Fran Lowry

May 31, 2013

HOLLYWOOD, Florida — Pharmacologic therapy for parents who have attention-deficit/hyperactivity disorder (ADHD) improves their parenting skills, especially if their children also have the disorder.

In a small trial of 38 parent-child dyads with ADHD, treatment of the parents with lisdexamfetamine dimesylate (LDX) enhanced their ability to help their children do homework and also caused them to interact with their children in a more positive, nurturing way.

This in turn improved the behavior of their children, according to the results of the study, presented here in a poster session at the New Clinical Drug Evaluation Unit (NCDEU) 53rd Annual Meeting.

Studies show that one quarter to one third of children with ADHD have a parent who meets some ADHD diagnostic criteria, and this may adversely affect the child's ability to improve, lead investigator James G. Waxmonsky, MD, from Florida International University College of Medicine, in Miami, told Medscape Medical News.

"Our center really focuses on pediatric ADHD, but for years, we would have parents come in with their children, and as their child gets assessed and treated, the parents would say, 'That sounds like me,' or, 'That sounds like my spouse, what can you do for adults?' " Dr. Waxmonsky said.

"We started to wonder, since so many children with ADHD will also have a parent with the disorder, what impact this would have on the child's improvement, because we are asking the parent to do things like give a daily medication, structure their child's day, be very consistent and persistent in the way they interact with their child, but if they have attention and organizational issues, this may be very difficult for them," he said.

Treatment Naive

The investigators recruited 38 parents who met the criteria for ADHD but had never been treated and who also had children with ADHD. "It took a while to find and enroll the families. We also had a higher attrition rate, in part because many of the adults had never been treated with stimulants before, and they did not like the side effects," Dr. Waxmonsky explained.

Of the 38 dyads enrolled, 26 finished the study.

All the adult participants met full Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for ADHD and had a child between the ages of 5 and 15 years with ADHD. The adults were first optimized on LDX (mean dose, 50 mg) during a 3-week period.

In the first phase of the study, the parent-child pairs completed 2 laboratory interactions, once with the parent on a blinded, optimal LDX dose, and once on placebo. The children were unmedicated for both interactions.

The interactions included doing homework, playing, and having family problem-solving discussions, as appropriate for the age of the children.

These activities were videotaped to record both negative and positive behaviors that parents and children exhibited.

Dr. James Waxmonsky

"For example, we wanted to see how many times did the parent repeat themselves, how many negative comments or positive comments did they make, how much did the child argue, whine, or complain," Dr. Waxmonsky explained.

In the second phase of the study, the parents were randomly assigned to continue blinded, optimized treatment with LDX or placebo for an additional month, and then the parent-children pairs were again brought in for a final interaction.

Improved Behavior in Kids

Significant reductions in ADHD symptoms in the parents were seen in the first phase, but despite this, they did not exhibit any changes in their parenting behavior. However, there were significant reductions in child negative behaviors during the homework task (P = .023).

In the second phase of the study, however, the parents who had undergone continuous treatment with LDX used significantly more praise (P = .013), were more verbally responsive to their child (P = .044), and reduced their verbalizations (P = .043) and commands (P = .018) compared with their behaviors during phase 1 of the study.

Additionally, the parents who were treated continuously with LDX increased their use of praise 3-fold (P = .003), whereas for the parents receiving placebo, rates of praise did not increase.

"The parents said less, especially in the homework task, and what they said had a more positive tone. If the child said something, the parents were more likely to respond in a shorter time period," Dr. Waxmonsky said.

"Interestingly, the child behaved much better. The kids were all unmedicated, but the improvement in the child behavior, just by adjusting the parent medication, was almost as much as if we had medicated the child."

It may be that treating parents' ADHD does something that allows the children to behave better, Dr. Waxmonsky speculated.

"The parents then react to their children's improved behavior and adjust their parenting, become more positive. They learn they don't have to repeat themselves and become more encouraging and nurturing in their interactions with their children."

The group plans to continue the study in hopes of reproducing these results in a larger sample.

"We're very interested now in seeing if giving adults with ADHD pharmacological treatment also helps them maximize the gain from behavioral parent training, so that if they go through such training sessions, do they get more out of them if their ADHD is under control? That is our next step," Dr. Waxmonsky said.

A Fine Study

"Previous research has shown that when depressed parents are treated, and their depression goes into remission, their children benefit, with improved health and well-being and fewer behavior problems," Alan J. Gelenberg, MD, Shively/Tan Professor and chair, Department of Psychiatry, Pennsylvania State University, in Hershey, commented to Medscape Medical News.

"Dr. Waxmonsky's fine study demonstrates that when parents suffer from ADHD, are treated, and improve, their children benefit. Building on previous work, this study shows that not only do parents report improved behavior in their children but that a laboratory simulation confirms that it is true."

The study was supported by an investigator-initiated grant from Shire. Dr. Waxmonsky reports a financial relationship with Shire. Dr. Gelenberg reports no relevant financial relationships.

New Clinical Drug Evaluation Unit 53rd Annual Meeting. Abstract 3. Presented May 29, 2013.

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