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The Ways in Which Parents Think About Parenting, Themselves, and Their Child May Affect Treatment Outcomes for Children With ADHD
Although numerous studies on the treatment of ADHD have been conducted, most have been limited to examining the effectiveness of particular treatments (e.g. medication, behavioral therapy, neurofeedback, dietary interventions, etc.) without regard to how aspects of parents' thinking may impact treatment outcome. Because parents are ultimately responsible for implementing prescribed treatments, it is possible that how parents think about themselves and their child could influence children's outcomes through the influence these beliefs have on parents' willingness/ability to consistently implement the treatments that have been recommended.
It is not difficult to imagine examples of how this could occur. Parents who believe their child has no control over non-compliant behavior may feel that imposing limits and consequences is pointless. They may, therefore, be unwilling to comply with recommendations that are part of behavioral treatment. Similarly, parents who lack confidence in their parenting ability, or who have low self-esteem in general, may find it difficult to enforce consequences or consistently administer medication when faced with resistance from their child. In other families, parents who believe the problematic behavior of their ADHD child is always deliberate and willful, and are unwilling to consider that ADHD symptoms are a contributing factor, may frequently react with anger and punitive discipline, and be unwilling to implement the kind of parenting strategies that can be more helpful for many children with ADHD.
Despite these reasons for hypothesizing that parents' thinking about their child, themselves, and their parenting may influence children's treatment outcomes, there has been virtually no research conducted on this important topic. A study published in the December 2000 issue of the Journal of Abnormal Child Psychology (Hoza, B. et al. Parent cognitions as predictors of child treatment response in ADHD, 28, 569-583), however, provides an interesting initial look at this understudied area.
This study was conducted in conjunction with the MTA study, the largest treatment study of ADHD ever conducted. In the MTA study, 579 6-12 year-old children with the combined type of ADHD were randomly assigned to one of four different treatment conditions -- careful medication management; intensive behavioral treatment, the combination of careful medication management and intensive behavioral treatment; and routine community care.
The current study included 105 children and parents from 2 of the 6 MTA study sites who agreed to participate in an "add-on" investigation to the main study. These parents completed a number of measures designed to assess their self-esteem, their feelings of parenting efficacy (i.e. how confident they felt about their parenting skills), the adaptiveness of their discipline strategies, and the types of attributions they made about their child's behavior (i.e. did they consistently blame their child's non-compliant behavior problems on lack of effort and/or poor mood as opposed to recognizing that such behavior could also reflect other factors, including the impact of ADHD).
These aspects of parents thinking and disciplinary strategies were collected separately for mothers and fathers prior to any child receiving treatment. Fourteen months later, parent and teacher reports of children's ADHD symptoms and oppositional/defiant behaviors were collected. The authors could then examine whether parental thinking and disciplinary strategies influenced children's outcome even after treatment benefits had been taken into account. They predicted that regardless of which treatment a child received, the outcome would be better when parents had higher self-esteem, reported more adaptive disciplinary strategies, and held more adaptive attributions about themselves and their child.
Results
For mothers, self-esteem and self-report of dysfunctional discipline both had a significant impact on child outcome. Across all 4 treatment groups (i.e. medication management, behavioral intervention, combined treatment, and community care) children whose mothers had higher self-esteem and who used fewer dysfunctional disciplinary strategies were doing better (i.e. their parents and teachers reported they were showing fewer ADHD symptoms and less oppositional behavior).
For fathers, the use of fewer dysfunctional disciplinary strategies also predicted more positive outcomes. In addition, children did better when their fathers were less likely to "blame" their child's non-compliance on lack of effort and/or bad mood. Finally, there was a strong trend indicating that high parenting efficacy for fathers (i.e. having confidence in one's ability to handle the demands of parenting) predicted more positive child outcomes.
In addition to examining how aspects of parental thinking and disciplinary style related to children's outcomes, it is also interesting to look at the relationship between these variables. For mothers and fathers, higher self-esteem was associated with a more positive disciplinary style. And, parents who felt more confident in their parenting ability (i.e. higher parental efficacy scores) were less likely to endorse dysfunctional disciplinary strategies or blame their child's non-compliance on lack of effort.
Summary And Implications
The major findings of this study: parental cognitions and parental reports of dysfunctional disciplinary strategies predicted children's treatment outcomes 14 months later. It is important to emphasize that these factors had a significant impact on children's outcomes even after all gains associated with treatments received in the MTA study had been taken into account.
For mothers, self-esteem emerged as a significant predictor of child treatment response. The authors speculate that perhaps mothers with low self-esteem experience doubts about their parenting ability, thus making them prone to engage in dysfunctional disciplinary practices which have a negative affect on child outcome. Among fathers, those with higher feelings of parental efficacy, and were less prone to blame children's non-compliance on poor effort and/or bad mood, had children who were doing better. The authors suggest that this may occur because feelings of efficacy in fathers encourage more positive involvement with their child and fewer dysfunctional disciplinary practices.
Although the exact mechanisms by which these aspects of parental thinking influence treatment outcome cannot be determined from this study alone, the results provide strong evidence that such factors can play an important role. The authors argue that, because parents are the implementers of treatment for children with ADHD, parental factors such as those examined here should be considered as possible targets for treatment. As was demonstrated here, even when children are receiving the most careful medication treatment and/or the most systematic behavioral treatment available, certain aspects of parental thinking can still have an important influence on treatment success.
An encouraging aspect of these results is that they underscore the critical role parents play in the development of children with ADHD. For parents who question whether they can play an important role in promoting their child's healthy development above and beyond making sure their child takes the right medication, these data clearly indicate they can. How parents think about themselves, and how confident they feel in their role as parents, may have a meaningful impact on the success of whatever treatment(s) their child is receiving. This paper will hopefully stimulate additional work in this important area.
Note: This article originally appeared in Attention Research Update, an online newsletter written by Dr. David Rabiner, a Duke University psychologist and former member of CHADD's Professional Advisory Board. You can learn more about Attention Research Update and sign up for a free subscription at www.helpforadd.com.