Cognitive-behavioral depression treatment for mothers of children with attention-deficit/hyperactivity disorder

A pragmatic randomised controlled trial of the effectiveness and cost-effectiveness of Well Parent Japan in routine care in Japan: The training and nurturing support for mothers (TRANSFORM) study

BACKGROUND

Well Parent Japan (WPJ) is a new hybrid group parent training programme combining sessions to improve mothers' psychological well-being with a culturally adapted version of the New Forest Parenting Programme (NFPP). This study investigates the effectiveness and cost-effectiveness of WPJ against treatment as usual (TAU) within Japanese child mental health services.

METHODS

TRANSFORM was a pragmatic multi-site randomised controlled trial (RCT) with two parallel arms. Altogether 124 mothers of 6-12-year-old children with DSM-5 ADHD were randomised to WPJ (n = 65) or TAU (n = 59). Participants were assessed at baseline, post-treatment and three-month follow-up. The primary outcome was parent-domain stress following intervention. Secondary outcomes included maternal reports of child-domain stress, parenting practices, parenting efficacy, mood, family strain, child behaviour and impairment. Objective measures of the parent-child relationship were collected at baseline and post-treatment. Data analysis was intention to treat (ITT) with treatment effects quantified through analysis of covariance (ANCOVA) via multilevel modelling. An incremental cost-effectiveness ratio (ICER) assessed WPJ's cost-effectiveness.

RESULTS

WPJ was superior to TAU in reducing parent-domain stress post-treatment (adjusted mean difference = 5.05, 95% CI 0.33 to 9.81, p = .036) and at follow-up (adjusted mean difference 4.82, 95% CI 0.09 to 9.55, p = .046). Significant WPJ intervention effects were also observed for parenting practices, parenting efficacy and family strain. WPJ and TAU were not significantly different post-intervention or at follow-up for the other secondary outcomes. The incremental cost of WPJ was 34,202 JPY (315.81 USD). The probability that WPJ is cost-effective is 74% at 10,000 JPY (USD 108.30) per one-point improvement in parenting stress, 92% at 20,000 JPY (216.60 USD). The programme was delivered with high fidelity and excellent retention.

CONCLUSIONS

WPJ can be delivered in routine clinical care at modest cost with positive effects on self-reported well-being of the mothers, parenting practices and family coping. WPJ is a promising addition to psychosocial interventions for ADHD in Japan.

Adult attention-deficit/hyperactivity symptoms and parental cognitions: a meta-analysis

Introduction

Attention-deficit/hyperactivity disorder (ADHD) symptoms in adults interfere with parental functioning. Dysfunctional parental cognitions may play a role in this impairment. Despite the importance of parental cognitions on parents and children's outcomes, up to now, no systematic review or meta-analysis of these findings is available. To fill this gap, this meta-analysis aimed to evaluate the relationship between adult ADHD symptoms and parental cognitions.

Methods

We conducted searches in Web of Science, PubMed, and ProQuest from January 2000 to June 2023. Studies were included if they provided data on the relationship between parental ADHD symptoms and parental cognitions by means of a row correlational coefficient, or means and standard deviation were reported for each study group. A random-effects model was used. Publication bias was assessed by funnel plot and Rosenthal's fail-safe N. Moderator analyses were conducted by means of subgroup analysis and meta-regression analyses.

Results

Fifteen published papers were included (N = 2851), and 51 effect sizes were analysed. The weighted mean effect size was small but significant (Fisher's Z = 0.186, k = 15, 95% CI [0.120 - 0.252], z = 5.539, p < 0.001), indicating that ADHD symptoms in adults are associated with more negative and less positive parental cognitions. The Fail-Safe N analysis suggested a robust effect. Tweedie's trim and fill results suggested that five studies were missing; after five missing studies had been imputed, the mean overall effect size dropped to 0.116 (0.080 - 0.152). There was significant heterogeneity among effect sizes. The methodology of the study was found to be a significant moderator. Meta-regression analyses revealed that the lower age of the parent and the child were related to more negative parental cognitions.

Discussion

Though the analysis might be inflated by publication bias, our results suggest a significant association between ADHD symptom level and dysfunctional parental cognitions. Biased negative perceptions of the parental role, the child and co-parenting may play a central mediator role between parental ADHD and parent and child outcomes. Given the familiar nature of ADHD, targeting dysfunctional parental cognitions in parent training programs is warranted.

Systematic review registration

osf.io/pnur7.

Cognitive-Based Interventions for Improving Psychological Health and Well-Being for Parents of Children with Developmental Disabilities: A Systematic Review and Meta-analysis

This review aims to systematically summarize existing evidence to determine the effectiveness of cognitive-based interventions (CBIs) on psychological health and well-being among parents of children with developmental disabilities (DD). Six databases were searched to identify eligible randomized controlled trials (RCTs) from their inception to April 2023. The revised Cochrane Risk of Bias tool for RCTs was applied to assess the risk of bias and the certainty of evidence was evaluated using the Grading of Recommendation, Assessment, Development and Evaluation. Meta-analyses were conducted using a random-effects model. Twenty-five RCTs involving 1915 participants were identified. The results indicated that CBIs reduced parental stress levels (Hedges' g = - 0.69), depressive symptoms (g = - 0.95), anxiety levels (g = - 0.78), and parental distress (g = - 0.29), and improved parental well-being (g = 0.62) and parent‒child relationships (g = 0.43) postintervention compared with the active/inactive control groups. Subgroup analysis of the effectiveness of interventions using mindfulness-based interventions and cognitive behavioural therapy showed positive effects. The favourable intervention duration and participant targets were also identified in this review. Furthermore, the effects of CBIs were impacted by the different types of DD among the children. This review highlighted the positive effects of CBIs on parental stress levels, depressive symptoms, anxiety levels, parental distress levels, parental well-being levels, and parent‒child relationships. Future well-designed RCTs are needed to further investigate the effects of MBIs and CBT interventions on children with DD and their parents, as well as the factors and mechanisms of action affecting the efficacy of these interventions.

The Two-Factor Structure of the Parent Cognitive Error Questionnaire: A Measure of Parental Cognitive Errors in Relation to Child Problems

This study evaluated the factor structure of the scores from a parent rating scale, the Parent Cognitive Error Questionnaire (PCEQ), which measures parents' attributions of child misbehavior and problems. The factor structure of the scores of the PCEQ was examined among 199 children (ages 7-11; mean age: 8.64 years, 58.30% boys, 53.80% White) with Attention-Deficit/Hyperactivity Disorder (ADHD), Predominantly Inattentive Presentation. Reliability and validity of the factors were assessed. Two factors emerged from this sample: (1) parent-specific cognitive errors (self-blame for child problems), and (2) child-specific cognitive errors (child-blame for child problems). Both were related to parent-rated parental depression, parenting satisfaction, parenting self-efficacy, and child ADHD and Oppositional Defiant Disorder (ODD) symptoms. After adjusting for child-specific cognitive errors, parent-specific errors were related to parent-rated parent depressive symptoms, and after adjustment for parent-specific cognitive errors, child-specific cognitive errors were related to parent-rated child ADHD and ODD symptoms. A two-factor structure for the PCEQ scores from this sample was found with evidence of reliability and validity of factors, showing promise for measuring sources of parental attributions regarding child problems.

Predictors of Depressive Symptoms in Caregivers of Children with Attention-Deficit/Hyperactivity Disorder: A One-Year Follow-Up Study

This 1-year follow-up study examined the predictive values of the demographics, depressive symptoms, stress-coping orientations, and perceived family support of caregivers as well as the internalizing, externalizing and ADHD symptoms of children with attention-deficit/hyperactivity disorder (ADHD) at baseline on the depressive symptoms of the caregivers after 1 year. A total of four hundred caregivers of children with ADHD were recruited. The baseline levels of the caregivers' depressive symptoms, stress-coping orientations, and perceived family support and the internalizing and externalizing problems of the children were assessed using the Center for Epidemiological Studies Depression Scale, the Coping Orientation to Problems Experienced, Family Adaptation, Partnership, Growth, Affection, Resolve Index, and the Child Behavior Checklist For Ages 6-18, respectively. Their predictions for the caregiver's depressive symptoms 1 year after the baseline were examined using linear regression analysis. In total, 382 caregivers of children with ADHD underwent the follow-up assessment 1 year from the baseline. A marital status of being separated or divorced, less effective coping and depressive symptoms orientation, and children with internalizing problems and ADHD symptoms at baseline were positively associated with the caregivers' depressive symptoms at follow-up, whereas the caregivers' perceived family support and an emotion-focused coping orientation at baseline were negatively associated with depressive symptoms at follow-up. Multiple characteristics of the caregivers and children with ADHD at baseline predicted the caregivers' depressive symptoms 1 year later.

