Children With ADHD Treated With Long-Term Methylphenidate and Multimodal Psychosocial Treatment: Impact on Parental Practices

SPECIAL SECTION

Children With ADHD Treated With Long-Term Methylphenidate and Multimodal Psychosocial Treatment: Impact on Parental Practices LILY HECHTMAN, M.D., HOWARD ABIKOFF, PH.D., RACHEL G. KLEIN, PH.D., BRIAN GREENFIELD, M.D., JOY ETCOVITCH, M.A., LORNE COUSINS, PH.D., KAREN FLEISS, PSY.D., MARGARET WEISS, M.D., AND SIMCHA POLLACK, PH.D.

ABSTRACT Objective: To test the hypothesis that multimodal psychosocial intervention, which includes parent training, combined with methylphenidate significantly enhances the behavior of parents of children with attention-deficit/hyperactivity disorder (ADHD), compared with methylphenidate alone and compared with methylphenidate and nonspecific psychosocial treatment (attention control). Method: One hundred three children with ADHD (ages 7–9), free of conduct and learning disorders, who responded to short-term methylphenidate therapy were randomized for 2 years to receive either (1) methylphenidate treatment alone; (2) methylphenidate plus psychosocial treatment that included parent training and counseling, social skills training, academic assistance, and psychotherapy; or (3) methylphenidate plus attention control treatment. Parents rated their knowledge of parenting principles and negative and positive parenting behavior. Children rated their parents’ behavior. Results: Psychosocial treatment led to significantly better knowledge of parenting principles but did not enhance parenting practices, as rated by parents and children. Significant improvement in mothers’ negative parenting occurred across all treatments and was maintained. Conclusions: In nonconduct-disordered, stimulant-treated children with ADHD, parent training does not improve self-rated parental behavior. The benefits of brief stimulant treatment for negative parental behavior are sustained with extended treatment. J. Am. Acad. Child Adolesc. Psychiatry, 2004;43(7):830–838. Key Words: attention-deficit/hyperactivity disorder, long-term stimulant treatment, psychosocial treatment, parental practices.

Negative parent–child interactions in families of children with ADHD are well documented. Relative to other children, children with ADHD are less compliant

Accepted January 30, 2004. Drs. Hechtman and Greenfield are with the Department of Psychiatry, McGill University and Montreal Children’s Hospital, Montreal, Quebec, Canada; Drs. Abikoff, Klein, and Fleiss are with the NYU Child Study Center, New York University School of Medicine, New York; Ms. Etcovitch is with Montreal Children’s Hospital, Montreal, Quebec, Canada; Dr. Cousins is with McGill University and the Summit School, Montreal, Quebec, Canada; Dr. Weiss is with the University of British Columbia, British Columbia Children’s and Women’s Hospital, Vancouver, British Columbia, Canada; and Dr. Pollack is with the Department of Computer Information Systems and Decision Science, St. John’s University, Queens, NY. The study was supported NIMH grants RO1 MH44848 (H.A.) and RO1 MH44842 (L.H.). Correspondence to Dr. Hechtman, McGill University Health Center, Department of Child Psychiatry, 4018 St. Catherine Street West, Montreal, Quebec, Canada H3Z 1P2; e-mail: [email protected]. 0890-8567/04/4307–0830©2004 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/01.chi.0000128785.52698.19

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and more negative. Parents, in what has been termed a “negative-reactive” response pattern (Johnston, 1996), are relatively more controlling, coercive, disapproving, and punitive (Barkley and Cunningham, 1980; Barkley et al., 1984, 1985a, 1996; Befera and Barkley, 1985; Tallmadge and Barkley, 1983; Woodward et al., 1998). Mothers are also relatively less responsive to positive behavior and less likely to reward appropriate behavior (Barkley et al., 1985b). Although interactions improve over time (Barkley et al., 1984, 1985b; Befera and Barkley, 1985), they remain problematic through adolescence (Barkley et al., 1992; Danforth et al., 1991; Edwards et al., 2001). The quality of parent–child interactions has clinical implications for children with ADHD (Barkley, 1998; Campbell and Ewing, 1990; Woodward et al., 1998). Poor parental child management has been linked to lesser adaptive capacity (Shelton et al., 1998), whereas authoritarian parenting predicts poor peer relationJ. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:7, JULY 2004

