Mindfulness-Enhanced Behavioral Parent Training for Clinic-Referred Families of Children With ADHD: A Randomized Controlled Trial

Abstract

Objective: This study evaluated the efficacy of a mindfulness-enhanced behavioral parent training (BPT) group program compared to standard BPT in families of children with ADHD. Method: Parents (N = 63) of children (aged 6–11) diagnosed with ADHD were randomly assigned to either mindful or standard BPT, and participated in 12 weekly 2-hr group sessions. Parents completed a series of questionnaires assessing mindful parenting, parenting stress, harsh discipline practices, behavioral dysregulation, and child ADHD symptoms, before and after completing the group intervention. Results: Parents in the mindful group had decreased harsh discipline practices and improved self-regulation compared to parents in the standard group. Both groups improved in parenting sense of competence and child ADHD symptoms. No significant group differences were found in mindful parenting or parenting stress. Conclusion: There are some important parental benefits to enhancing BPT with mindfulness.

Keywords

behavioral parent training mindfulness ADHD randomized controlled trial parenting

Introduction

Behavioral parent training (BPT) is a widely used, evidence-based treatment for families of children with ADHD (Daley et al., 2018; Pelham & Fabiano, 2008). In BPT, parents learn to increase appropriate child behavior through the use of praise, directed attention, and tangible rewards. Inappropriate child behaviors are decreased by having parents use planned ignoring, removal of privileges, and natural/logical consequences in a calm and neutral way. Research has demonstrated that BPT programs decrease parent-reported child behavior problems and observed parent and child negative behaviors (Kaminski & Claussen, 2017). However, the ability of BPT programs to be maximally effective remains limited by a variety of factors, such as parental psychopathology and environmental stressors (Weisenmuller & Hilton, 2021). Furthermore, it has been proposed that parental ability to implement the BPT skills effectively is impaired by parental emotional dysregulation (Maliken & Katz, 2013).

Parenting a child with ADHD is associated with higher levels of negative emotions (Corcoran et al., 2017; Fischer, 1990) and higher levels of parenting stress (Deault, 2010), which in itself increases the need for more self-regulation among these parents. Emotionally dysregulated parents are more likely to engage in overreactive and dysfunctional discipline behaviors with their children (e.g., yelling, losing control, making hurtful or critical comments, cursing, holding grudges) (Zhang et al., 2020). This is concerning because coercive (i.e., harsh and critical) parenting can lead to the development of dysfunctional parent–child relations and to the development of externalizing behavior problems in children (Prinzie et al., 2006; Wiggins et al., 2015). Adding to higher levels of negative emotions, parenting stress, and harsh parenting practices, the high heritability of ADHD (Thapar et al., 2007) suggests that many parents of children with ADHD also have problems with self-regulation of their affect, behavior, and emotions. Thus, the need for these parents to address their own self-regulation is greater than for typical parents. Moreover, these coercive and maladaptive patterns of parent–child interactions are reinforced and habitual over time, such that parental responses become automatized and highly resistant to change (Dumas, 2005; Snyder, 2016).

Mindfulness training, which focuses on attention regulation (i.e., increasing awareness of the present moment), acceptance, and nonjudgmental observation, has been proposed as a method to specifically target emotional regulation and automatic responding in parents and to enhance the effectiveness of standard behavioral parent training (SBPT) programs (Dumas, 2005). Mindful parenting involves full attention and awareness of child cues, nonjudgmental acceptance of parent and child expectations, identification of strong emotions that could ignite automatic cognitive and behavioral patterns, self-regulation in parental responding, and compassion for self and child (Duncan et al., 2009). A model of mindful parenting (Duncan et al., 2009) proposes that parental mindfulness cultivates parenting capacity and well-being, which contributes to improved parenting practices and parent–child relationships, which in turn enhances child outcomes. Thus, it has been suggested that standard BPT programs that focus on improving parenting practices can be additionally enhanced with parental mindfulness, particularly for ADHD within families (Cassone, 2015).

Mindfulness-based interventions have been incorporated into cognitive-behavioral approaches and been shown to improve emotional regulation among adults (Eberth & Sedlmeier, 2012; Gu et al., 2015). Reviews of mindfulness-based interventions for child and adult ADHD have shown positive effects on core ADHD symptoms (Cairncross & Miller, 2016; Evans et al., 2018). Preliminary research suggests that mindfulness may be an effective way to improve parental self-regulation as well. Parents of children and youth with ADHD that attended an 8-week mindfulness parenting group program (MYmind), concurrently with a child/youth mindfulness program, had significantly lower levels of parenting stress and overreactivity at the end of treatment compared to baseline (Haydicky et al., 2015; van de Weijer-Bergsma et al., 2012; van der Oord et al., 2012). Parental functioning effects were stronger at 6- to 8- week follow-up. The studies were limited by small sample sizes (less than 25), lack of control group or lack of randomization to groups, and non-blind raters.

