Attendance and Engagement in Parent Training Predict Child Behavioral Outcomes in Children Pharmacologically Treated for Attention-Deficit/Hyperactivity Disorder and Severe Aggression

Abstract

Objectives: We examined the association of parent training (PT)-related factors with therapeutic success in the Treatment of Severe Childhood Aggression (TOSCA) study. Our aims were (1) to evaluate demographic and clinical characteristics as predictors of parent attendance and engagement in PT and (2) to examine the associations of parent attendance and engagement in PT with study-targeted child behavior outcomes (i.e., attention-deficit/hyperactivity disorder [ADHD] and disruptive behavior symptoms). TOSCA was a randomized clinical trial evaluating the effect of placebo versus risperidone when added to PT and psychostimulant for childhood ADHD with severe aggression. Methods: Data for 167 parents and children 6-12 years old with ADHD, oppositional defiant disorder (ODD) or conduct disorder, and severe physical aggression were examined. Analyses used generalized linear models. Results: Most parents (72%) attended seven or more of nine sessions. The average parental engagement, that is, the percentage of PT elements fully achieved across participants and sessions, was 85%. The average therapist rating of goal completion was 92%. Parents of non-white and/or Hispanic children (p = 0.01) and children with lower intelligence quotient (p = 0.02) had lower PT attendance; parents with lower family incomes (p = 0.01) were less engaged. Attendance and engagement predicted better scores on the primary child behavior outcomes of disruptive behavior (Nisonger Child Behavior Rating Form Disruptive Behavior Total) and ADHD and ODD symptoms, adjusting for baseline severity. Conclusions: When the clinical picture is sufficiently severe to warrant prescribing an atypical antipsychotic, PT is feasible for families of children with ADHD and co-occurring severe aggression. The promotion of attendance and engagement in PT is important to enhance clinical outcomes among this challenging population. Methods for overcoming barriers to participation in PT deserve vigorous investigation, particularly for those with low family income, non-white race, Hispanic ethnicity, or when children have lower cognitive level.

Evaluating the Feasibility of the Incredible Years Attentive Parenting Program as Universal Prevention for Racially Diverse Populations

“…And only one gender difference (out of five outcomes investigated) emerged that indicated girls benefited more than boys in peer problems after their parents completed the IY Attentive Parenting Program. While some studies suggested no differences in PT attendance among ethnic-racially diverse families (e.g., Dumas et al, 2007), others found ethnic-racial minorities were less likely to attend (e.g., Joseph et al, 2019). The underlying factor beneath the mixed findings with ethnicity and race may be the cultural responsiveness of the PT and the facilitator.…”

“…In addition to treatment outcomes, we also evaluated parents' attendance in the IY Attentive Parenting Program. Consistent with prior PT studies (Joseph et al, 2019), we examined whether demographic (e.g., race and gender) and clinical characteristics (e.g., parenting stress and child psycho pathology) would account for parents' attendance in the IY Attentive Parenting Program. Studying the attendance rate in an implementation study is crucial to understanding the feasibility of PT.…”

“…Moreover, findings have been mixed related to these demographic and clinical characteristics as predictors of attendance. For instance, compared with White families, racial minority families were found to either attend fewer (e.g., Joseph et al, 2019) or the same amount of PT sessions (e.g., Baker et al, 2011; Dumas et al, 2007).…”

“…We also hypothesized these results would be similar across diverse families given past research with the IY BASIC Parenting Program (Kim et al, 2008; Leijten et al, 2017; Reid et al, 2001). Due to limited prior research on treatment utilization and inconsistent findings (e.g., Baker et al, 2011; Dumas et al, 2007; Joseph et al, 2019), we did not set any a priori hypothesis around attendance patterns in this study.…”

An investigation of predictors of attendance for fathers in behavioral parent training programs for children with ADHD

“…Another study, which examined the outcome of behavioral parent training for children and their families, also found that children's ODD symptoms were a significant predictor of attendance. This could be as a result of parents' lack of understanding about skills being taught, or lack of ability to implement these appropriately in conjunction with their children's needs (Joseph et al, 2018). Other studies illustrate that there can, in fact, be a decline among sessions with those families of children who have higher ratings of oppositional defiant disorder.…”