Research protocol for a pragmatic randomized controlled effectiveness and cost effectiveness study of Well Parent Japan (WPJ) for Japanese mothers of children with ADHD: The TRaining And Nurturing Support FOR Mothers TRANSFORM study (Preprint)

Background

Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder associated with numerous functional deficits and poor long-term outcomes. Internationally, behavioral interventions are recommended as part of a multimodal treatment approach for children with ADHD. Currently, in Japan, there are limited interventions available to target ADHD. Well Parent Japan (WPJ), a new hybrid parent-training program, provides a culturally acceptable and effective way to help support Japanese children with ADHD and their parents.

Objective

This pragmatic multicenter randomized controlled trial aims to provide preliminary evidence about the effectiveness and cost-effectiveness of WPJ evaluated against treatment as usual (TAU) within routine Japanese mental health services.

Methods

Mothers of children (aged 6-12 years) diagnosed with ADHD were recruited from child and adolescent mental health care services at three hospital sites across Japan (Fukui, Fukuoka, and Okinawa). The mothers were randomized to receive immediate treatment or TAU. The effectiveness and cost-effectiveness of WPJ over TAU at the end of the intervention and at 3-month follow-up will be evaluated. The primary outcome is maternal parent domain stress in the parenting role. The following secondary outcomes will be explored: child behavior, including severity of ADHD symptoms; parenting practices; emotional well-being; and the parent-child relationship and maternal child domain parenting stress. Data analysis will follow intention-to-treat principles with treatment effects quantified through analysis of covariance using multilevel modeling. An incremental cost-effectiveness ratio will be used to analyze the cost-effectiveness of the WPJ intervention.

Results

Study funding was secured through a proof-of-concept grant in July 2018. Approval by the institutional review board for the data collection sites was obtained between 2017 and 2019. Data collection began in August 2019 and was completed in April 2022. Participant recruitment (N=124) was completed in May 2021. Effectiveness and cost-effectiveness analyses are expected to be completed by July 2022 and December 2022, respectively. These timelines are subject to change owing to the COVID-19 pandemic.

Conclusions

This is the first multisite pragmatic trial of WPJ based on the recruitment of children referred directly to routine clinical services in Japan. This multisite randomized trial tests the effectiveness of WPJ in children and families by comparing WPJ directly with the usual clinical care offered for children diagnosed with ADHD in Japan. We also seek to assess and compare the cost-effectiveness of WPJ with TAU in Japan.

Trial Registration

International Standard Randomised Controlled Trial Number ISRCTN66978270; https://www.isrctn.com/ISRCTN66978270

International Registered Report Identifier (IRRID)

DERR1-10.2196/32693

Testing the effects of a prenatal depression preventive intervention on parenting and young children's self-regulation and functioning (EPIC): protocol for a longitudinal observational study

BACKGROUND

Perinatal depression is a pervasive public health concern that disproportionately affects low-income women and can have negative impacts on parenting and child developmental outcomes. Few interventions focus on preventing perinatal depression. Previous studies suggest that Mothers and Babies is efficacious in preventing the worsening of depressive symptoms and the onset of postpartum depression. This manuscript presents the protocol of the EPIC study (Effects of a Prenatal Depression Preventive Intervention on parenting and young children's Self-Regulation and Functioning) to test the effects of Mothers and Babies on parenting and child developmental outcomes through 54 months postpartum. EPIC is an observational study that builds on a completed cluster-randomized trial (CRT). Innovations of this study are direct observations of a subsample of mother-child dyads and the inclusion of fathers/caregivers' variables as moderators of maternal mental health.

METHODS

For this study, we plan to enroll 738 women with children under 30 months old, ≥18 years old, and who speak English or Spanish. Additionally, 429 fathers, partners, or other adult caregivers will be recruited through women participating in the study. Women will be recruited through the parent study (intervention and control participants) or through one of 10 home visiting programs in Illinois (control participants). Data collection will take place through maternal self-report at five time points (when the child is 30, 36, 42, 48, and 54 months), paternal self-report at three time points (when the child is 30, 42, and 54 months), and through mother-child observations at three time points (when the child is 36, 42, and 48 months). Outcome domains include maternal mental health, cognitive-behavioral and parenting skills, and child self-regulation and functioning. Moderators include the contributions of fathers/caregivers, race-ethnicity, and socioeconomic disadvantage. Power and sample size were calculated assuming a two-sided 5% type I error rate and assumed analyses on the individual level.

DISCUSSION

This study has several key strengths and innovations, as well as great potential significance to influence the long-term trajectories of parenting and child development via prenatal intervention.

TRIAL REGISTRATION

The study was retrospectively registered at ClinicalTrials.gov (Identifier: NCT04296734 ) on March 5, 2020.

Effectiveness comparisons of various psychosocial therapies for children and adolescents with depression: a Bayesian network meta-analysis

The existence of depression among children or adolescents can trigger a sequence of burdens on themselves, their families and even the whole society, which cause both physical and economic impacts. Our network meta-analysis (NMA) was aimed at comparing them with each other for evaluating the optimal psychosocial therapy to help children and adolescents with depression to improve their mental health. Based on several biomedical databases, a system of search strategies was conducted for searching randomized controlled trials (RCTs) which published from their inception on October, 1st 2018 without language restriction. We carried out an expression analysis for comparing the efficacy of various psychosocial therapies using Bayesian NMA. A battery of analyses and assessments, such as conventional meta-analysis and risk of bias, were performed concurrently. Only 32 of RCTs which involved 2677 participants were eventually included in our analyses from the 19,176 of initial citation screening. In addition, in terms of various valid assessment instruments, interpersonal psychotherapy [standard mean difference (SMD) = -1.38, Credible interval (CrI) - 2.5, - 0.20)], computer cognitive-behavioral therapy (SMD = -1.36, CrI - 2.59, - 0.14), cognitive-behavioral therapy (SMD = -1.16, CrI - 2.15, - 0.18), had significantly better effects than the named control group. All together, these results suggest that interpersonal psychotherapy might be the best approach to improve the depressive state among children and adolescents. This study may provide an excellent resource for future endeavors to utilize psychosocial interventions and may also serve as a springboard for creative undertakings as yet unknown.

Transdiagnostic Associations Among Parental Causal Locus Attributions, Child Behavior and Psychosocial Treatment Outcomes: A Systematic Review

Parents' interpretations of the cause of their children's behavior, i.e., parental attributions, are linked to parenting behavior and child development. However, it is not yet known whether parental attributions are systematically associated with children's internalizing and externalizing symptoms and behavior or psychosocial treatment engagement and outcomes across diagnostic categories. This systematic review aimed to fill this knowledge gap using a transdiagnostic perspective to synthesize the literature on the associations between parent-causal and child-responsible attributions and children's internalizing and externalizing behavior, treatment engagement, and treatment outcomes for parents and children. A total of 67 studies were identified. Overall, biased child-responsible attributions were associated with elevated child internalizing and externalizing symptoms and behavior across diagnoses, while findings on the association between parent-causal attributions and child behavior were inconsistent. The link between parental attributions and treatment engagement was also mixed, varying across treatment type, child diagnosis, and focus of attributions. Regarding treatment outcomes, less biased parent-causal and child-responsible attributions were linked to post-treatment improvements in children's behaviors, while mixed findings were reported on post-treatment improvements in parental attributions. Findings are discussed with a focus on approaches to enhance the effectiveness of assessment and psychosocial treatment approaches across diagnostic categories with consideration of parental attributions.

Efficacy of a Home Visiting Enhancement for High-Risk Families Attending Parent Management Programs: A Randomized Superiority Clinical Trial

IMPORTANCE

Antisocial behavior and adult criminality often have origins in childhood and are best addressed early in the child's life using evidence-based parenting programs. However, families with additional risk factors do not always make sufficient changes while attending such programs; these families may benefit from additional support.

