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Clinical Child and Family Psychology Review (CCFP) pp1130-ccfp-481521 March 10, 2004 12:33 Style file version Nov. 07, 2000

Clinical Child and Family Psychology Review, Vol. 7, No. 1, March 2004 (°
C 2004)

Enhancements to the Behavioral Parent Training Paradigm

for Families of Children With ADHD: Review
and Future Directions

Andrea M. Chronis,1,3 Anil Chacko,2 Gregory A. Fabiano,2 Brian T. Wymbs,2

and William E. Pelham, Jr.2

Behavioral parent training (BPT) is one of the empirically supported psychosocial treatments
for ADHD. Over many years and in many studies, BPT has been documented to improve
both child ADHD behavior and maladaptive parenting behavior. In some studies, BPT has
also been found to result in benefits in additional domains, such as parenting stress and child
classroom behavior. However, the BPT literature on children selected as having ADHD lags
behind research conducted on BPT for children selected as having oppositional defiant and
conduct disorders (ODD and CD, respectively) with regard to examination of factors that may
limit treatment attainment, compliance, and outcomes, such as single parenthood, parental
psychopathology, and child comorbidity. Because of the high degree of comorbidity between
ADHD and ODD/CD, it is difficult to separate the two BPT literatures. The parameters of BPT
(e.g., format and setting), parent factors, and child factors that may contribute to treatment
outcomes for families of children with ADHD are reviewed here and recommendations for
future BPT research in the area of ADHD are made.
KEY WORDS: ADHD; parent training; psychosocial treatment; treatment outcome; parenting.

Attention-deficit/hyperactivity disorder (ADHD) to increase positive outcomes with their children

is a chronic, pervasive, childhood disorder. The inat-
tentive, hyperactive, and impulsive behaviors that
characterize ADHD often lead to impairment in
the parent–child relationship and contribute to
increased stress among parents of children with the
disorder (Fischer, 1990). Over time, parents may de-
velop maladaptive and counterproductive parenting
strategies to deal with these problems (Patterson,
DeBaryshe, & Ramsey, 1989). It follows that effective
treatment for ADHD must include working directly
with parents to modify their parenting behaviors
1 Department of Psychology, University of Maryland, College Park,
Maryland.
2 Department of Psychology, University at Buffalo, State University
of New York, New York.
3 Address all correspondence to Andrea Chronis, Department of
Psychology, University of Maryland, College Park, Maryland
20742; e-mail: achronis@psyc.umd.edu.
(Pelham, Wheeler, & Chronis, 1998). Effectively
modifying poor parenting practices is of utmost
importance, as poor parenting is one of the more
robust predictors of negative long-term outcomes in
children with behavior problems (Chamberlain &
Patterson, 1995). Behavioral parent training (BPT)
is one of the most effective ways to change parenting
and therefore treat ADHD (e.g., Pelham et al.,
1998).
BPT has a long, successful history as a treat-
ment for children with ADHD (Pelham et al., 1998),
oppositional defiant disorder (ODD), and conduct
disorder (CD; Brestan & Eyberg, 1998), as well as
many internalizing disorders (e.g., Silverman et al.,
1999). BPT has been influenced greatly by the work
of Patterson and Gullion (1968), Hanf (1969), and
Forehand and McMahon (1981), most of whom fo-
cused their research on noncompliant and aggressive
children. On the basis of the pioneering work of these

1
1096-4037/04/0300-0001/0 °
C 2004 Plenum Publishing Corporation
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2 Chronis, Chacko, Fabiano, Wymbs, and Pelham
researchers, BPT explicitly provides parents with be-
havior modification techniques that are based on so-
cial learning principles. Parents are taught to identify
and manipulate the antecedents and consequences of
child behavior, target and monitor problematic be-
haviors, reward prosocial behavior through praise,
positive attention, and tangible rewards, and decrease
unwanted behavior through planned ignoring, time
out, and other nonphysical discipline techniques. A
typical BPT curriculum is presented in Table I.
BPT has resulted in improvements for children
with ADHD in several important areas. We iden-
tified 28 studies of BPT for children with ADHD
that included 1,161 treated children (see Table II).
Across these studies, BPT was effective in improv-
ing parent ratings of problem behavior and observed
negative parent and child behaviors. In some cases,
BPT also resulted in improvements in other domains,
such as parental reports of stress (e.g., Anastopolous,
Shelton, DuPaul, & Guevremont, 1993), and social
behavior and acceptance (Pelham et al., 1988). The
children treated in these studies ranged in age from
3 to 14 years, with the average age across studies
being 7.9 years. All studies used a social learning
approach to treatment, and the majority utilized treat-
ment manuals specifically describing the intervention.
Most BPT studies lasted between 8 and 12 sessions
with some notable, lengthier exceptions (i.e., MTA
Cooperative Group, 1999a). Overall, though hetero-
Table I. Typical Sequence of Sessions for Parent Training in a
Clinical Behavioral Intervention
Parent traininga
1. Overview of the child’s disorder, social learning theory,
and behavior management principles
2. Establishing a home/school daily report card/establishing
a home behavior checklist/rewarding home and school
behavior
3. Attending to appropriate behavior (e.g., compliance) and
ignoring minor, inappropriate behaviors (e.g., whining)
4. Giving effective commands and reprimands
5. Establishing and enforcing rules/When. . . then
contingencies
6. Time-out procedures
7. Home point system-reward and response cost
8. Enforcing contingencies outside of the home; planning
ahead for misbehavior outside the home
9. Problem-solving techniques
10. Maintenance of program after weekly therapist contact
ends
a Every consultation contact includes a functional assessment
of child’s current progress toward treatment goals, and these
goals/treatment strategies are continually added, deleted, and
modified based on the effectiveness of current treatment and
the child’s current functional impairment.
12:33 Style file version Nov. 07, 2000
geneous in design (e.g., randomized, controlled clini-
cal trials, single-subject case studies), and employing
various enhancements (e.g., school interventions, so-
cial skills training), Pelham et al. (1998) reviewed and
determined that BPT for ADHD meets the American
Psychological Association (APA) Division 53 cri-
teria for well-established, evidence-based treatment
(Lonigan, Elbert, & Johnson 1998). Although stud-
ies of BPT for children with ODD or CD histori-
cally failed to report rates of comorbid ADHD, most
ADHD BPT studies report high comorbidity rates be-
tween these disorders (e.g., Jensen et al., 2001). Fur-
ther, recent treatment studies in the areas of ODD
and CD have suggested that children with comor-
bid ADHD or hyperactivity responded equally well
to psychosocial treatments (Conduct Problems Pre-
vention Research Group, 2002; Hartman, Stage, &
Webster-Stratton, 2002; Webster-Stratton, Reid, &
Hammond, 2001a). Thus, it is likely that results of
BPT studies of ODD/CD may be extended to chil-
dren with ADHD. When ADHD BPT studies are
combined with the BPT studies for ODD and CD
(Brestan & Eyberg, 1998), there is clearly a substan-
tial, convincing evidence base supporting the effec-
tiveness of BPT for ADHD. However, several large
gaps in this literature exist.
Although the empirical evidence supports the
use of BPT in addressing multiple issues faced by
families of children with ADHD, not all families
benefit from BPT equally. A seminal review con-
ducted by Miller and Prinz (1990) summarized many
of the issues surrounding nonoptimal response to BPT
for children with CD, including but not limited to:
multiple environmental stressors such as low socioe-
conomic status (SES), single parenthood, insularity
(e.g., Kazdin, 1990; Wahler, 1980; Webster-Stratton &
Hammond, 1990), parental adjustment factors such
as marital discord (e.g., Kent & O’Leary, 1976) and
psychopathology (e.g., McMahon, Forehand, Greist,
& Wells, 1981; Webster-Stratton & Hammond, 1990),
and inappropriate parental expectations regarding
parental involvement and child improvement during
BPT (Plunkett, 1984). As a result of these findings,
attention has turned to enhancing BPT to increase
the probability of positive outcomes for children with
ODD or CD, for example, by adding treatment com-
ponents addressing these issues or modifying the
format of these programs for specific populations
(e.g., maritally distressed parents; Dadds, Sanders,
Behrens, & James, 1987). Although many of the cor-
relates associated with poor treatment outcome in
families of children with ODD and CD (e.g., marital
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Table II. Summary of Behavioral Parent Training Studies With Parents of Children With Attention-Deficit/Hyperactivity Disorder
Mean Number of Follow up
Study Study N age Manual used sessions Format length Enhancements Results
Anastopoulos et al. (1993) 34 8.12 Barkley (1987,1990) 9 group 2 months None BPT > WL
Barkley et al. (2000) 158 4.75 Barkley (1987) 10 + 5 group 2 years 1 group included intensive BPT + SI = SI > BPT = Control
Clinical Child and Family Psychology Review (CCFP)

monthly booster school intervention

Barkley et al. (1992) 61 13.8 Barkley (1987) range 8–10 group 3 months None BPT = problem solving training =
structural family therapy
Danforth (1998) 8 5.58 Danforth (1998) 8 individual 6 months None BPT endpoint measures > baseline measures
Danforth (1999) 2 4 Danforth (1998) 8 individual 6 months None BPT endpoint measures > baseline measures
Dubey, O’Leary, and 44 8.42 Becker (1971) 9 not reported 9 months BPT = Parent Education > WL
Kaufman (1983)
Erhardt and Baker (1990) 2 5.42 Baker (1989); Barkley (1981); 10 individual not reported None BPT endpoint measures > baseline measures
Forehand and McMahon (1981);
Patterson (1975)
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Firestone et al. (1981) 43 7.32 Patterson (1971) 9 individual/ not reported None BPT + medication = medication > BPT
group

3
Horn et al. (1991)
Horn, Ialongo, Popovich,
and Peradotto (1987)
Horn et al. (1990)
96 8.27 Patterson (1976); Forehand 12 group 9 months 2 groups added medication, BPT + medication = medication = BPT =
and McMahon (1981); all BPT included child No treatment
Barkley (1981); Becker (1971) self-control training
19 9.58 Patterson (1976) 8 group 1 month self-control training Combined BPT + child treatment = BPT =
child treatment alone
42 8.76 Barkley (1981); Forehnad and 12 group 8 months self-control training + BPT + child treatment > BPT = child
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McMahon (1981); Patterson (1976) 3 school consultations treatment

