Children With ADHD Treated With Long-Term Methylphenidate and Multimodal Psychosocial Treatment:...

S P E C I A L S E C T I O N

Children With ADHD Treated With Long-TermMethylphenidate and Multimodal PsychosocialTreatment: 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., ANDSIMCHA 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 dis-

order (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 prin-

ciples 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, stimu-

lant-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 chil-dren with ADHD are well documented. Relative toother children, children with ADHD are less compliant

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; Barkleyet al., 1984, 1985a, 1996; Befera and Barkley, 1985;Tallmadge and Barkley, 1983; Woodward et al., 1998).Mothers are also relatively less responsive to positivebehavior and less likely to reward appropriate behavior(Barkley et al., 1985b). Although interactions improveover time (Barkley et al., 1984, 1985b; Befera andBarkley, 1985), they remain problematic through ado-lescence (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 tolesser adaptive capacity (Shelton et al., 1998), whereasauthoritarian parenting predicts poor peer relation-

Accepted January 30, 2004.Drs. Hechtman and Greenfield are with the Department of Psychiatry, Mc-

Gill University and Montreal Children’s Hospital, Montreal, Quebec, Canada;Drs. Abikoff, Klein, and Fleiss are with the NYU Child Study Center, NewYork University School of Medicine, New York; Ms. Etcovitch is with MontrealChildren’s Hospital, Montreal, Quebec, Canada; Dr. Cousins is with McGillUniversity and the Summit School, Montreal, Quebec, Canada; Dr. Weiss iswith the University of British Columbia, British Columbia Children’s andWomen’s Hospital, Vancouver, British Columbia, Canada; and Dr. Pollack iswith the Department of Computer Information Systems and Decision Science,St. John’s University, Queens, NY. The study was supported NIMH grants RO1MH44848 (H.A.) and RO1 MH44842 (L.H.).

Correspondence to Dr. Hechtman, McGill University Health Center, De-partment of Child Psychiatry, 4018 St. Catherine Street West, Montreal, Que-bec, Canada H3Z 1P2; e-mail: [email protected]/04/4307–0830©2004 by the American Academy of Child

and Adolescent Psychiatry.DOI: 10.1097/01.chi.0000128785.52698.19

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:7, JULY 2004830

ships (Hinshaw et al., 1997), contributes to the devel-opment and maintenance of disruptive behaviors(August et al., 1999; Patterson et al., 1992), and mayincrease the risk of negative outcomes (Weiss andHechtman, 1993).Methylphenidate treatment of the child with

ADHD has been shown to improve negative maternalbehavior. However, the impact of child treatment onpositive maternal behaviors is less consistent (i.e., Bark-ley, 1989).Few studies have reported on the efficacy of parental

management therapies. Parents of children withADHD reported reduced stress, increased self-esteem,and reduced severity of their child’s symptoms afterbrief parent training, compared with waitlist controls,with gains sustained over 2 months (Anastopoulos etal., 1992). Problematically, independent evaluationswere not undertaken. In a small sample, Horn et al.(1987) found no difference between behavioral parenttraining and cognitive behavioral self-control, singly orcombined. In a related study, parent training with andwithout cognitive-behavioral self-management did notdiffer, but both were superior to a waitlist control (Fal-lone, 1999). Pisterman et al. (1989) reported signifi-cant improvement in observed child compliance andparent–child interaction in preschoolers with ADHDwhose parents received parent training compared withwaitlist controls. Treatment effects were maintainedbut did not extend beyond behaviors specifically tar-geted by treatment. Others have reported improvementin parent–teenager interactions after behavioral or ed-ucational treatment (Barkley et al., 1992, 2001; Mc-Cleary and Ridley, 1999). However, in the absence ofcontrols for nonspecific treatment effects, it is difficultto infer treatment efficacy from studies that rely onwaitlist controls. Moreover, waitlists may have negativeeffects, further complicating the interpretation of dif-ferences between treatment and waitlist comparisons.Parent training has been examined as an added com-

ponent to stimulant treatment. Pollard et al. (1983)reported that the combination of methylphenidate andparent training was more effective than either treat-ment alone. However, the study relied on a crossoverdesign, with only three children, thus limiting itsmeaningfulness. In a larger study, Firestone et al.(1981, 1986) failed to obtain benefit from adding par-ent training to stimulant treatment. Horn et al. (1987)contrasted stimulant treatment to parent training alone

