Parenting Interventions for ADHD

Abstract

Objective: To evaluate the evidence base relating to the effectiveness of parent-administered behavioral interventions for ADHD. Method: A systematic review of randomized controlled trials or non-randomized but adequately controlled trials for children with ADHD or high levels of ADHD symptoms was carried out across multiple databases. For meta-analyses, the most proximal ratings of child symptoms were used as the primary outcome measure. Results: Eleven studies met inclusion criteria (603 children, age range = 33-144 months). Parenting interventions were associated with reduction in ADHD symptoms (Standardized Mean Difference [SMD] = 0.68; 95% confidence interval [CI] [0.32, 1.04]). There was no evidence of attenuation of effectiveness after excluding studies where medication was also used. Parenting interventions were also effective for comorbid conduct problems (SMD = 0.59; 95% CI [0.29, 0.90]) and parenting self-esteem (SMD = 0.93; 95% CI [0.48, 1.39]). Conclusion: These findings support clinical practice guidelines and suggest that parenting interventions are effective. There is a need to ensure the availability of parenting interventions in community settings.

Keywords

ADHD parenting interventions behavioral interventions

Introduction

ADHD is a neuro-developmental disorder often diagnosed clinically in early childhood and is characterized by developmentally inappropriate levels of inattention, impulsivity, and/or hyperactivity. These characteristics can lead to impairment in academic and social functioning (Chronis, Jones, & Raggi, 2006). ADHD is a common disorder, affecting at least 5% of school-aged children (Polanczyk, de Lima, Horta, Biederman, & Rohde, 2007). Co-morbidity with other childhood behavioral and developmental disorders, such as oppositional defiant disorder, conduct disorder, and learning disorders, is frequent. ADHD is also a risk factor for the development of disruptive behavior and other mental health disorders, accidents, obesity, academic difficulties, and poor outcomes in adulthood (Shaw et al., 2012). Given these factors, there is an important role for early recognition and intervention.

In relation to the treatment of children with ADHD, recent clinical practice guidelines from the American Academy of Pediatrics (AAP; 2011) recommend the role of behavioral interventions, particularly for pre-school-aged children. These recommendations are based on existing evidence including reviews of the literature focusing on pre-schoolers (Charach et al., 2013) and other literature reviews (Pelham & Fabiano, 2008; Pelham, Wheeler, & Chronis, 1998) that consider the effectiveness of psychosocial interventions for ADHD in children. Clinical practice guidelines from other countries such as those from the National Institute for Health and Clinical Excellence (NICE; 2008) in England have gone even further, recommending behavioral interventions first where the severity of ADHD is mild or moderate. As previous reviews (Pelham et al., 1998; Pelham & Fabiano, 2008; Sonuga-Barke et al., 2013) assessing the role of behavioral interventions for ADHD have tended to include different types of psychological treatments (e.g., parent-administered, teacher-administered, and combined parent- and teacher-administered behavioral interventions, as well as direct work with affected children and adolescents), there is a need for a focused systematic review of the evidence base for parent-administered behavioral interventions. This specific focus on studies that evaluate parent-administered interventions is important as these interventions might be relatively more feasible to offer and implement in routine clinical practice. We undertook a systematic review and meta-analysis of relevant peer-reviewed, published literature to collate available empirical evidence on the effectiveness of parent-administered behavioral interventions for reducing symptoms.

Method

For the purpose of this review, parent-administered behavioral interventions were defined as those interventions directed toward the parents of children with ADHD or with high levels of ADHD symptoms involving inattention, hyperactivity, and impulsivity. Research evaluating interventions aiming to provide parents with strategies to manage their child’s behavior with the goal of reducing undesirable behaviors, such as inattention, hyperactivity, and impulsivity, was considered suitable for inclusion in this review.

Search Terms and Inclusion Criteria

Initial search keywords were developed to identify the literature relating to behavioral interventions for ADHD—within which parenting interventions are included. This was done for a larger systematic review of non-pharmacological interventions for ADHD (Sonuga-Barke et al., 2013), and all papers identified were categorized in terms of their relevance to this specific review based on the inclusion criteria shown below. The search terms used are shown in Appendix A, and search databases can be found in Appendix B. Searches were carried out several times to ensure that up-to-date literature was captured, with a final search conducted on February 5, 2013. In addition to the database searches, hand searching of identified systematic reviews was also carried out.

The inclusion criteria for this review were as follows:

Papers had to have been peer-reviewed and written in English.

Participants either had an ADHD diagnosis or were above cutoff point on a validated ADHD measure or ADHD sub-scale on a broad-band rating scale, for example, the Strengths and Difficulties Questionnaire (Goodman, 1997).

Children were between 3 and 18 years of age.

Studies were randomized controlled trials (RCTs) or non-randomized but adequately controlled trials.

All trials were included irrespective of intervention quality/characteristics. Trials were only excluded if a specific co-morbidity was an inclusion criterion into the study (e.g., Fragile X).

Only studies where the unique effect of parent training on ADHD outcomes could be analyzed were included. We therefore excluded studies where there was no ADHD outcome or where the parenting intervention was combined with a teacher and/or child intervention so that the unique impact of parent training could not be established.

Trials were included irrespective of control arm type. The control arm quality order was designated as follows: (a) placebo, (b) active control, (c) Treatment as Usual (TAU), and (d) no treatment, wait-list Control (WLC). Where trials had two comparator arms (e.g., WLC and attention control as well as the active treatment), the arm representing the most rigorous control was selected (i.e., attention control over a WLC).