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ships (Hinshaw et al., 1997), contributes to the development and maintenance of disruptive behaviors (August et al., 1999; Patterson et al., 1992), and may increase the risk of negative outcomes (Weiss and Hechtman, 1993). Methylphenidate treatment of the child with ADHD has been shown to improve negative maternal behavior. However, the impact of child treatment on positive maternal behaviors is less consistent (i.e., Barkley, 1989). Few studies have reported on the efficacy of parental management therapies. Parents of children with ADHD reported reduced stress, increased self-esteem, and reduced severity of their child’s symptoms after brief parent training, compared with waitlist controls, with gains sustained over 2 months (Anastopoulos et al., 1992). Problematically, independent evaluations were not undertaken. In a small sample, Horn et al. (1987) found no difference between behavioral parent training and cognitive behavioral self-control, singly or combined. In a related study, parent training with and without cognitive-behavioral self-management did not differ, but both were superior to a waitlist control (Fallone, 1999). Pisterman et al. (1989) reported significant improvement in observed child compliance and parent–child interaction in preschoolers with ADHD whose parents received parent training compared with waitlist controls. Treatment effects were maintained but did not extend beyond behaviors specifically targeted by treatment. Others have reported improvement in parent–teenager interactions after behavioral or educational treatment (Barkley et al., 1992, 2001; McCleary and Ridley, 1999). However, in the absence of controls for nonspecific treatment effects, it is difficult to infer treatment efficacy from studies that rely on waitlist controls. Moreover, waitlists may have negative effects, further complicating the interpretation of differences between treatment and waitlist comparisons. Parent training has been examined as an added component to stimulant treatment. Pollard et al. (1983) reported that the combination of methylphenidate and parent training was more effective than either treatment alone. However, the study relied on a crossover design, with only three children, thus limiting its meaningfulness. In a larger study, Firestone et al. (1981, 1986) failed to obtain benefit from adding parent training to stimulant treatment. Horn et al. (1987) contrasted stimulant treatment to parent training alone J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:7, JULY 2004

and combined with high and low methylphenidate doses. Parent training plus medication was not superior to high-dose medication alone. A study by Schachar et al. (1997) had the unusual positive feature of providing treatment for 1 year. Methylphenidate or placebo was administered in conjunction with parent training or parent self-help. No treatment differences were obtained, but compliance was poor. Among kindergarten children with elevated activity, impulsivity, and inattention, Barkley and colleagues (Barkley, 2000; Shelton et al., 2000) failed to find advantages of 8 months of parent training compared with no intervention. As was the case in the trial by Schachar et al. (1997), compliance was poor. The current study evaluates the adjunctive efficacy of extended multimodal psychosocial treatment (MPT) in children with ADHD treated with methylphenidate (M). The study tests whether 2 years of methylphenidate combined with a comprehensive, long-term psychosocial treatment (M + MPT) confers significantly better function than methylphenidate alone. We report here on parental knowledge, attitudes, and practices. Other outcomes (e.g., children’s social, academic, and emotional function) are presented in companion papers (Abikoff et al., 2004a,b; Hechtman et al., 2004). We hypothesized that the combination treatment would be superior to methylphenidate alone with regard to reports of parental knowledge, attitudes, and parenting practices. Additionally, we predicted that the superiority of the combination over methylphenidate alone would result from the specific parenting component of the psychosocial treatment provided and not from its nonspecific features. Therefore, it was hypothesized that the combination of methylphenidate and psychosocial treatment would be superior to methylphenidate plus attention control treatment. In addition, it was hypothesized that relative advantages associated with 1 year of combined treatment would persist beyond the period of intensive intervention. Hence, we predicted superiority of methylphenidate plus psychosocial treatment during a second year of maintenance treatment. We hypothesized that treatment groups would demonstrate different patterns of function over time. Specifically, significant incremental improvement during year II were predicted with com831