OBJECTIVE

To evaluate the efficacy of adding a 10-session, structured home parent support (HPS) intervention to enhance outcomes for high-risk families attending the Incredible Years Parent (IYP) program.

DESIGN, SETTING, AND PARTICIPANTS

A randomized clinical superiority trial of 126 parents of children aged 3 to 7 years with conduct problems compared the IYP program plus HPS with treatment as usual of the IYP program alone. Child behavior measures were collected before and after treatment and at the 6-month follow-up. Recruitment from 19 IYP groups began February 13, 2013, and follow-up data collection was completed June 4, 2015. All data were analyzed using an intention-to-treat design with last observation carried forward. Statistical analysis took place from May 20, 2015, to March 31, 2016.

INTERVENTION

Parents were randomly assigned to receive IYP program plus HPS or IYP alone.

MAIN OUTCOMES AND MEASURES

The primary outcome measure was the posttreatment change in Eyberg Child Behavior Inventory Total Problem Scale (ECBI-P) score. Secondary outcomes included maintenance of change on the ECBI-P score, ECBI Intensity Scale score, and Social Competence Scale score at the 6-month follow-up; percentage of child behavior scores in the clinical range after treatment; retention; and attendance.

RESULTS

A total of 126 parents (112 women and 14 men; mean [SD] age, 34.7 [8.4] years) were included; 63 parents were randomly assigned to each intervention group. Analysis of variance using intention to treat showed no significant difference between groups after treatment (P = .62). At follow-up, there was a medium effect (d = 0.63) showing a significant benefit from IYP plus HPS of 3.6 (95% CI, 0.8-6.5) on the ECBI-P score (F1,124 = 6.3; P = .01). Families receiving the IYP plus HPS intervention had significantly fewer children with child behavior scores in the clinical range after treatment (9 of 51 [17.6%]) compared with families receiving the IYP program alone (18 of 45 [40.0%]), and this status was maintained at follow-up. The HPS intervention had better retention than the IYP program (dropout, 7 [5.6%] vs 16 [12.7%]) as well as better attendance.

CONCLUSIONS AND RELEVANCE

In this trial, the IYP plus HPS intervention significantly improved outcomes for the most vulnerable families at 6 months. This study demonstrated that the HPS intervention is an effective addition to the IYP program to improve engagement and implementation of IYP program strategies and enhance child behavior outcomes for the most vulnerable families.

TRIAL REGISTRATION

http://anzctr.org.au Identifier: ACTRN12612000878875.

The Relationship Between Parental Affective Temperament Traits and Disruptive Behavior Disorders Symptoms in Children With ADHD

OBJECTIVE

This study investigated the relationship between parental affective temperaments and the oppositional defiant disorder (ODD) and conduct disorder (CD) symptoms of children with ADHD.

METHOD

The sample consisted of 542 treatment-naive children with ADHD and their biological parents. Children were assessed via both parent- and teacher-rated behavioral disorder scales. Parental affective temperament and ADHD symptoms were measured by self-report inventories. The relationships between psychiatric variables were evaluated using structural equation modeling.

RESULTS

According to parent-rated behavioral disorder scales, paternal cyclothymic and maternal irritable temperaments were associated with ODD scores, and maternal depressive temperament was associated with CD scores. In terms of teacher-rated behavioral disorder scales, maternal anxious temperament was associated with ODD scores, and paternal cyclothymic and maternal depressive temperaments were associated with CD scores.

CONCLUSION

These results suggest that certain parental affective temperaments are related to an increase in symptoms of disruptive behavioral disorders in children with ADHD.

Maternal Functioning Differences Based on ADHD Subtype

OBJECTIVE

Maternal functioning differences in parenting stress, parental efficacy, and parenting behaviors were examined for mothers of children with ADHD.

METHOD

Participants included 29 mothers of children with ADHD, Predominantly Inattentive Type (ADHD-I) and 38 mothers of children with ADHD, Predominantly Hyperactive-Impulsive or Combined Type (ADHD-HI/C).

RESULTS

Findings suggest that mothers of children with ADHD-HI/C reported significantly greater parenting stress and engaged in more negative parenting behaviors than mothers of children with ADHD-I.

CONCLUSION

This study suggests that tailoring behavioral parent training based on ADHD subtype may be particularly helpful for parents of children with ADHD-HI/C.

Behavioral Observations of Parents With ADHD During Parent Training

OBJECTIVE

Several studies suggest that parental ADHD impedes behavioral parent training (BPT) outcomes. Parental ADHD symptoms exhibited during BPT may interfere with the acquisition of new skills. This study explored the observed behavior of parents with ADHD during BPT.

METHOD

Parents of children with ADHD attending group BPT completed self-ratings of their ADHD symptoms. Parents indicating a moderate level of ADHD symptoms were administered a clinical interview, and 37.3% of parents met ADHD criteria based on Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) clinician-rated symptom counts.

RESULTS

Parents with high ADHD symptoms displayed more total and off-task violations compared with parents with low ADHD symptoms, although no significant differences emerged for other behaviors (i.e., working quietly, using materials appropriately, and remaining in seat), absences, or tardiness.

CONCLUSION

Parental ADHD symptoms were manifested during BPT. Future research should clarify the nature of parental behavior in BPT as a possible mechanism explaining the relation between parental ADHD and impaired BPT outcomes.

Improved Parent Cognitions Relate to Immediate and Follow-Up Treatment Outcomes for Children With ADHD-Predominantly Inattentive Presentation

We investigated treatment effects on parenting self-efficacy and parent cognitive errors, and whether these parent cognitions are related to short- and long-term outcomes in parenting behaviors in psychosocial treatment for youth with attention-deficit/hyperactivity disorder, predominantly inattentive presentation (ADHD-I). In a randomized controlled trial across two sites (University of California, San Francisco, and University of California, Berkeley), 199 children between the ages of 7 and 11 were randomized to the Child Life and Attention Skills (CLAS; n = 74) program, parent-focused treatment (PFT; n = 74), or treatment as usual (TAU; n = 51). Parents reported on self-efficacy, cognitive errors, positive parenting, and negative parenting prior to treatment, immediately after treatment, and in the next school year at follow-up. Compared to TAU, CLAS and PFT had higher posttreatment parenting self-efficacy, and CLAS alone had lower posttreatment parent cognitive errors. At follow-up, only CLAS had improved parent cognitive errors compared to TAU. No other between-group differences were found in parenting self-efficacy or cognitive errors. Improved parenting self-efficacy was associated with improved posttreatment negative parenting outcomes for PFT and CLAS, and improved parent cognitive errors were also related to improvements in positive and negative posttreatment parenting outcomes for CLAS. Posttreatment parenting self-efficacy mediated follow-up negative parenting outcomes for CLAS and posttreatment parent cognitive errors mediated improved follow-up positive and negative parenting outcomes for CLAS. PFT and CLAS led to enhanced parenting self-efficacy, and CLAS appears especially robust in improving parent cognitive errors both in the short and long term. Pathways provide support for the possibility of parent cognitions as mediators of treatment effects on parenting; clinical focus on such cognitions may be useful.

Association Between Changes in Caregiver Depressive Symptoms and Child Attention-Deficit/Hyperactivity Disorder Symptoms

OBJECTIVE

Depression is highly prevalent among caregivers of children with attention-deficit/hyperactivity disorder (ADHD). We examined the association between caregiver depressive symptom trajectories and changes in child ADHD symptoms.

METHODS

We analyzed data from a randomized trial of 2 ADHD care management systems for children aged 6 to 12 years and their caregivers (n = 156 dyads). Child ADHD symptoms were measured using the Swanson, Nolan, and Pelham rating scale (SNAP-IV). Caregiver depressive symptoms were measured using the Quick Inventory of Depressive Symptomatology (QIDS). Measures were assessed at baseline, 6 months, and 12 months. We used multivariable models to examine associations between changes in caregiver depressive symptoms and changes in child ADHD symptoms.