Klein and Abikoff (1997) 86 7.8 Becker (1971); O’Leary and 8 individual 1 month school intervention BPT/SI + medication = medication > BPT/SI
O’Leary (1972); Patterson (1975);
Patterson and Guillion (1971)
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McLeary and Ridley (1999)
Miller and Kelley (1994)
MTA cooperative group
(Conners et al., 2001; MTA)
Cooperative group 1999a,b;
Pelham et al., 2000;
Swanson et al., 2001)
103 14.2 not reported 10 group not reported video tape training BPT endpoint measures > baseline measures
4 10.17 No, but well described not reported individual not reported None BPT endpoint measures > baseline measures
579 8.5 MTA study manual based on 27 group + individual/ ongoing intensive school behavioral Behavior therapy (including BPT) +
Barkley (1987); Forehand 8 individual group intervention/medication/STP medication = medication management =
and McMahon (1981) active behavior therapy > faded behavior
therapy = community comparison
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Clinical Child and Family Psychology Review (CCFP)

Table II. (Continued)

Mean Number of Follow up
Study Study N age Manual used sessions Format length Enhancements Results
O’Leary and Pelham (1978) 7 8.75 Becker (1971) average of 9 individual/ not reported Daily report card in school BPT endpoint measures > baseline measures
O’Leary et al. (1976) 17 10.0 No, but well-described 1 for the group not reported Daily report card in school BPT > control group
parent and 1 individual
for the teacher
Pelham and Hoza (1996) 258 9.10 Barkley (1981); Cunningham et al. 8 group not reported STP BPT endpoint measures > baseline measures
(1997); Forehand and McMahon (1981)
Pelham et al. (1980) 8 8.3 Patterson (1976) 12 individual/ not reported School intervention; BPT endpoint measures > baseline measures
pp1130-ccfp-481521

Pelham et al. (1988)
Pelham (1977)
group academic/self-
instruction tutoring
32 7 O’Leary et al. (1976); O’Leary 9.7 individual not reported Social skills training and BPT endpoint measures > baseline measures
and Pelham (1978); Pelham school consultation
(1978, 1982); Pelham et al. (1980)
1 9 Patterson (1971) 14 individual not reported School consultation BPT endpoint measures > baseline measures

