Sequential treatment of ADHD in mother and child (AIMAC study): importance of the treatment phases for intervention success in a randomized trial

Background: The efficacy of parent-child training (PCT) regarding child symptoms may be reduced if the mother has attention-deficit/hyperactivity disorder (ADHD). The AIMAC study (ADHD in Mothers and Children) aimed to compensate for the deteriorating effect of parental psychopathology by treating the mother (Step 1) before the beginning of PCT (Step 2). This secondary analysis was particularly concerned with the additional effect of the Step 2 PCT on child symptoms after the Step 1 treatment. Methods: The analysis included 143 mothers and children (aged 6–12 years) both diagnosed with ADHD. The study design was a two-stage, two-arm parallel group trial (Step 1 treatment group [TG]: intensive treatment of the mother including psychotherapy and pharmacotherapy; Step 1 control group [CG]: supportive counseling only for mother; Step 2 TG and CG: PCT). Single- and multi-group analyses with piecewise linear latent growth curve models were applied to test for the effects of group and phase. Child symptoms (e.g., ADHD symptoms, disruptive behavior) were rated by three informants (blinded clinician, mother, teacher). Results: Children in the TG showed a stronger improvement of their disruptive behavior as rated by mothers than those in the CG during Step 1 (Step 1: TG vs. CG). In the CG, according to reports of the blinded clinician and the mother, the reduction of children’s disruptive behavior was stronger during Step 2 than during Step 1 (CG: Step 1 vs. Step 2). In the TG, improvement of child outcome did not differ across treatment steps (TG: Step 1 vs. Step 2). Conclusions: Intensive treatment of the mother including pharmacotherapy and psychotherapy may have small positive effects on the child’s disruptive behavior. PCT may be a valid treatment option for children with ADHD regarding disruptive behavior, even if mothers are not intensively treated beforehand. Trial registration: ISRCTN registry ISRCTN73911400. Registered: 29 March 2007

Adaptive Multimodal Treatment for Children with Attention-Deficit-/Hyperactivity Disorder: An 18 Month Follow-Up

The Cologne Adaptive Multimodal Treatment (CAMT) study demonstrated that adaptive and individually tailored multimodal treatment for attention-deficit/hyperactivity disorder (ADHD) [consisting of behavior therapy (BT) and/or stimulant medication] is highly effective. This study reports findings of the 18 month follow-up assessment. Parents and teachers completed broad range behavior scales (Child Behavior Checklist/Teacher Report Form) and standardized ADHD and oppositional defiant disorder/conduct disorder symptom rating scales. Children that used medication to treat ADHD at follow-up (N = 32) and those that did not (N = 34) were analyzed separately. Parents did not report significant changes in child behavior from posttest to follow-up. Teacher ratings revealed some aggravation of ADHD symptoms in children that received medication, but this was not significant after Bonferroni correction. The initial advantage of combined treatment over BT was no longer evident. It can be concluded that treatment for ADHD that is tailored to the assessed needs of children results in large treatment effects that are maintained for at least 18 months

Long-Term Course After Adaptive Multimodal Treatment for Children With ADHD: An 8-Year Follow-Up

Objective: This study reassessed adolescents and young adults (15-22 years old) who received individually tailored multimodal treatment for ADHD (behavior therapy and/or stimulant medication) during childhood 6 to 12 years after treatment (M = 8.8 years, SD = 1.6). Method: All participants (N = 75) provided information about their social functioning. Most parents (83%) completed behavior rating scales. Results: Participants demonstrated significant improvement in behavior during the follow-up period with effect sizes on ADHD symptoms of d = 1.2 and 68% of the former patients in the normal range at follow-up. Participants reported elevated rates of grade retention (51%), school dropout (13%), special education service use (17%), school change (47%), and conviction (16%), but few were unemployed (4%). Conclusion: This study provides evidence that the effects of individually tailored multimodal treatment for ADHD in childhood are maintained into adolescence and young adulthood. No hints could be found that continued medication results in a more favorable long-term outcome

Long-Term Effectiveness of Guided Self-Help for Parents of Children With ADHD in Routine Care-An Observational Study