Research is sparse in combining mindfulness and standard BPT approaches. To date, there are only two known published studies examining the effectiveness of enhancing parent training with mindfulness compared to standard BPT. Coatsworth and colleagues (2014) used a randomized controlled design to test the effects of a mindfulness-enhanced behavioral intervention among parents and youth aged 12 to 13 years, who were recruited from schools and communities. They found that the mindfulness-enhanced program improved mindfulness (e.g., emotional awareness of youth), parent–youth relationship quality (e.g., positive approach to emotions, more understanding), and youth behavior management (e.g., inductive reasoning, monitoring), particularly for fathers compared to mothers. Effects were generally stronger at the 1-year follow up. However, they did not specifically recruit for families of youth with ADHD.

A more recent randomized controlled study compared a traditional program of 10 to 12 sessions of BPT with nonviolent resistance to a program with the same BPT intervention but enhanced with one session of mindfulness training for families of children aged 6 to 15 years with ADHD and child behavior problems (Gershy et al., 2017). As expected, both interventions resulted in reductions in child externalizing symptoms. They also found that both interventions reduced emotional dysregulation in parents, particularly for fathers in the mindfulness-enhanced parent group. However, the interventions were delivered in an individual, rather than group, format and may have had insufficient dosage of mindfulness instruction and practice because there was only one 90-min session of mindfulness among the 10- to 12-sessions of behavioral intervention.

Our study aims to evaluate the incremental effectiveness of a mindfulness-enhanced group parent training program to improve parenting outcomes in families of children with ADHD. We predicted that, in comparison to parents in the SBPT group who would improve from preintervention to postintervention, parents in the mindfulness-enhanced behavioral parent training (MBPT) group would have even greater improvements in self-regulation and sense of competence, and lower levels of stress and harsh parenting practices at postintervention compared to preintervention.

Method

Participants

Sixty-three parents of children between the ages of 6 and 11 years participated. Parents were recruited from the ADHD clinic at the local tertiary children’s hospital. As part of standard clinical care, families had received a psychiatric assessment conducted by psychiatrists or psychologists. This consisted of a clinical interview with parents/guardians and review of parent and teacher rating scales of child attention and behavior (that is, Weiss Symptom Record; Weiss, 2010), along with relevant documentation (such as report cards). The assessment confirmed child ADHD diagnosis based on criteria from the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013). Parents of children who had an intellectual disability, psychosis, or pervasive developmental disorder, as well as parents who did not speak and understand English, were excluded. Prior engagement in BPT intervention was not an exclusion criteria.

Interested and eligible parents were randomly assigned to one of two parallel groups: standard BPT or mindful BPT. To maintain balanced groups, participants were block randomized based on medication status and gender of their child. Refer to Figure 1 for details regarding randomization participant flow. The final sample size was 63, with 34 and 29 parents in the MBPT and SBPT groups, respectively.

Figure 1.

Summary of participant flow.

On average, the sample consisted predominantly of mothers around 40 years of age. The majority of parents were married or common-law and highly educated. Most participating parents had sons with ADHD with an average age of 9 years. At pretreatment, 31.7% of children had a combined presentation, 28.6% had a predominantly inattentive presentation, and 6.3% had a predominantly hyperactive-impulsive presentation. Of those taking medication at pretreatment, 68.5% were on long-acting stimulants (e.g., Biphentin, Concerta, Adderall), 7.9% were on intermediate or short-acting stimulants (e.g., Dexedrine, Ritalin), 21.1% were on non-stimulant medications for ADHD (e.g., Atomoxetine, Guanfacine), and 2.5% were on medications for anxiety or mood (e.g., Fluoxetine). 28.6% of families had reported taking a parenting class before, and although they did not specify if it was specific to BPT, those families attended an average of only 2.31 sessions (SD = 0.70), an average of 2.06 years ago (SD = 1.20), with 52.9% attending at least 3 or more years ago. Refer to Table 1 for more demographic details.

Table 1.

Demographic Characteristics.

N = 63	Variable	SBPT group		MBPT group		Statistic
N = 63	Variable	(%)	M (SD)	(%)	M (SD)	Statistic
Child age			9.2 (2.6)		9.3 (1.3)	t(1, 58) = −0.094, p = .925
Child gender	Female	20.7		26.5		χ²(1) = .288, p = .591
Child gender	Male	79.3		73.5
Child baseline ADHD total symptom level			29.48 (10.30)		32.65 (11.24)	t(1, 61) = −1.157, p = .252
Child ADHD presentations	Combined	37.9		41.2		χ²(3) = 3.787, p = .285
	Inattentive	24.1		38.2
	Hyperactive-impulsive	3.4		5.9
	Subthreshold	34.5		14.7
Child medication	Yes	34.4		44.1		χ²(1) = .607, p = .436
Child medication	No	65.5		55.9
Child comorbidities	Aggression		19.97 (3.56)		20.97 (5.04)	t(1, 61) = 0.834, p = .407
	Conduct problems		16.03 (3.31)		15.94 (3.28)	t(1, 61) = −0.112, p = .911
	Anxiety		26.48 (6.69)		27.82 (7.17)	t(1, 61) = 0.763, p = .449
	Depression		25.14 (4.79)		25.03 (5.94)	t(1, 61) = −0.079, p = .937
Parent age			40.9 (7.3)		41.0 (7.4)	t(1, 61) = −0.119, p = .905
Parent gender	Female	85.7		94.1		χ ²(1) = 1.240, p = .265
Parent gender	Male	14.3		5.9
Ethnicity	White	72.4		76.5		χ²(2) = 0.392, p = .822
	East Asian	13.8		14.7
	Other	13.8		8.8
Marital status	Married/common-law	82.8		88.2		χ²(1) = 0.383, p = .536
Marital status	Single/widowed/separated/divorced	17.2		11.8
Parent education	High school or equivalent	10.3		5.9		χ²(4) = 7.883, p = .096
	Trade school	0		5.9
	Some college/university	13.8		23.5
	College/university degree	58.6		29.4
	Graduate school	17.2		35.3
Household income	<US$50,000	12.5		15.2		χ²(3) = 5.464, p = .141
	US$50,000–US$99,999	20.8		30.3
	US$100,000–US$149,999	50.0		21.2
	≥US$150,000	16.7		33.3