and combined with high and low methylphenidatedoses. Parent training plus medication was not superiorto 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 con-junction with parent training or parent self-help. Notreatment differences were obtained, but compliancewas poor.Among kindergarten children with elevated activity,

impulsivity, and inattention, Barkley and colleagues(Barkley, 2000; Shelton et al., 2000) failed to findadvantages of 8 months of parent training comparedwith no intervention. As was the case in the trial bySchachar 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 methyl-phenidate (M). The study tests whether 2 years ofmethylphenidate combined with a comprehensive,long-term psychosocial treatment (M + MPT) conferssignificantly better function than methylphenidatealone.We report here on parental knowledge, attitudes,

and practices. Other outcomes (e.g., children’s social,academic, and emotional function) are presented incompanion papers (Abikoff et al., 2004a,b; Hechtmanet al., 2004).We hypothesized that the combination treatment

would be superior to methylphenidate alone with re-gard to reports of parental knowledge, attitudes, andparenting practices. Additionally, we predicted that thesuperiority of the combination over methylphenidatealone would result from the specific parenting compo-nent of the psychosocial treatment provided and notfrom its nonspecific features. Therefore, it was hypoth-esized that the combination of methylphenidate andpsychosocial treatment would be superior to methyl-phenidate plus attention control treatment.In addition, it was hypothesized that relative advan-

tages associated with 1 year of combined treatmentwould persist beyond the period of intensive interven-tion. Hence, we predicted superiority of methylpheni-date plus psychosocial treatment during a second yearof maintenance treatment. We hypothesized that treat-ment groups would demonstrate different patterns offunction over time. Specifically, significant incrementalimprovement during year II were predicted with com-

TREATMENT OF PARENTAL PRACTICES IN ADHD

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:7, JULY 2004 831

bined treatment relative to methylphenidate alone andmethylphenidate plus an attention control. In the lattertwo groups, a flattening or attenuation of treatmenteffects 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 cen-ters in New York and Montreal between 1990 and 1995. Medica-tion-free boys and girls, 7.0 to 9.9 years of age, met diagnostic andseverity criteria for ADHD. Because treatment included 2 years ofmethylphenidate, children had to exhibit meaningful benefit in a5-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 psycho-social treatment (M + ACT) (n = 35).

Multimodal Psychosocial Treatment.MPT integrated several com-ponents to target specific functional domains. Psychosocial treat-ments were fully manualized before study initiation (manualsavailable from the senior author). Each component was deliveredweekly during the first year (requiring twice-weekly visits) andmonthly during the second year (requiring twice-monthly visits). A75% attendance rate was required.Parents received group parental management training for 4

months, and individual parent training thereafter. Treatments spe-cific to each domain (social function, academic performance, emo-tional adjustment) are detailed in papers that report on theseoutcomes (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 under-standing of ADHD; establish attentive, positive interactions; anddeliver contingency management. Trained clinical psychologistsmet parents weekly for sixteen 1.5-hour sessions, with four to fiveparental dyads. Homework assignments and detailed summarysheets were used to promote technique acquisition and generaliza-tion. Parents were taught to keep behavioral and reinforcementcharts.

Understanding Parent–Child Relationships and Principles of Be-havioral Management. Parents were alerted to four factors in par-ent–child relationships: child and parent characteristics, situationalconsequences, and familial stressors.

Parental Positive Attending Skills. It was stressed that behavioralmanagement is not effective in the absence of a warm relationship.To augment positive parental attention, a 15- to 20-minute “specialtime” was implemented daily through an activity selected by thechild. The parent was instructed to remain as noncorrective andnondirective as possible.

Effective Commands. Parents were taught to extend positive at-tention for appropriate behavior, to follow through on commands,to provide simple direct statements with eye contact and no dis-tractions, and to have commands repeated.

Home Token System. Parents were trained to deliver tokens forhome behavior, for school behaviors recorded on daily report cards,and for social performance during sessions. Tokens were traded forprivileges. Parents were taught to institute “response cost” or pun-ishment for noncompliance or misbehavior after positive interac-

tions were established. Time out was used only for aggression andnoncompliance. Details were addressed, such as length of time out,appropriate locations, and conditions. Preventing problems andtime out in public settings were taught after parents mastered it athome.