4
Pisterman et al. (1989) 46 4.15 Forehand and McMahon (1981); 10 group and group/ 3 months None BPT > WL
Barkley (1981) 2 individual individual
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Pisterman et al. (1992) 57 4.13 Forehand and McMahon (1981); 12 group none None BPT > WL
Barkley (1981)
Pollard et al. (1984) 3 range 6–7 Barkley (1981); Forehand and 8 individual not reported Medication BPT + medication = BPT = medication
McMahon (1981)
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Sonuga-Barke et al. (2001) 78 3 Weeks, Thompson, and Laver- 8 individual 15 weeks None BPT > attention control > WL
Bradbury (1999)
Stableford, Butz, Hasazi, 1 11 No, but well described not reported individual not reported None BPT endpoint measures > baseline measures
Leitenberg, and Peyser
(1976)
Thurston (1979) 18 range 6–9 Mederios and Thurston (1974) range 8–12 individual none Parent, child, and sibling BPT = medication > WL
interactions with
modeling + feedback
Tynan, Schuman, and Lampert 55 7.5 Barkley (1987) 8 group not reported Child social skills training BPT endpoint measures > Baseline measures
(1999)
Notes. BPT = Behavioral Parent Training; ADHD = Attention-deficit/hyperactivity disorder; SI = School intervention; WL = Wait-list control.
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Clinical Child and Family Psychology Review (CCFP) pp1130-ccfp-481521
Enhancements to Parent Training for ADHD
problems, parental psychopathology, low SES) have
also been documented for families of children with
ADHD, surprisingly few studies have been conducted
for the purpose of enhancing BPT for families of chil-
dren with ADHD who may be at risk for poor treat-
ment response. Such an ideographic approach may be
necessary given the chronic nature of ADHD, the high
rates of child comorbidity (e.g., August, Realmuto,
MacDonald, Nugent, & Crosby, 1996), and parental
psychopathology present in this population.
This paper reviews the literature addressing im-
portant factors related to nonoptimal BPT outcomes
within three important domains: (1) Parameters of
BPT; (2) Parent factors; and (3) Child factors. Ad-
ditionally, treatment studies that have directly ad-
dressed these factors will be discussed. In some cases,
the authors will discuss studies conducted on children
with other externalizing disorders because few stud-
ies exist that specifically selected children diagnosed
with ADHD and because the diagnostic overlap is so
high in studies of children with ODD and CD. Finally,
recommendations for future research with families of
children diagnosed with ADHD will be made.
PARAMETERS OF BPT
Format
The format of BPT has changed considerably
over the past two decades. Initially, BPT was a clinic-
based treatment in which the therapist, parent, and
sometimes the child attended individual family ses-
sions (Forehand & McMahon, 1981; Patterson &
Gullion, 1968). Recent research has attempted to un-
derstand how best to maximize gains experienced by
families during and following BPT through modifica-
tions in the format, process, and procedures designed
to enhance maintenance.
Individual BPT offers several advantages over
group-based approaches, including increased flexi-
bility on the part of the therapist and parent in
terms of pace, content, individual attention provided
to idiosyncratic problems of the child/parent, and
potentially more active involvement by the parent.
However, individual BPT is also costly, time consum-
ing, and inefficient (Webster-Stratton, 1984). Alter-
natively, group-based BPT is far more cost-effective
than individually based BPT, provides opportunities
for social support with similar others, and most often
produces equivalent effects to individually adminis-
tered BPT ([Webster-Stratton, 1984). Furthermore,
March 10, 2004 12:33 Style file version Nov. 07, 2000
5
in a study on utilization of individual/clinic-based
versus group/community-based BPT for families of
children at risk for developing behavioral disorders,
Cunningham, Bremner, and Boyle (1995) found that
certain groups of parents were more likely to utilize
group/community BPT, including families who spoke
English as a second language and families of children
with more severe problems. Although this study in-
volved children in an at-risk population rather than
children diagnosed with a disruptive behavior disor-
der (DBD), the results suggest that group-based BPT
offered in community settings may present a cost-
effective treatment format that can be perceived as
less stigmatizing by some families.
Although these findings suggest advantages to
group-based BPT, individual BPT with the child may
be more beneficial for some parents than group
BPT (Webster-Stratton & Herbert, 1994). In particu-
lar, Parent–Child Interaction Therapy (PCIT; Eyberg
& Boggs, 1998)—an intervention that teaches skills
to parents through modeling, in-vivo practice, and
on-line feedback—may prove beneficial for families
who require more intensive, individualized treat-
ment, find it difficult to implement skills at home,
have interpersonal difficulties that preclude effec-
tive functioning in a group setting, or those with
extremely maladaptive parenting techniques. In fact,
research has indicated that individual PCIT can be
more beneficial than a group-based, didactic treat-
ment for children with behavioral difficulties (Eyberg
& Matarazzo, 1980). Recently, researchers have be-
gun to modify traditional PCIT to maximize effi-
ciency, cost, and outcomes through administering
PCIT in a group format (e.g., Auerbach, Nixon,
Forrest, Gooley, & Gemke, 1999) or by abbreviat-
ing traditional PCIT (e.g., Nixon, Sweeney, Erickson,
& Touyz, 2003). To the best of our knowledge, the
effectiveness of PCIT for children with ADHD, in
either an individual or group format, has not been
directly studied, although many of the children in-
cluded in PCIT efficacy studies had comorbid ADHD
(e.g., Schuhmann, Foote, Eyberg, Boggs, & Algina,
1998).
Variations in the process of BPT have also been
studied. Traditional BPT has involved didactic in-
struction, in which the content, particularly solutions
to parenting problems, is presented by the therapist.
Although these procedures ensure that specific tech-
niques are reviewed, some researchers have suggested
that a didactic approach may reflect a view that the
parent has a “deficit” and the therapist is responsi-
ble for “fixing” the problem (see Webster-Stratton &
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Clinical Child and Family Psychology Review (CCFP) pp1130-ccfp-481521 March 10, 2004
6 Chronis, Chacko, Fabiano, Wymbs, and Pelham
Herbert, 1994 for a discussion of this issue). A more
collaborative approach to BPT is now emphasized in
both group and individual formats (e.g., Lawton &
Sanders, 1994; Prinz & Miller, 1996; Webster-Stratton
& Herbert, 1994). This collaborative approach in-
cludes actively involving parents in the therapeutic
process by soliciting ideas and feelings from parents,
mutually determining treatment goals that are spe-
cific to the needs and concerns of the family, and
teaching and suggesting, rather than dictating, pos-
sible alternative approaches to problems. A collabo-
rative approach to group BPT has been shown to be
an effective method of conducting group-based BPT
(Webster-Stratton, 1981, 1984).
Another variation of BPT format, incorpo-
rated in the group-based programs developed by
Cunningham and Webster-Stratton, includes the use
of videotape modeling. The incorporation of video-
tapes as a means of enhancing comprehension of
BPT material has been implemented for several years.
Videotape modeling has been shown to be more ef-
fective in teaching parents specific discipline tech-
niques than written presentations, lectures, and role-
play (Flanagan, Adams, & Forehand, 1979; O’Dell,
Krug, Patterson, & Faustman, 1980; O’Dell, Mahoney,
Horton, & Turner, 1979). More recently, several re-
searchers have extended the use of videotaped mod-
eling to address global parenting behavior and at-
titudes (Cunningham et al., 1995; Webster-Stratton,
1996). The use of videotapes, live modeling, or both
has been theorized to be a more effective method of
presentation, particularly for less educated, less ver-
bally sophisticated parents (Webster-Stratton, 1996).
Although the use of videotapes as a method of teach-
ing behavioral techniques has been used for decades,
little attention has been paid to the use of this method
with families of children with ADHD. The use of
videotapes may have particular relevance to this
group, as relatively complicated BPT techniques can
be illustrated visually, thus improving understand-
ing of the material and subsequent effective imple-
mentation, particularly for parents who may them-
selves have trouble attending to lecture-format BPT
classes. This, and the use of other methods of pre-
senting material (e.g., using Palm-pilot technology
to remind parents to practice parenting techniques
in the home and aide in target behavior tracking)
to parents of children with ADHD have yet to be
studied.
Two outstanding examples of programs that in-
corporate role-play, videotaped modeling, and dis-
cussions through a group-based, collaborative ap-
12:33 Style file version Nov. 07, 2000
proach are Webster Stratton’s Incredible Years pro-
gram (Webster-Stratton, 1996), and the Community
Parent Education Program (COPE; Cunningham,
Bremner, & Secord, 1997). Incredible Years has been
developed over the past 20 years and has been ex-
tensively studied through several randomized clini-
cal trials with clinical (Webster-Stratton, 1984, 1994;
Webster-Stratton & Hammond, 1997) and at-risk
populations (Gross et al., 2003; Webster-Stratton,
1998), demonstrating improvements for treated chil-
dren across domains of functioning. Furthermore, im-
provements for these children have been maintained
at both short- (Webster-Stratton, 1984) and long-term
(Webster-Stratton, 1990) follow-up. Incredible Years
appears to be a promising program for families of
children with ADHD, as research has indicated that
children with ODD or CD and high levels of ADHD
symptoms appear to benefit equally from the program
(Hartman et al., 2002). An important next step is to
evaluate the efficacy of this program for children di-
agnosed with ADHD.
Like Incredible Years, COPE utilizes a coping-
videotape modeling-problem solving process. This
process involves group members working together
to solve common parenting problems presented in
videotaped parent–child interactions and develop-
ing solutions within parent-led subgroups. These
subgroups then discuss their solutions within the
larger group, facilitated by a therapist. Subgroups
ensure increased participation of individual mem-
bers, and may be a less intimidating context for
some parents to voice opinions. In a series of studies
(Cunningham et al., 1995; Cunningham, Davis,
Bremner, Dunn, & Rzasa, 1993), involving at-
risk children with residential treatment providers
as therapists, COPE improved attendance, treat-
ment participation, and outcomes following treat-
ment. Although the COPE model appears promis-
ing, and has been adopted in some prominent ADHD
clinics (e.g., Pelham, Fabiano, Gnagy, Greiner, &
Hoza, in press), studies using this approach with an
ADHD, ODD, or CD population have yet to be
conducted.
Collectively, the field of BPT has moved in the
direction of enhancing traditional BPT to maximize
attendance, adherence, and outcomes for children and
their families. Future work in this area is needed to
examine which variations in format are most effec-
tive for families of children with ADHD in general,
and specifically for families with different characteris-
tics (e.g., less educated parents, single parents, parents
with attention problems).
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Enhancements to Parent Training for ADHD
Maintenance Programs
Researchers have long recognized that parents
of children with ADHD, ODD, and CD often require
ongoing support with regard to parenting (Chacko,
Fabiano, Williams, & Pelham, 2001; Eyberg, Edwards,
Boggs, & Foote, 1998). Yet, long-term, intensive treat-
ment can be time-consuming and expensive, and may
therefore result in poor compliance. Programming for
maintenance and relapse prevention is particularly
important for families of children with ADHD, as the
disorder typically follows a chronic course, and par-
ents will therefore be confronted with a number of im-
portant developmental transitions (e.g., issues of ado-
lescent autonomy) after an initial parenting program
is completed. Unfortunately, the effectiveness of BPT
maintenance and relapse prevention strategies have
not yet been studied with families of children with
ADHD, a group particularly in need of long-term,
chronic care. The degree of consistency with which
parents maintain the gains obtained in an 8-week par-
enting class, how the use of medication is moderated
by the use of a behavioral intervention, such as BPT,
and parents’ ability to generalize the skills learned in
BPT to new behaviors as they arise are examples of
important clinical questions awaiting further study.
Eyberg and colleagues (1998) suggest the use
of several promising components that may enhance
maintenance of BPT treatment gains for young
children with ODD/CD, including increasing par-
ent’s self-monitoring behaviors, the use of fading
sessions, periodic contacts after treatment termina-
tion, and booster sessions. Another approach that
may enhance generalization is the use of “self-
directed” or “self-administered” treatment. “Self-
directed” or “self-administered” treatments involve
the use of self-help books, alone or in combina-
tion with videotapes, which teach parents how to
manage child behavior using BPT techniques. Al-
though these treatments typically produce smaller
effects than therapist-led treatments, some have
demonstrated efficacy with families of children with
behavior problems (Sanders, Markie-Dadds, Tully,
& Bor, 2000; Webster-Stratton, Hollinsworth, &
