Multifamily Therapy for Children With ADHD in Hong Kong: The Different Impacts on Fathers and Mothers

Abstract

Objective: Medication combined with psychosocial intervention is the recommended treatment for ADHD. What is not clear is which of the parents participate in psychosocial interventions, and whether the impacts are different for fathers and mothers. This is important because of the different roles fathers and mothers have in shaping their child’s development. This article examines the impact of multifamily therapy on a sample of fathers and mothers from Hong Kong whose children suffer from ADHD. Method: Fathers and mothers ratings on ADHD severity, parent–child relationship, parenthood stress, and parental self-esteem were compared between those who attended multifamily therapy and those who attended psychoeducation talks. Results: Fathers and mothers of the multifamily group, but not the psychoeducational group, reported reduction of child ADHD symptom severity. When the reduction was clinically significant, mothers reported an increased sense of competence while fathers reported improved father–child relationship. Conclusion: Fathers and mothers experienced different gains from attending MFT. Fathers’ involvement in their child’s treatment should be encouraged and facilitated.

Keywords

ADHD multifamily therapy Chinese children

Introduction

ADHD is a highly comorbid neurodevelopmental disorder affecting 5% to 7% of children (Polanczyk, Willcutt, Salum, Kieling, & Rohde, 2014) and associated with a wide range of impairments that include behavioral problems, relationship difficulties, and academic underachievement. Parents also experience high levels of parenting stress and conflictual parent–child relationships, low parental self-esteem, and low sense of competence which in turn can affect family functioning and the children’s developmental trajectory (Deault, 2010). A combination of medication and psychosocial interventions is the recommended treatment approach (National Institute for Health and Clinical Excellence [NICE], 2008).

Among psychosocial approaches, parent behavior training (PBT) has received the most attention, and there is evidence that it reduces parental reports of ADHD symptomatology and conduct problems, lowers parenting stress, and improves parenting skills and parenting self-esteem (Coates, Taylor, & Sayal, 2015; Daley et al., 2014; Gerdes, Haack, & Schneider, 2012; Heath, Curtis, Fan, & McPherson, 2015). However, with the exception of a small number of studies, it is often unclear which of the parents participated in the intervention. More importantly, few addressed whether the effects of intervention was different for mothers and fathers. That it is important to examine fathers’ and mothers’ perspectives separately is supported by (a) fathers and mothers differ in their interactions and contributions toward their child’s development, (b) concordance of symptom severity as reported by fathers and mothers is at best moderate (Langberg et al., 2010; Sollie, Larsson, & Morch, 2013), and (c) fathers may be more reluctant to seek help even when they have difficulties interacting with their child (Niec, Barnett, Gering, Triemstra, & Solomon, 2015). In his review, Fabiano (2007) discussed possible barriers to father participation in PBT, which included the scheduling, content, and mode of delivery of PBT sessions, and suggested (a) to explicitly invite and arrange treatment schedules that make it possible for fathers to attend; (b) fathers and mothers should complete ratings separately; (c) reframe interventions as a means to enhance skills rather than implying a skills deficit; and (d) include activities between parents and child so as to improve parenting skills.

The prevalence of ADHD in Hong Kong is very similar to that in the West (Leung et al., 1996). Typical of Chinese families, parents in Hong Kong place great emphasis on children’s academic success, conformity, and obedience, which are construed as indicators of parenting success (Chao, 1994). For families with a child suffering from ADHD, underachievement becomes the predominant source of stress for parents as well as the child. At the same time, the disruptive nature of ADHD symptoms is frowned upon as signs of “poor parenting” and “lack of discipline.” Attempts from parents to “control” the child’s behaviors lead to cycles of frustration and demoralization. Mothers tend to be the main caretaker of their children, while fathers are the breadwinners whose interactions with their child may be less intense (Ma & Lai, 2014). Such differences in roles and experiences may result in fathers and mothers having different perceptions about their child’s behaviors. In examining the paternal and maternal experiences in caring for Chinese children with ADHD in Hong Kong, Ma and Lai (2016) found that mothers reported higher levels of parental stress and perceived their child’s ADHD symptoms to be more serious than fathers did.