Note. SBPT = standard behavioral parent training; MBPT = mindfulness-enhanced behavioral parent training.

Procedures

All parents, in both the SBPT and MBPT groups, attended 12 consecutive weeks of 2-hr group treatment sessions. Each group consisted of approximately 10 to 12 participants. In SBPT, parents learned about ADHD and techniques to manage child behavior, such as child-centered play, differential attention, incentive charts, collaborative problem-solving, and limit setting. Content was adapted from established BPT programs such as the Community Parent Education Program (COPE; Cunningham et al., 2009), and Incredible Years (Webster-Stratton, 2006), as well as ADHD-specific content from Barkley (2013) and the Center for Children and Families (n.d.). Each SBPT session involved (a) 40-min group check-in about home practice and trouble-shooting, (b) 20-min presentation of new topic, (c) 10-min break, (d) 20-min video review and discussion (using videos from the COPE program that presents parenting errors and group discussion to identify mistakes and alternative strategies), and (e) 30 min of addressing questions and preparing home practice assignment. Parents in the mindful BPT group received a full session on mindfulness in the second session, along with learning a variety of formal (i.e., longer planned meditations) and informal (i.e., quick attention to daily activities) mindfulness techniques (e.g., 3-min SOBER coping space, mindful walking, body scan, meta compassion) in every subsequent session, before learning the same child behavior management techniques as the standard BPT group. The mindfulness components were drawn from mindfulness-based cognitive therapy (MBCT; Segal et al., 2002) and mindfulness-based stress reduction (MBSR) and its application to mindful parenting (Kabat-Zinn, 1990). Thus, the mindfulness component of the MBPT intervention in this study presented standard mindfulness exercises from MBCT and MBSR, whereas previous mindfulness interventions for parents have emphasized mindful parenting dimensions and activities more specifically. Each MBPT session involved (a) 30-min group check-in about home practice and trouble-shooting, (b) 30-min mindfulness exercise and discussion, (c) 10-min break, (d) 20-min presentation of new topic, and (e) 30 min of addressing questions and preparing home practice assignment. Thus, the MBPT group received 1 session plus 30 min more time per session on mindfulness, whereas the SBPT group received 1 session plus 30 min more time per session on review and discussion of behavior management. Refer to Table 2 for an overview of the weekly session content for the two treatment groups.

Table 2.

Overview of Treatment Session Content.

Session number	Standard BPT	Mindful BPT
1	Introductions and ADHD overview	Introductions and ADHD and mindfulness overview
2	Executive functioning and school strategies	More about mindfulnessRaisin exercise; body scan
3	Child-centered play	Sitting meditation + executive functioning and school strategies
4	Effective commands	SOBER coping space + child-centered play
5	Ignoring	STOP autopilot + commands
6	Incentive charts	Body scan + ignoring
7	Troubleshooting	Sitting meditation + incentives
8	Collaborative problem solving	Meta compassion + troubleshooting
9	Consequences	Listening meditation + collaborative problem-solving
10	Time-out	Turning toward negative space + consequences
11	Wrap-up	Body scan and SOBER + time-out
12	Review	Walking meditation + wrap-up

Note. BPT = behavioral parent training.

Two trained clinicians facilitated each group. Each group consisted of at least one doctoral-level clinical psychologist who was experienced in BPT, through their clinical doctoral training. The mindfulness-enhanced component was delivered by clinicians with formal training in mindfulness, which included, at minimum, a 5-day MBCT professional training and an 8-week MBSR online course. Both mindful and standard BPT groups were run concurrently. Thus, there were four facilitating clinicians (i.e., two dyads, each consisting of a psychologist and a mental health professional, that is, psychiatrist or occupational therapist), during each round of groups. Clinicians were assigned to group conditions in counterbalanced order, to ensure that each round of groups was not run by the same pair of clinicians. Standardized manuals of the interventions were used for both groups. All sessions were audiotaped, and 20% of the sessions were randomly selected for auditing by research assistants, which revealed a high degree of treatment fidelity (90% for the MBPT intervention and 93% for the SBPT intervention). Twenty percent of the audited sessions were double-coded, and inter-rater reliability for the fidelity coding was high at 94.4%.

Measures

All participants completed a number of questionnaires at preintervention, and the same questionnaires at postintervention. Participants completed measures online via Research Electronic Data Capture (REDCap), an application for building and managing online surveys and databases quickly and securely (Harris et al., 2009). Participants received an honorarium of CAD$20 for completing the pregroup and postgroup questionnaires.