Kolpacoff, 1989), and may be worthwhile mainte-
nance tools. Although widely used and incorpo-
rated in BPT (e.g., MTA Cooperative Group, 1999a;
Pelham et al., 1998; Pelham et al., in press), these
approaches have yet to be systematically manipu-
lated in studies of children with ADHD, and may
prove to be useful enhancements to BPT for this
population.
March 10, 2004 12:33 Style file version Nov. 07, 2000
7
Setting
Weisz and Hawley (1998) discuss the fact that
until recently, most efficacy studies have been con-
ducted in university-based psychology or psychiatry
clinics. BPT for ADHD is no exception (see Table II).
As a result, these studies often include intact, middle-
to upper-middle class samples, and fail to adequately
represent lower SES families, who tend to have prob-
lems with service attainment, compliance, and re-
sponse. For example, studies have shown that low-
income and minority children with ADHD are less
likely to have their special education services needs
met (Bussing & Zima, 1998) and are less likely to
adhere to prescribed stimulant medication regimens
(Borden, Brown, & Clingerman, 1985; Firestone,
1982). Similarly, low SES has been shown to con-
tribute to poor compliance with and outcome follow-
ing BPT for noncompliant children (McMahon et al.,
1981). Results of the MultiModal Treatment Study
for ADHD (MTA) also suggest differential treatment
response based on SES (Rieppi et al., 2002). For ex-
ample, behavior therapy in the MTA study resulted in
incremental benefit over medication alone on ADHD
symptoms for more educated families; however, blue-
collar families showed incremental benefit of behav-
ior therapy over medication alone for ODD symp-
toms whereas white-collar families did not. Although
contradictory, these findings from the MTA do not
support the notion that less educated families cannot
benefit from behavior therapy such as BPT. Yet, given
findings related to poorer treatment compliance with
medication (Borden, et al., 1985; Firestone, 1982) and
BPT (e.g., McMahon et al., 1981) among low-income
families, it is unclear to what extent the MTA findings
generalize to real-world situations in which families
are provided with fewer prompts and incentives for
treatment compliance. More studies of BPT for chil-
dren with ADHD from low-income families, or fam-
ilies that are less likely to present at university-based
clinics, are sorely needed.
To illustrate the need for community-based ef-
fectiveness studies addressing the challenges com-
monly encountered with community populations, the
ambitious prevention study conducted by Barkley
and colleagues (2000) should be considered. BPT
was offered to parents of disruptive children enter-
ing kindergarten based on screening conducted in an
entire school district. Surprisingly, BPT had no ben-
eficial impact on multiple measures of outcome. The
authors speculated that one reason for these results
was likely that only 13% of parents attended nine or
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8 Chronis, Chacko, Fabiano, Wymbs, and Pelham
more of the 14 BPT sessions, indicating that 87% of
parents in the treatment group did not receive the in-
tended intervention. This finding may be related to
the fact that, although initial screening took place in
a school district, BPT sessions were held in a medi-
cal center setting rather than in the community. The
authors noted in their discussion of these perplexing
results that “. . . when such a program is taught at a
medical center, as was our program, as opposed to
neighborhood schools in the evenings, parental at-
tendance was consistently poorer and fewer minority
families participated” (pp. 328–329). In this setting,
the treatment, though already shown to be efficacious
in reducing problematic behavior, was not effective at
engaging and retaining parents in this community pre-
vention sample. The Barkley et al. (2000) study pro-
vides an excellent example of the need to continue to
develop and enhance BPT for children with ADHD
in ways that will maximize its effectiveness and palata-
bility in nonclinic (e.g., school, community) settings,
and broaden the beneficial outcomes obtained from
the intervention.
In an attempt to break down the many bar-
riers posed to many parents by clinic-based BPT
programs, especially stressors and obstacles asso-
ciated with attendance at treatment sessions (e.g.,
work schedules, travel time, transportation costs, child
care; Cunningham, 1998; Cunningham et al., 2000;
Kazdin, Holland, & Crowley, 1997; Kazdin & Wassell,
1999), Cunningham’s large-group, community-based
program (COPE) is designed to make BPT more
easily accessible for parents in need of services
(Cunningham et al., 1995). COPE attempts to meet
the needs of working parents by offering classes
in convenient neighborhood schools during the
day as well as at night and providing child care
(Cunningham, 1998). Notably, COPE has demon-
strated greater service utilization, cost effectiveness,
reductions in child management problems, and im-
proved maintenance of treatment gains relative to the
outcome of at-risk children and parents who attended
clinic-based BPT (Cunningham et al., 1995). Again,
despite the encouraging findings of Cunningham and
his colleagues, the efficacy of COPE for parents of
children with ADHD, ODD, or CD has not been sys-
tematically studied thus far.
Given that pediatricians are often the first profes-
sionals to evaluate children for ADHD, researchers
have also begun to study assessment and treatment
practices in pediatric settings (American Academy
of Pediatrics, 2000, 2001; Brown et al., 2001). This
movement was based on the notion that far more chil-
12:33 Style file version Nov. 07, 2000
dren with ADHD are seen in pediatric settings than
in mental health settings. Results of survey studies
assessing current practices suggest that pediatricians
often use nonevidence-based strategies for assessing
ADHD (e.g., observations of child behavior during
office visits) and often rely on pharmacotherapy as
the first-line treatment for children with the disorder
(Wolraich et al., 1990). Although many pediatricians
in this survey reported using at least some behavioral
strategies with their patients, only 22% of parents re-
ported that this was the case. Despite the conclusions
of the APA Task Force suggesting that BPT is an em-
pirically supported treatment for ADHD, we could
not find any studies of BPT for children with ADHD
conducted in pediatric or primary care settings. Future
studies of this kind are needed, as they may increase
the availability of BPT for families that are less likely
to present at university-based psychology clinics and
reduce the likelihood that stimulant medication will
be used as the first-line, or only, treatment for children
with ADHD who first present to their pediatricians.
Samples recruited in pediatric settings may also be
less likely to reflect sampling biases that exist in most
clinic-based research.
PARENTAL FACTORS
Parental psychopathology in general, and mater-
nal depression specifically, is perhaps the most widely
studied barrier to optimal treatment response follow-
ing BPT for children with ODD and CD (e.g., Griest
& Forehand, 1982; Webster-Stratton, 1985a; Webster-
Stratton, 1992a). Furthermore, it has been shown that
parental problems are associated with higher dropout
rates from and poorer compliance with BPT pro-
grams (e.g., McMahon et al., 1981). These findings
are not surprising given that distressed individuals
often lack the motivation or organization to com-
plete effortful tasks that require ongoing work, such as
the consistent implementation of behavioral manage-
ment techniques taught in BPT. Although recent stud-
ies have indicated that parental psychopathology may
negatively affect response to BPT for ADHD (e.g.,
Sonuga-Barke, Daley, & Thompson, 2002), the role
of parental psychopathology in ADHD treatment has
received relatively less attention, despite recognition
that there is a greater prevalence of psychopathol-
ogy in parents of children with ADHD compared
to parents of nonproblem children (e.g., Cantwell,
1972; Fischer, 1990; Mash & Johnston, 1990; Nigg &
Hinshaw, 1998). We review below the studies that
have investigated parental psychopathology in light
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Enhancements to Parent Training for ADHD
of BPT treatment outcome, most of which were con-
ducted with families of children with ODD or CD. We
also review the role of parent cognitions in treatment
and other associated parent issues, such as single par-
enthood and father involvement in treatment. Finally,
we review studies of the efficacy of adjunctive treat-
ment components targeting specific parent problem
areas, such as depression, marital problems, or lim-
ited social support, as well as others utilizing general
interventions aimed at reducing distress in multiple
areas.
Maternal Depression
Although most pronounced in children with co-
morbid ODD or CD, mothers of children with ADHD
are more likely to experience depressive symptoms
and episodes of major depression than mothers of
nondisordered children (Chronis, Lahey, Pelham,
et al., 2003a; Nigg & Hinshaw, 1998). Evidence sug-
gesting that parents of children with ADHD may be
at greater risk for depression is concerning in light of
all that is known about the impact of maternal depres-
sion on children. The vast literature examining mater-
nal depression has consistently documented a greater
likelihood of internalizing and externalizing problems
and poorer social and academic functioning among
their children, less consistency and greater negativity
in parenting behavior, more negative expectations re-
garding child behavior, and greater interparental con-
flict (see reviews by Beardslee, Bemporand, Keller, &
Klerman, 1983; Cummings & Davies, 1994a; Downey
& Coyne, 1990). Taken together, these findings set the
stage for a transactional model in which child exter-
nalizing behavior and parental psychopathology exert
reciprocal negative influences on one another (see
Cummings & Davies, 1999; Patterson, 1982). From
this, one may conclude that psychosocial treatment
for ADHD should include assessment and treatment
of parental psychopathology, as these problems may
impact parents’ ability to effectively implement be-
havior management techniques.
Several well-established BPT programs for non-
compliant or oppositional children address some of
these issues (e.g., Forehand & Long, 1996; Webster-
Stratton, 1992b); however, relatively few studies have
evaluated the incremental benefit of adding a par-
ent enhancement component to standard BPT for
noncompliant, aggressive, or conduct-disordered chil-
dren, and only one unpublished study has looked
at such interventions in a population selected for
ADHD specifically. Webster-Stratton evaluated the
March 10, 2004 12:33 Style file version Nov. 07, 2000
9
incremental effects of an ADVANCE videotape skills
component, which involved training parents to cope
with interpersonal distress through improved com-
munication, problem-solving, and self-control skills
(Webster-Stratton, 1994). The addition of this treat-
ment component produced improvements in par-
ent communication, problem solving skills, and con-
sumer satisfaction beyond the standard BPT group.
Both treatment groups (BPT alone and BPT plus
ADVANCE) reported comparable reductions in par-
enting stress, depressive symptoms on the BDI,
and mother- and father-reported child adjustment.
More recently, Sanders, Markie-Dadds, Tully, and
Bor (2000) evaluated the impact of their “Triple P-
Positive Parenting Program” in high-risk families with
preschool-aged children. Results of this study sug-
gested that the enhanced behavioral family inter-
vention (BPT plus partner support and coping skills
to address stress, depression, anxiety and other par-
ent problems) resulted in few differences beyond
standard BPT on most outcome measures; however,
the enhanced intervention resulted in more reli-
able change in child behavior and a greater nor-
malization rate at posttreatment than standard BPT.
Sanders and McFarland (2000) evaluated the rela-
tive effects of BPT and an integration of BPT and
cognitive-behavioral treatment derived from several
well-established models for depressed mothers of dis-
ruptive children. Results suggested that the adjunc-
tive intervention had a positive, incremental effect on
outcome at follow-up for distressed families, but no
incremental effect beyond BPT at posttreatment.
Only one parent treatment study selected moth-
ers of children diagnosed with ADHD; however,
the vast majority of these children were diagnosed
with comorbid ODD or CD. In their randomized,
controlled study, Chronis and colleagues (Chronis,
Gamble, Roberts, & Pelham, 2002; Chronis, Roberts,
Pelham, & Gamble, under review) directly targeted
maternal stress and depression using an empiri-
cally supported, cognitive-behavioral treatment pack-
age for individuals at risk for depression. Follow-
ing participation in a summer treatment program
(STP; Pelham, Greiner, & Gnagy, 1997) and BPT,
mothers of children with ADHD were randomly as-
signed to receive the Coping with Depression Course
(Lewinsohn, Hoberman, and Clarke, 1989) immedi-
ately or after a 7-month wait-list period. Regard-
less of initial levels of depressive symptomatology or
depression histories, improvements in self-reported
depressive symptoms, self-esteem, and cognitions
about child behavior were found for mothers in the
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10
immediate treatment group relative to the wait-list
control group. The largest effect sizes on these mea-
sures were found for mothers who reported at least
mild depressive symptoms at pretreatment evalua-
tion. However, no effects of the intervention were
found on maternal ratings of child behavior. We spec-
ulate that the reason for this finding may be that chil-
dren had already improved dramatically as a result of