Parent/Family Therapy. The 16-week group parent training wasfollowed by 8 months of 1-hour weekly sessions with parent dyadsand monthly sessions with the nuclear family. Monthly sessionscontinued during year II.

Therapy-Integrated Systems, Family Therapy, and Behavioral Man-agement. Individual sessions with parents reinforced parental imple-mentation of behavioral management. Treatment also addressedmarital discord and parental pathology as they affected parent–childrelationships. In addition, family sessions were intended to addressissues such as familial communication, parent–child alliances, andsibling rivalry. The transition to the second year was eased by twoparent groups that reviewed parenting techniques.

Attention Control Psychosocial Treatment. ACT controlled fornonspecific aspects of MPT, such as professional time and atten-tion, as well as child and parental involvement. Its componentsparalleled those of MPT, without specific remedial or therapeuticcontent. It included a parent support group for 16 weeks (equiva-lent to group behavioral management training) and individual par-ent support for 8 months (paralleling individual parent counseling).Issues discussed in groups included the nature of ADHD and prob-lems that typically arise at home. Educational material aboutADHD; general parenting principles; the need for consistency,structure, and clarity; and avoidance of parental disagreement werecommunicated. Unlike MPT, ACT did not include instructions forimplementing behavioral management, positive attending skills,and time out. Individual sessions consisted of general discussionsand provided support. Marital discord, parental pathology, andfamily dynamics were not discussed. Monthly sessions continued inthe second year. Treatment was delivered by bachelor’s-level ormaster’s-level psychologists other than those involved in MPT.

Measures

The assessment of parental behavior included mothers’ and fa-thers’ self-ratings and children’s ratings of their parents. Childrenwere evaluated twice before experimental treatment, once at pre-treatment when children were medication free and again at the endof a 5-week open methylphenidate trial, with a partial set of assess-ments that consisted of the Parent Practices Scale and Parent Per-ception Inventory. All measures were repeated after 6, 12, 18, and24 months to identify the timing of hypothesized treatment differ-ences.

Parent Self-Ratings

Knowledge of Behavioral Principles. This scale, which assessesknowledge of parenting behavioral principles, has high reliabilityand internal consistency and appears valid (O’Dell et al., 1979).The scale, reduced from 50 to 30 items for this study, was com-pleted by mothers.

Being a Parent Scale. Completed by fathers and mothers, the scalegenerates 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

HECHTMAN ET AL.

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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 andfather’s positive and negative parenting (Hazzard et al., 1983) onpositive and negative behaviors (5-point scale, “never” to “a lot”).High internal consistency and convergent and discriminant validityhave been reported.

Data Analysis

Analyses of variance tested for group differences at pretreatment.None were significant except for socioeconomic status. There wereno significant group × site or group × site × time interactions.Repeated measures over time for dependent variables were mod-

eled as a mixed model analysis of covariance implemented in ProcMixed (SAS v8.1, Cary, NC), controlling for socioeconomic status.Empirical data exploration indicated that an unstructured covari-ance model best fit the data. Model parameter estimates and theirstandard errors were generated via maximum likelihood functions.Differential treatment effects within the first year compared sta-

tus at pretreatment and at medication baseline to status at 6 and 12months. For hypothesized differential maintenance effects, ProcMixed analyses (covarying socioeconomic status) compared the 12,18, and 24 months data for differential patterns of change. Theabove tests yield main effects for group and time, and group × timeinteraction 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. Fulltables with F values are available from the authors.

RESULTS

Subject characteristics are detailed elsewhere (Kleinet 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 largemedical centers in New York and Montreal between1990 and 1995. Medication-free boys and girls metdiagnostic and severity criteria for ADHD. Becausetreatment included 2 years of methylphenidate, chil-dren had to exhibit meaningful benefit in a 5-weekopen trial of methylphenidate.

Year I Treatment Effects

Outcomes during year I were examined relative toscores at (1) pretreatment and (2) the end of the 5-weekmethylphenidate trial only on the Parent PracticesScale and Children’s Perception of Parental Practices.

Year I Treatment Effects From Pretreatment

Knowledge of Behavioral Principles. A significantgroup × time interaction was found for knowledge of

behavioral principles (p < .000). As shown in Table 1,parents in the M + MPT group reported significantlygreater improvement in knowledge of behavioral prin-ciples compared with other parents (M, p < .05; M +ACT, p < .000). The significant advantage of M +MPT indicates that parent training accomplished itseducational goal and documents the internal validity ofthe parent training procedures.

