Personalized Treatment of Mothers With ADHD and Their Young At-Risk Children: A SMART Pilot

Abstract

Rationale Young children of mothers with adult attention-deficit/hyperactivity disorder (ADHD) are at risk for ADHD by virtue of genetics and environmental factors. Moreover, parent ADHD is associated with maladaptive parenting and poor child behavioral treatment response. Thus, a combined approach consisting of behavioral parent training (BPT) and maternal stimulant medication (MSM) may be needed to effectively treat ADHD within families. However, providing combined BPT+MSM initially to all families may be unnecessarily burdensome since not all families likely need combined treatment. The purpose of this study is to examine how to combine, sequence, and personalize treatment for these multiplex families in order to yield benefits to both the parent and child, thereby impacting the course of child ADHD and disruptive behavior symptoms. Study Design and Preliminary Experiences This paper presents our rationale for, design of, and preliminary experiences (based on N = 26 participants) with an ongoing pilot Sequential Multiple Assessment Randomized Trial (SMART) designed to answer questions regarding the feasibility and acceptability of study protocols and interventions. This manuscript also describes how the subsequent full-scale SMART might change based on what is learned in the SMART pilot, and illustrates how the full-scale SMART could be used to inform clinical decision making about how to combine, sequence, and personalize treatment for complex children and families in which a parent has ADHD.

Adaptive Interventions in Child and Adolescent Mental Health

“…Chronis-Tuscano, Wang, Strickland, Almirall, and Stein (2015) present the design and rationale of a SMART pilot study to examine feasibility and acceptability considerations in the development of an adaptive intervention for mothers with ADHD with children (ages 3–8 years) who are at risk for ADHD by virtue of genetics and environmental factors. The pilot considers four sequences of interventions, which differ in terms of (i) whether to begin treatment with behavioral parent training (BPT) alone or maternal stimulant medication (MSM) alone, and, in the second stage, (ii) whether to continue with first-stage treatment or combine BPT+MSM.…”

Parent ADHD and Evidence-Based Treatment for Their Children: Review and Directions for Future Research

“…The SMART design involves two or more randomizations in order to examine optimal sequencing of interventions. In this study, we are recruiting mothers with ADHD who have young children (ages 3-8 years) with elevated child ADHD symptoms who have never been treated with child ADHD medications (Chronis-Tuscano, Wang, Strickland, Almirall, & Stein, 2016). The focus on young children is consistent with intervention early in the child's development to delay or prevent the need for child stimulant medication since psychosocial treatments are recommended before medication in young children with ADHD (Greenhill et al, 2006).…”

“…In our SMART, families are first randomized to receive 8 weeks of either maternal stimulant medication (MSM) or BPT. After 8 weeks of initial treatment, participants are then randomized to either continue with the same treatment modality for a second 8 weeks (with as-needed modifications to address non-response) or the alternative treatment is added (see Chronis-Tuscano et al, 2016, for additional details regarding study design, treatment protocols, and outcome measures). Outcomes measured include maternal ADHD symptoms and functioning, parenting (measured via questionnaires and laboratory observations), and child symptoms and functioning.…”

Do parental ADHD symptoms reduce the efficacy of parent training for preschool ADHD? A secondary analysis of a randomized controlled trial

“…However, based on the limitations of the literature and the current study, as well as a recent pilot study by Chronis-Tuscano et al (2016) suggesting addressing the parent’s ADHD symptoms may enhance intervention effects, researchers at present should continue to assess parent ADHD symptoms when evaluating interventions for child ADHD.…”