RESULTS

From baseline to 12 months, children of caregivers with improved depressive symptoms had significantly greater reductions in SNAP-IV scores (change score: -1.43) compared with those whose depressive symptoms did not change (change score: -0.97) or worsened (change score: -0.23, p = 0.003). In adjusted models, improved caregiver depressive symptoms were associated with greater reductions in SNAP-IV scores over the 12-month period. Compared with those with worsening caregiver depressive symptoms, children whose caregivers showed no significant changes in depressive symptoms had a -0.78 point (95% confidence interval [CI]: -1.40 to -0.17) greater reduction in the SNAP-IV score, and those children whose caregiver depressive symptoms improved had a -1.31 point greater reduction in the SNAP-IV score (95% CI: -1.97 to -0.66).

CONCLUSION

Given the longitudinal association between caregiver depressive symptom and child ADHD symptom trajectories, interventions that address the behavioral health needs of the family unit may offer promise for urban children with ADHD.

Comparison of Depression and Burnout Levels of Mothers of Children with Attention-Deficit Hyperactivity Disorder Before and After Treatment

OBJECTIVE

This study aimed to compare the depression and burnout levels of mothers of children having attention-deficit/hyperactivity disorder (ADHD) between the child's pre- and posttreatment periods.

METHOD

The study sample consisted of 40 children aged between 4 and 10 years and their mothers. Initially, 40 cases participated, but during the follow-up, 19 cases dropped out. The Beck Depression Inventory (BDI), the Maslach Burnout Inventory (MBI), and the Turgay DSM-IV Based Child and Adolescent Behaviour Disorders Screening and Rating Scale (T-DSM-IV-S) were used.

RESULTS

Among the mothers, posttreatment BDI scores, MBI-emotional exhaustion, and personal accomplishment were significantly lower than the pretreatment scores. In the treatment's second month, all T-DSM-IV-S subscale scores showed a statistically significant decrease.

CONCLUSIONS

It was concluded that treatment of children with ADHD would have a favorable impact on their mothers' depressive symptoms, which would consequently decrease negative parental attitudes, hence reducing the risk of behavioral disorder in children with ADHD and exerting a positive effect on their treatment.

Mediators and Moderators of the Relation between Parental ADHD Symptomatology and the Early Development of Child ADHD and ODD Symptoms

The present study examined mediators and moderators of the relation between parental ADHD symptomatology and the development of child attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) symptoms across the preschool years. Participants included 258 (138 boys) 3-year-old children (M = 44.13 months, SD = 3.39) with and without behavior problems and their parents who took part in a 3-year longitudinal study. Maternal ADHD symptoms predicted later ADHD symptoms in children, controlling for early child symptomatology. Both family history of ADHD and paternal comorbid psychopathology predicted later child ADHD and ODD symptoms, but they did not account for the association between maternal and child ADHD symptoms. Although paternal ADHD symptoms were associated with age 3 child ADHD symptoms, they did not significantly predict later child ADHD symptoms controlling for early symptomatology. Family adversity moderated the relation between maternal ADHD and child ADHD symptoms, such that the relation between maternal and child ADHD symptoms was stronger for families with less adversity. Maternal overreactive parenting mediated the relation between maternal ADHD symptoms and later child ADHD and ODD symptoms. Our findings suggest that targeting paternal comorbid psychopathology and maternal parenting holds promise for attenuating the effects of parental ADHD on children's ADHD.

Child and Adolescent Adherence With Cognitive Behavioral Therapy for Anxiety: Predictors and Associations With Outcomes

Cognitive behavioral therapy (CBT) for anxiety disorders is effective, but nonadherence with treatment may reduce the benefits of CBT. This study examined (a) four baseline domains (i.e., demographic, youth clinical characteristics, therapy related, family/parent factors) as predictors of youth adherence with treatment and (b) the associations between youth adherence and treatment outcomes. Data were from 279 youth (7-17 years of age, 51.6% female; 79.6% White, 9% African American), with Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.) diagnoses of separation anxiety disorder, generalized anxiety disorder, and/or social phobia, who participated in CBT in the Child/Adolescent Anxiety Multimodal Study. Adherence was defined in three ways (session attendance, therapist-rated compliance, and homework completion). Multiple regressions revealed several significant predictors of youth adherence with CBT, but predictors varied according to the definition of adherence. The most robust predictors of greater adherence were living with both parents and fewer youth comorbid externalizing disorders. With respect to outcomes, therapist ratings of higher youth compliance with CBT predicted several indices of favorable outcome: lower anxiety severity, higher global functioning, and treatment responder status after 12 weeks of CBT. Number of sessions attended and homework completion did not predict treatment outcomes. Findings provide information about risks for youth nonadherence, which can inform treatment and highlight the importance of youth compliance with participating in therapy activities, rather than just attending sessions or completing homework assignments.

Mom-net: Evaluation of an internet-facilitated cognitive behavioral intervention for low-income depressed mothers

OBJECTIVE

Evaluate an Internet-facilitated cognitive-behavioral treatment intervention for depression, tailored to economically disadvantaged mothers of young children.

METHOD

Economically disadvantaged mothers (N = 266) of preschool aged children, who reported elevated levels of depressive symptoms, were randomized to either the 8-session, Internet-facilitated intervention (Mom-Net) or to Motivational Interviewing and Referral to Services (MIRS). Outcomes were measured using the Patient Health Questionnaire 9 (PHQ-9; Spitzer et al., 1999), the Structured Clinical Interview for Diagnostic and Statistical Manual for Mental Disorders-Fourth Edition-Text Revised (DSM-IV-TR) Axis I Disorders (SCID; First, Spitzer, Gibbon, & Williams, 2002), and the Hamilton Depression Rating Scale (HDRS; Hamilton, 1960).

RESULTS

Relative to participants in the MIRS condition, participants in Mom-Net demonstrated significantly greater reduction in depression as indexed by self-report questionnaire (primary outcome), interviewer-rated symptoms, and diagnostic outcomes.

CONCLUSIONS

Results suggest that the Mom-Net intervention is effective as a remotely delivered intervention for economically disadvantaged mothers. (PsycINFO Database Record

ADHD and the Development of Depression: Commentary on the Prevalence, Proposed Mechanisms, and Promising Interventions

Attention-deficit/hyperactivity disorder (ADHD) has been identified as a significant risk factor for the development of later depression. Furthermore, their comorbid presentation results in greater levels of impairment than either disorder in isolation. Research has pointed to several causal mechanisms by which ADHD co-occurs with depression including the persistence of ADHD symptoms, reward responsivity, and emotion dysregulation as well as parenting/family factors and maternal depression. Stemming from this mechanistic research, interventions have been developed in recent years that aim to prevent depression in youth with ADHD. The Behaviorally Enhancing Adolescents Mood (BEAM) Program and The Integrated Parenting Intervention for ADHD (IPI-A) have both demonstrated promising results. Directions for future research are discussed with an emphasis on neurobiological mechanisms and the dissemination/implementation of interventions to reduce risk for depression among youth with ADHD in community care settings.

Maternal ADHD, Parenting, and Psychopathology Among Mothers of Adolescents With ADHD

OBJECTIVE

This study describes the parenting and psychopathology of mothers with ADHD of adolescents with ADHD (MCA), non-ADHD mothers of adolescents with ADHD (CA), and non-ADHD mothers of adolescents without ADHD (COMP).

METHOD

Two sets of pairwise comparisons: (a) COMP versus CA and (b) CA versus MCA were conducted. We hypothesized that CA would experience greater distress in parenting and psychopathology compared with COMP and that MCA would experience even more impairment compared with CA.

RESULTS

Few differences emerged in comparisons of CA and COMP, with the exception of CA reporting greater parent-adolescent conflict and internalizing problems. In contrast, differences consistently emerged in comparisons of MCA and CA showing more difficulty for MCA in parenting and psychopathology.

CONCLUSION

These findings underscore the need for treatments that address parental ADHD when adolescent ADHD is the intended target.

Patterns of Enrollment and Engagement of Custodial Grandmothers in a Randomized Clinical Trial of Psychoeducational Interventions

The authors used Andersen's (2008) behavior model to investigate patterns of enrollment and treatment engagement among 343 custodial grandmothers who participated in a randomized clinical trial of three psychosocial interventions:(a) a behavioral parenting program, (b) a cognitive behavioral coping program, or (c) an information-only condition. Treatment completion was superior to that typically found with birth parents, even though the grandmothers and their target grandchildren both had high levels of mental and physical health challenges. Compliance did not differ significantly by condition but was higher among grandmothers who self-reported less positive affect, were older, and were using mental health professionals. Treatment satisfaction was highest in grandmothers who attended more treatment sessions, reported lower annual family income, had a health problem, and were using mental health professionals. The practice and policy implications of these findings are discussed, especially in terms of strategies for enhancing the engagement of custodial grandfamilies in future psychoeducational interventions.