Parent Practices Scale. No significant treatment dif-ferences were obtained on mothers’ self-rated behavior(Table 1). A significant time effect on negative, but notpositive, behaviors indicates that mothers in all groupsrated themselves as engaging in less negative behavior(p < .000). This improvement was apparent after 6months of treatment.

Being a Parent Scale. Mothers’ and fathers’ parentalsatisfaction and efficacy yielded no significant advan-tage for M + MTP over the other two groups (M andM + ACT) ( Table 2). Mothers’ ratings of parentalsatisfaction and efficacy improved during year I acrossall treatments (p < .000) (Table 2). This improvementwas evident by 6 months. In contrast, fathers’ ratingsshowed no time effect.

Children’s Perception of Parental Practices. Children’sratings of their mothers’ and fathers’ positive behaviorshowed no differential treatment effects (Table 3).Across the three groups, children rated their mothersand fathers as significantly less negative (p < .000 and.01, respectively). This change was evident by 6months (Table 3).

Year I Treatment Effects From Medication Baseline

These analyses examine treatment outcomes relativeto ratings obtained at the end of the 5-week methyl-phenidate trial.

Parent Practices Scale. Ratings of parenting practicesshowed no significant group × time interactions, indi-cating a lack of differential treatment effect comparedwith status at the end of the methylphenidate trial(Table 1). In addition, no time effects occurred, indi-cating that the improvement, found at 6 months andthereafter, had occurred during the brief methylpheni-date trial.

Children’s Perception of Parental Practices. As shownin Table 3, children’s perceptions of parents’ practicesdid not reveal differential treatment effects or time ef-fects from medication baseline. As with parent ratings,



time effects at 6 and 12 months had mostly occurred bythe end of the brief methylphenidate trial.

Year II Treatment Effects

During year I, we failed to obtain evidence of supe-riority for M + MPT over M alone. This failure pre-cludes testing the hypothesis that advantages associatedwith 1 year of intensive M + MPT are maintained overa second year. Nonetheless, year II outcomes informthe hypothesis that M + MPT leads to incrementallysuperior function relative to the other treatments (Mand M + ACT).

Knowledge of Behavioral Principles. In year II, moth-ers of children in the M + MPT and M groups ratedthemselves as having significantly better knowledge ofbehavioral principles than mothers of children in the

M + ACT group (p < .000). The M + MPT and Mgroups did not differ significantly (Table 1).

Parent Practices Scale. Results of the group × timeinteraction did not support superior efficacy for M +MPT in parental positive and negative behaviors overyear II (Table 1).

Being a Parent Scale. During year II, no treatmentgroup differences were obtained in mothers’ or fathers’ratings of parenting satisfaction as indicated by a non-significant group × time interaction (Table 2). Moth-ers’ satisfaction improved significantly during year IIacross all groups (p < .01).

Children’s Perception of Parental Practices. Children’sratings are depicted Table 3. No treatment differenceswere found during year II for mothers’ and fathers’positive and negative practices.

TABLE 1Mothers’ Self-Ratings of Knowledge of Behavioral Principles and Parenting Skills

Measure

Treatment Group

M M + MPT M + ACT

Mean SD Mean SD Mean SD

Knowledge of behavioral principlesa,b,c

Pretreatment 14.1 5.2 11.9 5.2 12.1 4.46 mo 17.2 5.9 18.4 5.5 12.6 5.312 mo 16.4 6.5 19.1 5.4 13.3 5.618 mo 15.9 6.4 17.8 7.1 12.7 5.724 mo 17.1 5.7 17.1 7.3 12.0 4.7

Parent Practices ScalePositive behaviorPretreatment 3.2 0.6 3.2 0.5 3.3 0.6Medication baseline 3.2 0.6 3.2 0.4 3.4 0.56 mo 3.3 0.6 3.3 0.4 3.2 0.612 mo 3.2 0.6 3.3 0.5 3.2 0.618 mo 3.3 0.6 3.2 0.4 3.2 0.524 mo 3.2 0.6 3.2 0.5 3.3 0.7

Negative behaviorc

Pretreatment 1.6 0.5 1.7 0.4 1.6 0.4Medication baseline 1.4 0.5 1.5 0.4 1.2 0.46 mo 1.4 0.4 1.4 0.4 1.3 0.412 mo 1.4 0.6 1.4 0.4 1.2 0.418 mo 1.4 0.6 1.3 0.4 1.1 0.324 mo 1.4 0.4 1.3 0.4 1.1 0.3

Note: Full tables with F values are available from the authors. M = methylphenidate; MPT = multimodal psychosocialtreatment; 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.