the STP and BPT (children were already within the
nonclinical range on the Conners at the conclusion of
the STP), leaving little room for improvement.
Notably, all of these studies evaluating adjunc-
tive parent treatment components implemented ad-
junctive interventions following BPT (i.e., during
the maintenance phase). Perhaps parental problems
should be addressed prior to BPT, so that parents will
be better prepared to make changes in their behav-
ior management techniques. Future studies are rec-
ommended that attempt to identify the optimal or-
dering of interventions addressing child behavior and
co-occurring parent problems that result in maximum
benefits to the child and parent–child system.
Parental ADHD
Not surprisingly, higher rates of adult ADHD
have been found in parents of children with ADHD
(e.g., Alberts-Corush, Firestone, & Goodman, 1986;
Chronis et al., 2003b). Likewise, there is an increased
risk for ADHD in offspring of parents with ADHD
(Biederman, Faraone, & Monuteaux, 2002). Associ-
ations between parent ADHD and higher levels of
family conflict and less family cohesion have been
documented (Biederman et al., 2002). Further, it
is likely that parental ADHD may interfere with
the treatment of ADHD in their children (Weiss,
Hectman, & Weiss, 2000). For example, parents with
ADHD may experience difficulty consistently ad-
hering to a treatment plan, may become disrup-
tive or have difficulty sustaining attention during
BPT sessions, and may be less compliant in ad-
ministering their children’s medication as a result
of their own forgetfulness. Consistent with this, re-
cent findings have suggested that high levels of ma-
ternal ADHD symptoms limit improvement shown
by children with ADHD following BPT (Sonuga-
Barke et al., 2002). These findings suggest that
parental ADHD is an important focus of clinical
consideration.
Only one case study attempted to directly ad-
dress impairment in parenting as a result of parent
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Chronis, Chacko, Fabiano, Wymbs, and Pelham
ADHD. When working with the family of a child
with ADHD, Evans, Vallano, and Pelham (1994) ob-
tained limited response from BPT due to maternal
ADHD. When the child’s mother was medicated to
treat her own ADHD symptoms, her parenting and
consequently, the child’s behavior improved. How-
ever, this was a single case study, and larger, well-
controlled trials have yet to address the negative im-
pact of parental ADHD on parenting and treatment
response.
Parental Substance Abuse and Antisocial
Personality Disorder
Studies have consistently found that, with the ex-
ception of parental ADHD, heightened rates of sub-
stance use and psychological disorders in parents of
children with ADHD are most common in children
with comorbid conduct problems or antisocial behav-
ior (Chronis et al., 2003b; Lahey et al., 1988; Lahey,
Russo, Walker, & Piacentini, 1989). Likewise, the co-
morbidity of ADHD and CD in children is associ-
ated with the most severe cases of parental aggres-
sion and illegal activity (Lahey et al., 1988, 1989).
Because 20–56% of children with ADHD are also
diagnosed with CD (Barkley, 1998), children with co-
morbid ADHD/CD are an important group to exam-
ine with regard to parental disorders.
The negative effects of parental substance abuse
and antisocial behavior on parenting have been doc-
umented. Even when they do not abuse alcohol, par-
ents of children with ADHD have been found to drink
more than parents of nonproblem children (Chronis
et al., 2003b; Cunningham, Benness, & Siegel, 1988;
Molina, Pelham, & Lang, 1997). Experimental manip-
ulations of child behavior have resulted in increases
in parental alcohol consumption following interac-
tions with child confederates behaving like they had
ADHD (Pelham, et al., 1997, 1998, 2000). These find-
ings support the notion that child ADHD behavior
may, in part, contribute to increases in parental al-
cohol consumption, which has been found to be re-
lated to negative parenting behaviors (Lang, Pelham,
& Atkeson, 1999). Thus, parental drinking and de-
viant child behaviors likely have reciprocal effects on
one another.
Several researchers have found that the relation-
ship between maternal antisocial behavior and child
conduct problems is mediated by negative parent-
ing practices. (Bank, Forgatch, Patterson, & Fetrow,
1993; Rhule, McMahon, & Spieker, 2002). It fol-
lows from these studies that parents with substance
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Enhancements to Parent Training for ADHD
use disorders and antisocial characteristics may be in
particular need of intensive assistance with parent-
ing. Moreover, antisocial characteristics are highest
in families in which fathers are absent or not partici-
pating (Pfiffner, McBurnett, & Rathouz, 2001), which
introduces the related problem of poor paternal par-
ticipation in parenting and BPT programs discussed
later in this review. At this point, no studies have di-
rectly targeted parental substance abuse and antiso-
cial behavior in BPT treatment studies, which is an
important extension of this work, particularly for fam-
ilies of children with comorbid ADHD/CD.
Marital Problems
As in families of children with ODD or CD
(Dadds & Powell, 1991; Johnson & O’Leary, 1987;
Mahoney, Jouriles, & Scavone, 1997) and behavior
problems in general (Christensen, Philips, Glasgow,
& Johnson, 1983; Oltmanns, Broderick, & O’Leary,
1977; Porter & O’Leary, 1980), parents of children
with ADHD report more marital problems than par-
ents of nonproblem children (Befera & Barkley, 1985;
Murphy & Barkley, 1996). Parents of children with
ADHD, ODD, and CD also reportedly disagree more
frequently about childrearing issues and exhibit more
negative verbal behaviors during childrearing dis-
cussions than parents of nonclinic-referred children
(Dadds & Powell, 1991; Johnston & Behrenz, 1993;
Mahoney et al., 1997). For example, in a sample of
70 families of children with ADHD, parental agree-
ment about childrearing was associated with fewer
child behavior problems, greater marital adjustment,
and less marital conflict (Harvey, 2000). Despite no-
table exceptions (Johnston, 1996), further research
has exhibited that parents of children with ADHD
and comorbid ODD/CD report more marital dissat-
isfaction than parents of children with ADHD alone
(Barkley, Anastopoulos, Guevremont, & Fletcher,
1992; Barkley, Fischer, Edelbrock, & Smallish, 1991).
Developmental researchers have consistently
demonstrated a link between marital discord and
child externalizing behavior problems in nonclinic
populations (for reviews, see Davies & Cummings,
1994; Emery, 1982; Grych & Fincham, 1990). The
relationship between interparental discord and child
behavior problems is bi-directional: interparental dis-
cord has been shown to both predict and be a conse-
quence of child behavior problems. The reciprocal na-
ture of this relationship has been substantiated across
intact and divorced families, and clinic-referred and
March 10, 2004 12:33 Style file version Nov. 07, 2000
11
nonclinic-referred children and families (Cummings
& Davies, 1994a; Emery, 1999). However, the mere
exposure to marital distress or interparental discord
is not necessarily indicative of child maladjustment
(Fincham, Grych, & Osborne, 1994). Marital relations
researchers have noted that the strength of the asso-
ciation between discord and child maladjustment is
dependent upon the content (i.e., child or nonchild
related), form (i.e., violent or nonviolent), and fre-
quency of conflict as well as whether or not the conflict
was resolved (Davies & Cummings, 1994).
Considering the identified association between
marital conflict management and negative parent-
ing behavior (Webster-Stratton & Hammond, 1999),
it is not surprising that marital dissatisfaction has
been found to predict child outcome following BPT
for noncompliant or aggressive children (Webster-
Stratton, 1994; Webster-Stratton & Hammond, 1990).
With this in mind, research efforts have been di-
rected at learning how interparental functioning may
be affected during the course of BPT. Dadds and col-
leagues (1987b) demonstrated that parents participat-
ing in BPT who displayed clinically significant lev-
els of marital dissatisfaction at pretreatment tended
to direct aversive behaviors towards their spouses
(e.g., negative feedback, argumentativeness, noncom-
pliance, ignoring) when their child was misbehaving.
Similarly, Anastopoulos and colleagues (1993) found
that although BPT resulted in concurrent improve-
ments in overall child ADHD symptoms, parenting
self-esteem, and parental stress, BPT did not signif-
icantly improve marital satisfaction in couples that
began BPT reporting low marital satisfaction.
Despite findings suggesting that ADHD in chil-
dren is associated with a host of marital problems in
their parents, there has not been a BPT program de-
veloped or tested for maritally distressed parents of
children with ADHD. However, such programs have
been evaluated for parents of children with ODD or
CD (or, in some cases, children referred for noncom-
pliance and aggression). In the first of these stud-
ies, Griest and colleagues (1982) randomly assigned
families who completed BPT to receive “parent en-
hancement therapy,” which addressed parents’ per-
ceptions of their children’s behavior and parents’ per-
sonal, marital, and extrafamilial adjustment. Results
of this study suggested that BPT plus enhancement
therapy was more effective in improving child be-
havior and parents’ use of behavioral strategies dur-
ing home observations and better maintenance at the
2-month follow-up assessment than BPT alone. In a
more recent pilot study, Dadds et al. (1987) showed
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12
that the addition of partner support training (PST)
to BPT led to improvements in child behavior and a
reduction in the frequency of aversive interactions be-
tween parents. In a larger study examining group dif-
ferences between the response of maritally discordant
and nondiscordant couples of children to BPT-only
and BPT+ PST treatments, results suggested that the
adjunctive PST better maintained the effects of BPT
at 6-month follow-up in maritally discordant parents
of children with ODD or CD, but did not have an
added benefit for maritally-satisfied parents (Dadds,
Schwartz, & Sanders, 1987). Taken together, these
findings suggest that clinicians providing BPT should
assess for the presence of marital dissatisfaction or in-
terparental discord, as these problems may interfere
with the maintenance of BPT treatment gains if left
untreated.
Parent Cognitions
Over the past 20 years, there has been a great deal
of research supporting the link between parent cog-
nitions regarding their children and parenting behav-
ior (Bugental & Johnston, 2000; Miller, 1995). These
studies suggest that when parents view their children
as responsible for their misbehavior, they are more
likely to respond negatively to such behavior (Dix &
Grusec, 1985; Slep & O’Leary, 1998). Studies that exist
addressing attributions about child ADHD behavior
have found that, compared to parents of control chil-
dren, parents of children with ADHD tend to make
more negative attributions for their children’s misbe-
havior, particularly oppositional and aggressive be-
haviors, and such attributions may contribute to more
negative parenting behavior (Johnston & Freeman,
1997). Findings also suggest that parents of children
with ADHD may fail to focus on positive behav-
iors that occur in the context of ADHD or opposi-
tional/aggressive behaviors. They may also “give up”
trying to manage their children’s behavior because
of beliefs that certain behaviors are beyond their
control.
Parent cognitions may also be related to other
forms of psychopathology commonly present in par-
ents of children with ADHD (e.g., depression).
Observational studies have shown that maternal
depressive symptoms are more closely related to neg-
ative perceptions of child behavior than to observed
child behavior (Rickard, Forehand, Wells, Griest, &
McMahon, 1981; Rogers & Forehand, 1983). This sug-
gests that depressed mothers may be exaggerating the
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Chronis, Chacko, Fabiano, Wymbs, and Pelham
severity of, or may simply have less tolerance for, their
children’s misbehavior. One recent study, however,
supports the accuracy of depressed mothers’ reports
of child behavior (Querido, Eyberg, & Boggs, 2001).
In this study, mothers with greater levels of depressive
symptomatology provided reports of child behavior
that were highly consistent with laboratory observa-
tions of child behavior.
Recent findings from the MTA study suggested
that parental cognitions about themselves, their
ADHD children, and their parenting were signifi-
cant predictors of child treatment outcome, beyond
the effects of treatment group (Hoza et al., 2000).
Specifically, low self esteem in mothers, low parent-
ing efficacy in fathers, and fathers’ attributions for
child noncompliance were associated with poorer
response to behavioral, pharmacological, and com-
bined treatments for ADHD (behavioral and com-
bined treatment components included intensive BPT
programs).
Parental expectations regarding their involve-
ment in BPT, their child’s involvement in BPT, the
duration of treatment, the focus of treatment, and
the effectiveness of the treatment for their child,
may affect a parent’s attendance and engagement
in treatment. Studies have shown that discrepancies
between parental expectations and the actual de-
mands of therapeutic approaches predict treatment
attendance and dropout (Plunkett, 1984; Nock
& Kazdin, 2001). In fact, parental expectations
regarding treatment have been found to predict
treatment attendance and dropout above putative
factors (e.g., SES, parental stress/psychopathology,
and severity of child’s problem; Nock & Kazdin,
2001). No treatment studies, however, have included
components addressing parental expectations of