Parenting Interventions for ADHD: A Systematic Literature Review and Meta-Analysis

OBJECTIVE

To evaluate the evidence base relating to the effectiveness of parent-administered behavioral interventions for ADHD.

METHOD

A systematic review of randomized controlled trials or non-randomized but adequately controlled trials for children with ADHD or high levels of ADHD symptoms was carried out across multiple databases. For meta-analyses, the most proximal ratings of child symptoms were used as the primary outcome measure.

RESULTS

Eleven studies met inclusion criteria (603 children, age range = 33-144 months). Parenting interventions were associated with reduction in ADHD symptoms (Standardized Mean Difference [SMD] = 0.68; 95% confidence interval [CI] [0.32, 1.04]). There was no evidence of attenuation of effectiveness after excluding studies where medication was also used. Parenting interventions were also effective for comorbid conduct problems (SMD = 0.59; 95% CI [0.29, 0.90]) and parenting self-esteem (SMD = 0.93; 95% CI [0.48, 1.39]).

CONCLUSION

These findings support clinical practice guidelines and suggest that parenting interventions are effective. There is a need to ensure the availability of parenting interventions in community settings.

Parental psychopathology in families of children with attention-deficit/hyperactivity disorder and exposed to maternal smoking during pregnancy

BACKGROUND

Both genetic and environmental factors have been implicated in the etiology of attention-deficit/hyperactivity disorder (ADHD). We had previously suggested that exposure to maternal smoking during pregnancy (MSDP) may be a valid basis for delineating a distinct subtype of ADHD, where children exposed to MSDP present with a more severe clinical picture. Here, we examine the psychopathology of parents in this group, to better understand the etiology of ADHD.

METHODS

Using the Family Interview for Genetic Studies in a sample of 514 families of children with ADHD, we collected data pertaining to lifetime parental psychopathology. Families were stratified based on maternal smoking during the complete gestational period. The frequency of different disorders was compared using the χ2 statistic.

RESULTS

In the group where mothers smoked during pregnancy, both parents were significantly more likely to have antisocial personality disorder, and problems with alcohol and drug abuse. Mothers had a significantly higher frequency of major depressive disorder (MDD), while fathers showed a trend for both MDD and bipolar disorder.

CONCLUSIONS

Based on the pattern of psychopathology in parents of children exposed to MSDP, as well as earlier reports of the severe clinical, behavioral, and cognitive phenotype in these children, combined with the large body of epidemiological evidence, we propose that these children present a distinct subtype of ADHD with comorbid conduct disorder. Furthermore, we propose that MSDP may be a proxy measure to help delineate this subtype.

Beyond symptom control for attention-deficit hyperactivity disorder (ADHD): what can parents do to improve outcomes?

Attention-deficit hyperactivity disorder (ADHD) and its associated behavioural manifestations develop and progress as the result of complex gene-environment interactions. Parents exert a substantial influence and play a major role in their child's social environment. Despite this, recent evidence has suggested that adapting the child's environment via parenting interventions has minimal effects on child ADHD symptoms when analysing data from informants who are probably blind to treatment allocation. However, adverse parenting and family environments may act as a source of environmental risk for a number of child outcomes beyond ADHD symptoms. This is a narrative review that critically discusses whether parenting interventions are beneficial for alternative functioning outcomes in ADHD including neuropsychological, academic and social functioning and disruptive behaviour and how parenting and familial environments may be associated with these outcomes. In addition, the review explores how parental depression and parenting efficacy impact on capacity for optimal parenting and whether parenting interventions benefit parents too. A review of the evidence suggests that with modification, parenting interventions are beneficial for a number of outcomes other than ADHD symptom reduction. Improving the parent-child relationship may have indirect benefits for disruptive behaviour. Furthermore, parenting behaviours may directly benefit child neuropsychological, academic and social functioning. Parenting interventions can have therapeutic benefits for parents as well as children, which is important as parent and child well-being is likely to have a transactional relationship. Evaluation of the clinical success of parenting interventions should focus on a wider range of outcomes in order to aid understanding of the multifaceted benefits that they may be able to offer. Parenting interventions should not be seen as a redundant adjunct to medication in multi-modal treatment approaches for ADHD; they have the potential to target outcomes that, at present, medication seems less able to improve.

Summer Treatment Programs for Youth with Attention-deficit/hyperactivity Disorder

Children with attention-deficit/hyperactivity disorder (ADHD) require intensive treatments to remediate functional impairments and promote the development of adaptive skills. The summer treatment program (STP) is an exemplar of intensive treatment of ADHD. STP intervention components include a reward and response-cost point system, time-out, use of antecedent control (clear commands, establishment of rules and routines), and liberal praise and rewards for appropriate behavior. Parents also participate in parent management training programming to learn how to implement similar procedures within the home setting. There is strong evidence supporting the efficacy of the STP as an intervention for ADHD.

Parent predictors of adolescents' explanatory style

The current study tested the prospective relations (six month lag) between three aspects of the parent-child relationship at Time 1 (T1) and adolescents' explanatory styles at Time 2 (T2): caregiving behaviors, parents' explanatory style for their own negative events, and parents' explanatory style for their children's negative events. The sample included 129 adolescents aged 11 to 14 years at baseline and their parents. Adolescents reported on their own explanatory style and their parents' caregiving behaviors; parents self-reported on their caregiving behaviors and their explanatory style for their own and their children's events. Regression analyses identified maternal acceptance as a significant predictor of T2 adolescents' explanatory style. Marginal effects emerged for fathers' psychological control and fathers' explanatory style for their children's events. Findings suggest that the ways parents - especially mothers - interact with their children may play a role in adolescents' cognitive vulnerability to depression.

Family support programs and adolescent mental health: review of evidence

Family support programs aim to improve parent wellbeing and parenting as well as adolescent mental and behavioral health by addressing the needs of parents of adolescents experiencing or at risk for mental health problems. Family support programs can be part of the treatment for adolescents diagnosed with mental or behavioral health problems, or family support programs can be delivered as prevention programs designed to prevent the onset or escalation of mental or behavioral health problems. This review discusses the rationale for family support programs and describes the range of services provided by family support programs. The primary focus of the review is on evaluating the effectiveness of family support programs as treatments or prevention efforts delivered by clinicians or peers. Two main themes emerged from the review. First, family support programs that included more forms of support evidenced higher levels of effectiveness than family support programs that provided fewer forms of support. Discussion of this theme focuses on individual differences in client needs and program adaptions that may facilitate meeting diverse needs. Second, family support prevention programs appear to be most effective when serving individuals more in need of mental and behavioral health services. Discussion of this theme focuses on the intensity versus breadth of the services provided in prevention programs. More rigorous evaluations of family support programs are needed, especially for peer-delivered family support treatments.

Parental quality of life and depressive mood following methylphenidate treatment of children with attention-deficit hyperactivity disorder

AIM

This naturalistic study investigated the associations between quality of life and depressive mood in parents and symptom changes in attention-deficit hyperactivity disorder (ADHD) children.

METHODS

At baseline and at weeks 4 and 8, the parents evaluated their children, who were receiving treatment with osmotic-release oral system methylphenidate (mean dosage 36.3 ± 15.5 mg/day), using the Swanson, Nolan, and Pelham - Fourth Edition (SNAP-IV-18) scale. The parents evaluated themselves using the Beck Depression Inventory (BDI) and the World Health Organization Quality of Life Assessment, Brief Version (WHOQOL-BREF).