Objective:To assess long-term effectiveness of guided self-help for parents of children with ADHD under routine care conditions. Method: 6- to 12-year-old children diagnosed with ADHD were enrolled in an observational study on a 1-year telephone-assisted parent-administered behavioral intervention. N = 136 families who completed the intervention participated in a follow-up assessment. Pre-, post-, and follow-up data were analyzed by repeated measures ANOVA with planned contrasts. Clinical significance was analyzed according to the reliable change index. Results: Child ADHD symptoms (primary outcome), oppositional defiant disorder (ODD) symptoms, overall behavioral problems, and quality of life improved during the intervention. There was a further improvement in ADHD symptoms at follow-up, with a medium effect size. Improvements during treatment in ODD symptoms, overall behavioral problems, and quality of life were maintained at follow-up. Conclusion: The findings suggest that telephone-assisted self-help interventions may result in a long-term reduction of child behavior problems

Effectiveness of outpatient cognitive-behavioral therapy for adolescents under routine care conditions on behavioral and emotional problems rated by parents and patients: an observational study

Few studies have examined the effectiveness of outpatient cognitive-behavioral therapy (CBT) delivered in routine care settings for children and adolescents with mental disorders. This observational study examined changes in behavioral and emotional problems of adolescents with mental disorders during routine outpatient CBT delivered at a university outpatient clinic and compared them with a historical control group of youths who received academic tutoring of comparable length and intensity. Assessments were made at the start and end of treatment (pre- and post-assessment) using parent ratings of the German versions of the Child Behavior Checklist (CBCL) and self-ratings of the Youth Self-Report (YSR) scale. For the main analysis, 677 adolescents aged 11aEuro'21 years had complete data. Changes from pre- to post-assessment showed significant reductions in mental health problems on both parent- and self-ratings. Pre- to post-effect sizes (Cohen's d) were small-to-medium for the total sample (d = 0.23 to d = 0.62) and medium-to-large for those adolescents rated in the clinical range on each (sub)scale at the start of treatment (d = 0.65 to d = 1.48). We obtained medium net effect sizes (d = 0.69) for the CBCL and YSR total scores when patients in the clinical range were compared to historical controls. However, a substantial part of the sample remained in the clinical range at treatment end. The results suggest that CBT is effective for adolescents with mental disorders when administered under routine care conditions but must be interpreted conservatively due to the lack of a direct control condition

Guided self-help interventions for parents of children with ADHD - concept, referral and effectiveness in a nationwide trial. An observational study

Objectives: The effects of guided self-help interventions for parents of children with AMID have already been proven in randomized controlled trials. The objective of this study was to assess the effectiveness of this novel form of intervention under routine care conditions in a nationwide trial. Method: Registered pediatricians as well as child and youth psychiatrists enrolled 274 children between 6 and 12 years old (83.6% male) diagnosed with ADHD to a self-help program for parents of children with ADHD. The program lasted for 1 year and consisted of eight booklets with advice for parenting children with ADHD as well as complementary telephone consultations (14 calls, up to 20 minutes each). The course of the ADHD symptoms and the comorbid symptoms as well as the development of the child's individual problems were assessed in a pre-post design. Results: 63 % of the enrolled parents adhered to the program until the end. The families who cancelled the program did not differ concerning the severity of ADHD symptoms, but they did more often show an impaired familial and social background, and their children received pharmacological treatment more often. Three-fourths of the children who completed the program had received pharmacological treatment at the beginning of the program. The children had more severe ADHD symptoms than a clinical control group. During the intervention, ADHD symptoms as well as psychosocial functioning improved with large effect sizes of d> 0.9. Additionally, comorbid oppositional and emotional symptoms decreased. Conclusions: These results indicate that guided self-help programs for families with children with ADHD are effective, also as an addition to pharmacological treatment

Treatment satisfaction following routine outpatient cognitive-behavioral therapy of adolescents with mental disorders: a triple perspective of patients, parents and therapists

The present study investigates treatment satisfaction (TS) rated by multiple informants (patient, parent, therapist) following routine outpatient cognitive-behavioral therapy (CBT) within a large sample (n=965) of clinically referred adolescents aged 11-20years. Moreover, potential predictors of TS were analyzed (patient-related variables, mental disorder characteristics, socio-demographic factors and treatment variables). Overall, our results show a high treatment satisfaction in patient, parent and therapist ratings, with the therapists being the most critical raters (completely/predominantly satisfied: 87.8% in patient, 92.0% in parent, and 64.0% in therapist ratings). Correlations between the three raters were only small to moderate, but statistically significant. Regression analysis examining differential effects found that mental disorder characteristics (parent- and patient-reported symptoms at post) and treatment variables (especially cooperation of patients and parents as rated by therapists) explained most of the variance in TS, whereas patient-related or socio-demographic variables did not emerge as relevant predictors of TS. The amounts of explained variance were R-adj(2) = 0.594 in therapist rating, R-adj(2) = 0.322 in patient rating and R-adj(2). = 0.203 in parent rating