HECHTMAN ET AL.


Influence of Oppositional Defiant Disorder onTreatment Outcome

The presence of oppositional defiant disorder had noinfluence on any treatment group contrasts (data areavailable from the first author).

DISCUSSION

The current study was implemented with the expec-tation that, among children with ADHD treated withstimulants, adding 1 year of multimodal psychosocialtreatment followed by a second year of maintenancetreatment would contribute to improved parental be-havior and parent–child relationships. The parenttraining components were specifically designed to rem-edy problematic family features common to children

with ADHD. Parents who received parent training de-veloped significantly superior knowledge, thus indicat-ing that principles of optimal parental managementwere acquired and that treatment was adequately de-livered. Unexpectedly, parents’ increased knowledge ofbehavioral principles did not contribute to changes inparenting. Thus, results fail to document that the ad-dition of an ambitious parenting program providesbenefit over optimal medication treatment to parentsof young children with ADHD, in spite of increasedawareness of parental principles.Negative, but not positive, parental behavior im-

proved significantly across all treatments, suggestingthat stimulant medication improves family relation-ships. Gains occur early during treatment and appearstable over 2 years. Whether rated by parents or chil-

TABLE 2Mothers’ and Fathers’ Parenting Satisfaction and Efficacy

Measure

Treatment Group

M M + MPT M + ACT


Being a Parent ScaleMothers’ satisfactiona,b

Pretreatment 35.3 7.0 35.3 6.7 37.8 7.46 mo 38.7 7.0 39.4 8.0 41.0 6.712 mo 37.8 8.0 38.9 7.7 38.5 7.418 mo 38.7 6.8 40.5 7.6 41.5 7.024 mo 39.3 6.5 40.7 6.5 41.4 7.5

Mothers’ efficacya

Preatment 58.0 10.4 60.1 9.3 62.5 11.16 mo 64.1 10.5 67.4 10.7 67.5 10.812 mo 64.4 11.6 66.2 11.3 66.0 10.818 mo 62.9 11.7 68.5 12.2 68.4 12.024 mo 63.7 7.8 69.7 8.9 69.5 12.4

Fathers’ satisfactionPretreatment 38.5 7.9 38.2 6.4 37.7 4.66 mo 38.4 6.6 39.5 7.7 38.3 7.012 mo 39.8 7.7 40.0 5.3 38.0 6.318 mo 39.9 9.3 38.6 7.1 41.3 6.024 mo 40.6 7.2 40.6 6.7 38.8 3.8

Fathers’ efficacyPretreatment 61.2 12.5 63.5 10.5 62.8 10.16 mo 63.4 11.6 60.5 13.9 62.3 10.612 mo 66.6 10.5 63.8 11.7 64.0 10.818 mo 64.2 14.5 62.6 11.1 65.9 13.624 mo 66.2 11.4 66.4 12.6 62.2 11.9

Note: Group × time interactions: none significant. Full tables with F values are available from the authors.a 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.



dren, there was no change in positive parenting, a find-ing consistent with some of the literature. It appearsthat negative and positive aspects of parental behaviorare not reciprocal and may be regulated through dif-ferent mechanisms.Because parents in the psychosocial and attention

control groups were actively involved in the therapeuticprocess, there was potential for bias in favor of psycho-social treatment. In light of this potential bias, theabsence of significant treatment differences in parentreports is all the more compelling and attests to the lackof adjunctive efficacy of parent training in childrenwith ADHD who are well treated with stimulants.