Demographics and background

Demographic characteristics (e.g., age, gender, marital status, ethnicity, household income, child medication status) were gathered on this questionnaire. Comorbid conditions (i.e., aggression, conduct problems, anxiety, depression) in the child was measured using the Behavior Assessment System for Children–Second Edition (BASC-2; Reynolds & Kamphaus, 2004), Parent Rating Scales.

Parenting outcomes

Four questionnaires were used to assess parenting outcomes regarding mindful parenting, parenting efficacy, parenting stress, and parenting practices. The Interpersonal Mindfulness in Parenting Scale (IEM-P; Duncan, 2007) is a 10-item questionnaire that measures parents’ present-centered attention, emotional awareness, nonjudgmental openness, and nonreactivity toward their children during parenting interactions. Items are rated on a 5-point Likert-type scale, with higher total scores reflecting more mindfulness in parenting. Previous studies have demonstrated the reliability and validity of the IEM-P (Coatsworth et al., 2014; Duncan, 2007). Internal consistencies for the subscales ranged from 0.42 to 0.68, and 0.73 for the total score, which are consistent with those found in previous studies. Only the total score was used for this study.

The 7-item Efficacy subscale was used from the Parenting Sense of Competence (PSOC; Johnston & Mash, 1989) scale. It is rated on a 6-point scale, with higher scores reflecting greater sense of parenting efficacy.

The Parenting Stress Index–short version (PSI-SF; Abidin, 1995) was used, and two of the three subscales were included in this study: Parental Distress and Parent–Child Dysfunctional Interaction. There are 24 items, rated on a 5-point Likert-type scale, with higher scores reflecting more parenting stress.

The Parenting Scale (PS) is a 30-item measure that assesses parenting discipline practices using three subscales: Laxness, Overreactivity, and Verbosity (Arnold et al., 1993). The total score was used in this study as a measure of harsh parenting practices. Items are rated on a 7-point scale, with higher total scores reflecting dysfunctional parenting behaviors that play a key role in coercive interactions. Based on this measure’s scoring instructions, the clinical cut-off for the total score is 3.1, and the normal range starts at a total score of 2.6.

Self-regulation

The Behavior Rating Inventory of Executive Function–Adult Version (BRIEF-A; Roth et al., 2005) is a 75-item self-report measure of executive functioning in adults. Only the Behavioral Regulation Index (i.e., Inhibit, Shift, Emotional Control, Self-Monitor) was included in this study as a measure of parental behavioral dysregulation. Items are rated on a 3-point Likert-type scale, with higher scores reflecting greater executive dysfunction. This measure uses T-scores, with scores of 50 and under reflecting the normal range, scores of 60 and above reflecting the clinical range, and scores of 51 to 59 reflecting the borderline clinical range.

Child outcome

The ADHD Rating Scale-IV (ADHD-IV; DuPaul et al., 1998) is an 18-item measure of child inattentive and hyperactive-impulsive symptoms. Items are rated on a 4-point Likert-type scale, with higher scores indicating greater difficulties in ADHD symptoms.

Group engagement

Six items from the Treatment Evaluation Inventory–Short Form (TEI-SF; Kelley et al., 1989) was used to assess parental acceptability of the group intervention. Items are rated on a 5-point Likert-type scale, with higher scores indicating greater treatment acceptability.

Clinicians completed weekly ratings, using a 4-point scale (0: none to 3: maximal), of each participant’s (from both the SBPT and MBPT groups) homework completion of parenting strategies based on parental report during check-in at the beginning of each weekly session. Clinicians also completed weekly ratings of each participants’ in-session engagement using a 4-point scale (0: none to 3: maximal), as well as marked attendance. Parents in the MBPT group were asked to provide weekly ratings (0: none, 1: once/twice this week, 2: a few times this week, 3: daily) of the frequency of using informal quick mindful practices (e.g., 1-min breathing space) versus formal planned meditations (e.g., 10-min body scan).

Analysis

Available case analysis was used, such that participants without observed outcomes (i.e., those who dropped out and did not complete the posttreatment data) were excluded. This study had 28.4% of missing data, which are classified as “missing at random” as it is unrelated to the study intervention, measurements, or observed variables (Rubin, 1976). However, intent-to-treat analysis was not used, as no recommendation regarding imputation can be made for trials with missing data exceeding 20% (Armijo-Olivo et al., 2009).

A series of mixed analyses of variance (ANOVAs) were conducted with one between-subjects grouping factor (MBPT group vs. SBPT group) and one within-subject repeated measures factor (preintervention vs. postintervention time point) on mindfulness, parental distress, parent–child dysfunctional interaction, PSOC, harsh discipline practices, parents’ behavioral dysregulation, and child ADHD. Follow-up tests of the interaction looked at the effect of time for each treatment group. Partial eta-square (η²) is reported as the measure of effect size for ANOVAs, with standard interpretations of the magnitude scale as follows: .01 small, .06 medium, and .14 as large (Cohen, 1988). The Benjamini–Hochberg procedure was used to correct for multiple comparisons (Thissen et al., 2002). This method controls the false discovery rate, which we set to 10% in this study, such that 10% of the significant results would be considered false positives. The technique detailed by McDonald (2015) was used to determine which p values were significant after controlling for the false discovery rate. Only the controlled significant interactions were reported in this study. One-way ANOVAs were conducted to examine treatment differences on group engagement (treatment acceptability, attendance, homework completion, and session engagement).