All studies meeting the above criteria were included regardless of the focus of the study (e.g., symptom reduction, parental function, etc.) and/or outcomes measured (as long as there was at least one ADHD specific outcome). The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow chart (Figure 1) demonstrates the number of papers identified in the initial search and the process of identifying the final papers included in this review. All papers were reviewed by two independent researchers at each stage, and any discrepancies were resolved through discussion within the review team.

Figure 1.

PRISMA flow chart.

Data Extraction

Design and sample information from included trials was entered into Review Manager software (RevMan 5.1; Nordic Cochrane Center, Copenhagen, Denmark) to create a systematic record of study features. Data were extracted for the following areas: study characteristics, participant characteristics, intervention and control characteristics, outcomes and main findings. Pre and post means and standard deviations were extracted for all papers, where possible, on the following outcome variables: ADHD characteristics (primary outcome), conduct problem symptoms, parental well-being, parental sense of competence (parenting self-esteem), parenting stress, and parenting behavior. Data were extracted by one researcher and independently checked by another. Variables examined for the meta-analysis were based on a pragmatic assessment of the outcomes included in each study. Although there is no recognized minimum number of studies necessary for a meta-analysis, the literature suggests that the median number of studies included in meta-analyses tends to be three (Davey, Turner, Clarke, & Higgins, 2011). Therefore, for the purposes of analysis, only variables where three or more studies presented relevant data were included in the analysis.

Statistical Analysis

Individual effect sizes (i.e., standardized mean difference [SMD]) for each study were based on the recommended formula: mean pre–post intervention group change minus the mean pre–post control group change divided by the pooled pre-test standard deviation with a bias adjustment. SMDs for trials in each domain were combined using the inverse-variance method where the reciprocal of their variance is used to weight the SMD from each trial before being combined to give an overall estimate. Given the heterogeneity of studies included in terms of their assessments of ADHD, their sample characteristics, and the implementation of treatments within domains, we decided a priori to use a random effects model (Field & Gillett, 2010).

Results

Eleven studies involving 603 children were included in the meta-analysis (Anastopoulos, Shelton, DuPaul, & Guevremont, 1993; Barkley, Shelton, Crosswait, Moorehouse, & Fletcher, 2000; Bor, Sanders, & Markie-Dadds, 2002; Herbert, Harvey, Roberts, Wichowski, & Lugo-Candelas, 2013; Hoath & Sanders, 2002; Jones, Daley, Hutchings, Bywater, & Eames, 2007; Pisterman et al., 1992; Sonuga-Barke, Daley, Thompson, Laver-Bradbury, & Weeks, 2001; Sonuga-Barke, Thompson, Daley, & Laver-Bradbury, 2004; Thompson et al., 2009; Van Den Hoofdakker et al., 2007). Table 1 provides details of study characteristics and Table 2 a breakdown of outcome measures used in each study relating to variables included in the meta-analysis.

Table 1.

Characteristics of Studies Included in the Meta-Analysis.

Study	Diagnosis	Design	Duration of treatment	Concurrent stimulant medication %	Participant selection by treatment response?	Treatment	Control condition	N^aTC	Age range in months	Gender % male
Anastopoulos, Shelton, DuPaul, and Guevremont (1993)	DSM-III-R	2 group controlled but not randomized trial comparing parent training only against a waiting list control	9 weekly sessions	21% (n = 7), no breakdown for intervention and control	No selection	Behavioral parent training	Waiting list	19 15	75-123 M = 97.7	74
Barkley, Shelton, Crosswait, Moorehouse, and Fletcher (2000)	DSM–III-R or CPRS	4 group comparing Parent Training (PT) only against Special Treatment Classroom (STC) only against PT and STC against no treatment control	10 weekly parent training sessions plus monthly booster sessions	No	No selection	Behavioral parent training	No Treatment Control	39 42	54-72	64
Bor, Sanders, and Markie-Dadds (2002)	DSM-IV	3 group RCT comparing standard and enhanced behavioral intervention against waiting list control	15 wk Standard 17 wk enhanced	No	No selection	Enhanced behavioral Family Intervention (Triple P) plus additional partner support and coping skills training	Waiting list	15 27	Enhanced 40.41 (mean)^b WLC 42.81 (M)^b	68^b
Herbert, Harvey, Roberts, Wichowski, and Lugo-Candelas (2013)	DISC and BASC 2-PRS	2 group RCT comparing behavioral intervention against waiting list control	14 sessions	24% (n = 4) in intervention; 7% (n = 1) in control	No selection	Behavioral parent training (The Parenting your Hyperactive Preschooler)	Waiting list	17 14	34-76 (M = 54.92)	74^c
Hoath and Sanders (2002)	Yes but type not specified	2 group RCT comparing behavioral intervention against waiting list control	9 sessions (5 weekly group sessions followed by 4 weekly telephone consultations)	80% in intervention and 64% in control	No selection	Enhanced Behavioral Family Intervention (Triple P) plus additional partner support and coping skills training	Waiting list	9 11	60–108 Intervention 95.78 (M) Control 89.55 (M)	80
Jones, Daley, Hutchings, Bywater, and Eames (2007)	SDQ	2 group RCT comparing behavioral intervention against waiting list control	12 week	No	No selection	Behavioral Parent training (Incredible Years basic 12) based on principles of social learning theory	Waiting list	50 29	Behavioral 46.5 Control 45.9	68
Pisterman et al. (1992)	Parent or Teacher SNAP	2 group RCT comparing behavioral intervention against waiting list control	12 sessions usually weekly	9% intervention and 5% control ^d	No selection	Attention training behavioral intervention aimed at shaping on-task behavior, enhancing compliance and implementing time-out procedures for non-compliance	Waiting list	23 22	Behavioral M = 46.78 Control M = 52.41	91
Sonuga-Barke, Daley, Thompson, Laver-Bradbury, and Weeks (2001)	PACS	3 group RCT comparing Behavioral parent training against parent counseling against waiting list control	8 week	no	No selection	Behavioral parent training (New Forest Parenting Program) which included introducing parents to a range of strategies specifically designed to target the underlying etiology of ADHD	Parent Counseling. Eight 1 hr sessions that did not contain any training in behavioral strategies but that discussed and explored issues of concern to the parent.	30 28	33 - 39	62^c
Sonuga-Barke, Thompson, Daley, and Laver-Bradbury (2004)	PACS	2 group RCT comparing behavioral parent training against waiting list control	8 week	no	No selection	Behavioral parent training (New Forest Parenting Program) that included introducing parents to a range of strategies specifically designed to target the underlying etiology of ADHD	Waiting list	59 30^e	33-39	Not reported
Thompson et al. (2009)	PACS	2 group RCT comparing behavioral parent training against treatment as usual	8 week	no	No selection	Behavioral parent training (New Forest Parenting Program) that included introducing parents to a range of strategies specifically designed to target the underlying etiology of ADHD	Treatment as usual. Participants received no treatment from study, but received contact information for other health professionals and agencies.^f	17 13	30-77	76
Van Den Hoofdakker et al. (2007)	DSM-IV DISC	2 group RCT comparing behavioral parent training and TAU against treatment as usual alone	12 sessions over 5 months	50% no breakdown for intervention and control	No selection	Twelve 120-min sessions of behavioral parent training that drew on the techniques of Barkley (1987), (1990) and Forehand and McMahon (1981)	Treatment as usual. Clinicians were instructed to provide care as usual including medication, psycho-education, counseling, and crisis management whenever necessary.	47 47	48–144 M = 89	81