Medication is the main modality of treatment for children with ADHD in Hong Kong. The availability of psychosocial interventions is inconsistent and, if available, are mostly symptom-focused with a behavioral training approach (Cheung et al., 2015). It is against this background, and with the family context in mind, that our team examined the use of multifamily therapy (MFT) as an adjunct treatment to help families with children with ADHD. MFT, which involves working with groups of families systemically, has been successfully applied in a variety of disorders and settings, but has only recently been investigated in children and young people with mental health problems. The approach blends family therapy and group therapy, so that families with similar difficulties experience mutual sharing and support, and in the process, evaluate their difficulties in a new light. The processes that facilitate change lie in the provision of a therapeutic context in which professionals serve as group leaders and, through participation in activities, families are encouraged to develop more functional interactions and communications. Through the creation of multiple perspectives, and actively seeking solutions rather than relying on experts, families are empowered and change becomes possible (Asen, 2002; Asen & Scholz, 2009). The MFT model used in this study was adapted from the model developed in the United Kingdom by Asen and Scholz (2009) and took into account the needs and concerns of the families within the sociocultural context of Hong Kong.

Initial findings by Ma, Lai, and Xia (2018) reported a reduction in the parent-rated severity of ADHD symptoms after attending MFT, but there was no significant change in parenting self-esteem, parenting stress, and parent–child relationship scores. What was not examined was whether there was a relationship between the improved ADHD scores and parenting experiences and whether attending MFT impacted fathers and mothers differently. This study will address this gap by (a) examining the relationship between changes in perceived ADHD symptoms and parenting experiences and (b) analyzing maternal and paternal ratings separately. We hypothesized that fathers would perceive their child’s ADHD symptoms to be less severe, experience less parenting stress, and report better parenting self-competence than mothers. Fathers would also report a more distant relationship with their child than mothers would. We also expected that the reduction in ADHD severity would impact parenting experiences differently for fathers and mothers because of their different roles in the family context.

Method

The study adopted a quasi-experimental design that compared pre- and postintervention ratings between an experimental (MFT) and a control (psychoeducation) group.

Sample Recruitment

A sample of children between the ages of 6 and 12 years who fulfilled the criteria for a clinical diagnosis of ADHD according to Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013) were recruited by convenient sampling. Invitations were sent to a district hospital-based child and adolescent mental health service as well as community child psychiatry clinics. Interested parents were first invited to attend a half-day introduction session during which an overview of ADHD and its treatment was introduced, followed by an explanation about the purpose and arrangement of the study. Parents could then choose to attend either the MFT (experimental group) or another psychoeducation talk (control group). To fulfill the inclusion criteria for MFT, at least one parent from the family needed to commit to completing the MFT sessions with their child, and parents had to be able to understand Cantonese, which was the language used in the MFT meetings. Exclusion criteria were (a) children with intellectual disability, (b) parents with untreated psychiatric disorders and/or intellectual disability, and (c) families considered at risk of child abuse or domestic violence, in which case family therapy and/or liaison with social welfare services were initiated. All the sessions were held during weekends so as to facilitate both parents to attend. The two groups also continued with their clinical treatment as recommended by clinicians.

Design of the MFT Program and Psychoeducational Talks

Details about the design of the MFT program have been reported in Ma, Wan, and Wong (2013). Briefly, the MFT program consisted of three phases over a 6-month period. The first phase was a half-day (4 hours) psychoeducational talk and group sharing which also served as recruitment and orientation about the study. The second phase was a 4-day program (32 hours) held over two consecutive or alternate weekends, depending on the availability of the families. The third phase was a two half-day reunions (total 6 hours) 2 months apart to provide positive reinforcement and address issues that arose. Each MFT group consisted of four to seven families. The control group attended two half-days of psychoeducational talks over a 3-month period, delivered by clinicians on topics relating to symptoms of ADHD, behavioral problems, parenting strategies, as well as school and homework issues.

