Examining Behavioral Parent Training as an Intervention for Children With ADHD

Behavioral Parent Training (BPT) has been shown to be an effective intervention in the treatment of children with attention/deficit-hyperactivity disorder (ADHD), but there are many different techniques and they are often used in conjunction with each other, making it difficult to assess their effectiveness.

Researchers in the Netherlands recently examined which techniques are most effective, and presented their findings in a poster at the recent American Professional Society of ADHD and Related Disorders (APSARD) 2021 Virtual Conference. Lead author Tycho Dekkers, PhD, explains the research and its findings in this video.

Read the transcript:

My name is Tycho Dekkers, and I work as an assistant professor at the University of Amsterdam and as a postdoctoral researcher at the University of Groningen, both in the Netherlands. I'll talk about a study we did on behavioral parent training for children with ADHD.

As we know from a bunch of studies and meta-analysis, behavioral parent training is an effective intervention for children with ADHD. Almost all guidelines mention behavioral parent training as an evidence-based treatment for children with ADHD.

However, the problem is that there are many, many therapeutic techniques that could be considered as behavioral. All these behavioral parent training interventions consist of a package of multiple of these techniques.

There's large heterogeneity between all these intervention programs in what techniques they use. The question is, actually, which of these techniques are particularly associated with the effectiveness of these interventions. That's something we don't know much about yet.

Research Method (1:15)

What we did is we requested all the manuals of all the studies that did behavioral parent training in children with ADHD. Then we created a taxonomy of 39 different behavioral techniques. We scored all these manuals on all these techniques.

We received the large majority of all these manuals. We scored the dosage in terms of the percentage of sessions and the number of sessions in which these techniques were used or weren't used.

What we did next is that we did a meta-regression analysis investigating whether the dosage of a specific technique or a category of techniques was associated with the effect of the behavioral parent training. We included 29 randomized controlled trials. These studies, in total, included 138 relevant effects, so most studies included more than one outcome measure.

Study Results (2:16)

The main effects we found were that behavioral parent training had a medium-sized effect size on 5 outcomes of parenting behaviors, because we particularly focused on parenting as an outcome measure.

On positive parenting, negative parenting, parent-child relationship, parenting sense of competence, and parental mental health, we found medium-sized effects, which were quite robust to a publication bias. There was no difference between properly blinded and unblinded outcome measures.

That added up to the evidence we already had that behavioral parent training is an effective intervention for children with ADHD and, in this case, specifically for parenting outcomes.

Then we move on to the main hypothesis of our study. The main part of our study is that we investigated which techniques are particularly associated with higher or lower effectiveness. There were three main findings that were important.

The first one is that techniques that focused on manipulating the antecedents of behavior, so, for example, parents learning to anticipate for potential misbehavior of their child later on, had quite a positive effect on parenting competence and parental mental health.

The higher the dosage of these antecedent behavioral techniques, the more competent parents felt and the more their increased, improved mental well-being.

The second main result was that providing positive consequences, so, for example, offering your child a reward after he did something desirable—particularly, we found the largest effect on social reward, so, for example, the reward being to do something nice together—had a positive effect on negative parenting. Negative parenting practices decreased more when the dosage of providing positive consequences was higher.

The third effect was that we found that psychoeducation techniques and generalization techniques had a negative effect on positive parenting and the parent-child relationship. The more psychoeducation, the more generalization techniques were in these behavioral parent training programs, the lower the effect on positive parenting and the parent-child relationship.

Discussion of Findings (4:58)

What does this mean? A tentative conclusion of this meta-analysis is that behavioral parent training for children with ADHD should deliver antecedent techniques, like anticipating for the misbehavior of the child, and positive-consequent techniques, like offering social rewards, being very consistent, at a high dosage. All the other techniques, particularly psychoeducation and generalization techniques, might be delivered at a lower dosage.

The limitation, however, of the study, which is quite important, is that we tried to isolate the effects of these techniques, but you have to realize that in these trials, all these techniques were never offered in isolation. They were always offered in combination with other techniques. These combined effects or the effects of the sequence of different techniques, we could not investigate in the current study.

Future studies that we are planning and already doing should investigate, for example, using micro-trials, so only a few sessions working with parents, to investigate the effect of separate techniques in isolation.

When we better know the effects of these separate techniques, that could help us to ultimately improve existing behavioral parent training programs to make them more effective as an intervention for parents of children with ADHD.

Reference

Dekkers T, Hornstra R, van der Oord S, et al. Effective components of parent training for children with ADHD: a meta-regression analysis on parenting outcomes. Poster presented at the American Professional Society of ADHD and Related Disorders (APSARD) 2021 Virtual Conference; January 15-17, 2021; Virtual.

Tycho Dekkers, PhD, is an assistant professor at the University of Amsterdam, postdoctoral researcher at the University Medical Center Groningen, and clinician and coordinator of the ADHD team at Levvel Child and Adolescent Psychiatry, Amsterdam, the Netherlands. He obtained his PhD, which was about the association between ADHD and risk-taking behavior, in 2020, and he currently studies the effectiveness of psychosocial interventions for children with ADHD.