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bined treatment relative to methylphenidate alone and methylphenidate plus an attention control. In the latter two groups, a flattening or attenuation of treatment effects during year II was predicted. METHOD Details of the design and its rationale are presented in Klein et al. (2004). Briefly, the study was conducted at two large medical centers in New York and Montreal between 1990 and 1995. Medication-free boys and girls, 7.0 to 9.9 years of age, met diagnostic and severity criteria for ADHD. Because treatment included 2 years of methylphenidate, children had to exhibit meaningful benefit in a 5-week open trial of methylphenidate. Treatments Children were randomly assigned for 2 years to (1) M alone (n = 34), (2) M + MPT (n = 34), (3) M plus attention control psychosocial treatment (M + ACT) (n = 35). Multimodal Psychosocial Treatment. MPT integrated several components to target specific functional domains. Psychosocial treatments were fully manualized before study initiation (manuals available from the senior author). Each component was delivered weekly during the first year (requiring twice-weekly visits) and monthly during the second year (requiring twice-monthly visits). A 75% attendance rate was required. Parents received group parental management training for 4 months, and individual parent training thereafter. Treatments specific to each domain (social function, academic performance, emotional adjustment) are detailed in papers that report on these outcomes (Abikoff et al., 2004a,b; Hechtman et al., 2004). Parent Training. Parent training was based, in part, on Barkley’s (1987, 1990) program. It is designed to increase parental understanding of ADHD; establish attentive, positive interactions; and deliver contingency management. Trained clinical psychologists met parents weekly for sixteen 1.5-hour sessions, with four to five parental dyads. Homework assignments and detailed summary sheets were used to promote technique acquisition and generalization. Parents were taught to keep behavioral and reinforcement charts. Understanding Parent–Child Relationships and Principles of Behavioral Management. Parents were alerted to four factors in parent–child relationships: child and parent characteristics, situational consequences, and familial stressors. Parental Positive Attending Skills. It was stressed that behavioral management is not effective in the absence of a warm relationship. To augment positive parental attention, a 15- to 20-minute “special time” was implemented daily through an activity selected by the child. The parent was instructed to remain as noncorrective and nondirective as possible. Effective Commands. Parents were taught to extend positive attention for appropriate behavior, to follow through on commands, to provide simple direct statements with eye contact and no distractions, and to have commands repeated. Home Token System. Parents were trained to deliver tokens for home behavior, for school behaviors recorded on daily report cards, and for social performance during sessions. Tokens were traded for privileges. Parents were taught to institute “response cost” or punishment for noncompliance or misbehavior after positive interac-