Ethical approval was obtained from the Joint Chinese University of Hong Kong and New Territories East Cluster Ethical Committee. Written consent was obtained from the parents after they chose to participate.

Data Collection

Data were collected at the beginning and the end of the intervention (3 months apart). Besides basic sociodemographic information, children’s clinical data were collected from clinicians responsible for the clinical management, and included (a) diagnosis and comorbid conditions, and (b) dose and types of medications used and whether these were modified during the course of the study.

Each participating parent completed a set of self-administered questionnaires which included (a) Strengths and Weaknesses of ADHD-symptoms and Normal-behaviors (SWAN) rating scale, parent version, (b) Parent–Child Relationship (PCR) scale, (c) Parenthood Stress Questionnaire (PSQ), and (d) Parenting Sense of Competence (PSOC). PCR and PSQ were adapted and shortened from their originals so that parents did not have to complete too lengthy a set of questionnaires.

Instruments

SWAN rating scale

The SWAN scale was developed by Swanson et al. (2005) by rephrasing the 18 ADHD items of Swanson, Nolan, Pelham-IV (SNAP-IV) scale, which is a Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; APA, 1994) based rating scale, into neutral or positive statements. Respondents rate the child’s behaviors on a 7-point scale by comparing the child’s behaviors against that of other children of the same age. Scores of each statement range from −3 (far above average) to +3 (far below average), with an anchor on average behavior. In so doing, it avoids focusing on symptom presence, with the advantage that ratings become normally distributed. Higher scores denote more severe ADHD behaviors. A Chinese translation is available and has demonstrated good internal consistency (Cronbach’s α = 0.95 for total score), test–retest reliability (Intraclass Correlation Coefficient [ICC] = 0.87), and validity (Area under Curve [AUC] = 0.83; Chan, Lai, Luk, Hung, & Leung, 2014; Lai et al., 2013). For the purpose of this study, the SWAN total score of the parent version was used.

PCR scale

This was adapted from Fine, Moreland, and Schwebel (1983) to assess parent–child relationship from the parental perspective. Seven items were used to measure the parents’ perceived emotional closeness with the child, amount of trust offered to the child, clarity of parent role, anger toward the child, frequency of discussion with the child to face problems, and the feeling of being respected and appreciated by the child. Items were rated on a 5-point Likert-type scale (1 = never, 5 = always). The question concerning anger toward the child was reverse-scored. High scores denote better parent–child relationship. The internal consistency of the scale in this study was acceptable (Cronbach’s α = 0.73).

PSQ

The PSQ consisted of 10 items extracted from the Swedish Parenthood Stress Questionnaire (Ostberg & Hagekull, 2000). The items selected were based on their relevance to the objectives of this study and assessed parental stress in relation to child care that included feelings of incompetence, role restriction, social isolation, marital relationship problems, health, and financial hardships. Responses were rated on a 5-point Likert-type scale (1 = strongly disagree, 5 = strongly agree). Higher scores denote higher level of stress. Internal consistency in this study was marginal (Cronbach’s α = 0.66).

PSOC scale

Developed by Gibaud-Wallston and Wandersmann (1978), the PSOC consists of 17 items which can be grouped into PSOC-efficacy and PSOC-satisfaction subscales. Items are rated on a 1 to 5 Likert-type scale (1 = strongly agree, 5 = strongly disagree). Negatively worded items are reverse-scored. In this study, scores of the two subscales were combined to give a total score and served as an indicator of parenting self-esteem. Higher scores indicate a higher parenting self-esteem. Internal consistency in this study was marginal (Cronbach’s α = 0.64).

Data Analyses

SPSS version 22 was used for statistical analyses. Independent samples t tests were used to compare ratings of the experimental and control groups, and between mothers and fathers. Paired sample t tests were used to compare ratings in the pre- and postintervention phases. Mixed-model ANOVA was used to examine for interaction effects, and parental education levels were included as covariates. Pearson’s correlations were used to examine the relationship between children’s ADHD symptoms and parenting measures and parent–child relationships.