treatment, although some BPT programs explicitly
target such expectancies or attributions within
the context of treatment (e.g., Cunningham et al.,
1997).
These findings, although limited to a handful
of studies, imply that parent cognitions about them-
selves, their children, and treatment may be an im-
portant target for intervention. In particular, target-
ing parental cognitions may be particularly beneficial
for parents of children with ADHD in general, and
particularly for those who are depressed or predis-
posed in some way to patterns of negative thinking.
Many of the adjunctive cognitive-behavioral compo-
nents to BPT discussed in this review include com-
ponents that attempt to directly modify dysfunctional
parental cognitions.
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Enhancements to Parent Training for ADHD
Single Mothers
Single parenting has long been identified as a
risk factor for the development of psychopathology in
children (Rutter et al., 1975). Single parents, typically
single mothers, are more likely to experience daily
hassles and stressful life changes, to be more socially
isolated, and to receive less emotional and parental
support (Blechman, 1982; Weinraub & Wolf, 1983).
These problems may influence maternal adjustment,
parenting behavior, parental perceptions of child be-
havior, and child development (e.g., Hetherington,
Cox, & Cox, 1978, 1981).
Single mother families of children with CD have
been shown to experience greater perceived stress, re-
port more child problems, and use less effective par-
enting approaches with their children than married
parents of children with CD (Webster-Stratton, 1989).
Furthermore, children with CD from single mother
households exhibit greater observed deviant behavior
than children from intact families (Webster-Stratton,
1989). Although most of the extant literature involv-
ing single parents of behaviorally disordered children
is exclusive to single-parent families of CD children,
it is reasonable to assume that many of the corre-
lates, factors, and processes are similar in families of
children with ADHD. In fact, some studies of sin-
gle mothers of children with ADHD have demon-
strated that these parents, as compared to married
mothers of children with ADHD, are more sensitive
to laboratory manipulations of child-related stress
(Lang et al., 1999; Pelham et al., 1997, 1998, 2000).
Given these findings, further research is needed to ex-
plore possible differences between single versus mar-
ried mothers of children with ADHD in the areas
of personal adjustment, interpersonal relationships,
and parenting behavior. Resulting knowledge may en-
hance the development of adjunctive treatments for
these parents.
Given that single parent status has been shown
to predict poorer response to BPT for children
with ODD and CD (Webster-Stratton & Hammond,
1990; Kazdin, Mazurick, & Bass, 1993), some re-
searchers have evaluated adjunctive components
specifically targeted toward single-parent families.
Pfiffner and colleagues (1990) used a social prob-
lem solving skills intervention adapted from the work
of D’Zurilla and Goldfried (1971) as an adjunct to
BPT. Dadds and McHugh (1992) used a modified
form of a partner support training method devel-
oped in their laboratory to improve the parents’ so-
cial support by placing a parent-appointed individ-
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13
ual in an ally role. Dadds and McHugh (1992) did
not find any incremental benefit of ally support train-
ing beyond the effects of BPT; however, Pfiffner and
colleagues (1990) found relatively greater improve-
ments on parent ratings of externalizing child be-
havior at follow-up for parents who received BPT
plus the adjunctive social problem solving skills in-
tervention, relative to parents who received BPT
alone. No acute treatment effects were found beyond
the effects of BPT. As yet, no comparable studies
have been conducted with families of children with
ADHD.
Father Participation in Parent Training
Father involvement has long been a goal of par-
ent trainers. The involvement of fathers is impor-
tant for a number of reasons, including the facili-
tation of social support within the family unit and
consistency in parenting and discipline. In addition,
in families where fathers report low parenting ef-
ficacy, children do not respond as well to standard
ADHD treatments (Hoza et al., 2000). Father in-
volvement also appears to be an important predic-
tor of treatment continuation for families engaged
in BPT (Clark & Baker, 1983). Given the impor-
tance of father involvement, many prominent BPT
researchers have called for the adaptation of BPT
formats to encourage, include, and engage fathers
in treatment (e.g., Levine, 1993; Miller & Prinz,
1990).
Fathers share parenting responsibilities (Russell
& Russell, 1987), have responsibilities generally re-
served for the person in the father role (e.g., playing
ball games; Marsiglio, 1993; Russell & Russell, 1987),
and like mothers of children with ADHD, struggle to
control their child’s behavior and experience stress
related to parenting a difficult child (e.g., Mash &
Johnston, 1983; Pelham, Greiner, & Gnagy, 1997).
However, father involvement in BPT studies for
children with ADHD is often specifically precluded
by the study methods (e.g., Sonuga-Barke, Daley,
Thompson, Laver-Bradbury, & Weeks, 2001), ignored
(e.g., Horn et al., 1991), or minimized (e.g., Barkley,
Guevremont, Anastopoulos, & Fletcher, 1992). This
failure to study fathers is concerning, given that this
gap in the literature was highlighted over 10 years
ago (Miller & Prinz, 1990), and that some research
has documented that fathers of children with DBDs
may benefit from participation in BPT (Schuhmann
et al., 1998).
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14
Currently, there is little information on the ef-
fectiveness of BPT for fathers. To date, studies that
have specifically studied the effectiveness of BPT for
fathers yielded equivocal findings (Firestone, Kelly,
& Fike, 1980; Martin, 1977; Webster-Stratton, 1985b),
yet all have limitations. Some work has suggested that
in-vivo practice is particularly important for fathers
(Adesso & Lipson, 1981), and the one study that doc-
umented a beneficial impact of BPT for fathers in-
cluded in-vivo practice and on-line feedback from
clinicians (Schuhmann et al., 1998). Clearly, more
research is needed on the effectiveness of BPT for
fathers, and how existing programs may need to be
modified to improve father engagement and there-
fore outcomes for children with ADHD.
CHILD FACTORS
Developmental Considerations
We have reported elsewhere that, although most
of the studies evaluating the effectiveness of BPT
were conducted on elementary-aged children with
ADHD, BPT has the strongest empirical support for
young children with the disorder (Pelham et al., 1998).
Although BPT with children of any age is based on the
same basic behavioral principles, slight modifications
may be made for children of different ages or devel-
opmental levels (e.g., more frequent, tangible rewards
provided for younger children, behavioral contracts
utilized with adolescents).
BPT approaches developed for adolescents have
generally involved working with parents and ado-
lescents to develop more effective communication,
negotiation, and problem solving strategies in the
context of a developmentally sensitive behavior
management program (Barkley, Edwards, & Robin,
1999). Parents and teens work together to arrive
at behavioral contracts that specify clear behav-
ioral expectations that are associated with parent-
provided privileges or rewards when adolescents meet
these expectations. Only two studies have evalu-
ated the effects of these interventions for adoles-
cents with ADHD, and have provided mixed sup-
port for their effectiveness. Barkley and colleagues
(1992) compared the treatment outcomes of ado-
lescents with ADHD whose families participated
in BPT, problem-solving and communication train-
ing (PSCT), or structural family therapy (SFT).
They found that all three treatments led to statisti-
cally significant gains at posttreatment and 3-month
follow-up. However, there were no significant
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Chronis, Chacko, Fabiano, Wymbs, and Pelham
between-treatment differences and the significant
posttreatment gains failed to result in clinically signif-
icant reliable change or recovery (Jacobson & Truax,
1991). McCleary and Ridley (1999) studied the effec-
tiveness of a group-based BPT program for families
of adolescents with ADHD. Although the results of
the study suggested that parents improved their par-
enting skills and ability to use effective behavioral
management techniques, these data are limited by the
lack of a control or alternate treatment group to ad-
just for the effect of time. Lastly, Robin (1998) advo-
cates the use of a bio-behavioral family systems ap-
proach to treating adolescents with ADHD. Similar
to Henggeler and colleagues’ (1998), multisystemic
approach for treating antisocial youth, Robin sug-
gests the use of a comprehensive intervention, includ-
ing BPT, PSCT, parent–teen negotiations, medication,
and school consultation, to treat the functional impair-
ment faced by adolescents across multiple domains.
As for elementary-aged children with ADHD, treat-
ment components in each of these domains are likely
necessary for adolescents; however, Robin’s model
for comprehensive treatment has not yet been sub-
ject to empirical testing. Thus, its utility as a treatment
for adolescents with ADHD is unknown. Clearly, fur-
ther research is needed to conclusively determine the
therapeutic benefit of BPT for treating adolescent
ADHD (for a review and recommendations for future
adolescent treatment studies, see Smith, Waschbusch,
Willoughby, & Evans, 2000).
Child Comorbidity
ADHD commonly co-occurs with other child-
hood disorders, particularly ODD, CD, and learning
disorders, and also with internalizing disorders, such
as anxiety (Pliszka, 2000). In fact, in the MTA study,
only 31.8% of the participants were diagnosed with
ADHD alone; 29.5% were diagnosed with ADHD
and either ODD or CD, 14% were diagnosed with
both ADHD and an anxiety disorder, and 24.7% were
diagnosed with ADHD, ODD or CD, and an anxiety
disorder (Jensen et al., 2001). Results of MTA intent-
to-treat analyses suggested that children with pure
ADHD or ADHD and ODD or CD often responded
similarly to interventions, with the largest improve-
ments found for interventions including medication
(Jensen et al., 2001). In contrast, children with comor-
bid ADHD and anxiety responded best to interven-
tions including behavior therapy. In fact, for children
with comorbid anxiety disorders, behavioral treat-
ment alone yielded comparable effects as medication
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alone and combined treatment on both ADHD and
anxiety symptoms (MTA Cooperative Group, 1999b).
This is likely because all of the MTA behavioral treat-
ment conditions were individualized in that parents,
teachers, and STP staff identified target behaviors
based on each child’s impaired areas of functioning
(which, in these cases, included anxiety). We have ar-
gued elsewhere (Pelham & Fabiano, 2001) that behav-
ior modification is a part of effective treatments for
virtually every childhood disorder (e.g., ODD, CD,
anxiety, depression, autism). Indeed, BPT is a part of
the empirically supported treatments for all of these
disorders (Lonigan et al., 1998).
Good behavioral treatments are based on a func-
tional analysis of problematic behaviors, not simply
those symptoms that are specific to a diagnosis of
ADHD. Additional treatment components (e.g., ex-
posure, relaxation) may be added as needed to ad-
dress problems that are less amenable to behavioral
techniques, but should always be based on an individ-
ualized assessment. Thus, it may be argued that when
based on a functional analysis of behavior, BPT can ef-
fectively address most co-occurring disorders as well
as ADHD. Future studies are recommended that ex-
amine the effectiveness of BPT for comorbid children,
as well as the effectiveness of additional treatment
components for children with comorbid conditions.
Impairment Across Multiple Settings and Domains
By definition, children with ADHD experience
impairment in multiple settings (e.g., at home, school,
and in social situations) and across multiple domains,
including social relationships with family members,
teachers, and peers, academic performance, and dis-
ruptive school behavior. Comprehensive treatments
involve intensive behavior modification in each of
these settings to address all domains of impairment.
Thus, BPT for children with ADHD is rarely im-
plemented in the absence of concurrent behavioral
school interventions, and interventions aimed at im-
proving the child’s peer relationships (e.g., social skills
training, intensive summer treatment programs).
School Interventions
Because the DSM-IV definition of ADHD re-
quires cross-situational impairment, virtually every
child with ADHD will experience problematic school
behavior and functional impairment in their social
March 10, 2004 12:33 Style file version Nov. 07, 2000
15
relationships with adults or peers and/or in their
academic performance. For this reason, school-based
interventions are an important adjunct to BPT for
families of, or at risk for, children with ADHD.
Many of the ADHD BPT studies presented in
Table II included school-based interventions in the
form of very brief behavioral consultations with
teachers (e.g., Horn, Ialongo, Greenberg, Packard,
& Smith-Winberry, 1990), comprehensive and sus-
tained school-based consultation and intervention
(e.g., MTA Cooperative Group, 1999a; O’Leary &
Pelham, 1978; Pelham et al., 1988; Pelham, Schnedler,
Bologna, & Contreras, 1980), or the placement
of a child in a classroom that included intensive
contingency management strategies (e.g., Barkley