RESULTS

A significant reduction in SNAP-IV-18 scores and improvements in parental BDI scores and parental WHOQOL-BREF scores were observed. The decrease in BDI scores from baseline to 8 weeks was significantly associated with increases in WHOQOL-BREF sub-domain scores from baseline to 8 weeks, with a greater decrease at 4 weeks and after. The decrease in the SNAP-IV-18 hyperactivity-impulsivity score was significantly associated with increases in WHOQOL social sub-domain scores from baseline to 8 weeks. For those patients who showed a 25% or greater decrease in the SNAP-IV-18 total scores from baseline to 8 weeks, the decreases in the SNAP-IV-18 total score and in the inattention and hyperactivity-impulsivity scores were significantly associated with a decrease in BDI scores from baseline to 8 weeks.

CONCLUSION

Methylphenidate treatment for ADHD was associated with both symptom alleviation in children with ADHD and improvement in parental depressive mood and quality of life, suggesting that the effects of treatment could go beyond symptom improvement in ADHD.

Group-based parent training programmes for improving parental psychosocial health

BACKGROUND

Parental psychosocial health can have a significant effect on the parent-child relationship, with consequences for the later psychological health of the child. Parenting programmes have been shown to have an impact on the emotional and behavioural adjustment of children, but there have been no reviews to date of their impact on parental psychosocial wellbeing.

OBJECTIVES

To address whether group-based parenting programmes are effective in improving parental psychosocial wellbeing (for example, anxiety, depression, guilt, confidence).

SEARCH METHODS

We searched the following databases on 5 December 2011: CENTRAL (2011, Issue 4), MEDLINE (1950 to November 2011), EMBASE (1980 to week 48, 2011), BIOSIS (1970 to 2 December 2011), CINAHL (1982 to November 2011), PsycINFO (1970 to November week 5, 2011), ERIC (1966 to November 2011), Sociological Abstracts (1952 to November 2011), Social Science Citation Index (1970 to 2 December 2011), metaRegister of Controlled Trials (5 December 2011), NSPCC Library (5 December 2011). We searched ASSIA (1980 to current) on 10 November 2012 and the National Research Register was last searched in 2005.

SELECTION CRITERIA

We included randomised controlled trials that compared a group-based parenting programme with a control condition and used at least one standardised measure of parental psychosocial health. Control conditions could be waiting-list, no treatment, treatment as usual or a placebo.

DATA COLLECTION AND ANALYSIS

At least two review authors extracted data independently and assessed the risk of bias in each study. We examined the studies for any information on adverse effects. We contacted authors where information was missing from trial reports. We standardised the treatment effect for each outcome in each study by dividing the mean difference in post-intervention scores between the intervention and control groups by the pooled standard deviation.

MAIN RESULTS

We included 48 studies that involved 4937 participants and covered three types of programme: behavioural, cognitive-behavioural and multimodal. Overall, we found that group-based parenting programmes led to statistically significant short-term improvements in depression (standardised mean difference (SMD) -0.17, 95% confidence interval (CI) -0.28 to -0.07), anxiety (SMD -0.22, 95% CI -0.43 to -0.01), stress (SMD -0.29, 95% CI -0.42 to -0.15), anger (SMD -0.60, 95% CI -1.00 to -0.20), guilt (SMD -0.79, 95% CI -1.18 to -0.41), confidence (SMD -0.34, 95% CI -0.51 to -0.17) and satisfaction with the partner relationship (SMD -0.28, 95% CI -0.47 to -0.09). However, only stress and confidence continued to be statistically significant at six month follow-up, and none were significant at one year. There was no evidence of any effect on self-esteem (SMD -0.01, 95% CI -0.45 to 0.42). None of the trials reported on aggression or adverse effects.The limited data that explicitly focused on outcomes for fathers showed a statistically significant short-term improvement in paternal stress (SMD -0.43, 95% CI -0.79 to -0.06). We were unable to combine data for other outcomes and individual study results were inconclusive in terms of any effect on depressive symptoms, confidence or partner satisfaction.

AUTHORS' CONCLUSIONS

The findings of this review support the use of parenting programmes to improve the short-term psychosocial wellbeing of parents. Further input may be required to ensure that these results are maintained. More research is needed that explicitly addresses the benefits for fathers, and that examines the comparative effectiveness of different types of programme along with the mechanisms by which such programmes bring about improvements in parental psychosocial functioning.

Self-Esteem Reactivity Among Mothers of Children with Attention-Deficit/Hyperactivity Disorder: The Moderating Role of Depression History

This study examined self-esteem reactivity to a variety of contextual cues in a sample of women prone to depression. Participants were 49 mothers of children with attention-deficit/hyperactivity disorder. Across a 9-month time-period, participants completed weekly measures of self-esteem, perceived stress, positive and negative affect, and child disruptive behavior. Results indicated that mothers reported lower self-esteem during weeks they experienced greater stress, lower positive affect, higher negative affect, and more inattentive, overactive, and oppositional behavior in their children. Depression history moderated these relationships such that mothers with prior histories of depression reported greater self-esteem reactivity to these cues than never depressed mothers.

Development and preliminary evaluation of an integrated treatment targeting parenting and depressive symptoms in mothers of children with attention-deficit/hyperactivity disorder

OBJECTIVE

More than 50% of mothers of children with attention-deficit/hyperactivity disorder (ADHD) have a lifetime history of major depressive disorder (MDD). Maternal depressive symptoms are associated with impaired parenting and predict adverse developmental and treatment outcomes for children with ADHD. For these reasons, we developed and examined the preliminary efficacy of an integrated treatment targeting parenting and depressive symptoms for mothers of children with ADHD. This integrated intervention incorporated elements of 2 evidence-based treatments: behavioral parent training (BPT) and cognitive behavioral depression treatment.

METHOD

Ninety-eight mothers with at least mild depressive symptoms were randomized to receive either standard BPT (n = 51) or the integrated parenting intervention for ADHD (IPI-A; n = 47). Participants were assessed at baseline, posttreatment, and 3- to 6-month follow-up on measures of (a) self-reported maternal depressive symptoms, (b) observed positive and negative parenting, and (c) observed and mother-reported child disruptive behavior and mother-reported child and family impairment.

RESULTS

The IPI-A produced effects of small to moderate magnitude relative to BPT on maternal depressive symptoms, observed negative parenting, observed child deviance, and child impairment at posttreatment and on maternal depressive symptoms, child disruptive behavior, child impairment and family functioning at follow-up. Contrary to expectations, the BPT group demonstrated moderate to large effects relative to IPI-A on observed positive parenting at follow-up.

CONCLUSIONS

This treatment development study provides encouraging preliminary support for the integrated intervention targeting parenting and depressive symptoms in mothers of children with ADHD. Future studies should examine whether this integrated intervention improves long-term developmental outcomes for children with ADHD. (PsycINFO Database Record (c) 2013 APA, all rights reserved).

Parents psychopathology of children with Attention Deficit Hyperactivity Disorder

Attention Deficit Hyperactivity Disorder (ADHD) is a disorder with extremely complex etiology, not yet well defined but certainly multi-factorial. This study investigated the possible etiopathogenetic role of ADHD symptoms and psychopathology disorders in parents of children with ADHD. We present a case-control study of parents of 50 children affected by ADHD and of 45 healthy children, matched to age and gender. Parents of ADHD children reported higher levels of ADHD symptoms, depressive disorders and Depressive Personality Disorders than parents of healthy children. Mothers displayed greater presence of depression, while fathers showed problems concerning alcohol use. The occurrence of ADHD symptoms, psychopathology and personality disorders in parents highlights the importance to integrate the treatment programs in the ADHD children with the screening and treatment for psychopathological symptoms of the parents.

Maternal depression and treatment gains following a cognitive behavioral intervention for posttraumatic stress in preschool children

The evidence base for cognitive behavioral therapy (CBT) to treat child emotional and behavioral symptoms following exposure to trauma in youth is compelling, but relatively few studies are available on preschool children and on moderators of treatment outcomes. This paper examines maternal and child characteristics as moderators of posttraumatic stress (PTS) treatment outcomes in preschool children. Outcome data from a previously published randomized trial in three to six year old preschool children with diagnostic interview data from participating mothers were used. Hypotheses were tested via hierarchical linear modeling. Maternal depression was associated with higher initial child posttraumatic stress disorder (PTSD) symptoms, and was associated with increasing PTSD symptom trends at follow up suggesting potential child PTSD symptom relapse. Maternal PTSD symptoms similarly predicted differential child separation anxiety symptom change but not child PTSD symptom change. Targeting dyads with child PTSD symptoms and maternal depression or PTSD symptoms with enhanced interventions may be a useful strategy to improve treatment maintenance.

