Anthony_Rostain_AIA_15_Bzb6ml.png.jpgPediatrics 2016; 137(1);e20152486
“Stimulant Medication and Psychotic Symptoms in Offspring of Parents With Mental Illness”
MacKenzie, L.E., Abidi, S., Fisher, H.L. et al.

Treatment of ADHD with stimulant medications carries many known risks including the development of psychotic symptoms which is considered to be a rare adverse event. It is reported that between 0.25% – 1.5% of children taking stimulants develop psychotic symptoms. However, little is known about the nature of these symptoms or about the potential for higher rates of psychosis in at-risk populations such as the children of parents with serious mental illness (SMI). Case reports and a chart review report that the rate of stimulant-induced psychosis in this group ranges from 8% to 20%. The authors of this paper set out study the rates and types of psychotic symptoms in children with parents suffering SMIs such as major depression, bipolar disorder and schizophrenia. They carefully evaluated 141 children (ages 6-21 years, average 11.8 years) in a study of developmental psychopathology in offspring of parents with SMI in Nova Scotia entitled “Families Overcoming Risks and Building Opportunities for Wellbeing.” The study employed several standardized interviews to inquire into a variety of psychiatric conditions including the occurrence and the nature of psychotic symptoms experienced by these children. All youths and parents were interviewed using the Kiddie SADS and three other interviews that probe for prodromal syndromes, psychotic-like experiences and proneness to schizophrenia. The rates of psychotic symptoms were reported for the entire sample and the rates were compared between children receiving stimulant medications (N=24) and those who never took a stimulant. Moderators such as parental diagnosis and presence or absence of ADHD in the child were also analyzed.

Of the 24 children receiving stimulant medication, 15 (62.5%) developed psychotic and related symptoms compared with 32 (27.4%) of the remaining 117 participants who had never taken stimulants. The adjusted odds ratio for psychotic symptoms due to stimulant medication was found to be 4.41. Further analyses revealed a stronger effect of stimulant medication (OR: 4.51) and a very weak effect of ADHD (OR: 1.16) on the development of psychosis. No differences were seen in rates of psychosis when analyzing parental psychopathology. Psychotic symptoms were seen in 37.5% of children of parents with schizophrenia, 34% of parents with bipolar disorder and 32% of parents with major depressive disorder. All of the children with medication-induced psychosis had parents with either bipolar disorder or depressive disorder. By far, the most common psychotic symptoms reported were hallucinations. Lastly, a sensitivity analysis was conducted to determine the temporal relationship between stimulant treatment and the onset of psychotic symptoms. Of the 15 individuals with current stimulant use, 25% developed symptoms; of the 126 participants without current stimulant use, 5% were experiencing psychotic symptoms. The Odds Ratio of developing psychotic symptoms from stimulants was 7.25. Moreover, a subset of children clearly developed psychosis as a result of taking stimulants.

This study was extremely well designed and implemented. It is the first of its kind to carefully document the frequency and nature of psychotic symptoms in children of parents with SMI, and to quantify the considerable added risk to those prescribed stimulant medication. It convincingly demonstrates the substantial risk these children face and suggests that clinicians should be cautious whenever prescribing stimulant medications to this group, and should carefully monitor for the onset of serious adverse effects.

Anthony_L_Rostain_MD_MA_-_ADHD_in_AdultsJournal of Clinical Child and Adolescent Psychology. 2014. DOI: 10.1080/15374416.2014.963858

“The Role of Parental ADHD in Sustaining the Effects of a Family-School Intervention for ADHD”

Dawson, A.E., Wymbs, B.T., Marshall, S.A., Mautone, J.A., Power, T.J.

This paper reports on the extent to which parental ADHD impacts child and parent functional outcomes of a multimodal family-school intervention designed to boost academic performance of 139 school-aged children with ADHD.

The initial results of this randomized controlled trial (N = 199) comparing an experimental intervention, the Family School Success Program (FSS) to an active-control condition, Coping with ADHD through Relationships and Education (CARE), revealed that participants in each group showed gains in the primary targeted outcomes.