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tions were established. Time out was used only for aggression and noncompliance. Details were addressed, such as length of time out, appropriate locations, and conditions. Preventing problems and time out in public settings were taught after parents mastered it at home. Parent/Family Therapy. The 16-week group parent training was followed by 8 months of 1-hour weekly sessions with parent dyads and monthly sessions with the nuclear family. Monthly sessions continued during year II. Therapy-Integrated Systems, Family Therapy, and Behavioral Management. Individual sessions with parents reinforced parental implementation of behavioral management. Treatment also addressed marital discord and parental pathology as they affected parent–child relationships. In addition, family sessions were intended to address issues such as familial communication, parent–child alliances, and sibling rivalry. The transition to the second year was eased by two parent groups that reviewed parenting techniques. Attention Control Psychosocial Treatment. ACT controlled for nonspecific aspects of MPT, such as professional time and attention, as well as child and parental involvement. Its components paralleled those of MPT, without specific remedial or therapeutic content. It included a parent support group for 16 weeks (equivalent to group behavioral management training) and individual parent support for 8 months (paralleling individual parent counseling). Issues discussed in groups included the nature of ADHD and problems that typically arise at home. Educational material about ADHD; general parenting principles; the need for consistency, structure, and clarity; and avoidance of parental disagreement were communicated. Unlike MPT, ACT did not include instructions for implementing behavioral management, positive attending skills, and time out. Individual sessions consisted of general discussions and provided support. Marital discord, parental pathology, and family dynamics were not discussed. Monthly sessions continued in the second year. Treatment was delivered by bachelor’s-level or master’s-level psychologists other than those involved in MPT. Measures The assessment of parental behavior included mothers’ and fathers’ self-ratings and children’s ratings of their parents. Children were evaluated twice before experimental treatment, once at pretreatment when children were medication free and again at the end of a 5-week open methylphenidate trial, with a partial set of assessments that consisted of the Parent Practices Scale and Parent Perception Inventory. All measures were repeated after 6, 12, 18, and 24 months to identify the timing of hypothesized treatment differences. Parent Self-Ratings Knowledge of Behavioral Principles. This scale, which assesses knowledge of parenting behavioral principles, has high reliability and internal consistency and appears valid (O’Dell et al., 1979). The scale, reduced from 50 to 30 items for this study, was completed by mothers. Being a Parent Scale. Completed by fathers and mothers, the scale generates two factors: parenting satisfaction, and parenting efficacy. Some norms and sensitivity to treatment effects have been reported (Johnston and Mash, 1989; Sonuga-Barke et al., 2001). Parenting Practices Scale. The scale yields mothers’ and fathers’ ratings of positive and negative parenting practices and parent– child interactions. It has high test–retest reliability and correlates

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:7, JULY 2004

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weakly, but significantly, with observed parent–child interactions (Strayhorn and Weidman, 1988). Child Ratings of Parental Behaviors Parent Perception Inventory. Children rate their mother’s and father’s positive and negative parenting (Hazzard et al., 1983) on positive and negative behaviors (5-point scale, “never” to “a lot”). High internal consistency and convergent and discriminant validity have been reported. Data Analysis Analyses of variance tested for group differences at pretreatment. None were significant except for socioeconomic status. There were no significant group × site or group × site × time interactions. Repeated measures over time for dependent variables were modeled as a mixed model analysis of covariance implemented in Proc Mixed (SAS v8.1, Cary, NC), controlling for socioeconomic status. Empirical data exploration indicated that an unstructured covariance model best fit the data. Model parameter estimates and their standard errors were generated via maximum likelihood functions. Differential treatment effects within the first year compared status at pretreatment and at medication baseline to status at 6 and 12 months. For hypothesized differential maintenance effects, Proc Mixed analyses (covarying socioeconomic status) compared the 12, 18, and 24 months data for differential patterns of change. The above tests yield main effects for group and time, and group × time interaction effects. The latter are the main interest of the study. To control for multiple tests, α was set at p < .01, two tailed; p values between .05 and .01 are reported as trends in the tables. Full tables with F values are available from the authors. RESULTS

Subject characteristics are detailed elsewhere (Klein et al., 2004). Briefly, 103 children were enrolled, 93% were boys ages 7.0 to 9.9 years (mean 8.2 ± 0.8), mostly white. The study was conducted at two large medical centers in New York and Montreal between 1990 and 1995. Medication-free boys and girls met diagnostic and severity criteria for ADHD. Because treatment included 2 years of methylphenidate, children had to exhibit meaningful benefit in a 5-week open trial of methylphenidate. Year I Treatment Effects

Outcomes during year I were examined relative to scores at (1) pretreatment and (2) the end of the 5-week methylphenidate trial only on the Parent Practices Scale and Children’s Perception of Parental Practices. Year I Treatment Effects From Pretreatment