et al., 2000). Researchers building state-of-the-art
prevention programs for children at-risk for devel-
oping ADHD and other conduct problems have also
coupled BPT with school interventions in studies
with Head Start children (Webster-Stratton, 1998;
Webster-Stratton, Reid, & Hammond, 2001a) and
as part of a sustained, multimodal prevention pro-
gram for at-risk elementary school children (Conduct
Problems Prevention Research Group, 1999). The
most common enhancement in BPT studies that in-
cluded school interventions for children with ADHD
(see Table II) and other conduct problems (e.g., ag-
gression; Lochman & Wells, 2002; Lochman, Whidby,
& FitzGerald, 2000) was the provision of a daily re-
port card (DRC; O’Leary, Pelham, Rosenbaum, &
Price, 1976). The DRC provides daily communication
to the parent regarding the child’s performance on
well-operationalized target behaviors, and the parens
are taught in BPT to use this feedback to imple-
ment home-based consequences contingent on goal
attainment. With the exception of the DRC, school-
based interventions typically include the same be-
havior management topics indicated for parents in
Table I.
A school-based intervention intuitively seems to
be an essential component of any ADHD treatment.
Consider the study conducted by Barkley et al. (2000).
In the only study to compare BPT alone, a school-
based treatment alone, and the combination of the
two, Barkley and colleagues (2000) reported that only
the groups that included the school-based compo-
nent benefited from the treatment. We previously
discussed the poor BPT attendance in this study, so
those children in the groups that contained the school-
based intervention are the only groups that actually
received the planned treatment potency. This study
illustrates the importance of including interventions
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16
across important functional domains (i.e., home and
school). One could reasonably presume that studies
that had high rates of compliance with BPT, but poor
compliance with classroom interventions, would find
the opposite pattern of results (i.e., improvement in
the home setting, but no improvement at school). That
is, unless a direct intervention is implemented target-
ing problematic behaviors exhibited in a particular
setting, it is not typically the case that treatment ef-
fects in one setting will generalize to another. In fact,
in our review of psychosocial treatments for ADHD,
we found larger effect sizes in the setting in which
treatments were directly implemented than in other
settings (Pelham, et al., 1998). Therefore, one can con-
clude that effective interventions will need to be im-
plemented in every setting in which a child is impaired
to achieve maximum effectiveness. Future studies will
need to further investigate the best methods for in-
tegrating home and school-based treatments for chil-
dren with ADHD, and to expand on the Barkley et al.
(2000) study by improving efforts to engage and retain
parents who initially participate. Such interventions
would act to maximize the likelihood of improvement
across both major domains of functioning.
Social Skills Training
Interpersonal difficulties are considered to be
one of the hallmark qualities of children with ADHD
(Whalen & Henker, 1985). Children with high lev-
els of hyperactivity, noncompliance, or aggression are
rated more negatively by peers on sociometric mea-
sures (Erhardt & Hinshaw, 1994; Pelham & Bender,
1982) and are more likely to be rejected by peers
(Hinshaw & Melnick, 1995). Thus, peer relationships
are an important target of comprehensive treatment
for ADHD. As Coie and Dodge (1998) have doc-
umented, poor peer relationships are predictive of
negative long-term outcomes for disruptive children.
Behavioral social skills training (BSST) interventions
are focused on developing and reinforcing the use of
appropriate social skills (e.g., communication, coop-
eration, participation, validation; Kavale, Forness, &
Walker, 1999). Recently, three studies of BPT for par-
ents of children with ADHD included BSST, which
demonstrated stronger and more generalized treat-
ment effects for the combined treatment versus BSST
alone (Frankel, Myatt, Cantwell, & Feinberg, 1997;
Pfiffner & McBurnett, 1997; Sheridan, Dee, Morgan,
McCormick, & Walker, 1996). Notably, one study
of children with ODD, CD, and ADHD compared
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Chronis, Chacko, Fabiano, Wymbs, and Pelham
BPT alone, BSST alone, the combination of BPT and
BSST, and a no treatment control group (Webster-
Stratton & Hammond, 1997). This study found that all
treatments resulted in significant behavioral improve-
ments for parents and children. However, greater and
more generalized effects were found for the com-
bined BPT and BSST group, which demonstrated im-
provements across home, school, and peer domains.
These results suggest that combining standard BPT
with BSST may result in more robust effects for par-
ents and children than BPT alone.
Summer Treatment Program
The STP (Pelham, Greiner, et al., 1997) is an
intensive, 8-week outpatient program that combines
evidence-based ADHD treatment components, in-
cluding weekly, group-based BPT, a token or point
system, positive reinforcement (i.e., praise), effective
commands, time out, a DRC, social skills training,
and problem solving skills training. These treatments
are implemented across recreational and academic
settings to improve children’s peer relationships, in-
teractions with adults, academic performance, and
self-efficacy (Pelham et al., 1998; Pelham, et al.,
in press).
Many studies have demonstrated the effective-
ness of STP components (e.g., Pelham et al., 1993;
for a review see Pelham et al., in press); two stud-
ies have documented the improvement gained from
the STP by comparing pretreatment with posttreat-
ment assessments (Pelham et al., 2000; Pelham &
Hoza, 1996); others have demonstrated the effective-
ness of the STP within the context of a comprehen-
sive behavioral intervention that included long-term
BPT and school intervention (e.g., MTA Cooperative
Group, 1999a). To date, two controlled crossover stud-
ies have provided support for the STP treatment pack-
age (Chronis, Fabiano, et al., in press; Pelham et al.,
2002). Thus, the existing literature suggests that the
STP is an effective intervention that intensively ad-
dresses the social functioning of children with ADHD
beyond that which can be accomplished via traditional
clinic-based BPT.
The STP always includes BPT as part of the inten-
sive treatment package. Parents attend BPT classes
one evening per week while the children and their
siblings participate in recreational activities super-
vised by their counselors. One of the most remark-
able outcomes of the STP is incredibly high parent
attendance in weekly BPT classes—routinely around
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Enhancements to Parent Training for ADHD
100% (Pelham et al., in press). These rates dwarf those
found in other studies of BPT treatment (e.g., Barkley
et al., 2000). It is likely that an intensive child-based
treatment component that the children enjoy, coupled
with the daily feedback from staff on child perfor-
mance, and the formal (in BPT classes) and informal
(e.g., in dismissal lines) social support provided from
interacting with other parents who share similar prob-
lems combine to truly engage parents in treatment. In
fact, the consumer satisfaction ratings for parents and
children who participate in the STP are uniformly high
(Pelham & Hoza, 1996). Given that consumer dissat-
isfaction with treatment is one of the largest barriers
to treatment continuation (Kazdin et al., 1997), the
STP explicitly targets this barrier to treatment. Fur-
thermore, as we discussed above, BPT alone is not
expected to impact functional domains that are not
targeted directly (e.g., academic progress, peer re-
lationships). Given the domain specificity of effects
along with the absence of evidence for the effective-
ness of clinic-based BSST, the STP is an important
enhancement to BPT for children with ADHD, as it
explicitly targets functional domains such as peer re-
lationships often not treated in traditional BPT pro-
grams. Overall, the STP appears to be an outstanding
model for enhanced BPT.
Medication
It is estimated that approximately 75% of chil-
dren diagnosed with ADHD are medicated with
stimulants (Rowland et al., 2002). Stimulant medi-
cation has been shown to have large, beneficial ef-
fects on a number of outcome measures, includ-
ing ADHD symptoms (see Swanson, McBurnett,
Christian, & Wigal, 1995, for a review). Many stud-
ies have compared BPT to stimulant medication and
combined BPT and stimulant medication (Firestone,
Kelly, Goodman, & Davey, 1981; Horn et al., 1991;
Klein & Abikoff, 1997; MTA Cooperative Group,
1999a; Pollard, Ward, & Barkley, 1983). For example,
the MTA study included four groups: (1) Behavioral
Treatment (BT; included BPT, intensive school inter-
vention, and the STP); (2) Medication Management
(MedMgt); (3) Combined Behavioral Treatment and
Medication Management (Comb); and (4) a Com-
munity Comparison control (CC; of which approx-
imately two-thirds were medicated; Pelham, 1999).
Although medication in this study was effective in re-
ducing ADHD symptoms, for the socially valid targets
of treatment (i.e., areas of impaired functioning), only
March 10, 2004 12:33 Style file version Nov. 07, 2000
17
the Comb treatment resulted in improved social skills
and improved parent–child relationships, including
harsh and ineffective parenting (Hinshaw et al., 2000).
Secondary analyses support the superiority of the
Comb treatment (Conners et al., 2001; Swanson et al.,
2001). Importantly, when parents were asked to rate
their satisfaction with treatment, they overwhelm-
ingly endorsed the treatment conditions that included
BPT (Pelham et al., in press). As treatment palatabil-
ity is essential for treating a chronic disorder, these
are very important results, which highlight BPT as a
necessary component of comprehensive treatment for
ADHD.
These results are not surprising. Parents of chil-
dren with ADHD commonly report problems with
morning and evening routines, and these are typically
times when stimulant medication treatment is imprac-
tical because of side effects such as insomnia. There-
fore, even if a child is medicated for the entire school
day and early evening, there are clearly times par-
ents need behavioral strategies to help them manage
their child’s behavior. The results of the MTA study
further suggest that for a child on medication, BPT
is required to increase the chances that the child be-
haves within normative limits and improves in im-
portant functional domains. Perhaps then, medica-
tion for ADHD may be best thought of as another
possible enhancement to BPT for children and fam-
ilies who do not respond to the standard treatment.
Viewing stimulant medication as a BPT enhancement
confers a host of important research questions that
need to be addressed. For example, how might the
sequence of BPT and medication impact treatment
response? Although it has not yet been studied, it
has been hypothesized that administering medication
first may decrease parents’ (and teachers’) motiva-
tion to make changes in their attempts to manage
child behavior. Alternatively, if BPT is administered
first, and parents implement the strategies taught,
there is evidence that their children may respond to
lower doses of stimulant medication (e.g., Pelham,
1999).
Finally, given the literature presented herein sug-
gesting that ADHD is associated with a host of fam-
ily problems, it is unlikely that stimulant medication
for children is sufficient to treat the multiple mental
health needs and pervasive impairment common in
these families. Indeed, we recently found that late-
afternoon stimulant dosing for children with ADHD
did not result in improvements in parent mood and
functioning (Chronis, Pelham, Gnagy, Roberts, &
Aronoff, 2003b). Clearly, behavior modification is a
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18
necessary component of comprehensive treatment for
ADHD.
CONCLUSIONS AND DIRECTIONS FOR
FUTURE RESEARCH WITH FAMILIES
OF CHILDREN WITH ADHD
The current review addressed many issues that
are relevant to the BPT literature for families of chil-
dren with ADHD. In general, a substantial evidence
base exists indicating that BPT is an effective treat-
ment for ADHD (Pelham et al., 1998). As ADHD
is associated with impairments in multiple domains,
treatment in clinical practice or large clinical trials
(e.g., MTA Cooperative Group, 1999a) often involves
additional treatment components, such as behav-
iorally oriented classroom interventions to address
academic and social functioning in the school setting,
social skills training or intensive summer treatment
programs to address peer relationships, and concur-
rent stimulant medication. The literature reviewed
herein suggests that many important issues that are
potentially relevant to the successful implementation
of BPT for children with ADHD have been largely un-
derstudied in the ADHD literature. We reviewed fac-
tors related to: (1) the parameters of BPT programs,
including the format, process, and setting; (2) asso-
ciated parental factors that may be related to poor
treatment response, including parental psychopathol-
ogy, marital distress, parental cognitions, single par-
enthood, and father involvement; and (3) child factors
that should be a focus of consideration in BPT im-
plementation, including developmental level, comor-
bidity, and impairment in domains beyond the home
setting (i.e., at school, with peers). All of these factors
have either been shown to be related to BPT outcome
in children with ADHD or should be a focus of future
investigation because existing literature in the areas
of ODD and CD suggests that they may be important
mediators or moderators of response to BPT.
