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Randomized Controlled Trial
. 2025 Feb 19;86(1):24m15463.
doi: 10.4088/JCP.24m15463.

Sequencing Stimulant Medication and Behavioral Parent Training in Multiplex ADHD Families: A Pilot SMART

Joyce H L Lui  1   2 , Andrea Chronis-Tuscano  3 , Daniel Almirall  4 , Kathryn B Whitlock  5 , William French  6 , Mark A Stein  6
Affiliations
Randomized Controlled Trial

Sequencing Stimulant Medication and Behavioral Parent Training in Multiplex ADHD Families: A Pilot SMART

Joyce H L Lui et al. J Clin Psychiatry. .

Abstract

Objective: To examine the effects of treatment sequence of parent stimulant medication (MED) and behavioral parent training (BPT) on child, maternal, and parenting outcomes among multiplex attention-deficit/hyperactivity disorder (ADHD) families using a pilot Sequential Multiple Assignment Randomized Trial (SMART) design.

Methods: To be eligible, mothers had to meet DSM-IV diagnostic criteria for ADHD, and their children had to have elevated ADHD symptoms. Thirty-five mother-child dyads were randomized at baseline and again at week 8. The resulting 4 sequences were MED MED, BPT-BPT, MED-BPT, and BPT MED. Outcomes included child ADHD symptoms, child impairment, maternal ADHD symptoms, and parenting at week 16. Data were collected from September 2012 to December 2016.

Results: The BPT-MED sequence demonstrated the most favorable outcomes for child ADHD symptoms (effect size= -0.36) and child impairment (effect sizes -0.33 to -0.51). All 3 sequences involving medication demonstrated similar impact on maternal ADHD symptoms (effect sizes ranged from -0.32 to -0.48). The BPT-MED (effect sizes ranged from 0.30 to 0.35) had the most favorable effects on positive parenting outcomes. For negative parenting outcomes, BPT-MED (effect size= -0.50 for self report) and BPT-BPT (effect size= -0.08 for observation) had the most favorable outcomes.

Conclusions: Overall, based on this pilot SMART, combination treatment may be helpful for most multiplex ADHD families, and sequencing treatments with BPT first followed by stimulant medication for the mother may be the most promising approach to improve child ADHD symptoms, impairment, and parenting. These results require replication with a fully powered SMART design. We conclude with considerations for implementing a model of care for multiplex ADHD families.

Trial Registration: ClinicalTrials.gov identifier: NCT01816074.

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Figures

Figure 1.
Figure 1.. CONSORT Diagram
Figure 2.
Figure 2.. Trajectories of Child ADHD Symptoms and Impairment Across Treatment Sequences
Abbreviations: ADHD = attention-deficit/hyperactivity disorder, BPT = behavioral parenting training, CGI-S = clinical global impressions scale-severity, Conners = Conners 3rd edition (ages 7–8 years) or Conners Early Childhood Scale (ages 4–6 years), MED = maternal stimulant medication, IRS = Child Impairment Rating Scale.
Figure 3.
Figure 3.. Trajectories of Maternal ADHD Symptoms Across Treatment Sequences
Abbreviations: ADHD = attention-deficit/hyperactivity disorder, BPT = behavioral parenting training, CAARS = Conners Adult ADHD Rating Scale, MED = maternal stimulant medication.
Figure 4.
Figure 4.. Trajectories of Positive and Negative Parenting Across Treatment Sequences
Abbreviations: ADHD = attention-deficit/hyperactivity disorder, APQ = Alabama Parenting Scale, BPT = behavioral parenting training, MED = maternal stimulant medication.
See this image and copyright information in PMC

References

    1. Kleppesto TH, Eilertsen EM, van Bergen E, et al. Intergenerational transmission of ADHD behaviors: genetic and environmental pathways. Psychol Med. 2024;54(7):1309–1317. - PubMed
    1. Faraone SV, Larsson H. Genetics of attention deficit hyperactivity disorder. Mol Psychiatry. 2019;24(4):562–575. - PMC - PubMed
    1. Johnston C, Chronis-Tuscano A. Parental ADHD: relations to parenting, child behavior, and treatment outcomes. J Abnorm Child Psychol. 2017;45(3):411–413. - PubMed
    1. Chronis-Tuscano A, Wang CH, Woods KE, et al. Parent ADHD and evidence-based treatment for their children: review and directions for future research. J Abnorm Child Psychol. 2017;45(3):501–517. - PMC - PubMed
    1. Harold GT, Leve LD, Barrett D, et al. Biological and rearing mother influences on child ADHD symptoms: revisiting the developmental interface between nature and nurture. J Child Psychol Psychiatry. 2013;54(10):1038–1046. - PMC - PubMed

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