Behavioral Versus Nonbehavioral Guided Self-Help for Parents of Children With Externalizing Disorders in a Randomized Controlled Trial

Self-help interventions for parents, which have a behavioral basis, are considered to be an effective treatment option for children with externalizing disorders. Nonbehavioral approaches are widely used but have little empirical evidence. The main objective of this trial was to compare the efficacy of a behavioral and a nonbehavioral guided self-help program for parents. Families of children (aged 4-11 years) diagnosed with attention-deficit/hyperactivity disorder (ADHD) or oppositional defiant disorder (ODD) were randomized to either a behavioral or a nonbehavioral guided self-help program including 8 parenting booklets and 10 counseling telephone calls. The analyses considered the ratings of 5 informants: blinded clinician, therapist, participant, (her or his) partner, and teacher. Of the 149 families randomized to treatment (intention-to-treat sample [ITT]), 110 parents completed the intervention (per-protocol sample [PP]). For the 4 primary outcome measures (blinded clinician- and participant-rated ADHD and ODD) at post assessment, the analysis revealed a treatment advantage for the behavioral group in blinded clinician-rated ODD symptoms (ITT: d = 0.37; PP: d = 0.35). Further treatment differences, all in favor of the behavioral group (ITT and PP), were detected in therapist ratings (i.e., ODD) and participant ratings (e.g., parental self-efficacy [only PP], negative parenting behavior, parental stress). In both samples, no differences were found at post-assessment for ratings of the partner and the teacher, or at the 12-month follow-up (only participant ratings available). Behavioral guided self-help shows some treatment advantage in the short term. No superiority over nonbehavioral therapy was detected 12 months after treatment termination

Parent- and Teacher-Rated Effectiveness of Cognitive-Behavioral Therapy for Children and Adolescents Under Usual Care Conditions in a University Outpatient Clinic

Compared to randomized controlled trials, studies examining the effectiveness of cognitive behavioral therapy (CBT) in children and adolescents with mental disorders are rare, and a teacher perspective is scarce. The present study investigated the effectiveness of routine CBT in 519 patients aged 6-18years with mental disorders. Changes in mental health problems were assessed in teacher (Teacher Report Form, TRF) and parent rating (Child Behavior Checklist, CBCL) and were analyzed within the total sample, yielding statistically significant, small to medium effect sizes (teacher rating: d=.74-2.39; parent rating: d=.65-1.18). Changes in a subgroup of patients with elevated symptom scores at treatment start were compared to a historical control group receiving weekly academic tutoring. Net total score effect sizes lay between d=0.98 and d=1.29 for teacher rating (parent rating: d=0.84 to d=1.01). Nevertheless, a substantial number of patients remained in the clinical range. Symptom changes during family- and patient-based CBT interventions did not differ from treatments including additional school-based interventions, as was also the case for the comparison of treatments with and without additional pharmacotherapy

Parent- and therapist-rated treatment satisfaction following routine child cognitive-behavioral therapy

This observational study examined treatment satisfaction (TS) following routine outpatient cognitive-behavioral therapy (CBT) in a large sample of children (n = 795; aged 6 to 10 years). TS was investigated in parent and therapist rating. Means, standard deviations and inter-rater correlations were calculated to investigate TS. Regression analysis was conducted to examine potential correlates of TS (patient-related variables, mental disorder characteristics, socio-demographic factors and treatment variables). High TS in parent and therapist rating was found, with therapists showing a lower degree of TS than parents (completely or predominantly satisfied: parent rating 94.1%, therapist rating 69.5%). A statistically significant, moderate inter-rater correlation was found. Regression analysis explained 21.8% of the variance in parent rating and 57.2% in therapist rating. Most of the TS variance was explained by mental disorder characteristics (parent-rated symptoms and therapist-rated global impairment at treatment end) and by treatment variables (especially the therapist-rated cooperation of parents and patients), whereas socio-demographic and patient-related variables did not show any relevant associations with TS. Based on these results, to optimize TS, therapists should concentrate on establishing a sustainable cooperation of parents and children during therapy, and work to achieve a low global impairment at treatment end