Our results parallel those of other controlled studiesof parent training combined with stimulant treatment.The significant decreases in negative parenting second-ary to methylphenidate likely represent clinically mean-ingful change because negative interactions have beenshown to be detrimental to children’s functioning andmay affect outcome deleteriously. Results are also con-sistent with well-documented indirect effects of short-term stimulant treatment on parent–child interactionsand extend these findings by indicating that emanativeeffects of medication on parental behavior continueover time and are not time limited. Unlike trials thatadminister stimulant treatment twice daily only on

TABLE 3Children’s Ratings of Mothers’ and Fathers’ Parenting Practices

Children’s Ratings

Treatment Group

M M + MPT M + ACT


Mothers’ positive practicesPretreatment 22.3 3.0 23.1 4.1 22.8 5.0Medication baseline 23.2 2.9 22.1 3.2 23.1 3.26 mo 22.7 3.0 23.5 2.8 23.2 2.812 mo 23.8 2.6 23.6 2.0 23.1 2.418 mo 23.9 2.9 22.6 3.0 23.8 2.724 mo 23.4 2.6 22.8 2.6 23.9 2.5

Mothers’s negative practicesa,c


Fathers’ positive practicesPretreatment 22.5 3.3 23.3 5.7 23.1 6.6Medication baseline 22.7 3.3 21.6 3.5 23.0 3.26 mo 22.6 3.1 23.2 3.6 23.3 3.012 mo 23.1 3.0 22.4 3.7 22.9 3.518 mo 23.1 3.5 22.9 3.3 23.8 2.624 mo 23.3 3.1 22.0 4.2 23.4 2.6

Fathers’ negative practicesb,d


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.

HECHTMAN ET AL.


school days, children in this study (and the MTA [mul-timodal treatment assessment] study) received methyl-phenidate t.i.d. 7 days per week. It is not clear thatsimilar positive effects can be expected from less ad-equate stimulant regimens. Indeed, the MTA medica-tion treatment “as usual” was inferior to systematicallytitrated t.i.d. medication (MTA Cooperative Group,1999). Optimally managed medication appears essen-tial for improvement, and we found no support forfurther benefit with the addition of psychosocial inter-vention.It is conceivable that families whose child did not

receive the combined treatment sought additionaltreatments elsewhere, and therefore no advantage couldbe obtained for combined treatments. To our knowl-edge, families did not seek outside treatment, but thepossibility remains.

Limitations

The study relied on parent and child reports of par-enting 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 etal., 2001). However, the acceptability, impracticality,and costs of in-home interventions with school-agechildren limit their general utility.Our negative results apply to children with ADHD

who respond to a short-term trial of stimulants. Parenttraining and counseling may have beneficial effects inchildren with ADHD who are not medicated or notresponsive to stimulant medication.The study was limited to 7- to 9-year-old children,

and results may not apply to younger or older childrenwith ADHD. Parent training and counseling have beenreported to be clinically effective in younger childrenwith ADHD (Pisterman et al., 1989; Sonuga-Barke etal., 2001). Further, educational and behavioral pro-grams have been reported to have some positive impacton interactions of parents and their adolescents withADHD (Barkley et al., 1992, 2001; McCleary andRidley, 1999).We excluded children who met criteria for conduct

disorder. However, children with two symptoms ofconduct disorder as well as comorbid oppositional de-fiant disorder were included. As noted, the presence ofoppositional defiant disorder did not result in differ-ential treatment outcomes. It is uncertain whether dif-

ferent results would have been obtained in childrenwith ADHD and full-fledged conduct disorder.Therapists who conducted the parenting interven-

tions for MPT group were different from therapists forthe ACT group. Thus, theoretically, if ACT therapistswere warmer and more positive, they could have in-duced greater improvements, thus precluding the pos-sible superiority of MPT. This possibility is highlyunlikely because children on medication alone whowere not exposed to any therapists were no differentfrom children in groups that received psychosocialtreatments. Findings indicate that professional atten-tion in psychosocial treatments did not contribute tochange in parents’ behavior as perceived by themselvesor their children.It is possible that improvement, as indexed by de-

creases in mothers’ negative parenting practices andincreases in mothers’ satisfaction, was a function oftime and not a medication effect. However, many ofthese improvements began after the brief medicationtrial.

Clinical Implications

In children with ADHD without conduct disorder,well-titrated stimulant treatment significantly improvesparenting practices without further benefits accruedfrom psychosocial interventions. Such interventions af-fect parents’ knowledge of behavioral principles but notpractices, as assessed through parent and child reports.Initial benefits of stimulant medication on parentingpractices and attitudes appear maintained with ex-tended treatment.

Disclosure: Dr. Hechtman is a member of the Advisory Board of ShirePharmaceutical 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 onthe speakers roster for Shire Pharmaceutical Co., Janssen Ortho, andEly Lilly.