To examine clinical significance of statistically significant group differences in outcomes, two approaches were used: (a) reliable change index (RCI) to determine that the magnitude of change is statistically reliable, and (b) anchor criterion based on scoring norms to show movement from a clinical to more normative range of functioning. Logistic regressions and chi-square analyses were used to compare the two approaches of clinical significance between treatment groups, respectively. All analyses were conducted using SPSS version 24.

Results

Group Differences at Pretreatment

No pretreatment differences between groups on any of the dependent measures or demographic data were found (see Table 1).

Relationships Between Outcomes

A series of independent correlations among outcome variables at postintervention are presented in Table 3. Results were collapsed across both the SBPT and MBPT groups. Of note, mindful parenting was significantly and negatively related to harsh parenting practices, parenting distress, and parents’ behavioral dysregulation and approached significance and positively related to parental sense of competence.

Table 3.

Correlations Among Outcome Variables.

Variable	1	2	3	4	5	6	7
1. Mindful parenting	—	−0.511p = .000	−0.344p = .006	−0.033p = .79	0.246 p = .052	−0.428p = .001	0.007p = .96
2. Parenting practices		—	0.462p = .000	0.353p = .005	−0.176p = .168	0.440p = .000	0.145p = .257
3. Parental distress			—	0.400p = .001	−0.411p = .001	0.359p = .004	0.261p = .385
4. Parent–child dysfunction				—	−0.129p = .313	0.086p = .502	0.294p = .019
5. Parenting sense of competence					—	−0.195p = .125	−0.092p = .473
6. Behavioral dysregulation						—	0.152p = .235
7. Child ADHD							—

Note. Correlations in bold are significant; correlations in italics are approaching significance.

Group Differences in Outcomes

Mean scores and standard deviations for the dependent variables are presented in Table 4, in addition to significant post hoc group comparisons.

Table 4.

Outcomes Between Groups and Across Time.

Variable	Group	PreinterventionM (SD)	PostinterventionM (SD)	Main effects of time	Main effects of group	Interaction effects
Mindful parenting	Mindful	26.7 (3.70)	28.00 (3.50)	F(1, 61) = 0.008, p = .931, η² = .000	F(1, 61) = 2.700, p = .106, η² = .012	F(1, 61) = 1.888, p = .174, η² = .030
Mindful parenting	Standard	27.4 (2.98)	27.4 (2.76)	F(1, 61) = 0.008, p = .931, η² = .000	F(1, 61) = 2.700, p = .106, η² = .012	F(1, 61) = 1.888, p = .174, η² = .030
Parental distress	Mindful	30.41 (7.15)	29.15 (8.12)	F(1, 61) = 0.325, p = .571, η² = .004	F(1, 61) = 0.087, p = .769, η² = .000	F(1, 61) = 1.392, p = .243, η² = .022
Parental distress	Standard	30.45 (9.28)	31.34 (9.76)	F(1, 61) = 0.325, p = .571, η² = .004	F(1, 61) = 0.087, p = .769, η² = .000	F(1, 61) = 1.392, p = .243, η² = .022
Parent–child dysfunctional interaction	Mindful	29.79 (8.08)	28.12 (6.94)	F(1, 61) = 0.709, p = .40, η² = .010	F(1, 61) = 0.341, p = .56, η² = .001	F(1, 61) = 3.749, p = .057, η² = .058
Parent–child dysfunctional interaction	Standard	29.97 (7.37)	31.03 (8.70)	F(1, 61) = 0.709, p = .40, η² = .010	F(1, 61) = 0.341, p = .56, η² = .001	F(1, 61) = 3.749, p = .057, η² = .058
Parenting sense of competence	Mindful	26.09 (7.25)	29.74 (5.28)	F(1, 61) = 0.034, p = .855, η² = .000	F(1, 61) = 11.136, p = .001, η² = .044	F(1, 61) = 1.614, p = .209, η² = .026
Parenting sense of competence	Standard	26.86 (6.24)	28.44 (6.70)	F(1, 61) = 0.034, p = .855, η² = .000	F(1, 61) = 11.136, p = .001, η² = .044	F(1, 61) = 1.614, p = .209, η² = .026
Harsh parenting practices	Mindful	3.43 (0.55)	2.93 (0.62)***	F(1, 61) = 0.294, p = .59, η² = .003	F(1, 61) = 26.63, p = .001, η² = .092	F(1, 61) = 4.68, p = .034, η² = .071
Harsh parenting practices	Standard	3.34 (0.49)	3.03 (0.60)	F(1, 61) = 0.294, p = .59, η² = .003	F(1, 61) = 26.63, p = .001, η² = .092	F(1, 61) = 4.68, p = .034, η² = .071
Behavioral dysregulation	Mindful	46.147 (1.31)	43.647 (1.54)*	F(1, 61) = 0.042, p = .839, η² = .001	F(1, 61) = 0.055, p = .815, η² = .000	F(1, 61) = 12.906, p = .001, η² = .175
Behavioral dysregulation	Standard	42.828 (1.42)	46.172 (1.67)**	F(1, 61) = 0.042, p = .839, η² = .001	F(1, 61) = 0.055, p = .815, η² = .000	F(1, 61) = 12.906, p = .001, η² = .175
Child ADHD	Mindful	32.65 (11.24)	29.26 (11.58)	F(1, 61) = 0.671, p = .416, η² = .011	F(1, 61) = 4.826, p = .032, η² = .073	F(1, 61) = 0.941, p = .336, η² = .011
Child ADHD	Standard	29.48 (10.30)	28.17 (11.18)	F(1, 61) = 0.671, p = .416, η² = .011	F(1, 61) = 4.826, p = .032, η² = .073	F(1, 61) = 0.941, p = .336, η² = .011