Note. DSM-III-R = Diagnostic and Statistical Manual of Mental Disorders (3rd ed., revised; American Psychiatric Association, 1987); DSM-IV = Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 2000); CPRS = Conners’ Parent Rating Scale; RCT = Randomized Controlled Trial; WLC = waitlist control; DISC = Diagnostic Interview Schedule for Children; BASC 2-PRS = Behavior Assessment System for Children 2–Parent Report Scale; SDQ = Strength and Difficulties Questionnaire; SNAP = Swanson Nolan and Pelham Questionnaire; PACS = Parent Account of Childhood Symptoms interview; TAU = treatment as usual.

N is the number of individuals in the Treatment (T) and Control (C) condition.

Values only reported for entire sample, before considerable attrition, and intention to treat analysis was not used.

In full sample.

Medication status was considered during randomization procedure.

20 out of the 30 control in this study were shared with the control group from Jones et al. (2007).

None of the TAU group received any intervention or parent training during the course of the study, so the group functioned as a no treatment group.

Table 2.

Study Outcome Measures.

Study	ADHD	Conduct problems	Parental self-esteem	Parental well-being	Parental stress	Parenting
Anastopoulos, Shelton, DuPaul, and Guevremont (1993)	ADHDRS	Not applicable (NA)	PSOC	NA	PSI	NA
Barkley et al. (2000)	CPRS	NA	NA	NA	NA	NA
Bor, Sanders, and Markie-Dadds (2002)	ECBI inattention	ECBI ODD and ECBI CD	PSOC	NA	NA	PS
Herbert et al. (2013)	DBRS	DBRS-ODD	NA	NA	NA	PS and Home Obs
Hoath and Sanders (2002)	CAP	ECBI	NA	DASS	DASS	PS
Jones, Daley, Hutchings, Bywater, and Eames (2007)	CPRS	NA	NA	NA	NA	NA
Pisterman et al. (1992)	Home Obs Attention	Home Obs Non-compliance	NA	NA	NA	Home Obs Compliance and reinforcement
Sonuga-Barke, Daley, Thompson, Laver-Bradbury, and Weeks (2001)	PACS ADHD	PACS Conduct	PSOC	GHQ 30	NA	NA
Sonuga-Barke, Thompson, Daley, and Laver-Bradbury (2004)	PACS ADHD	NA	PSOC	GHQ30	NA	NA
Thompson et al. (2009)	PACS ADHD	PACS conduct	PSOC	GHQ12	NA	GIPCI
Van Den Hoofdakker et al. (2007)	CPRS	NA	NA	NA	PSI	NA

Note. ADHDRS = Attention Deficit Hyperactivity Disorder Rating Scale (DuPaul, 1991); PSOC = Parenting Sense of Competence (Johnston & Mash 1989); PSI = Parenting Stress Index (Abidin, 1986); CPRS = Conners’ Parent Rating Scale (Conners, 2001); ECBI = Eyberg Child Behavior Inventory (Eyberg & Pincus, 1999); ODD = Oppositional Defiant Disorder; CD = Conduct Disorder; PS = Parenting Scale (Arnold, O’Leary, Wolff, & Acker, 1993); DBRS = Disruptive Behavior Rating Scale (Barkley & Murphy, 1998); Home obs = Home observation; CAP = Childhood Attention Scale (Edelbrook 1987, cited in Barkley, 1990); DASS = Depression, Anxiety & Stress Scale (Lovibond & Lovibond, 1995); PACS = Parental Account of Childhood Symptoms interview (Taylor, Sandberg, Thorley, & Giles, 1991); GHQ = General Health Questionnaire (Goldberg, 1982); GIPCI = Global Impressions of Parent Child Interaction (Brotman, Calzada, & Dawson-McClure, 2005).