Knowledge of Behavioral Principles. A significant group × time interaction was found for knowledge of J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:7, JULY 2004

behavioral principles (p < .000). As shown in Table 1, parents in the M + MPT group reported significantly greater improvement in knowledge of behavioral principles compared with other parents (M, p < .05; M + ACT, p < .000). The significant advantage of M + MPT indicates that parent training accomplished its educational goal and documents the internal validity of the parent training procedures. Parent Practices Scale. No significant treatment differences were obtained on mothers’ self-rated behavior (Table 1). A significant time effect on negative, but not positive, behaviors indicates that mothers in all groups rated themselves as engaging in less negative behavior (p < .000). This improvement was apparent after 6 months of treatment. Being a Parent Scale. Mothers’ and fathers’ parental satisfaction and efficacy yielded no significant advantage for M + MTP over the other two groups (M and M + ACT) ( Table 2). Mothers’ ratings of parental satisfaction and efficacy improved during year I across all treatments (p < .000) (Table 2). This improvement was evident by 6 months. In contrast, fathers’ ratings showed no time effect. Children’s Perception of Parental Practices. Children’s ratings of their mothers’ and fathers’ positive behavior showed no differential treatment effects (Table 3). Across the three groups, children rated their mothers and fathers as significantly less negative (p < .000 and .01, respectively). This change was evident by 6 months (Table 3). Year I Treatment Effects From Medication Baseline

These analyses examine treatment outcomes relative to ratings obtained at the end of the 5-week methylphenidate trial. Parent Practices Scale. Ratings of parenting practices showed no significant group × time interactions, indicating a lack of differential treatment effect compared with status at the end of the methylphenidate trial (Table 1). In addition, no time effects occurred, indicating that the improvement, found at 6 months and thereafter, had occurred during the brief methylphenidate trial. Children’s Perception of Parental Practices. As shown in Table 3, children’s perceptions of parents’ practices did not reveal differential treatment effects or time effects from medication baseline. As with parent ratings, 833

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TABLE 1 Mothers’ Self-Ratings of Knowledge of Behavioral Principles and Parenting Skills Treatment Group M Measure

M + MPT

M + ACT

Mean

SD

Mean

SD

Mean

SD

14.1 17.2 16.4 15.9 17.1

5.2 5.9 6.5 6.4 5.7

11.9 18.4 19.1 17.8 17.1

5.2 5.5 5.4 7.1 7.3

12.1 12.6 13.3 12.7 12.0

4.4 5.3 5.6 5.7 4.7

3.2 3.2 3.3 3.2 3.3 3.2

0.6 0.6 0.6 0.6 0.6 0.6

3.2 3.2 3.3 3.3 3.2 3.2

0.5 0.4 0.4 0.5 0.4 0.5

3.3 3.4 3.2 3.2 3.2 3.3

0.6 0.5 0.6 0.6 0.5 0.7

1.6 1.4 1.4 1.4 1.4 1.4

0.5 0.5 0.4 0.6 0.6 0.4

1.7 1.5 1.4 1.4 1.3 1.3

0.4 0.4 0.4 0.4 0.4 0.4

1.6 1.2 1.3 1.2 1.1 1.1

0.4 0.4 0.4 0.4 0.3 0.3

a,b,c

Knowledge of behavioral principles Pretreatment 6 mo 12 mo 18 mo 24 mo Parent Practices Scale Positive behavior Pretreatment Medication baseline 6 mo 12 mo 18 mo 24 mo Negative behaviorc Pretreatment Medication baseline 6 mo 12 mo 18 mo 24 mo

Note: Full tables with F values are available from the authors. M = methylphenidate; MPT = multimodal psychosocial treatment; ACT = attention control psychosocial treatment. a Group × time interaction at 6 months, p < .000; M + MPT > M + ACT, p < .000; M + MPT > M, p < .05; M > M + ACT, p < .05. b Group effect at 24 months; M and M + MPT > M + ACT, p < .000. c Time effect: Pretreatment versus 6 and 12 months, p < .000.