A meta-analysis of behavioral parent training for children with attention deficit hyperactivity disorder

This meta-analysis examined the effect of behavioral parent training on child and parental outcomes for children with attention deficit hyperactivity disorder. Meta-analytic procedures were used to estimate the effect of behavioral parent training on children with attention deficit hyperactivity disorder. Variables moderating the intervention effect were examined. Forty studies were included and generated an overall moderate effect size at post-treatment and a small effect size at follow-up. The majority of outcome categories were associated with a moderate effect size at post-treatment that decreased to a small effect size at follow-up. Parenting competence was the only outcome that had a large effect, which decreased to moderate at follow-up. The strength of the effect differed between questionnaire and observation measures. Behavioral parent training is an effective intervention for children with attention deficit hyperactivity disorder. Sustainability of the effects over time is a problem that awaits further scrutiny. Recommendations for further research and clinical practices are provided.

Disentangling the temporal relationship between parental depressive symptoms and early child behavior problems: a transactional framework

Despite the considerable amount of research demonstrating the relationship between parental depressive symptoms and child behavior problems, few studies have examined the direction of the relationship between these variables. Therefore, the purpose of this study was to examine transactional effects between parental depressive symptoms and child behavior problems. Participants were 209 parent-child dyads drawn from the Oregon Adolescent Depression Project who completed at least 2 of 4 annual questionnaire assessments between the child's age of 4 and 7 years. Structural equation modeling was used to examine the autoregressive paths from one year to the next year within each construct, as well as cross-lagged paths from one year to the next year between constructs. Findings indicated that parental depressive symptoms at each year predicted child behavior problems at the subsequent year and vice versa. No support was found for differential gender effects. These findings highlight the reciprocal relationship between parental depressive symptoms and child behavior problems and suggest intervention programs for young children should assess for and target parental depression when appropriate. Future research should examine these relationships across a broader developmental spectrum and in more diverse, heterogeneous samples.

Group-based parent training programmes for improving parental psychosocial health

BACKGROUND

Parental psychosocial health can have a significant effect on the parent-child relationship, with consequences for the later psychological health of the child. Parenting programmes have been shown to have an impact on the emotional and behavioural adjustment of children, but there have been no reviews to date of their impact on parental psychosocial wellbeing.

OBJECTIVES

To address whether group-based parenting programmes are effective in improving parental psychosocial wellbeing (for example, anxiety, depression, guilt, confidence).

SEARCH METHODS

We searched the following databases on 5 December 2012: CENTRAL (2011, Issue 4), MEDLINE (1950 to November 2011), EMBASE (1980 to week 48, 2011), BIOSIS (1970 to 2 December 2011), CINAHL (1982 to November 2011), PsycINFO (1970 to November week 5, 2011), ERIC (1966 to November 2011), Sociological Abstracts (1952 to November 2011), Social Science Citation Index (1970 to 2 December 2011), metaRegister of Controlled Trials (5 December 2011), NSPCC Library (5 December 2011). We searched ASSIA (1980 to current) on 10 November 2012 and the National Research Register was last searched in 2005.

SELECTION CRITERIA

We included randomised controlled trials that compared a group-based parenting programme with a control condition and used at least one standardised measure of parental psychosocial health. Control conditions could be waiting-list, no treatment, treatment as usual or a placebo.

DATA COLLECTION AND ANALYSIS

At least two review authors extracted data independently and assessed the risk of bias in each study. We examined the studies for any information on adverse effects. We contacted authors where information was missing from trial reports. We standardised the treatment effect for each outcome in each study by dividing the mean difference in post-intervention scores between the intervention and control groups by the pooled standard deviation.

MAIN RESULTS

We included 48 studies that involved 4937 participants and covered three types of programme: behavioural, cognitive-behavioural and multimodal. Overall, we found that group-based parenting programmes led to statistically significant short-term improvements in depression (standardised mean difference (SMD) -0.17, 95% confidence interval (CI) -0.28 to -0.07), anxiety (SMD -0.22, 95% CI -0.43 to -0.01), stress (SMD -0.29, 95% CI -0.42 to -0.15), anger (SMD -0.60, 95% CI -1.00 to -0.20), guilt (SMD -0.79, 95% CI -1.18 to -0.41), confidence (SMD -0.34, 95% CI -0.51 to -0.17) and satisfaction with the partner relationship (SMD -0.28, 95% CI -0.47 to -0.09). However, only stress and confidence continued to be statistically significant at six month follow-up, and none were significant at one year. There was no evidence of any effect on self-esteem (SMD -0.01, 95% CI -0.45 to 0.42). None of the trials reported on aggression or adverse effects.The limited data that explicitly focused on outcomes for fathers showed a statistically significant short-term improvement in paternal stress (SMD -0.43, 95% CI -0.79 to -0.06). We were unable to combine data for other outcomes and individual study results were inconclusive in terms of any effect on depressive symptoms, confidence or partner satisfaction.

AUTHORS' CONCLUSIONS

The findings of this review support the use of parenting programmes to improve the short-term psychosocial wellbeing of parents. Further input may be required to ensure that these results are maintained. More research is needed that explicitly addresses the benefits for fathers, and that examines the comparative effectiveness of different types of programme along with the mechanisms by which such programmes bring about improvements in parental psychosocial functioning.

Development and pilot evaluation of an Internet-facilitated cognitive-behavioral intervention for maternal depression

OBJECTIVE

Develop and pilot an Internet-facilitated cognitive-behavioral treatment intervention for depression, tailored to economically disadvantaged mothers of young children.

METHOD

Mothers (N = 70) of children enrolled in Head Start, who reported elevated levels of depressive symptoms, were randomized to either the 8-session, Internet-facilitated intervention (Mom-Net) or delayed intervention/facilitated treatment-as-usual (DI/TAU). Outcomes were measured using the Beck Depression Inventory (BDI-II; Beck, Steer, & Brown, 1996); the Patient Health Questionnaire 9 (PHQ-9; Spitzer et al., 1999), Behavioral Observations of Parent-Child Interactions using the Living in Family Environments coding system (LIFE; Hops, Davis, & Longoria, 1995); the Dyadic Parent-Child Interaction Coding Systems (DPICS; Eyberg, Nelson, Duke, & Boggs, 2005); the Parent Behavior Inventory (PBI; Lovejoy, Weis, O'Hare, & Rubin, 1999); and the Parenting Sense of Competence scale (PSOC; Gibaud-Wallston & Wandersman, 1978).

RESULTS

Mom-Net demonstrated high levels of feasibility as indicated by low attrition and high program usage and satisfaction ratings. Participants in the Mom-Net condition demonstrated significantly greater reduction in depression, the primary outcome, at the level of both symptoms and estimates of criteria-based diagnoses over the course of the intervention. They also demonstrated significantly greater improvement on a questionnaire measure of parent satisfaction and efficacy as well as on both questionnaire and observational indices of harsh parenting behavior.

CONCLUSIONS

Initial results suggest that the Mom-Net intervention is feasible and efficacious as a remotely delivered intervention for economically disadvantaged mothers.

Parent training interventions for Attention Deficit Hyperactivity Disorder (ADHD) in children aged 5 to 18 years

BACKGROUND

Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterised by high levels of inattention, hyperactivity and impulsivity that are present before the age of seven years, seen in a range of situations, inconsistent with the child's developmental level and causing social or academic impairment. Parent training programmes are psychosocial interventions aimed at training parents in techniques to enable them to manage their children's challenging behaviour.

OBJECTIVES

To determine whether parent training interventions are effective in reducing ADHD symptoms and associated problems in children aged between five and eigtheen years with a diagnosis of ADHD, compared to controls with no parent training intervention.

SEARCH METHODS

We searched the following electronic databases (for all available years until September 2010): CENTRAL (2010, Issue 3), MEDLINE (1950 to 10 September 2010), EMBASE (1980 to 2010 Week 36), CINAHL (1937 to 13 September 2010), PsycINFO (1806 to September Week 1 2010), Dissertation Abstracts International (14 September 2010) and the metaRegister of Controlled Trials (14 September 2010). We contacted experts in the field to ask for details of unpublished or ongoing research.