ADHD Symptoms

All 11 studies (Anastopoulos et al., 1993; Barkley et al., 2000; Bor et al., 2002; Herbert et al., 2013; Hoath & Sanders, 2002; Jones et al., 2007; Pisterman et al., 1992; Sonuga-Barke et al., 2001; Sonuga-Barke et al., 2004; Thompson et al., 2009; Van Den Hoofdakker et al., 2007) had a child ADHD symptom outcome (assessed using clinical interview or validated parental reported questionnaire). The overall SMD in the analysis for ADHD symptoms was significant and moderate (SMD = 0.68; 95% confidence interval [CI] = [0.32, 1.04]). Heterogeneity was also significant (χ² = 46.79, I² = 79%, p < .001; see Figure 2). We carried out three sensitivity analyses that confirmed that the findings were robust. The first sensitivity analysis removed both studies (Anastopoulos et al., 1993; Barkley et al., 2000) that were not RCTs—there was only slight attenuation of the strength of association (SMD = 0.61; 95% CI = [0.26, 0.95]). Heterogeneity for this sensitivity analysis remained significant (χ² = 28.33, I² = 72%, p < .001). A sensitivity analysis that removed the five studies (Anastopoulos et al., 1993; Herbert et al., 2013; Hoath & Sanders, 2002; Pisterman et al., 1992; Van Den Hoofdakker et al., 2007) that had allowed medication demonstrated not only that these findings were independent of medication status but also that the strength of the association increased (SMD = 0.77, 95% CI = [0.35, 1.19]). Heterogeneity for this sensitivity analysis remained significant (χ² = 17.54; I² = 71%, p = .004). The third sensitivity analysis removed the three studies (Anastopoulos et al., 1993; Hoath & Sanders, 2002; Van Den Hoofdakker et al., 2007) with children with a mean age of above 60 months and revealed that results were maintained for younger children (SMD = 0.65, 95% CI = [0.26, 1.04]). Heterogeneity for this sensitivity analysis remained significant (χ² = 27.35, I² = 74%, p < .001).

Figure 2.

Effect of parent-administered behavior training on ADHD symptoms.

Conduct Problems

Five studies (Bor et al., 2002; Herbert et al., 2013; Hoath & Sanders, 2002; Sonuga-Barke et al., 2001; Thompson et al., 2009) had a child conduct problem outcome (assessed using clinical interview or validated parental reported questionnaire). The overall SMD in the analysis for conduct problems was moderate (SMD = 0.59, 95% CI = [0.29, 0.90]). Heterogeneity was not significant (see Figure 3).

Figure 3.

Effect of parent-administered behavior training on conduct problems.

Parenting Self-Esteem

Five studies (Anastopoulos et al., 1993; Bor et al., 2002; Hoath & Sanders, 2002; Sonuga-Barke et al., 2001; Sonuga-Barke et al., 2004) included a measure of parenting self-esteem, all assessed using a parental self-report questionnaire (Johnston & Mash, 1989). The overall SMD in the analysis for parenting self-esteem was significant and large (SMD = 0.93, 95% CI = [0.48, 1.39]). Heterogeneity was also significant (χ² = 10.11, I² = 60%, p < .05; see Figure 4).

Figure 4.

Effect of parent-administered behavior training on parental self-esteem.

Parenting Stress

Three studies (Anastopoulos et al., 1993; Hoath & Sanders, 2002; Van Den Hoofdakker et al., 2007) included a measure of parenting stress, all assessed using parental self-report questionnaires. The overall SMD in the analysis for parenting stress was moderate but not significant (SMD = 0.50, 95% CI = [−0.12, 1.12]) Heterogeneity was not significant (χ² = 5.29, I² = 62%, p = .07).

Parental Well-Being

Four studies (Hoath & Sanders, 2002; Sonuga-Barke et al., 2001; Sonuga-Barke et al., 2004; Thompson et al., 2009) included measures of parental well-being, all assessed using parental self-report questionnaires. The overall SMD in the analysis for parental well-being was not significant (SMD = 0.23, 95% CI = [−0.26, 0.73]) whereas heterogeneity was significant (χ² = 8.88, I² = 66%, p < .001).

Parental Behavior

Four studies (Bor et al., 2002; Hoath & Sanders, 2002; Pisterman et al., 1992; Thompson et al., 2009) included measures of negative parental behavior, assessed using structured observation or parent self-report questionnaire. The overall SMD in the analysis for parental negative behavior was not significant (SMD = 0.34, 95% CI = [−0.27, 0.95]) whereas heterogeneity was significant (χ² = 9.69, I² = 69%, p < 0.001).

Discussion

For children with or at risk of ADHD, this systematic literature review revealed improvements in two important symptom-related outcomes as a result of parent-administered behavioral interventions. Specifically, it demonstrated that parent-administered behavioral interventions led to a moderate reduction in both ADHD symptoms and conduct problems. By focusing this review on parent-administered behavioral interventions, the findings provide considerable evidence to support the role of parenting interventions for children with ADHD and support the American Academy of Pediatrics (AAP, 2011) clinical guidelines. The sensitivity analyses were particularly pertinent for these guidelines as the improvement in ADHD symptoms was maintained for pre-school populations, suggesting that parent-administered behavioral interventions are effective for this group. Medication did not appear to enhance the improvements found and, in fact, the strength of the association was further increased when studies including medication were removed. This finding supports the growing body of evidence supporting the use of parent–administered behavioral interventions as opposed to medication for children with ADHD under the age of 6, thus providing further evidence to support clinical guidelines (AAP, 2011; NICE, 2008). It is worth highlighting that although this review considers international evidence, 6 of the 11 included studies used interventions developed in the United States and Canada (Anastopoulos et al., 1993; Barkley et al., 2000; Herbert et al., 2013; Jones et al., 2007; Pisterman et al., 1992; Van Den Hoofdakker et al., 2007). Furthermore, the interventions used in the studies were reasonably short-term in duration, ranging from 8 to 17 weeks. This suggests that parent-administered behavioral interventions might be a cost-effective treatment option. As these interventions are potentially accessible, they should be considered a feasible treatment option for young children with or at risk of ADHD.