Results

Sociodemographic Data

The experimental group consisted of 49 families, of which 39 returned both the pre- and postintervention questionnaires, representing a response rate of 79.6% (see Table 1). Twenty families had both parents attending the MFT, while 19 families had only one parent attending. Of those families where only one parent attended, there were 18 mothers and 1 father. In total, there were 38 mothers and 21 fathers. Most of the children were boys (n = 33, 85%), and the mean age was 8.4 years. Nine children (23%) had a comorbid diagnosis of autism spectrum disorder, four (10.3%) had specific learning difficulty and one (2.6%) had an anxiety disorder. Twenty-nine (74.4%) of them were already taking medication for ADHD by the time they joined the MFT (28 were taking stimulant medications, one had combination of stimulant and Atomoxetine). During the intervention period, nine children had modifications to their medication (one commenced stimulant medication, four had their stimulant doses increased, two changed from immediate release to extended release preparations of stimulants, and two changed from stimulant to nonstimulant medications).

Table 1.

Sociodemographic and Clinical Characteristics.

	Multifamily therapy group (MFT)(39 families)	Psychoeducation group(42 families)
Child characteristics
Mean age of child	8.4 years	7.9 years
Gender (male)	33 (84.6%)	33 (78.6%)
Taking medication at start of intervention	29 (74.4%)	9 (21.4%)
Family characteristics
2-parent families	31 (79.5%)	35 (83.3%)
Father’s education level
Primary	0 (0%)	3 (17.6%)
Secondary	13 (59.1%)	7 (41.2%)
Tertiary	9 (40.9%)	7 (41.2%)
Mother’s education level
Primary	0 (0%)	5 (13.9%)
Secondary	26 (68.4%)	17 (47.2%)
Tertiary	12 (32.6%)	13 (36.1%)

The control group consisted of 57 families, 42 of whom returned the pre- and postintervention questionnaires, representing a response rate of 73.7%. Eleven of the 42 families had both parents attending, while 31 had only one parent attending. Those with only one parent attending consisted of 25 mothers and six fathers. In total, there were 36 mothers and 17 fathers. Thirty-three (78.6%) of the children were boys, and the mean age was 7.9 years. Six children (14.3%) had a comorbid diagnosis of autism specturm disorder and three (7.2%) with specific learning difficulty. Relatively few of them (n = 9, 21.4%) were on medication for ADHD when they joined the study. Twenty-three (54.8%) were not on medication and information was missing for 10 (23.8%). During the period of the intervention, two of these nine children (all were on stimulants) had their stimulant doses increased, and none commenced medication.

Apart from a significant difference in rates of medication use, the control group also differed from the experimental group in having a small number of parents who had received only primary education, while all of the parents in the MFT group had received at least secondary school education.

Comparing Maternal and Paternal Ratings

The mean and standard deviations of all questionnaire scores are included in Table 2. There was an overall trend that mothers’ SWAN ratings were higher than fathers’ ratings, and mothers’ PSOC scores were lower than that of fathers. Their PCR and PSQ scores, however, were very similar. This was true for both the experimental and control groups and in both pre- and postintervention stages. The differences between control group mothers’ and fathers’ SWAN and PSOC ratings in the preintervention stage was statistically significant (SWAN: df = 49, t = −2.31, p < .05, effect size = 0.74; PSOC: df = 43, t = 2.18, p < .05, effect size = 0.67), but not for the experimental group or in the postintervention stage.

Table 2.

Comparison of Questionnaire Ratings Between Experimental and Control Groups Before and After Intervention.

