Andrea M Chronis

Keywords: ADHD, parent training, behavior problems, oppositional defiant disorder, conduct disorder

Behavioral parent training has been established as an empirically supported treatment for attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD). Parent training programs focus on teaching parents behavior modification techniques based on social learning principles. Parents are instructed to modify antecedents and consequences of child misbehavior by rewarding prosocial behavior through contingent praise, positive attention, and rewards, and extinguishing maladap-tive behavior through ignoring, response cost, and discipline techniques such as time-out. For parent training to be maximally effective, parents must implement these techniques consistently.

Although there is some evidence to suggest that participation in parent training may improve parent stress, parenting self-esteem, and marital adjustment, parent functioning is typically not addressed in most parent training programs. This is concerning when one considers evidence suggesting that parents' personal and marital problems are associated with poorer compliance with and outcomes following parent training. These findings are not surprising given that distressed individuals often lack motivation to complete effortful tasks that require ongoing work. Therefore, it can be concluded that standard treatment for children with ADHD and behavior problems should include assessment and treatment of parental psychopathology and/or marital discord, as these problems may impact parents' ability to effectively implement behavior management techniques.

Some well-established parent training programs address parent issues. For example, Forehand and Long's book, Parenting the Strong Willed Child, includes chapters on improving communication skills within the family (in parent-child interactions and marital interactions) and developing patience. The chapters discuss how parents' emotional reactions depend on how the parent thinks about her child's behavior, and outline stress management strategies such as changing negative patterns of thinking, removing oneself from stressful situations rather than responding with anger, taking breaks from the parenting role, using problem solving strategies, developing support systems, and attending to one's physical health (e.g., exercising, getting enough sleep, eating healthy). Webster-Stratton's Incredible Years includes four chapters devoted to controlling upsetting thoughts, "taking time out" from stress and anger, using effective communication skills, and problem solving for adults. Likewise, the parent training manual developed for the Multimodal Treatment Study for ADHD includes two sessions that focus on parent stress, anger, and mood management. These sessions present the relationship between thoughts, feelings, and behaviors related to parenting, relaxation techniques, and building social support networks. Although these programs recognize the value of attending to parents' thoughts and emotional well-being in order to optimize their ability to use behavioral parenting strategies, in most cases, it is unlikely that one or two sessions or book chapters will be sufficient to bring about significant change in negative thinking and depressive symptomatology, particularly for individuals for whom these issues may be most relevant.

Relatively few studies have evaluated the incremental benefit of adding a parent enhancement component to standard behavioral parent training for noncompliant, aggressive, or conduct-disordered children, and only one has examined such interventions in a population selected for ADHD specifically. Some of these studies have targeted a specific parent problem area, such as depression, marital problems, or limited social support, while others have utilized more general interventions aimed at reducing distress in multiple areas.

Five studies have evaluated adjunctive components addressing specific parent problems, including maternal depression, marital problems, and lack of social support. Sanders and McFarland (2000) evaluated the relative effects of parent training and an integration of parent training and cognitive-behavioral treatment for depressed mothers of disruptive children derived from several well-established models. Dadds, Schwartz, and Sanders (1987) evaluated the additive effect of partner support training for maritally distressed and nondistressed parents. Results of both studies, including parents of children referred for ODD or CD, suggested that adjunctive parent interventions had a positive, incremental effect on outcome at follow-up for distressed families, but no incremental effect beyond parent training at posttreatment.

Pfiffner, Jouriles, Brown, Etscheidt, and Kelly (1990) and Dadds and McHugh (1992) specifically targeted single-parent families in their adjunctive interventions. Pfiffner et al. used a social problem-solving skills intervention adapted from the work of D'Zurilla and Goldfried. Dadds and McHugh used a modified form of a partner support training method developed to improve the parents' social support by placing a parent-appointed individual in an ally role. They did not find any incremental benefit of ally support training beyond the effects of parent training; however, Pfiffner and colleagues found greater improvements of the problem solving intervention on parent ratings of externalizing child behavior at follow-up. Again, no acute treatment effects were found beyond the effects of parent training alone.