These interventions also improved parental self-esteem, suggesting that engagement in parent-administered interventions benefits not only the child but also the parent. However, we found no evidence for an improvement in parental well-being and a non-significant but moderate improvement for parental stress. There is evidence to suggest that parents of children with ADHD experience increased levels of stress and depression and reduced self-esteem (Johnston & Mash, 2001), and so, although it is encouraging that parent-administered interventions increase parental self-esteem, it is a concern that there were not similar improvements in parental well-being and parental stress. It is possible that the non-significant effect found for parental stress might be due to the lack of studies available to assess this outcome, and an increased number of studies might yield more favorable results. In contrast, parental well-being changes only showed a small effect. There is the possibility that parent-administered behavioral interventions might exacerbate symptoms of depression in parents, due to their requirement for parents to confront their difficulties with parenting. Greater consideration should therefore be given to the role of parental mood when using parent-administered behavioral interventions to treat ADHD. Practitioners considering the use of these interventions should prepare parents prior to their engagement in interventions by assessing mood and, if appropriate, consider parental referral for anti-depressant medication or cognitive-behavioral therapy (CBT). For example, CBT has been shown to be a useful tool for mothers of children with ADHD following a parent-administered intervention program in terms of improving mothers’ depressive symptoms, self-esteem, and stress (Chronis, Gamble, Roberts, & Pelham, 2006). This study also demonstrated improvements in maternal expectations and attributions relating to their child’s disruptive behavior and overall family impairment (Chronis, Gamble, et al., 2006). This suggests that for interventions where the parent is the agent of change, their well-being should be considered to optimize the outcome for the child, and this should form part of the treatment plan.

Strengths and Limitations

There are a number of factors that limit the breadth of this review. First, it was not possible to explore different mediators that might allow for an assessment of underlying mechanisms of change. Second, no data were available to elicit what impact ADHD symptoms had on other aspects of child functioning and how the interventions might affect this, for example, school readiness, academic attainment, and child social skills. Third, it was not possible to assess the possible role of moderators of outcome, particularly severity of the ADHD or parental mental health difficulties, including parental ADHD symptoms, which may also affect treatment effectiveness. Fourth, the mode of delivery (e.g., group vs. individual intervention) and implementation fidelity of each intervention might also lead to differing outcomes that were not assessed within this review. Finally, it is possible that the underlying philosophy of each program might lead to differences in effectiveness outcomes. The studies included in this review used a number of different interventions designed for different purposes. Two studies (Bor et al., 2002; Hoath & Sanders, 2002) used Triple P—an intervention designed and evaluated in Australia that assists parents of children with conduct disorder and associated difficulties. Four studies (Anastopoulos et al., 1993; Barkley et al., 2000; Herbert et al., 2013; Pisterman et al., 1992) used interventions developed and evaluated in North America, mostly designed to assist parents of children with disruptive behavior. Two studies (Jones et al., 2007; Van Den Hoofdakker et al., 2007) used interventions developed in North America that were used to treat disruptive behavior problems more generally but evaluated in the United Kingdom and the Netherlands. One ADHD-specific program was used in the other three studies (Sonuga-Barke et al., 2001; Sonuga-Barke et al., 2004; Thompson et al., 2009). The New Forest Parenting Program, designed and evaluated in the United Kingdom, has a focus on children with high levels of ADHD characteristics. Although these programs have demonstrated effectiveness overall, the success of individual treatment program types was beyond the scope of this review. However, it is possible that philosophical variance in the content and design of the intervention might lead to differences in their effectiveness.

This meta-analysis used ratings from participants who were most proximal to the intervention delivery (parent ratings). This might have resulted in rating bias, leading to inflated effect sizes for interventions due to the time investment parents make (Sonuga-Barke et al., 2013). Reported results may also reflect changes in parental perceptions or tolerance of symptoms rather than actual changes in ADHD behaviors. However, parent ratings reflect outcomes that clinicians would collect if evaluating interventions in real world non-research settings. Furthermore, findings showed that parental well-being, stress, and negative parental behavior did not improve. It is likely that if there was rating bias, similar improvements would have also been seen for these variables and, as such, this suggests that parent ratings are valid measures for evaluating outcomes following parent-administered behavioral interventions.

Clinical and Research Implications

Limited data were available on the long-term effectiveness of interventions. All but two studies (Barkley et al., 2000; Jones et al., 2007) collected long-term follow-up data for interventions at more than one post-intervention time point; however, only three studies (Pisterman et al., 1992; Sonuga-Barke et al., 2001; Thompson et al., 2009) provided follow-up data for pre-, post-, and follow-up time points for both intervention and control groups. Only two studies (Sonuga-Barke et al., 2001; Thompson et al., 2009) provided data in a format suitable for meta-analysis. Therefore, a meta-analysis of long-term outcomes could not be carried out in this review. Future studies should aim to incorporate follow-up assessments to assess long-term outcomes of the interventions, and these should be reported for both intervention and control groups. Making these data readily available would allow for more robust analyses of the longer term effectiveness of parent-administered behavioral interventions. This is important for future research because despite short-term benefits of behavioral interventions, the underlying ADHD may well persist and require further interventions.