p < .05. **p < .01. ***p < .001, denotes a significant post hoc comparison.

Parenting outcomes

Regarding mindful parenting, there was no evidence of a significant main effect, nor a group by time interaction. In terms of parenting distress, there was no evidence of a significant main effect, nor a group × time interaction. Similarly, there was no evidence of a significant main effect, nor group × time interaction effect for parent–child dysfunctional interaction. For PSOC, there was a significant main effect where both groups improved postintervention. However, there was no evidence of a significant group × time interaction.

In terms of harsh parenting practices, there was a significant main effect, and an interaction between treatment group and time. For MBPT, the simple main effect was significant, F(1, 61) = 27.655, p < .001, η² = .312, and post hoc comparisons revealed that parents in the MBPT group reported a reduction in harsh parenting practices from preintervention to postintervention. For SBPT, the simple main effect was not significant, F(1, 61) = 3.655, p < .001, η² = .057, indicating that those in the SBPT group did not differ in parenting scores from preintervention to postintervention. This is presented in Figure 2. Using the RCI, there was a significant association between the treatment approach and treatment response, χ²(1) ≥ 6.784, p = .009, such that the odds of parents significantly and reliably changing their parenting practices were 4.73 times higher if they were in the mindful BPT group than if in standard BPT. Furthermore, a marginally greater proportion of parents in the MBPT group (23.5%) than those in SBPT (3.8%) moved from the clinical range of using harsh parenting practices at pretreatment to the normal range at posttreatment, χ²(1) = 3.482, p = .062.

Figure 2.

Interaction between intervention group and time on harsh parenting practices.

In terms of parents’ behavioral regulation, a significant main effect was not present, while a significant group × time interaction was present. For MBPT, the simple main effect was significant, F(1, 61) = 5.129,p = .027, η² = .078, with post hoc comparisons indicating improved behavioral dysregulation following intervention for the MBPT group. For SBPT, the simple main effect was significant, F(1, 61) = 7.832, p = .007, η² = .114, and post hoc comparisons indicated that the behavioral regulation scores in the SBPT group worsened from preintervention to postintervention. This is shown in Figure 3. Using the RCI, there was a significant association between the treatment approach and treatment response, χ²(1) ≥ 8.142, p = .004, such that the odds of parents significantly and reliably changing their behavioral regulation skills were 11.25 times higher if they were in the mindful BPT group than if in standard BPT. Furthermore, there was a trend toward a greater proportion of parents in the MBPT group (17.6%) than those in SBPT (3.6%) who moved from the borderline clinical range of behavioral dysregulation at pretreatment to the normal range at posttreatment, χ²(1) = 3.745, p = .053.

Figure 3.

Interaction between intervention group and time on parents’ behavioral dysregulation.

Child outcome

For child ADHD symptoms, there was a significant main effect, which showed that child ADHD symptoms improved from preintervention to postintervention across both groups, while there was no significant group × time interaction.

Group Engagement

Both groups had high treatment acceptability (M = 4.38, SD = 0.42), attendance (M = 10.30, SD = 1.56), homework completion (M = 2.11, SD = 0.63), and session engagement (M = 2.45, SD = 0.56), with no significant group differences found on these variables, t(61) = −0.234, p = .816, t(61) = .685, p = .496, t(61) = −0.520, p = .605, t(61) = −0.013, p = .990, respectively.

Among the MBPT group, parents reported significantly more frequent use of informal quick mindfulness practices throughout the week (M = 1.95, SD = 0.58) than formal long mindful meditations (M = 1.27, SD = 0.59), t(20) = −5.62, p < .001. The types of mindfulness practice engaged at home were not significantly correlated to mindful parenting (e.g., awareness, non-reactivity, nonjudgment). Frequency of using informal quick mindfulness was not significantly correlated with any parenting or child outcomes at posttreatment, whereas the frequency of using formal meditations was significantly and inversely related to levels of harsh parenting practices at posttreatment (r = −.495, p < .05), but not to other outcomes (e.g., parental distress, parent–child dysfunctional interactions, PSOC, behavioral dysregulation, and child ADHD symptoms).

Discussion

This study is among the first to compare the efficacy of a mindfulness-enhanced versus a standard BPT group interventions among families with child ADHD. Both groups were equally efficacious at improving child ADHD symptoms and parenting sense of competency. This result replicates prior research that has established positive effects of BPT for families of children with ADHD. As predicted, mindfulness-enhanced BPT improved parental harsh discipline practices and parents’ own behavioral regulation, beyond standard BPT. However, no significant group differences were found in mindful parenting, or in parenting distress or parent–child dysfunctional interactions.