	Multifamily therapy group (MFT)(39 families)(38 mothers, 21 fathers)			Psychoeducation group(42 families)(36 mothers, 17 fathers)
	PreM (SD)	PostM (SD)	p value	PreM (SD)	PostM (SD)	p value
Maternal scores
SWAN	22.1 (15.2)	13.9 (13.7)	.000	18.3 (12.7)	16.6 (12.4)	ns
PCR	24.3 (3.6)	24.0 (3.9)	ns	25.5 (3.7)	25.7 (4.2)	ns
PSQ	31.7 (6.0)	32.3 (8.3)	ns	31.7 (4.1)	32.2 (5.0)	ns
PSOC	50.7 (8.2)	52.8 (7.4)	ns	50.1 (6.3)	50.7 (6.2)	ns
Paternal scores
SWAN	17.3 (7.7)	10.3 (12.1)	.003	10.7 (9.1)	11.4 (9.2)	ns
PCR	23.1 (3.2)	24.7 (4.1)	.027	24.1 (2.2)	25.5 (2.1)	.045
PSQ	30.2 (4.1)	30.1 (5.4)	ns	30.6 (3.2)	30.8 (5.0)	ns
PSOC	52.8 (5.1)	55.1 (6.1)	ns	55.2 (7.4)	53.8 (6.2)	ns

Note. SWAN = Strengths and Weaknesses of ADHD-symptoms and Normal-behaviors rating scale; PCR = Parent–Child Relationship scale. PSQ = Parenthood Stress Questionnaire. PSOC = Parenting Sense of Competence scale.

In the postintervention stage, mothers’ SWAN ratings saw a significant interaction effect between group and time, F(1, 65) = 6.09, p < .05, but the reduction was statistically significant only for experimental group (df = 35, t = 3.91, p < .001, Cohen’s d = 0.56). Fathers’ SWAN ratings did not see any interaction effect between group and time, but there was a main effect of group, and a statistically significant reduction of SWAN ratings by fathers of the experimental group was observed (df = 20, t = 3.36, p < .01, Cohen’s d = 0.69), The postintervention SWAN scores from experimental group fathers remained largely unchanged.

Concerning parenting measures, mothers’ PCR, PSQ, or PSOC scores saw no significant interaction or main effects of group and time. For fathers, however, significant main effect of time on PCR scores was observed, but not interaction effect between group and time. For both experimental and control groups, fathers’ PCR scores were significantly increased in the postintervention phase (experimental group: df = 20, t = −2.38, p < .05, Cohen’s d = 0.42; control group: df = 15, t = −2.18, p < .05, Cohen’s d = 0.67). These results suggested that when fathers attended the intervention, be it MFT or psychoeducation talks, they perceived their relationship with their child to have improved. There was no significant main or interaction effects on fathers’ PSQ or PSOC scores.

Relationship Between Clinically Significant Change in ADHD Symptoms and Parenting Measures

Despite both fathers and mothers of the experimental group reporting significantly reduced ADHD symptom severity in the postintervention stage and fathers reporting improved parent–child relationships, their ratings on parenting stress or parental sense of efficacy were not significantly improved. To further explore whether there was any relationship between reduced ADHD severity and parenting experiences, we grouped children from the experimental group according to whether their postintervention SWAN scores fell below clinical cutoff (Chan et al., 2014). As can be seen in Table 3, mothers whose child’s postintervention SWAN scores were below clinical cutoff endorsed significantly higher PSOC scores (t = 3.21, df = 26, p < .01), but their PCR or PSQ scores did not change. On the contrary, fathers whose child’s postintervention SWAN scores were below clinical cutoff endorsed significantly higher PCR scores (t = 2.387, df = 20, p < .05), but the same was not observed in their PSQ or PSOC scores. When these analyses were repeated by excluding those children whose medication was modified during the duration of the MFT, the results remained the same.

Table 3.

Comparing Experimental Group Parenting Measures Categorized by SWAN Cutoff.