Furthermore, none of the studies included cost-effectiveness analyses, and therefore, the potential economic benefits of parenting interventions can only be estimated through modeling assumptions. It is important that future RCTs of parenting interventions assess both the effectiveness and cost-effectiveness of interventions. Other studies exploring the effectiveness of parenting interventions for general disruptive behaviors have included these analyses and report that parenting interventions can be more cost-effective than other clinical interventions (Cunningham, Bremner, & Boyle, 1995). This should therefore be considered in future trials assessing the effectiveness of parent-administered interventions for ADHD.

Finally, it is understandable that clinicians might require more immediate options while considering the availability of and access to parenting interventions in their own clinical practice. Given this, clinicians could consider suggesting self-directed parenting interventions to parents of children with ADHD during the waiting period before behavioral interventions can be offered locally. Self-directed interventions, such as self-directed Triple P, have been evaluated for effectiveness in reducing conduct problems with some success (Sanders, Markie-Dadds, Tully, & Bor, 2000), although practitioner-led programs were shown to be more effective. Nevertheless, maintenance of outcomes has been found for this self-directed program (Sanders, Bor, & Morawska, 2007). Self-directed interventions are a potentially feasible, effective, and lower cost option for parents of children with or at risk of ADHD. There is a need for robust research to assess their cost-effectiveness and acceptability for parents of children with or at risk of ADHD.

Footnotes

Appendix A

Appendix B

Appendix C

Study	References	Reasons for exclusion
Al Ansari (2012)	Al Ansari A, Asiri MM. The impact of multimodal psychosocial intervention among children with ADHD. Bahrain Medical Bulletin, 2012;34(1):1-6.	No specific ADHD outcome
Antshel (2003)	Antshel KM, Remer R. Social skills training in children with ADHD: a randomized-controlled clinical trial. J Clin Child Adolesc Psychol. 2003;32:153-165.	No Parent Training
Barkley (1992)	Barkley RA, Guevremont DC, Anastopoulos AD, Fletcher KF. A comparison of three family therapy programs for treating family conflicts in adolescents with ADHD. J Consult Clin Psychol. 1992;60(3):450-462.	No control
Cunningham (1995)	Cunningham CE, Bremner R, Boyle R. Large group community based parenting programs for families of pre-schoolers at risk for disruptive behavior disorders: Utilization, cost effectiveness and outcomes. J Child Psychol Psychiatry. 1995;36(7):1141-1159.	Not a specific ADHD sample
Fabiano (2012)	Fabiano GA, Pelham WE, et al. A waitlist-controlled trial of behavioral parent training for fathers of children with ADHD. J Clin Child Adolesc Psychol. 2012;41:337-345.	No specific ADHD outcome
Fehlings et al (1991)	Fehlings DL, Roberts W, Humphries T, Dawe G: ADHD: Does cognitive behavioral therapy improve home behavior? J Dev Behav Pediatr. 1991;12:222-228.	Parent and Child intervention
Frankel (1997)	Frankel F, Myatt R, Cantwell DP, Feinberg DT. Parent-assisted transfer of children’s social skills training: effects on children with and without ADHD. J Am Acad Child Adolesc Psychiatry. 1997;36(8):1056-64.	Children with and without ADHD in one sample
Horn (1987)	Horn WF, Ialongo N, Popovich S, Peradotto D. Behavioral parent training and cognitive–behavioral self-control therapy with ADD-H children: Comparative and combined effects. J Clin Child Psychol. 1987;16(1):57-68.	No control group
Horn (1990)	Horn WF, Ialongo N, Greenberg G, Packard T. Additive effects of behavioral parent training and self-control therapy with ADHD children. J Clin Child Psychol.1990;19(2):98-110.	No control group
Horn (1991)	Horn WF, Ialongo NS, Pascoe JM, Greenberg G, Packard T, Lopez M et al. Additive effects of psychostimulants, parent training, and self-control therapy with ADHD children. J Am Acad Child Adolesc Psychiatry. 1991;30:233-240.	Parent and Child intervention
Ialango (1993)	Ialongo NS, Horn WF, Pascoe JM, Greenberg G, Packard T, Lopez M et al. The effects of a multimodal intervention with ADHD children: a 9-month follow-up. J Am Acad Child Adolesc Psychiatry. 1993;32(1):182-9.	Same data set as Horn et al 1990 No control group.
Molina (2008)	Molina BS, Flory K, Bukstein OG, Greiner AR, Baker JL, Krug V, Evans SW. Feasibility and preliminary efficacy of an after-school program for middle schoolers with ADHD: A randomized trial in a large public middle school. J Attention Disord. 2008;12(3):207-17.	No specific ADHD outcomes
MTA (Multimodal Treatment Study of Children With ADHD) Cooperative Group (1999)	MTA Cooperative Group (Multimodal Treatment Study of Children With ADHD): A 14-month randomized clinical trial of treatment strategies for ADHD. Arch Gen Psychiatry. 1999;56:1073-1086.	Parent, child, and teacher intervention
Pisterman (1989)	Pisterman S, McGrath P, Firestone P, Goodman JT, Webster I, Mallory R. Outcome of parent-mediated treatment of pre-schoolers with ADHD. J Consult Clin Psychol. 1989;57(5):628-35.	No ADHD outcomes
Sanders (2007)	Sanders MR, Bor W, Morawska A. Maintenance of treatment gains: a comparison of enhanced, standard, and self-directed Triple P-Positive Parenting Program. J Abnorm Child Psychol. 2007;35(6):983-98.	Not a specific ADHD sample
Schuhmann (1998)	Schuhmann EM, Foote RC, Eyberg SM, Boggs SR, Algina J. Efficacy of parent–child interaction therapy: Interim report of a randomized trial with short term maintenance. J Clin Child Psychol. 1998;27(1):34-45.	Not a specific ADHD sample. No specific ADHD outcomes
So (2008)	So CY, Leung PW, Hung SF. Treatment effectiveness of combined medication/behavioral treatment with Chinese ADHD children in routine practice. Behav Res Ther. 2008;46(9):983-92.	No control group
Strayhorn (1989)	Strayhorn JM, Weidman CS. Reduction of attention deficit and internalizing symptoms in pre-schoolers through parent–child interaction training. J Am Acad Child Adolesc Psychiatry. 1989;28(6):888-96.	Not a specific ADHD sample
Thorell (2009)	Thorell LB. The Community Parent Education Program (COPE): treatment effects in a clinical and a community-based sample. Clin Child Psychol Psychiatry. 2009;14(3):373-87.	Not a specific ADHD sample
Webster-Stratton (2011)	Webster-Stratton CH, Reid MJ, Beauchaine T. Combining parent and child training for young children with ADHD. J Clin Child Adolesc Psychol. 2011;40:191-203.	Parent and child intervention