In the area of ADHD, little research has focused
on differential response to variations in the param-
eters of BPT. Given that group-based interventions
are more cost-effective, efficient, may be less stigma-
tizing for some families, and, in studies conducted with
children with ODD or CD, show at least comparable
effects to individual formats, it is likely that group-
based BPT may be preferable to individual BPT as a
first-line treatment. In particular, the time and cost of
group-based BPT is far less than individually based
BPT. For example, in a study conducted by Webster-
Stratton (1984) of 35 families of children with CD
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Chronis, Chacko, Fabiano, Wymbs, and Pelham
randomly assigned to group or individual BPT found
that the total therapist time for group-based BPT was
48 hr, whereas therapist time for individual BPT was
251 hr. Thus, individually based treatments dramat-
ically increase clinician time with families with little
tradeoff in terms of improvement (Webster-Stratton,
1984). On the other hand, there is some evidence to
suggest that individual treatments (e.g., PCIT) may
be beneficial for certain families that present with
more severe psychopathology. Given the benefits of
both group- and individually based BPT, it can be ar-
gued that all parents of children with ADHD should
be initially enrolled in group-based BPT to maximize
clinical resources, with supplementary individual ses-
sions for those parents not attaining maximal benefit
with group-based BPT or for those parents who drop
out of group-based treatment. This approach allows
more intensive, individualized treatment to be imple-
mented with those families that require more inten-
sive services. However, this approach must be held
to empirical investigation, as no studies currently ex-
ist comparing individual and group BPT formats for
families of children with ADHD.
Additionally, researchers working with families
of children with conduct problems have noted the im-
portance of videotaped modeling and coping mod-
eling problem solving techniques in enhancing BPT
skills acquisition. Future studies that select children
with ADHD must be conducted to determine the op-
timal BPT format for these children and their par-
ents. Such studies may indicate for which children
more intensive, individualized approaches may be
necessary. Furthermore, given the chronic and perva-
sive nature of ADHD, evaluation of procedures for
maintenance and generalization of treatment effects
is also critical. These formatting issues await empirical
investigation.
It is also likely that, to reach some difficult pop-
ulations, it will be necessary to provide treatment
in community settings (e.g., schools, community cen-
ters) that are more accessible to low-SES families
and those from diverse backgrounds. Existing evi-
dence suggests that these settings may, in fact, lead
to improvements in attendance and compliance; yet,
community-based interventions (e.g., Cunningham’s
COPE Program; Cunningham et al., 1997) are rarely
studied for children diagnosed with ADHD. Many
children with ADHD first present to pediatricians’ of-
fices, and this is one location in which future treatment
studies should clearly be conducted to determine how
an effective psychosocial treatment, such as BPT,
integrated into a pediatrician’s office affects such
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Enhancements to Parent Training for ADHD
variables as treatment accessibility, cost, parent sat-
isfaction, and use of medication.
As discussed herein, it is likely that parents of
children with ADHD may also benefit from parent-
focused interventions that address the issues such
as parental psychopathology, marital problems, fa-
ther involvement, and issues relevant for single par-
ents and parents from disadvantaged backgrounds.
The ample evidence documenting the negative effects
of parent and family problems on compliance with
and outcomes following BPT reviewed herein sup-
ports the notion that child behavior problems should
include assessment and treatment of parental psy-
chopathology to maximize long-term effects of BPT.
(Griest & Forehand, 1982; McMahon et al., 1981;
Webster-Stratton, 1985a; Webster-Stratton, 1992a) In
fact, the BPT manual developed for the MTA study
(Wells et al., 1994) includes two sessions that focus on
parent stress, anger, and mood management. These
sessions cover the relationship between thoughts,
feelings, and behaviors related to parenting, relax-
ation techniques, and building and utilizing social sup-
port networks. Studies of adjunctive components to
address parent issues, mostly conducted on families of
children selected for ODD or CD, were reviewed in
this paper. Taken together, the results of these adjunc-
tive treatment studies provide mixed support for the
incremental benefit of interventions addressing par-
ents’ interpersonal problems beyond standard BPT
alone. Most often, adjunctive interventions resulted
in beneficial effects at follow-up assessment but not
at posttreatment, particularly in studies that selected
families experiencing distress in the area being tar-
geted (e.g., social support). The one study targeting
parents of children with ADHD (conducted in our
laboratory) found that an adjunctive CBT interven-
tion was effective in addressing maternal depressive
symptoms; yet, no effects of the intervention were
found on child behavior, likely because the adjunc-
tive intervention followed both the STP and BPT,
which left little room for improvement on measures
of child behavior (Chronis et al., 2002). It is rea-
sonable to assume that maximal benefits of adjunc-
tive enhancement treatments are more likely to oc-
cur in parents with impairment in areas being targeted
by enhancement components. Thus, general interven-
tions that address issues relevant to a wide variety of
parents (e.g., ADVANCE) or specific interventions
targeted at participants selected for the particular
problem (e.g., marital therapy for maritally-distressed
parents) appear most useful. Additional studies must
be conducted with families of children diagnosed with
March 10, 2004 12:33 Style file version Nov. 07, 2000
19
ADHD to establish first that adjunctive parent treat-
ments result in incremental benefits beyond BPT.
Studies must then address more refined questions,
such as the order in which treatment components
are introduced. For example, for depressed parents,
is it better to administer depression treatment before,
following, or concurrent with BPT? Furthermore, al-
though studies have addressed the incremental effects
of interventions addressing parental depression and
marital distress, no studies have attempted to address
other parental disorders that commonly occur in this
population (e.g., ADHD, substance abuse, antisocial
personality, anxiety disorders). These, and many re-
lated questions, await empirical investigation.
Although BPT has been identified as an empir-
ically supported treatment for children with ADHD,
relatively little research has been conducted on treat-
ments for adolescents with the disorder (Smith et al.,
2000). This is a particularly difficult group to treat,
and further treatment research in this area is surely
needed. Furthermore, few studies have looked at the
added benefit of social skills training, school inter-
ventions, and intensive summer treatment programs
beyond the effects of BPT alone. Such studies are nec-
essary to determine the intensity of treatment neces-
sary for most children with the disorder. The next step
will be to predict for whom additional or more inten-
sive services will be necessary to produce meaningful
improvements in ADHD symptoms and functional
impairment.
In addition, prominent reviews have recently
concluded that stimulant medication is superior to
BPT and other psychosocial interventions in ADHD
treatment when compared head-to-head in treat-
ment outcome studies (Jadad, Boyle, Cunningham,
Kim, & Schachar, 1999; Miller et al., 1998; although
see Fabiano & Pelham, 2002 for a discussion on
the limitations of these reviews). Although stimu-
lant medications are clearly effective in ameliorat-
ing many of the symptoms of ADHD across mul-
tiple settings (e.g., Swanson et al., 1995), results
of the MTA suggest that on important measures
of parenting (e.g., harsh and ineffective discipline),
combined behavioral–pharmacological interventions
were clearly superior to medication alone (Hinshaw
et al., 2000). Given these findings, and the multiple
issues described herein (e.g., parental psychopathol-
ogy, multiple areas of impairment, child comorbid-
ity), it is unlikely that medication alone is sufficient
for many, if not most, children with ADHD (Chronis
et al., 2003a,b). Thus, enhancements and modifica-
tions to optimize the effects of BPT for children
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20
with ADHD and their families are of utmost clinical
importance.
Ongoing Studies
In our ADHD laboratories at the State Univer-
sity of New York at Buffalo and the University of
Maryland, College Park, we have directed recent ef-
forts at unanswered questions related to family factors
in BPT. In addition to the study we described previ-
ously utilizing a cognitive-behavioral depression in-
tervention for mothers of children with ADHD, pilot
studies are underway that attempt to engage, retain,
and benefit single mothers and fathers of children with
ADHD in BPT.
Considering the factors and the complexities in-
volved in being a single parent of a child with ADHD,
ODD, and/or CD, a multi-component, comprehensive
treatment appears warranted. Although many of the
possible enhancements that we discuss are not exclu-
sive to single parents, we feel they are particularly
pertinent to single mothers. In an attempt to address
many of the issues faced by clinicians when treating
single mothers and their children in BPT, we have be-
gun a randomized, controlled trial of a BPT program
specifically targeting single mothers of children with
ADHD, ODD, and/or CD (see Chacko & Pelham,
2002; Wymbs & Pelham, 2002, for detailed descrip-
tions of the program). The Strategies To Enhance
Positive Parenting (STEPP) program is a weekly, 9-
session BPT program which focuses on enhancements
including: (1) addressing expectations of treatment
and readiness for change; (2) solving problems re-
lated to practical barriers to treatment; (3) improv-
ing engagement and retention of participants through
an exclusive single mother, collaborative, process-
oriented, group with smaller subgroups to increase
active participation among members; (4) expanding
the content to address a larger set of life problems
in addition to child management issues; (5) delivering
treatment through a combination of didactic teaching,
coping modeling problem solving, structured problem
solving therapy (D’Zurilla & Nezu, 1999), and group-
based PCIT methods; (6) enhancing maintenance of
treatment gains through self-directed/administered
treatments; and (7) using a concurrent enhanced child
social skills treatment with a reward system that is
contingent on both home- and clinic-based behavioral
goals.
In an attempt to engage fathers in their chil-
dren’s treatment, we have also piloted a BPT program
12:33 Style file version Nov. 07, 2000
Chronis, Chacko, Fabiano, Wymbs, and Pelham
aimed specifically at fathers of children with ADHD.
The Coaching Our Acting-Out Children: Heightening
Essential Skills (COACHES; Fabiano, Chacko, &
Pelham, 2002) program is a weekly, 8-session BPT
program. The program is designed to increase father
participation and engagement in BPT by including a
reinforcing, in-vivo sports activity as part of the BPT.
Sports skills training has long been included as a com-
ponent of effective child treatments (Pelham et al.,
in press), and the COACHES program extends that
format to BPT for fathers. During the first hour, fa-
thers review how to implement effective parenting
strategies in a group setting (e.g., praise, time out).
Concurrently, children practice soccer skill drills with
paraprofessional counselors, to increase athletic com-
petency (Pelham et al., in press; Pelham, Lang, et al.,
1997; Pelham & Hoza, 1996). Then, during the sec-
ond hour, parent and child groups merge for a soc-
cer game. The soccer game provides a context for fa-
thers to “coach” their children while practicing BPT
strategies (e.g., praise, effective commands), and for
clinicians to provide feedback on-line to the fathers
as the game progresses, a procedure shown to be ef-
fective for BPT with fathers (Schumann et al., 1998).
We expect that this context may motivate fathers to
participate more actively in BPT and reduce some of
the stigma associated with attending traditional treat-
ment programs. We are currently conducting a ran-
domized, controlled trial comparing traditional BPT
to COACHES for fathers of children with ADHD.
These efforts, although important issues in ad-
vancing a deeper understanding of family consider-
ations in BPT, address only the tip of the iceberg
in terms of what remains unknown about BPT for
ADHD. In the past 30 years, BPT was identified and
validated as an efficacious treatment for children with
ADHD. Researchers must now focus on modifying
and enhancing BPT to address the multiple impair-
ments present in families of children with ADHD to
achieve maximum clinical gains.
ACKNOWLEDGMENTS
During the preparation of this review, Gregory
Fabiano was supported by National Research
Scientist Award (NRSA) predoctoral fellowship
(MH64243-01A1). William Pelham was supported by
grants from the National Institute of Alcohol Abuse
and Alcoholism (AA11873), the National Institute
on Drug Abuse (DA12414), the National Institute of
P1: JLS
Clinical Child and Family Psychology Review (CCFP) pp1130-ccfp-481521
Enhancements to Parent Training for ADHD
Mental Health (MH 53554, MH62946), and the Na-
tional Institute of Neurological Disorders and Stroke
(NS39087).
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