Three studies looked at the incremental effect of more general parent interventions beyond parent training alone. In the first of these studies, the "parent enhancement therapy" addressed parents' perceptions of their children's behavior and parents' personal, marital, and extrafamilial adjustment (Griest et al., 1982). Results of this study suggested that parent training plus enhancement therapy was more effective in improving child behavior and parents' use of behavioral strategies during home observations and better maintenance at the 2-month follow-up assessment than parent training alone. In the second of these studies, the ADVANCE videotape skills component involved training parents to cope with interpersonal distress through improved communication, problem solving, and self-control skills (Webster-Stratton, 1994). The addition of this treatment component produced improvements in parent communication, problem-solving skills, and consumer satisfaction beyond the standard parent training group. Both treatment groups (parent training alone and parent training plus ADVANCE) showed comparable reductions in parenting stress, depressive symptoms on the BDI, and mother- and father-reported child adjustment. More recently, Sanders, Markie-Dadds, Tully, and Bor (2000) evaluated the impact of their "Triple P-Positive Parenting Program" in high-risk families with a preschool-aged child. Results of this study suggested that the enhanced behavioral family intervention (parent training plus partner support and coping skills to address stress, depression, anxiety, and other parent problems) resulted in few differences beyond standard parent training on most outcome measures; however, the enhanced intervention resulted in more reliable change in child behavior and a greater normalization rate at posttreat-ment than standard parent training.

Only one study selected mothers of children diagnosed with ADHD; however, the vast majority of these children were diagnosed with comorbid ODD or CD. In their randomized, controlled study, Chronis, Roberts, Pelham, and Gamble (2001) found that Lewinsohn's Coping with

Depression Course resulted in improvements on measures of maternal depressive symptomatology, self-esteem, and attributions and expectations related to child behavior at posttreatment that were maintained at follow-up. The largest effect sizes on these measures were found for mothers who reported at least mild depressive symptoms at pretreatment evaluation. However, no effects of the intervention were found on maternal ratings of child behavior.

Taken together, the results of these studies provide mixed support for the incremental benefit of interventions addressing parents' interpersonal problems beyond standard behavioral parent training alone. Most often, combined interventions have resulted in beneficial effects at follow-up assessment but not at posttreatment for parents of children with ODD or CD, particularly in studies that selected families experiencing distress in the area being targeted (e.g., social support). The one study targeting parents of children with ADHD found that an adjunctive CBT intervention was effective in addressing maternal symptomatology; yet, no effects of the intervention were found on child behavior.

Future studies are needed to address the important issue of how to best intervene with distressed parents of children with attention and behavior problems in order to remove or minimize the deleterious effects that parent problems have on the effectiveness of parent training. Most existing studies of adjunctive treatments introduced parent-focused treatment components in the maintenance phase (i.e., following parent training). Instead, it may prove useful to begin treatment by addressing and treating existing parent psychopathology. In doing so, parents may be better prepared for the demands of learning and consistently implementing behavior management strategies. Alternatively, behavioral parent training and cognitive-behavioral therapy may best be integrated in a manner that promotes their concurrent use. Future studies may randomly assign parents to the parent-focused intervention prior to, concurrent with, and following a behavioral parent training program to evaluate the optimal ordering of treatments.

Further, many of these studies focused on mothers of children with attention and behavior problems, likely due to mothers' traditional role as primary caregiver and the large literature documenting the relationship between maternal psychopathology (e.g., depression) and child adjustment. However, both mothers and fathers of these children may be suffering from a host of psychological problems, including anxiety disorders, marital distress, anger management problems, adult ADHD, and substance abuse. Future studies may address the benefit of matching adjunctive parent treatments to the needs of individual families, based on a comprehensive assessment of child and family problems.

See also: Attention-deficit/hyperactivity disorder—child

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