	Maternal scores (n = 38)M (SD)
	Preintervention			Postintervention
	SWAN not in clinical range	SWAN in clinical range	p value	SWAN not in clinical range	SWAN in clinical range	p value
	(n = 11)	(n = 27)	p value	(n = 19)	(n = 19)	p value
SWAN	3.0 (9.8)	29.9 (9.4)	.000	3.2 (7.4)	24.4 (9.1)	.000
PCR	23.2 (2.7)	24.7 (3.8)	ns	23.9 (3.7)	24.1 (4.1)	ns
PSQ	28.8 (8.3)	32.8 (4.3)	ns	30.8 (9.1)	34.5 (7.0)	ns
PSOC	52.1 (7.6)	50.0 (8.4)	ns	56.4 (7.5)	48.0 (5.8)	.003
	Paternal scores (n = 21)M (SD)
	Preintervention			Postintervention
	(n = 6)	(n = 15)	p value	(n = 9)	(n = 12)	p value
SWAN	8.7 (2.7)	20.7 (6.1)	.000	-0.9 (10.0)	18.8 (3.6)	.000
PCR	22.8 (4.4)	23.2 (2.7)	ns	27.0 (3.6)	22.9 (3.7)	.021
PSQ	29.3 (3.3)	30.6 (4.4)	ns	27.7 (6.4)	31.8 (3.7)	ns
PSOC	52.2 (5.3)	53.5 (5.5)	ns	58.8 (7.5)	52.9 (4.1)	ns

Note. SWAN = Strengths and Weaknesses of ADHD-symptoms and Normal-behaviors rating scale; PCR = Parent–Child Relationship scale; PSQ = Parenthood Stress Questionnaire; PSOC = Parenting Sense of Competence scale.

Comparison of Families Where Both Parents Attended Versus Only One Parent Attended

Questionnaire scores were also compared between families where both parents attended the interventions and those where only one parent attended. The results, as seen in Table 4, remained very similar. For both the experimental and control groups, there was no interaction effect of the number of parents attended and time on postintervention SWAN or parenting scores.

Table 4.

Comparing Families With Both Parents Attended Versus One Parent Attended.

	Multifamily therapy group (MFT) (39 families)
	Both parents attended(20 families)				One parent attended(18 mothers, 1 father)
	PreM (SD)	PostM (SD)	p value	Cohen’s d	PreM (SD)	PostM (SD)	p value	Cohen’s d
Maternal scores
SWAN	18.1 (15.6)	9.7 (11.2)	0.01	0.62	26.5 (13.7)	18.6 (14.9)	0.021	0.55
PCR	23.4 (3.0)	23.5 (4.3)	ns	–	25.3 (3.9)	24.4 (3.5)	ns	–
PSQ	30.9 (5.2)	29.2 (8.4)	ns	–	32.6 (7.0)	36.1 (6.7)	ns	–
PSOC	51.9 (6.6)	56.1 (7.5)	ns	–	49.3 (9.9)	49.1 (5.5)	ns	–
Paternal scores
SWAN	17.2 (7.9)	10.7 (12.3)	0.007	0.63
PCR	23.0 (3.2)	24.6 (4.2)	0.038	0.43
PSQ	30.1 (4.1)	29.9(5.5)	ns	–
PSOC	52.7 (5.2)	55.3 (6.3)	ns	–
	Control group (42 families)
	Both parents attended(11 families)				One parent attended(25 mothers, 6 fathers)
	PreM (SD)	PostM (SD)	p value	Cohen’s d	PreM (SD)	PostM (SD)	p value	Cohen’s d
Maternal scores
SWAN	14.0 (8.2)	11.9 (7.8)	ns	–	19.9 (13.9)	18.4 (13.4)	ns	–
PCR	25.8 (3.1)	26.0 (3.9)	ns	–	25.4 (3.9)	25.5 (4.4)	ns	–
PSQ	30.1 (5.0)	30.9 (4.9)	ns	–	32.4 (3.6)	32.7 (5.1)	ns	–
PSOC	50.8 (5.8)	51.4 (6.7)	ns	–	49.9 (6.6)	50.4 (6.2)	ns	–
Paternal scores
SWAN	7.0 (6.6)	9.9 (10.6)	ns	–	16.8 (9.8)	14.0 (6.5)	ns	–
PCR	24.3 (2.0)	25.9 (2.2)	ns	–	23.7 (2.6)	24.8 (1.9)	ns	–
PSQ	29.9 (3.2)	30.5 (5.5)	ns	–	36.8 (3.9)	37.5 (4.2)	ns	–
PSOC	54.8 (9.1)	52.1 (6.3)	ns	–	56.0 (4.1)	56.6 (5.4)	ns	–