Parenting and Child Outcomes

As predicted, parents in the MBPT group significantly improved in their parenting discipline practices (e.g., less reactive) and self-regulation (e.g., able to inhibit, shift flexibly, control emotional responses, and self-monitor), compared to those in the SBPT group. This is consistent with the aforementioned previous literature showing positive impacts of mindfulness on parenting and self-regulation, but our findings extend further by showing that these outcomes are even better than those of standard behavioral parent intervention. In fact, parents in the SBPT group showed a significant increase in behavioral dysregulation after intervention. This adverse effect in SBPT may be related to the strong emotions elicited while parents attempt to engage in BPT skills (e.g., active ignoring) (Allan & Chacko, 2018), and we have shown that enhancing BPT with mindfulness can be a promising way to reverse this deterioration in self-regulation and further enhance parenting skills. Previous research has supported the key contribution of mindfulness skills associated with nonreactivity on emotion regulation and psychological well-being (e.g., Heeren et al., 2015; Iani et al., 2018). Improvement in harsh parenting practices, including overreactivity, through mindfulness supports the incremental utility of mindfulness to target automatic, overreactive responding in parents, which helps to disrupt the coercive cycle of parent–child interaction patterns. Furthermore, our study found positive impacts of mindfulness among a sample of predominantly mothers, whereas previous literature found more significant impacts on fathers (e.g., Coatsworth et al., 2014; Gershy et al., 2017). We did not have enough fathers participating to compare parental gender differences in our sample, but our study differed from previous literature by using a sample of parents of kids with ADHD with a focus on behavioral outcomes rather than relationship outcomes, as well as incorporating a higher dosage of mindfulness training (i.e., 30 min across every session rather than a single 90-min session).

On the other hand, mindfulness-enhanced BPT did not significantly enhance feelings of parenting confidence, or improve child ADHD symptoms, over and above the positive effects of standard BPT. This speaks to the strength of the standard BPT approach without the need for enhancements, which is consistent with a review by Chronis and colleagues (2004) stating that adjunctive enhancements to BPT are more likely to affect parental impairment in the specific area targeted by the enhancement, rather than directly affecting child behavior.

Our study also did not show the predicted improvements in parenting stress among either group. This is inconsistent with previous literature that have shown positive effects of mindfulness or parent training independently on parenting stress (e.g., Campbell et al., 2017; Heath et al., 2015). Parents in our sample reported parenting stress levels within the normative range even at preintervention. Our sample showed a relatively high level of familial socioeconomic status (e.g., level of education, household income, dual parent families), which is often associated with lower levels of parenting stress (Conger et al., 2010). In addition, compared to another study that explored the effects of parent training on parenting stress within families of children with ADHD (Heath et al., 2015), the sample in our study consisted of a higher percentage of children not on medication. Given that pharmacological treatment for child ADHD has an equally significant impact on parenting stress as BPT (Theule et al., 2018), it is possible that the lower proportion of families receiving ADHD medication may have reduced the impact on parenting stress among our sample. When examining the sample together, our study did find that higher levels of mindful parenting were significantly associated with lower levels of parenting distress at posttreatment. This is similar to previous findings of a negative correlation between pretest mindful parenting and posttest parenting stress (Haydicky et al., 2015).

Mindfulness

Contrary to expectations, MBPT did not significantly improve mindful parenting compared to SBPT over time. This contrasts findings from previous studies (e.g., Haydicky et al., 2015), which found mindfulness training improved mindful parenting from pretreatment to posttreatment. These studies differed from our current study in four key aspects: (a) treatment content was only on mindfulness, rather than combined with BPT; (b) mindfulness exercises included emphasis on family and parenting topics (e.g., morning stress and compassion meditation, role plays on parent–child interactions), rather than standard MBCT or MBSR practices; (c) concurrent child or youth mindfulness training, rather than parent-only intervention; and (d) used a different measure of mindfulness (e.g., Mindful Attention Awareness Scale; Brown & Ryan, 2003), rather than a brief version of mindful parenting. Thus, future MBPT programs could investigate the effects of mindfulness dosage, but literature reviews have generally found inconsistent associations between mindfulness dosage and treatment outcomes (e.g., Khoury et al., 2013; Metcalf & Dimidjian, 2014). Future studies could also compare among mindfulness training alone, parenting-enhanced mindfulness (e.g., MYmind program), and mindfulness-enhanced BPT, with and without concurrent child/youth intervention. The measure of mindful parenting used in this study was brief, with low internal consistencies in the subscales. A longer version of this measure has been developed to correspond to the five dimensions proposed in the model of mindful parenting (Duncan et al., 2009). The longer version has shown stronger reliability and good validity and may be more sensitive to treatment effects compared to the short version (de Bruin et al., 2014).