time effects at 6 and 12 months had mostly occurred by the end of the brief methylphenidate trial. Year II Treatment Effects

During year I, we failed to obtain evidence of superiority for M + MPT over M alone. This failure precludes testing the hypothesis that advantages associated with 1 year of intensive M + MPT are maintained over a second year. Nonetheless, year II outcomes inform the hypothesis that M + MPT leads to incrementally superior function relative to the other treatments (M and M + ACT). Knowledge of Behavioral Principles. In year II, mothers of children in the M + MPT and M groups rated themselves as having significantly better knowledge of behavioral principles than mothers of children in the 834

M + ACT group (p < .000). The M + MPT and M groups did not differ significantly (Table 1). Parent Practices Scale. Results of the group × time interaction did not support superior efficacy for M + MPT in parental positive and negative behaviors over year II (Table 1). Being a Parent Scale. During year II, no treatment group differences were obtained in mothers’ or fathers’ ratings of parenting satisfaction as indicated by a nonsignificant group × time interaction (Table 2). Mothers’ satisfaction improved significantly during year II across all groups (p < .01). Children’s Perception of Parental Practices. Children’s ratings are depicted Table 3. No treatment differences were found during year II for mothers’ and fathers’ positive and negative practices. J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:7, JULY 2004

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TABLE 2 Mothers’ and Fathers’ Parenting Satisfaction and Efficacy Treatment Group M Measure Being a Parent Scale Mothers’ satisfactiona,b Pretreatment 6 mo 12 mo 18 mo 24 mo Mothers’ efficacya Preatment 6 mo 12 mo 18 mo 24 mo Fathers’ satisfaction Pretreatment 6 mo 12 mo 18 mo 24 mo Fathers’ efficacy Pretreatment 6 mo 12 mo 18 mo 24 mo

M + MPT

M + ACT

Mean

SD

Mean

SD

Mean

SD

35.3 38.7 37.8 38.7 39.3

7.0 7.0 8.0 6.8 6.5

35.3 39.4 38.9 40.5 40.7

6.7 8.0 7.7 7.6 6.5

37.8 41.0 38.5 41.5 41.4

7.4 6.7 7.4 7.0 7.5

58.0 64.1 64.4 62.9 63.7

10.4 10.5 11.6 11.7 7.8

60.1 67.4 66.2 68.5 69.7

9.3 10.7 11.3 12.2 8.9

62.5 67.5 66.0 68.4 69.5

11.1 10.8 10.8 12.0 12.4

38.5 38.4 39.8 39.9 40.6

7.9 6.6 7.7 9.3 7.2

38.2 39.5 40.0 38.6 40.6

6.4 7.7 5.3 7.1 6.7

37.7 38.3 38.0 41.3 38.8

4.6 7.0 6.3 6.0 3.8

61.2 63.4 66.6 64.2 66.2

12.5 11.6 10.5 14.5 11.4

63.5 60.5 63.8 62.6 66.4

10.5 13.9 11.7 11.1 12.6

62.8 62.3 64.0 65.9 62.2

10.1 10.6 10.8 13.6 11.9

Note: Group × time interactions: none significant. Full tables with F values are available from the authors. Time effects: year I, pretreatment versus 6 and 12 months, p < .000. b Time effects: year II, 12 versus 18 and 24 months, p < .01. a

Influence of Oppositional Defiant Disorder on Treatment Outcome

The presence of oppositional defiant disorder had no influence on any treatment group contrasts (data are available from the first author). DISCUSSION