REFERENCES

Abikoff H, Hechtman L, Klein RG et al. (2004a), Symptomatic improve-ment in children with ADHD treated with long-term methylphenidateand multimodal psychosocial treatment. J Am Acad Child Adolesc Psy-chiatry. 43:802–811

Abikoff H, Hechtman L, Klein RG et al. (2004b), Social functioning inchildren with ADHD treated with long-term methylphenidate and mul-timodal psychosocial treatment. J Am Acad Child Adolesc Psychiatry.43:820–829



Anastopoulos AD, Guevremont DC, Shelton TL, DuPaul GJ (1992), Par-enting stress among families of children with attention deficit hyperac-tivity disorder. J Abnorm Child Psychol 20:503–520

August GJ, Realmuto GM, Joyce T, Hektner JM (1999), Persistence anddesistance of oppositional defiant disorder in a community sample ofchildren with ADHD. J Am Acad Child Adolesc Psychiatry 38:1262–1270

Barkley RA (1987), A Clinician’s Guide to Parent Training. New York:Guilford

Barkley RA (1989), Hyperactive girls and boys: stimulant drug effects onmother-child interactions. J Child Psychol Psychiatry 30:379–390

Barkley RA (1990), Attention Deficit Hyperactivity Disorder: A Handbook forDiagnosis and Treatment. New York: Guilford

Barkley RA (1998), Attention-deficit hyperactivity disorder. Sci Am279:66–71

Barkley RA (2000), Commentary on the multimodal treatment study ofchildren with ADHD. J Abnorm Child Psychol 28:595–599

Barkley RA, Cunningham CE (1980), The parent-child interactions ofhyperactive children and their modification by stimulant drugs. In:Treatment of Hyperactive and Learning Disabled Children, Knights R,Bakker D, eds. Baltimore: University Park Press

Barkley RA, Edwards G, Laneri M, Letcher K, Metevia L (2001), Theefficacy of problem-solving communication training alone, behaviormanagement training alone, and their combination for parent-adolescent conflict in teenagers with ADHD and ODD. J Consult ClinPsychol 69:926–941

Barkley RA, Karlsson J, Pollard S (1985a), Effects of age on mother-childinteractions of hyperactive children. J Abnorm Child Psychol 13:450–462

Barkley RA, Karlsson J, Strzelecki E, Murphy JV (1984), Effects of age andRitalin dosage on the mother-child interactions of hyperactive children.J Consult Clin Psychol 52:750–758

Barkley RA, Guevremont DC, Anastopoulos AD, Fletcher KE (1992), Acomparison of three family therapy programs for treating family con-flicts in adolescents with attention-deficit hyperactivity disorder. J Con-sult Clin Psychol 60:450–462

Barkley RA, Karlsson J, Pollard S, Murphy JV (1985b), Developmentalchanges in the mother-child interactions of hyperactive boys: effects oftwo dose levels of Ritalin. J Child Psychol Psychiatry 26:705–715

Barkley RA, Shelton TL, Crosswait C et al. (1996), Preliminary findings ofan early intervention program with aggressive hyperactive children. AnnN Y Acad Sci 794:277–289

Befera MS, Barkley RA (1985), Hyperactive and normal girls and boys:mother-child interaction, parent psychiatric status and child psychopa-thology. J Child Psychol Psychiatry 26:439–452

Campbell SB, Ewing LJ (1990), Follow-up of hard-to-manage preschoolers:adjustment at age 9 and predictors of continuing symptoms. J ChildPsychol Psychiatry 31:871–889

Danforth JS, Barkley RA, Stokes TF (1991), Observations of parent-childinteractions with hyperactive children: research and clinical implica-tions. Clin Psychol Rev 11:703–727

Edwards G, Barkley RA, Laneri M, Fletcher K (2001), Parent-adolescentconflict in teenagers with ADD and ODD. J Abnorm Child Psychol29:557–572

Fallone GP (1999), Treatment for maternal distress as an adjunct to parenttraining for children with attention deficit hyperactivity disorder. Disser-tation Abstracts International, Section B: The Sciences and Engineering, 60

Firestone P, Crowe D, Goodman JT, McGrath P (1986), Vicissitudes offollow-up-studies: differential-effects of parent training and stimulantmedication with hyperactives. Am J Orthopsychiatry 56:184–194

