org/10.1007/s12402-012-0092-4 CrossRefPubMedGoogle Scholar
- 30.Philipsen A, Graf E, Jans T, Matthies S, Borel P, Colla M, Gentschow L, Langner D, Jacob C, Gross-Lesch S, Sobanski E, Alm B, Schumacher-Stien M, Roesler M, Retz W, Retz-Junginger P, Kis B, Abdel-Hamid M, Heinrich V, Huss M, Kornmann C, Burger A, van Elst LT, Berger M (2014) A randomized controlled multicenter trial on the multimodal treatment of adult attention-deficit hyperactivity disorder: enrollment and characteristics of the study sample. Atten Defic Hyperact Disord 6(1):35–47. https://doi.org/10.1007/s12402-013-0120-z CrossRefPubMedGoogle Scholar
- 31.Sonuga-Barke EJ, Brandeis D, Cortese S, Daley D, Ferrin M, Holtmann M, Stevenson J, Danckaerts M, van der Oord S, Dopfner M, Dittmann RW, Simonoff E, Zuddas A, Banaschewski T, Buitelaar J, Coghill D, Hollis C, Konofal E, Lecendreux M, Wong IC, Sergeant J, European AGG (2013) Nonpharmacological interventions for ADHD: systematic review and meta-analyses of randomized controlled trials of dietary and psychological treatments. Am J Psychiatry 170(3):275–289. https://doi.org/10.1176/appi.ajp.2012.12070991 CrossRefPubMedGoogle Scholar