Discussion

This study adopted a quasi-experimental design and compared the impact of MFT versus psychoeducational talk as an adjunct treatment for Chinese children with ADHD in Hong Kong with a focus on the impact on mothers and fathers separately. One of the most notable results from our study is that both mothers and fathers from the MFT group, but not the psychoeducational group, rated their children’s ADHD symptoms to be significantly less severe in the postintervention stage. This echoes findings from both the parent behavioral interventions and MFT outcome literature, where symptom reduction has been repeatedly demonstrated (Coates et al., 2015; Gelin, Cook-Darzens, & Hendrick, 2018). Elements in MFT that are considered helpful toward symptom reduction include the development of therapeutic alliance, support and sharing from the group process, group cohesion, and reframing of symptoms (Gelin et al., 2018). Concurrently, Ma, Lai, and Wan (2017) used a structured questionnaire to evaluate participants’ post-MFT experience and found that 96% appreciated the mutual support they experienced, while 87% agreed that they gained new insights into their child’s developmental needs. The symptom reduction endorsed by our MFT parents may be a reflection of this feeling of being supported, as well as having the opportunity to observe and interact with their child outside of the daily struggles of homework and routines, that allowed them to see their child from different perspectives and reframe their behaviors. Another possibility that could have contributed to the reduced symptom severity is that a number of children had modifications made to their medication regime during the study period. However, as the majority of children were on stimulant medication with a duration of action during school hours, we would not expect their behaviors in the evenings, when most of the interactions with their parents took place, to be affected by the medication adjustment. It is also common for parents not to give the medication during weekends and holidays, which again means that changes in medication regime was unlikely to have affected the children’s behaviors at weekends. Indeed, when we repeated the analyses by excluding children whose medication was adjusted, the results were unchanged. That parents perceived their child’s symptoms to be less severe has important implications for clinical management. Clinicians’ decisions are, in part, informed by parental reports. If parents view their child as problematic because of their blinkered perspective or inappropriate expectations, this can potentially lead to excessive medication use, and negatively impact children’s self-evaluation and psychological development.

Our results also found that fathers’ attendance—be it MFT or psychoeducational talks—resulted in a subjective improvement in their relationship with their child. Although this improvement appeared not to be specific to MFT, and how this improvement was experienced needs to be better understood, our finding is a strong reminder that fathers should be actively encouraged to participate in the treatment process. Different from fathers, mothers did not report any changes in their relationship with their child in the postintervention phase, but there was an association between mothers’ increased sense of parenting competence and post-MFT ADHD symptom ratings falling below the level of clinical cutoff. These findings suggest that fathers and mothers reaped different benefits from attending MFT. From a sociocultural perspective, mothers in Chinese families typically assume the main caretaker role of their children, while fathers provide for the family. Long working hours, coupled with ADHD children’s struggles with homework (which tends to be supervised by mothers), mean that fathers may not have chance to spend time with their children on a daily basis. Inviting fathers to attend our interventions gave opportunities for them to be involved in their child’s treatment, and this could have helped them feel closer to their child. That fathers’ involvement promotes many aspects of children’s development is in no doubt (Fabiano, 2007). For mothers, whose “success” is deemed to be reflected in the “success” of their child (Chao, 1994), an increased sense of competence that was associated with perceiving their child’s behaviors to be “just like other children of the same age” is understandable. Parents’ improved sense of competence has been shown to be associated with more favorable ADHD outcomes (Johnson, Mah, & Regambal, 2010). Our findings also echoed that of Heath et al. (2015) in the context of behavioral parent training, where it was the “clinical significance of ADHD symptom reduction” rather than the magnitude per se that was most relevant to improvements in parenting self-efficacy. The benefits found in our study, if replicated and sustained, are important because they contribute to a more favorable developmental trajectory for children with ADHD, and lend support to the use of MFT as adjunct treatment.