Firestone P, Kelly MJ, Goodman JT, Davey J (1981), Differential effects ofparent training and stimulant medication with hyperactives: a progressreport. J Am Acad Child Psychiatry 20:135–147

Hazzard A, Christenser A, Margolin G (1983), Children’s perceptions ofparental behaviors. J Abnorm Child Psychol 11:49–60

Hechtman L, Abikoff H, Klein RG et al. (2004), Academic achievementand emotional status of children with ADHD treated with long-termmethylphenidate and multimodal psychosocial treatment. J Am AcadChild Adolesc Psychiatry 43:812–819

Hinshaw SP, Zupan BA, Simmel C, Nigg JT, Melnick S (1997), Peer statusin boys with and without attention-deficit hyperactivity disorder: pre-dictions from overt and covert antisocial behavior, social isolation, andauthoritative parenting beliefs. Child Dev 68:880–896

Horn WF, Ialongo N, Popovich S, Peradotto D (1987), Behavioral parenttraining and cognitive-behavioral self-control therapy with ADHDchildren: comparative and combined effects. J Clin Child Psychol16:57–68

Johnston C (1996), Parent characteristics and parent-child interactions infamilies of nonproblem children and ADHD children with higher andlower levels of oppositional-defiant behavior. J Abnorm Child Psychol24:85–104

Johnston C, Mash EJ (1989), A measure of parenting satisfaction andefficacy. J Clin Child Psychol 18:167–175

Klein RG, Abikoff H, Hechtman L, Weiss G (2004), Design and rationaleof controlled study of long-term methylphenidate and multimodal psy-chosocial treatment in children with ADHD. J Am Acad Child AdolescPsychiatry 43:792–801

McCleary L, Ridley T (1999), Parenting adolescents with ADHD: evalua-tion of a psychoeducation group. Patient Educ Counsel 38:3–10

MTA Cooperative Group (1999), A 14-month randomized clinical trial oftreatment strategies for attention deficit hyperactivity disorder(ADHD). Arch Gen Psychiatry 56:1073–1086

O’Dell SL, Tarler-Benlolol L, Flynn JM (1979), An instrument to measureknowledge of behavioral principles as applied to children. J Behav TherExp Psychiatry 10:29–34

Patterson GR, Reid JB, Dishion TJ (1992), Antisocial Boys. Eugene, OR:Castalia Press

Pisterman S, McGrath P, Firestone P, Goodman JT, Webster I, Mallory R(1989), Outcome of parent-mediated treatment of preschoolers withattention deficit disorder with hyperactivity. J Consult Clin Psychol57:628–635

Pollard S, Ward EM, Barkley RA (1983), The effects of parent training andRitalin on the parent-child interactions of hyperactive boys. Child FamBehav Ther 5:51–69

Schachar RJ, Tannock R, Cunningham C, Rkum PV (1997), Behavioral,situational and temporal effects of treatment of ADHD with methyl-phenidate. J Am Acad Child Adolesc Psychiatry 36:754–763

Shelton TL, Barkley RA, Crosswait C et al. (1998), Psychiatric and psy-chological morbidity as a function of adaptive disability in preschoolchildren with aggressive and hyperactive-impulsive-inattentive behavior.J Abnorm Child Psychol 26:475–494

Shelton TL, Barkley RA, Crosswait C et al. (2000), Multimethod psycho-educational intervention for preschool children with disruptive be-havior: two-year post-treatment follow-up. J Abnorm Child Psychol28:253–266

Sonuga-Barke EJS, Daley D, Thompson M, Laver-Bradbury C, Weeks A(2001), Parent-based therapies for preschool attention deficit/hyper-activity disorder: a randomized, controlled trial with a communitysample. J Am Acad Child Adolesc Psychiatry 40:402–408

Strayhorn JM, Weidman CS (1988), A parent practices scale and its relationto parent and child mental health. J Am Acad Child Adolesc Psychiatry27:613–618

Tallmadge J, Barkley RA (1983), The interactions of hyperactive and nor-mal boys with their fathers and mothers. J Abnorm Child Psychol11:565–579

Weiss G, Hechtman L (1993), Hyperactive Children Grown Up: ADHDChildren, Adolescents, and Adults. New York: Guilford Press

Woodward L, Taylor E, Dowdney L (1998), The parenting and familyfunctioning of children with hyperactivity. J Child Psychol Psychiatry39:161–169

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