The current study was implemented with the expectation that, among children with ADHD treated with stimulants, adding 1 year of multimodal psychosocial treatment followed by a second year of maintenance treatment would contribute to improved parental behavior and parent–child relationships. The parent training components were specifically designed to remedy problematic family features common to children J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:7, JULY 2004

with ADHD. Parents who received parent training developed significantly superior knowledge, thus indicating that principles of optimal parental management were acquired and that treatment was adequately delivered. Unexpectedly, parents’ increased knowledge of behavioral principles did not contribute to changes in parenting. Thus, results fail to document that the addition of an ambitious parenting program provides benefit over optimal medication treatment to parents of young children with ADHD, in spite of increased awareness of parental principles. Negative, but not positive, parental behavior improved significantly across all treatments, suggesting that stimulant medication improves family relationships. Gains occur early during treatment and appear stable over 2 years. Whether rated by parents or chil835

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TABLE 3 Children’s Ratings of Mothers’ and Fathers’ Parenting Practices Treatment Group M Children’s Ratings Mothers’ positive practices Pretreatment Medication baseline 6 mo 12 mo 18 mo 24 mo Mothers’s negative practicesa,c Pretreatment Medication baseline 6 mo 12 mo 18 mo 24 mo Fathers’ positive practices Pretreatment Medication baseline 6 mo 12 mo 18 mo 24 mo Fathers’ negative practicesb,d Pretreatment Medication baseline 6 mo 12 mo 18 mo 24 mo

M + MPT

M + ACT

Mean

SD

Mean

SD

Mean

SD

22.3 23.2 22.7 23.8 23.9 23.4

3.0 2.9 3.0 2.6 2.9 2.6

23.1 22.1 23.5 23.6 22.6 22.8

4.1 3.2 2.8 2.0 3.0 2.6

22.8 23.1 23.2 23.1 23.8 23.9

5.0 3.2 2.8 2.4 2.7 2.5

17.2 15.4 14.9 14.6 16.1 14.8

3.7 2.9 3.1 2.8 2.4 2.5

17.7 15.6 16.1 15.2 15.1 15.8

5.0 3.4 3.5 3.4 3.3 3.8

15.9 15.5 14.5 15.2 14.3 14.4

3.9 3.6 2.7 2.9 2.5 2.8

22.5 22.7 22.6 23.1 23.1 23.3

3.3 3.3 3.1 3.0 3.5 3.1

23.3 21.6 23.2 22.4 22.9 22.0

5.7 3.5 3.6 3.7 3.3 4.2

23.1 23.0 23.3 22.9 23.8 23.4

6.6 3.2 3.0 3.5 2.6 2.6

15.5 15.1 15.0 13.9 14.9 13.9

3.7 3.5 3.5 3.1 3.0 2.5

17.1 15.5 15.2 15.5 14.4 14.2

4.5 4.3 3.6 4.1 2.9 3.3

15.3 14.5 13.6 14.6 13.7 14.6

4.1 3.4 2.9 3.7 3.9 3.0

Note: Full tables with F values are available from the authors. a Group × time interactions: year II, p < .02. b Group × time interactions: year II, p < .04. c Time effects: pretreatment versus 6 and 12 months, p < .000. d Time effects: pretreatment versus 6 and 12 months, p < .01.

dren, there was no change in positive parenting, a finding consistent with some of the literature. It appears that negative and positive aspects of parental behavior are not reciprocal and may be regulated through different mechanisms. Because parents in the psychosocial and attention control groups were actively involved in the therapeutic process, there was potential for bias in favor of psychosocial treatment. In light of this potential bias, the absence of significant treatment differences in parent reports is all the more compelling and attests to the lack of adjunctive efficacy of parent training in children with ADHD who are well treated with stimulants. 836

Our results parallel those of other controlled studies of parent training combined with stimulant treatment. The significant decreases in negative parenting secondary to methylphenidate likely represent clinically meaningful change because negative interactions have been shown to be detrimental to children’s functioning and may affect outcome deleteriously. Results are also consistent with well-documented indirect effects of shortterm stimulant treatment on parent–child interactions and extend these findings by indicating that emanative effects of medication on parental behavior continue over time and are not time limited. Unlike trials that administer stimulant treatment twice daily only on J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:7, JULY 2004