Acknowledgements

The authors wish to thank Professor David Daley for his help with the literature search, checking of data extraction, and the meta-analyses.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by funding as part of the National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care (CLAHRC) Nottinghamshire, Derbyshire, and Lincolnshire, funded by a central grant from the NIHR and Nottinghamshire Healthcare NHS (National Health Service) Trust, University of Nottingham, and other Trusts in CLAHRC.

Author Biographies

Janine Coates, PhD, is a Lecturer in Psychology at Nottingham Trent University. Research interests include developmental psychology, behavioural disorders, and childhood disability in education settings.

John A. Taylor, PhD, is a Research Fellow in the Division of Epidemiology and Public Health, University of Nottingham. Research interests relate to health behaviour change and prevention, with recent work focusing on adolescent mental health and tobacco control in schools.

Kapil Sayal, PhD, MRCPsych, is a Clinical Associate Professor and Reader in Child & Adolescent Psychiatry at the University of Nottingham. He was a member of the National Institute for Health and Clinical Excellence (NICE) Guideline Development Group and Implementation group for ADHD. Research interests include developmental epidemiology, health services research, and child and adolescent mental health in schools and primary care.

References

Abidin

(1986). Parenting Stress Index (2nd ed.). Charlottesville, VA: Pediatric Psychology Press.

American Academy of Pediatrics. (2011). ADHD: Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics, 128, 1007-1022.

American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., revised). Washington, DC: Author.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

Anastopoulos

A. D.

Shelton

T. L.

DuPaul

G. J.

Guevremont

D. C.

(1993). Parent training for attention-deficit hyperactivity disorder: Its impact on parent functioning. Journal of Abnormal Child Psychology, 21, 581-596.

Arnold

D. S.

O’Leary

S. G.

Wolff

L. S.

Acker

M. M.

(1993). The Parenting Scale: A measure of dysfunctional parenting in discipline situations. Psychological Assessment, 5, 137-144.

Barkley

R. A.

(1987). Defiant children: A clinician’s manual for parent treating. New York, NY: Guilford Press.

Barkley

R. A.

(1990). Attention deficit hyperactivity disorder: A handbook for diagnosis and treatment. New York, NY: Guilford Press.

Barkley

R. A.

Murphy

K. R.

(1998). Attention deficit hyperactivity disorder: A clinical workbook (2nd ed.). New York, NY: Guilford Press.

10.

Barkley

R. A.

Shelton

T. L.

Crosswait

Moorehouse

Fletcher

(2000). Multi-method psycho-educational intervention for preschool children with disruptive behavior: Preliminary results at post-treatment. Journal of Child Psychology and Psychiatry, 41, 319-332.

11.

Bor

Sanders

M. R.

Markie-Dadds

(2002). The effects of the Triple P-Positive Parenting Program on preschool children with co-occurring disruptive behavior and attentional/hyperactive difficulties. Journal of Abnormal Child Psychology, 30, 571-587.

12.

Brotman

L. M.

Calzada

Dawson-McClure

(2005). GIPCI-R unpublished manuscript. New York: New York University.

13.

Charach

Carson

Fox

Ali

M. U.

Beckett

Lim

C. G.

(2013). Interventions for preschool children at high risk for ADHD: A comparative effectiveness review. Pediatrics, 131, 1584-1604.

14.

Chronis

A. M.

Gamble

S. A.

Roberts

J. E.

Pelham

W. E.

Jr. (2006). Cognitive-behavioral depression treatment for mothers of children with attention-deficit/hyperactivity disorder. Behavioral Therapy, 37, 143-158.

15.

Chronis

A. M.

Jones

Raggi

(2006). Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder. Clinical Psychology Review, 26, 486-502.

16.

Conners

C. K.

(2001). Conners Rating Scales–Revised. North Tonawanda, NY: Multihealth Systems.

17.

Cunningham

C. E.

Bremner

Boyle

(1995). Large group community-based parenting programs for families of preschoolers at risk for disruptive behaviour disorders: Utilization, cost effectiveness, and outcome. Journal of Child Psychology and Psychiatry, 36, 1141-1159.

18.

Davey

Turner

R. M.

Clarke

M. J.

Higgins

J. P.

(2011). Characteristics of meta-analyses and their component studies in the Cochrane Database of Systematic Reviews: A cross-sectional, descriptive analysis. BMC Medical Research Methodology, 11, Article 160.

19.

DuPaul

G. J.

(1991). Parent and teacher ratings of ADHD symptoms: Psychometric properties in a community based sample. Journal of Clinical Child Psychology, 20, 245-253.

20.

