An estimated 50% or more of parents with ADHD have a child with ADHD. The high heritability of the illness is of particular concern because some of its primary symptoms include impairments in executive functioning and emotional regulation—two factors that are likely to affect how parents respond to therapies designed to help them better manage their children, especially those who have ADHD.

Data indicates that parental ADHD is associated with poorer developmental and treatment outcomes for children with ADHD. But some past studies have cast doubt on whether treating parental ADHD will result in improved outcomes in their ADHD children, even when it does help the treated parent. This includes results for behavioral parenting training (BPT) for parents with ADHD.

A team at the University of Maryland, College Park, led by Dr. Andrea Chronis-Tuscano, recently reported results of a trial that took 6 years to complete, involving parent-child dyads, or pairs, with ADHD. The objective was to determine if treating ADHD parents with both an ADHD medication and an evidence-based behavioral parenting intervention (called I-BPT) designed to improve parenting skills relevant in caring for young children with ADHD would improve outcomes among the children—compared with outcomes in children whose parents received the parenting intervention alone, without medication.

The team’s senior member was Adelaide S. Robb, M.D., of Children’s National Hospital in Washington, D.C. Dr. Robb received BBRF Young Investigator grants in 2001 and 1992. The team’s results appeared in The Journal of Child Psychology and Psychiatry.

The researchers recruited 120 parent-child dyads, half randomly assigned to receive I-BPT alone, and half to be pretreated for several weeks daily with a stimulant medication (MAS-XR), which was then administered throughout the 10 to 11 sessions of I-BPT therapy. Dosages for the medication were arrived at in the weeks before I-BPT treatments started, beginning at 20mg/day and increasing, depending on tolerability, to a maximum of 60mg/day. In the end, about 71% of participants continued receiving the stimulant, at an average dose of 35mg/day. (The other participants switched to another medicine or never arrived at an optimal response to any medication.) The overall stimulant response rate was 85%, similar to that in other adult trials. The children in the trial had never received medication for their ADHD and did not during the trial.

The parents, average age in the late-30s, were 75% female, although the fraction of male participants considerably exceeded that in prior ADHD parenting trials. About a third of parents were Black or Hispanic, over 70% had at least a college education, and the average family income was $150,000. The typical child participant was about 6 years old; two-thirds were male.

I-BPT therapy was developed to treat parent mental health, using evidence-based cognitive-behavioral and organizational skills. The training begins with psychoeducation about ADHD and focuses on parenting skills such as being assertive, ignoring minor misbehavior, giving effective commands, working with privileges, interacting collaboratively with schools, emotion coaching, and time management. The main outcome in the trial, severity of the child’s illness, was assessed weekly over the course of the trial using a standard 7-item scale called CGI-S, which ranges from “normal—not at all ill” to “most extremely ill”; severity of the parent’s ADHD was assessed using a similar ratings scale. Assessments were also made on improvement or lack of improvement from the study’s baseline; and of the frequency of key parenting behaviors, based on self-reports. Parent-child interactions were assessed independently at baseline and following the treatment course.

Results showed that treating a parent’s ADHD with medication before beginning I-BPT therapy—compared with giving I-BPT alone—led to less severe ADHD symptoms for the parent as well as for their child, and improvements in various parenting behaviors.

Children whose parents received medication + I-BPT “showed faster improvement in clinical severity,” the researchers reported, noting “the addition of stimulant medication for the parent “produced incremental gains in child severity of small-to-moderate magnitude.” Nine months after the trial began, the CGI-S score for children whose parents received medication fell from an average of 4.52 to 3.67 (19%) compared with 4.31 to 3.96 (8%) among children whose parents received I-BPT alone.

Parents who received stimulants also had faster reductions in their own ADHD symptom severity scores, which fell from 3.52 to 2.96 (16%) after 9 months, compared to 4.24 to 3.98 (6%) in the I-BPT-only group.

Self-reported punitive practices and observed positive and negative parenting improved with I-BPT in both groups. But parents who received medication prior to beginning I-BPT were “more likely to praise their children and consistently follow through on consequences,” the team noted. The findings suggest medication “enhanced improvements in helpful parenting behaviors, whereas punitive practices decreased with I-BPT regardless of whether parents received ADHD medication.”

Future tests of the same strategy should try to determine if the results generalize to lower-income families, caregivers with less formal education, and families facing structural barriers to treatment, the team said. Despite this, they noted that 11% of families in the trial had annual income under $25,000 and 30% of parents had less than a bachelor’s degree, suggesting medication + I-BPT may be effective in a more diverse population.

Future analyses might also examine factors which may modify the results obtained in the current trial, such as severity of parental ADHD, amount of family impairment at baseline, and sociodemographic adversity, in order to identify which families are most likely to benefit from combined parental medication and behavioral treatments.

The team noted that there were “promising improvements” in various parenting measures following I-BPT, regardless of whether or not the parent was medicated. At the same time, they summed up, “when parent ADHD was addressed pharmacologically, children showed faster reductions in clinical severity, parents demonstrated faster reductions in their own clinical severity, and select parenting practices improved beyond behavioral intervention alone.”