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school days, children in this study (and the MTA [multimodal treatment assessment] study) received methylphenidate t.i.d. 7 days per week. It is not clear that similar positive effects can be expected from less adequate stimulant regimens. Indeed, the MTA medication treatment “as usual” was inferior to systematically titrated t.i.d. medication (MTA Cooperative Group, 1999). Optimally managed medication appears essential for improvement, and we found no support for further benefit with the addition of psychosocial intervention. It is conceivable that families whose child did not receive the combined treatment sought additional treatments elsewhere, and therefore no advantage could be obtained for combined treatments. To our knowledge, families did not seek outside treatment, but the possibility remains. Limitations

The study relied on parent and child reports of parenting practices, not direct parent–child observations, which might have yielded treatment differences. Parenting interventions that include home-based components might be more effective (Sonuga-Barke et al., 2001). However, the acceptability, impracticality, and costs of in-home interventions with school-age children limit their general utility. Our negative results apply to children with ADHD who respond to a short-term trial of stimulants. Parent training and counseling may have beneficial effects in children with ADHD who are not medicated or not responsive to stimulant medication. The study was limited to 7- to 9-year-old children, and results may not apply to younger or older children with ADHD. Parent training and counseling have been reported to be clinically effective in younger children with ADHD (Pisterman et al., 1989; Sonuga-Barke et al., 2001). Further, educational and behavioral programs have been reported to have some positive impact on interactions of parents and their adolescents with ADHD (Barkley et al., 1992, 2001; McCleary and Ridley, 1999). We excluded children who met criteria for conduct disorder. However, children with two symptoms of conduct disorder as well as comorbid oppositional defiant disorder were included. As noted, the presence of oppositional defiant disorder did not result in differential treatment outcomes. It is uncertain whether difJ. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:7, JULY 2004

ferent results would have been obtained in children with ADHD and full-fledged conduct disorder. Therapists who conducted the parenting interventions for MPT group were different from therapists for the ACT group. Thus, theoretically, if ACT therapists were warmer and more positive, they could have induced greater improvements, thus precluding the possible superiority of MPT. This possibility is highly unlikely because children on medication alone who were not exposed to any therapists were no different from children in groups that received psychosocial treatments. Findings indicate that professional attention in psychosocial treatments did not contribute to change in parents’ behavior as perceived by themselves or their children. It is possible that improvement, as indexed by decreases in mothers’ negative parenting practices and increases in mothers’ satisfaction, was a function of time and not a medication effect. However, many of these improvements began after the brief medication trial. Clinical Implications

In children with ADHD without conduct disorder, well-titrated stimulant treatment significantly improves parenting practices without further benefits accrued from psychosocial interventions. Such interventions affect parents’ knowledge of behavioral principles but not practices, as assessed through parent and child reports. Initial benefits of stimulant medication on parenting practices and attitudes appear maintained with extended treatment. Disclosure: Dr. Hechtman is a member of the Advisory Board of Shire Pharmaceutical Co., Eli Lilly, Janssen Ortho, and Purdue Pharma. She received research funding from Ely Lilly, Janssen Ortho, Purdue, Shire Pharmaceutical Co., and GlaxoSmithKline Beecham and is on the speakers roster for Shire Pharmaceutical Co., Janssen Ortho, and Ely Lilly. REFERENCES Abikoff H, Hechtman L, Klein RG et al. (2004a), Symptomatic improvement in children with ADHD treated with long-term methylphenidate and multimodal psychosocial treatment. J Am Acad Child Adolesc Psychiatry. 43:802–811 Abikoff H, Hechtman L, Klein RG et al. (2004b), Social functioning in children with ADHD treated with long-term methylphenidate and multimodal psychosocial treatment. J Am Acad Child Adolesc Psychiatry. 43:820–829

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