Eyberg

S. M.

Pincus

(1999). Eyberg Child Behavior Inventory and Sutter-Eyberg Student Behavior Inventory: Professional manual. Odessa, FL: Psychological Assessment Resources.

21.

Field

A. P.

Gillett

(2010). How to do a meta-analysis. British Journal of Mathematical and Statistical Psychology, 63, 665-694.

22.

Forehand

McMahon

(1981). The noncompliant child. New York, NY: Guilford Press.

23.

Goldberg

(1982). General health questionnaire manual. Windsor, UK: National Foundation for Educational Research.

24.

Goodman

(1997). The Strengths and Difficulties Questionnaire: A research note. Journal of Child Psychology and Psychiatry, 38, 581-586.

25.

Herbert

S. D.

Harvey

E. A.

Roberts

J. L.

Wichowski

Lugo-Candelas

C. I.

(2013). A randomized controlled trial of a parent training and emotion socialization program for families of hyperactive preschool-aged children. Behavioral Therapy, 44, 302-316.

26.

Hoath

F. E.

Sanders

M. R.

(2002). A feasibility study of Enhanced Group Triple P—Positive parenting program for parents of children with attention-deficit/hyperactivity disorder. Behavior Change, 19, 191-206.

27.

Johnston

Mash

E. J.

(1989). A measure of parenting satisfaction and efficacy. Journal of Clinical Child Psychology, 18, 167-175.

28.

Johnston

Mash

E. J.

(2001). Families of children with attention deficit hyperactivity disorder: Review and recommendations for future research. Clinical Child and Family Psychology, 4, 183-207.

29.

Jones

Daley

Hutchings

Bywater

Eames

(2007). Efficacy of the incredible years basic parent training program as an early intervention for children with conduct problems and ADHD. Child: Care Health and Development, 33, 749-756.

30.

Lovibond

P. F.

Lovibond

S. H.

(1995). The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behavioral Research Therapy, 33, 335-343.

31.

National Institute for Health and Clinical Excellence. (2008). Attention deficit hyperactivity disorder: Diagnosis and management of ADHD in children, young people, and adults (Clinical Guideline 72). London, England: Author.

32.

Pelham

W. E.

Jr. Fabiano

G. A.

(2008). Evidence-based psychosocial treatments for attention-deficit/hyperactivity disorder. Journal of Clinical Child Psychology, 37, 184-214.

33.

Pelham

W. E.

Jr. Wheeler

Chronis

(1998). Empirically supported psychosocial treatments for attention deficit hyperactivity disorder. Journal of Clinical Child Psychology, 27, 190-205.

34.

Pisterman

Firestone

McGrath

Goodman

J. T.

Webster

Mallory

Goffin

(1992). The role of parent training in treatment of preschoolers with ADDH. American Journal of Orthopsychiatry, 62, 397-408.

35.

Polanczyk

de Lima

M. S.

Horta

B. L.

Biederman

Rohde

L. A.

(2007). The worldwide prevalence of ADHD: A systematic review and metaregression analysis. American Journal of Psychiatry, 164, 942-948.

36.

Sanders

M. R.

Bor

Morawska

(2007). Maintenance of treatment gains: A comparison of enhanced, standard, and self-directed Triple P-Positive Parenting Program. Journal of Abnormal Child Psychology, 35, 983-998.

37.

Sanders

M. R.

Markie-Dadds

Tully

L. A.

Bor

(2000). The Triple P-Positive Parenting Program: A comparison of enhanced, standard, and self-directed behavioral family intervention for parents of children with early onset conduct problems. Journal of Consulting and Clinical Psychology, 68, 624-640.

38.

Shaw

Hodgkins

Herve

Young

Kahle

Woods

A. G.

Arnold

L. E.

(2012). A systematic review and analysis of long-term outcomes in attention deficit hyperactivity disorder: Effects of treatment and non-treatment. BMC Medicine, 10, Article 99.

39.

Sonuga-Barke

E. J.

Brandeis

Cortese

Daley

Ferrin

Holtmann

. . . Sergeant

(2013). Nonpharmacological interventions for ADHD: Systematic review and meta-analyses of randomized controlled trials of dietary and psychological treatments. American Journal of Psychiatry, 170, 275-289.

40.

Sonuga-Barke

E. J.

Daley

Thompson

Laver-Bradbury

Weeks

(2001). Parent-based therapies for preschool attention-deficit/hyperactivity disorder: A randomized, controlled trial with a community sample. Journal of the American Academy of Child & Adolescent Psychiatry, 40, 402-408.

41.

Sonuga-Barke

E. J.

Thompson

Daley

Laver-Bradbury

(2004). Parent training for attention deficit/hyperactivity disorder: Is it as effective when delivered as routine rather than as specialist care? British Journal of Clinical Psychology, 43, 449-457.

42.

Taylor

E. A.

Sandberg

Thorley

Giles

(1991). The epidemiology of childhood hyperactivity (Institute of Psychiatry, Maudsley Monographs). London, England: Oxford University Press.

43.

Thompson

M. J.

Laver-Bradbury

Ayres

Le Poideuin

Mead

Dodds

. . . Sonuga-Barke

E. J.

(2009). A small-scale randomized controlled trial of the revised new forest parenting program for preschoolers with attention deficit hyperactivity disorder. European Child & Adolescent Psychiatry, 18, 605-616.

44.

Van Den Hoofdakker

B. J.

Van der Veen-Mulders

Sytema

Emmelkamp

P. M.

Minderaa

R. B.

Nauta

M. H.

(2007). Effectiveness of behavioral parent training for children with ADHD in routine clinical practice: A randomized controlled study. Journal of the American Academy of Child and Adolescent Psychiatry, 46, 1263-1271.