Parents in the MBPT group reported more frequent practicing of informal, quick mindfulness exercises a few times weekly (e.g., 1-min breathing space, mindful driving), rather than formal, long mindful meditations (e.g., guided 10-min body scan), which were reported to be used only once or twice a week. Although the type of mindfulness exercises completed were not associated with mindful parenting skills, greater engagement in formal meditations at home during the course of intervention was significantly related to better parenting practices following intervention. This is consistent with findings from a previous study among adults with stress-related difficulties in which formal meditation home practice time was related to symptom improvement and well-being (Carmody & Baer, 2008).

Furthermore, it could be argued that informal mindfulness exercises are comparable to the open monitoring (OM) type of meditation (i.e., nonreactive perception of internal and external experiences), whereas the formal mindful meditations reflect the focused attention (FA) type of meditation (i.e., sustaining attention on a chosen object) (Lutz et al., 2008). Studies have shown differential effects of meditation type on neurocognitive laboratory tasks of attentional scope, suppression of distracting stimuli, and creativity (see Lippelt et al., 2014, for review), but the relationship between meditation type and functional outcomes have yet to be determined. Our findings suggest that FA meditation is associated with lower levels of harsh parenting practices, but parents of children with ADHD tend to use OM meditation more frequently.

Clinical Implications

Findings from this study demonstrate the incremental utility of enhancing SBPT interventions with mindfulness, particularly with regard to improving parents’ own behavioral-emotional dysregulation and harsh parenting practices. Reducing coercive parenting is an important outcome because it is significantly related to improved parenting stress and parent–child interactions, which are associated with lower levels of child attentional-behavioral problems. Furthermore, parental self-regulation is associated with the intergenerational transmission of self-regulation to their children (Bridgett et al., 2015). Thus, clinicians should consider assessing for baseline levels of parental discipline practices and behavioral-emotional dysregulation and recommend mindfulness-enhanced BPT for those parents who demonstrate particular impairment in these areas.

Although parents who participated in the mindfulness-enhanced group were more likely to engage in informal than formal mindful practices at home, reportedly due to practical time and energy considerations, the frequency of using formal planned meditations was associated with better parenting practices. Thus, future mindfulness-based parenting interventions should emphasize formal planned meditations to enhance outcomes. Although shortening formal meditations may make it more feasible for parents to complete, it is not yet known what dosage (e.g., duration of each meditation, frequency per week) is the optimal amount. Homework completion rates in parent training interventions are generally poor (average of 48%; Chacko et al., 2016); thus, including methods to problem solve barriers and provide ongoing support in-between BPT sessions (e.g., mobile reminders to track or implement home practice) will be beneficial (Chacko et al., 2013).

Limitations and Future Directions

Clinicians and parents were not blinded to the treatment group, as it was clear whether the group sessions addressed mindfulness or not. In addition, the outcomes were all based on parental self-report, and there were no specific measures of comorbidities (e.g., oppositional child behavior) or functional impairment that could affect outcomes. Future studies would benefit from multirater and/or multimethod approaches, such as including ratings of outcomes from teachers, or ratings of observations of parent–child interactions from clinicians who are blinded to the intervention group that the parents attended. The parent intervention used in this study was informed by several evidence-based treatments, but has not been previously evaluated in its current form. The two intervention groups differed in the presentation format during the 30 min of distinguishing content (i.e., SBPT received video review, whereas MBPT received experiential mindfulness activities). It is unclear if the format difference contributed to any differential effects, rather than the content alone.

Diagnosis of child ADHD was not confirmed using standardized interviews, normed measures, or inter-rater reliability. Changes in child medication were not tracked from pretreatment to posttreatment. Our parent sample wascomposed mostly of mothers. Future studies need to actively recruit fathers and determine whether mindfulness-enhanced behavioral parenting training produced similar, or perhaps stronger, effects. Available case analysis rather than intent-to-treat analysis was used. A larger sample would be needed to conduct path analyses or structural equation modeling to examine the relationships between mindful parenting and parent and child outcomes as proposed by the model of mindful parenting (Duncan et al., 2009). Long-term follow-up is needed to explore if the effects are maintained and/or if outcomes may improve/worsen over time.

Footnotes

Acknowledgements

We thank the parents who participated, the clinicians who helped to facilitate the groups (Drs. Daphne Dokis, Russet Jones, Julia Wong, Ryan Chan, and Ms. Miranda Doherty), and the research assistants Megan MacPherson and Jennifer Pooni.

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 a private donation through the B.C. Children’s Hospital Foundation and support from the Data Management team of the BC Children’s Hospital Research Institute.

ORCID iD

Janet W. T. Mah

Author Biographies

Janet W. T. Mah is a clinical child psychologist and principal investigator in the Outpatient Mental Health Department at BC Children’s Hospital. Her clinical expertise focuses on behavioral parent training and cognitive behavioral therapy. Her research interests focus on innovative psychosocial interventions, parenting cognitions related to treatment engagement and outcome, and stigma among cultural groups.

Candice Murray is a clinical child psychologist and former clinic head of the Provincial ADHD Program. She is actively involved with diagnostic assessments and treatments for youth and adults with ADHD, as well as public education to parents, teachers, and health professionals about ADHD.

Jake Locke is a psychiatrist with expertise in mindfulness-based interventions for mood and anxiety disorders.

Nicole Carbert is a research assistant, with a Master of Science in Population and Public Health. She has numerous research experiences on projects related to health behaviors among children and their parents.

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