However, parenting stress ratings remained unchanged in the postintervention phase. Studies that explored the relationship between parenting stress and ADHD found that while parents of children with ADHD experienced higher parenting stress than parents of typically developing children, the coexistence of externalizing and oppositional behaviors, executive function deficits, as well as parental ADHD also contributed to parenting stress (Hutchinson, Feder, Abar, & Winsler, 2016; Wiener, Biondic, Grimbos, & Herbert, 2016). Because our MFT program and psychoeducational talk did not address these co-existing conditions, it could be one of the reasons for parenting stress to be unchanged. Future MFT interventions should widen its focus and address externalizing problems and executive function deficits in its activities, while parental ADHD should also be assessed.

Our study was a preliminary effort in exploring the gender effects of psychosocial interventions in a Chinese context. Several limitations in the study need to be considered when interpreting the results. First, the experimental and control groups were not randomly assigned—Parents chose for themselves which intervention they wished to join. The positive changes observed in the MFT group could reflect the parents’ receptiveness of a family approach and openness toward discussing their difficulties, and is a positively biased response. Second, the sample size was relatively small. A larger sample and randomized design is needed to replicate the findings. Third, the follow-up duration was short—a longer follow-up period is needed to study the sustainability of the changes. Fourth, the MFT program only ran for 4 days, which was a relatively short course. The outcome might have been different if there were more sessions. However, in our planning stage, we were concerned that families might not be ready to commit to more sessions and might lead to dropout. Given our preliminary results, more sessions and wider focus to address externalizing problems and executive skills deficits in addition to ADHD symptoms should be considered in future studies. It would also have been informative to carry out structured postintervention interviews with the parents so as to obtain more understanding of, for example, how attending MFT changed the parents’ perception of their child’s ADHD symptoms, and how the father–child relationship was experienced and improved after attending either of the interventions. In addition, because only participating parents were asked to complete the questionnaires, we do not know if similar changes could have been perceived by the nonparticipating parent in the family, that is, whether the insights gained by the participating parent was transferred to the nonparticipating parent. Finally, children in this study were in their preadolescence. Whether MFT is effective in the adolescence period remains unknown. Parents have to face a different set of challenges when their children with ADHD enter adolescence, and it is relevant to examine whether MFT is effective in this older age group.

Overall, although this is a relatively small study, findings serve to highlight some important implications in the management of children with ADHD. First of all, MFT was efficacious in reducing both fathers’ and mothers’ perception of the severity of their child’s ADHD symptoms. Second, fathers and mothers experienced different gains from attending MFT—fathers perceived an improvement in father–child relationship, while mothers gained in sense of competence when they were able to see their child in a less pathological light. These positive changes are significant because they contribute to a more favorable developmental trajectory for children with ADHD. We suggest that MFT as an adjunct treatment for children with ADHD should be further studied and developed. Finally, the involvement of fathers in their child’s treatment is important and should be encouraged and facilitated.

Footnotes

Acknowledgements

The authors would like to thank Dr. Erica S. F. Wan and Ms. Julia Lo of the Department of Social Work, Chinese University of Hong Kong; for their role as MFT therapists.

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: The Research Grants Council (RGC) of Hong Kong financially supports this study (RGC Ref No CUHK449012).

Author Biographies

Kelly Y.C. Lai, MBBS, MRCPsych, is head of the Child and Adolescent Psychiatry Unit and associate professor in the Department of Psychiatry of the Chinese University of Hong Kong.

Joyce L. C. Ma, PhD R. S. W., is a clinical fellow & approved supervisor of the American Association for Marriage and Family Therapy, and professor of the Department of Social Work, The Chinese University of Hong Kong.

Lily L.L. Xia is post-doctoral fellow of the Department of Social Work of the Chinese University of Hong Kong.

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