SELECTION CRITERIA

Randomised (including quasi-randomised) studies comparing parent training with no treatment, a waiting list or treatment as usual (adjunctive or otherwise). We included studies if ADHD was the main focus of the trial and participants were over five years old and had a clinical diagnosis of ADHD or hyperkinetic disorder that was made by a specialist using the operationalised diagnostic criteria of the DSM-III/DSM-IV or ICD-10. We only included trials that reported at least one child outcome.

DATA COLLECTION AND ANALYSIS

Four authors were involved in screening abstracts and at least 2 authors looked independently at each one. We reviewed a total of 12,691 studies and assessed five as eligible for inclusion. We extracted data and assessed the risk of bias in the five included trials. Opportunities for meta-analysis were limited and most data that we have reported are based on single studies.

MAIN RESULTS

We found five studies including 284 participants that met the inclusion criteria, all of which compared parent training with de facto treatment as usual (TAU). One study included a nondirective parent support group as a second control arm.  Four studies targeted children's behaviour problems and one assessed changes in parenting skills. Of the four studies targeting children's behaviour, two focused on behaviour at home and two focused on behaviour at school. The two studies focusing on behaviour at home had different findings: one found no difference between parent training and treatment as usual, whilst the other reported statistically significant results for parent training versus control. The two studies of behaviour at school also had different findings: one study found no difference between groups, whilst the other reported positive results for parent training when ADHD was not comorbid with oppositional defiant disorder. In this latter study, outcomes were better for girls and for children on medication.We assessed the risk of bias in most of the studies as unclear at best and often as high. Information on randomisation and allocation concealment did not appear in any study report. Inevitably, blinding of participants or personnel was impossible for this intervention; likewise, blinding of outcome assessors (who were most often the parents who had delivered the intervention) was impossible.We were only able to conduct meta-analysis for two outcomes: child 'externalising' behaviour (a measure of rulebreaking, oppositional behaviour or aggression) and child 'internalising' behaviour (for example, withdrawal and anxiety). Meta-analysis of three studies (n = 190) providing data on externalising behaviour produced results that fell short of statistical significance (SMD -0.32; 95% CI -0.83 to 0.18, I(2) = 60%). A meta-analysis of two studies (n = 142) for internalising behaviour gave significant results in the parent training groups (SMD -0.48; 95% CI -0.84 to -0.13, I(2) = 9%). Data from a third study likely to have contributed to this outcome were missing, and we have some concerns about selective outcome reporting bias.Individual study results for child behaviour outcomes were mixed. Positive results on an inventory of child behaviour problems were reported for one small study (n = 24) with the caveat that results were only positive when parent training was delivered to individuals and not groups. In another study (n = 62), positive effects (once results were adjusted for demographic and baseline data) were reported for the intervention group on a social skills measure.The study (n = 48) that assessed parenting skill changes compared parent training with a nondirective parent support group. Statistically significant improvements were reported for the parent training group. Two studies (n = 142) provided data on parent stress indices that were suitable for combining in a meta-analysis. The results were significant for the 'child' domain (MD -10.52; 95% CI -20.55 to -0.48) but not the 'parent' domain (MD -7.54; 95% CI -24.38 to 9.30). Results for this outcome from a small study (n = 24) suggested a long-term benefit for mothers who received the intervention at an individual level; in contrast, fathers benefited from short-term group treatment. A fourth study reported change data for within group measures of parental stress and found significant benefits in only one of the two active parent training group arms (P ≤ 0.01).No study reported data for academic achievement, adverse events or parental understanding of ADHD.

AUTHORS' CONCLUSIONS

Parent training may have a positive effect on the behaviour of children with ADHD. It may also reduce parental stress and enhance parental confidence. However, the poor methodological quality of the included studies increases the risk of bias in the results. Data concerning ADHD-specific behaviour are ambiguous. For many important outcomes, including school achievement and adverse effects, data are lacking.Evidence from this review is not strong enough to form a basis for clinical practice guidelines. Future research should ensure better reporting of the study procedures and results.

Caregiver Depression and Youth Disruptive Behavior Difficulties

This study examines the rates of depressive symptoms and service use among caregivers whose children receive treatment for disruptive behavior disorders. Descriptive analyses examined preliminary baseline data from the Family Groups for Urban Youth with Disruptive Behaviors study for 212 caregivers to determine rates of caregiver depressive symptoms and lifetime mental health service use. Findings indicate that caregivers manifest substantially higher rates of depressive symptoms compared to national norms. Of those caregivers with clinically significant depressive symptoms, less than half reported ever receiving mental health services. Findings suggest that greater attention should be paid to identifying and treating caregiver depression among children receiving treatment for disruptive behavior disorders.

Family support in children's mental health: a review and synthesis

A comprehensive review of structured family support programs in children's mental health was conducted in collaboration with leadership from key national family organizations. The goals were to identify typologies of family support services for which evaluation data existed and identify research gaps. Over 200 programs were examined; 50 met criteria for inclusion. Programs were categorized by whether they were delivered by peer family members, clinicians, or teams. Five salient components of family support were identified: (a) informational, (b) instructional, (c) emotional, (d) instrumental, and (e) advocacy. Clinician-led programs were heavily represented (n = 33, 66%), followed by family-led (n = 11, 22%), and team-delivered (n = 6, 12%) programs. Key differences between programs delivered by clinicians or by peer family members were found in the degree of emphasis, research methodology, and outcomes. However, the content of the components was similar across all three program types. There are both important differences in emphasis across typologies of family support provided by clinicians, family members, or teams as well as important similarities in content. Family-delivered support may be an important adjunct to existing services for parents, although the research base remains thin. A research agenda to promote more rigorous evaluations of these services especially those delivered by peer family members is critical.

Review of Interventions for Parental Depression from Toddlerhood to Adolescence

Because of the recurrent course, significant burden, and intergenerational impact of depression, there is a great need for interventions for depressed parents and their children. This article reviews eight interventions that 1) aim to impact the functioning and well-being of 18-month to 18-year old children of depressed parents and 2) have been evaluated in controlled studies. The interventions are described and the empirical evidence of their efficacy is reviewed and critiqued. Existing research points to several promising intervention strategies, such as psychoeducation about parental depression, addressing parenting in adult depression treatment, promoting positive parent-child interactions, and teaching coping skills to children. Common limitations of the research in this area are small sample sizes, homogenous samples, and lack of replication. Implementation problems within the mental healthcare system are highlighted. Multi-component interventions seem to be a promising approach to address the complex impact parental depression has on children and the parent-child relationship. This review illustrates the need for more research on intervention models that can be implemented with children at various developmental levels.

Psychoeducational treatment and prevention of depression: the "Coping with Depression" course thirty years later

The "Coping with Depression" course (CWD) is by the far the best studied psychoeducational intervention for the treatment and prevention of depression, and is used in routine practice in several countries. The CWD is a highly structured cognitive-behavioral intervention, which has been adapted for several goals, contexts, and target populations. The efficacy of the CWD has been examined in 25 randomized controlled trials. We conducted a meta-analysis of these studies. The 6 studies aimed at the prevention of new cases of major depression were found to result in a reduced risk of getting major depression of 38% (incidence rate ratio was 0.62). The 18 studies examining the CWD as a treatment of depression found a mean effect size (Cohen's d) of 0.28. Direct comparisons with other psychotherapies did not result in any indication that the CWD was less efficacious. The CWD is a flexible treatment which can easily be adapted for different populations and this may have led researchers to use this intervention for complex target groups, which in turn may have resulted in a lower mean effect size. The CWD has contributed considerably to the development and innovation of prevention and treatment of depression in many target populations.

Attention-deficit/hyperactivity disorder in children and adolescents: closing diagnostic, communication, and treatment gaps

Nurses and nurse practitioners often play a key role in the management of children with attention-deficit/hyperactivity disorder (ADHD), a disorder that often persists into adolescence and adulthood. The diagnosis of ADHD requires careful history taking, use of standardized rating scales, and close attention to the patient's behavior and informants' reports. Stimulants appear to be most effective for patients with this diagnosis, but pharmacotherapy for ADHD should be combined with educational and behavioral interventions and careful follow-up to optimize treatment outcomes. Nurses and nurse practitioners must advocate to assist patients and families achieve goals at home and at school.