Subscribe Ask the Experts CTA xqcBwrFor children, these included rates of completing homework, academic productivity, and symptoms of ADHD and oppositional defiant disorder (ODD) as measured by the Swanson, Nolan and Pelham Questionnaire (SNAP).  Parental outcomes included parents’ view of their efficacy as their child’s educator, quality of the parent-teacher relationship, and quality of the parent-child relationship.  While both groups showed improvements, there were modest treatment effect sizes seen in the FSS group as compared to the CARE group in ratings of homework performance, self-reported parenting practices, and overall quality of school-family relationships (Power et al, 2012).

The last two outcomes were also better in the FSS group at a follow-up assessment conducted by the researchers three months after the conclusion of the study.

Given growing concern regarding the role that parental ADHD may play in moderating the effectiveness of treatments for children with ADHD (a topic that is thoroughly reviewed in the introduction section of this paper), these investigators went on to examine the impact of parental ADHD symptoms on the study’s outcomes.

Parental ADHD was determined by administering a self-report scale, the Conners’ Adult ADHD Rating Scale (CAARS) to 139 of the parent participants in the study.  Both dimensional and dichotomous ADHD variables were created but only the latter was used in the analysis because of the small size of the ADHD group (N = 23, or roughly 16% of the total).

Results showed that parental ADHD did not affect treatment outcome for either the experimental (FSS) or the control (CARE) condition at the end of the study period.  However, at the three month follow-up assessment, parental ADHD was associated with declines in treatment gains only in the FSS group, particularly in the quality of parent-teacher relationship and the child’s homework performance.  This finding surprised the investigators who hypothesized that ADHD parents in both groups would show declines in outcomes as compared to non-ADHD parents.

They concluded that the control condition may have provided ADHD parents with greater opportunities to develop strategies and to practice problem-solving skills on their own, whereas ADHD parents in the experimental condition might have become overly dependent on study clinicians to implement the parenting practices that were the focus of the intervention.

This study illustrates the importance of modifying parent-focused treatment interventions to the specific characteristics of the patient and family.  In particular, when parents of ADHD children also exhibit the symptoms of ADHD, it may be helpful to provide additional opportunities for them to develop strategies, cultivate resources, and practice parenting skills aimed at helping their ADHD children succeed at school.

CAARS = Conners’ Adult ADHD Rating Scale

CARE = Coping with ADHD through Relationships and Education

FSS = Family School Success Program

Power, T.J., Mautone, J.A., Soffer, S.L. Clarke, A.T., et al (2012). “A family-school intervention for children with ADHD: Results of a randomized clinical trial.” Journal of Clinical Child and Adolescent Psychology. 80: 611-623 DOI: 10.1037/a0028188.

http://medicalwritingtraining.com/Raising children is not easy. I should know. As a clinical psychologist, I’ve helped parents learn the skills they need to be better parents. And my experience raising three children confirmed my clinical experience. Parenting is a tough job under the best of circumstances but it is even harder if the parent has ADHD. For example, an effective parent establishes rules and enforces them systematically. This requires attention to detail, self-control and good organizational skills. Given these requirements, it is easy to see how ADHD symptoms interfere with parenting. These observations have led some of my colleagues to test the theory that treating ADHD adults with medication would improve their parenting skills. I know about two studies that tested this idea. In 2008, Dr. Chronis-Toscano and colleagues published a study using a sustained release form of methylphenidate for mothers with ADHD. As expected, the medication decreased their symptoms of inattention and hyperactivity/impulsivity. The medication also reduced the mothers use of inconsistent discipline and corporal punishment and improved their monitoring and supervision of their children. In a 2014 study, Waxmonsky and colleagues observed ADHD adults and their children in a laboratory setting once when the adults were off medication and once when they were on medication. They used the same sustained release form of amphetamine for all the patients. As expected, the medications reduced ADHD symptoms in the parents. This laboratory study is especially informative because the researchers made objective ratings of parent-child interactions rather than relying on the parent’s report of those interactions. Twenty parents completed the study. The medication led to less negative talk and commands and more praise by parents. It also reduced negative and inappropriate behaviors in their children. Both studies suggest that treating ADHD adults with medication will improve their parenting skills. That is good news. But they also found that not all parenting behaviors improved. That makes sense. Parenting is a skill that must be learned. Because ADHD interferes with learning, parents with the disorder need time to learn these skills. Medication can eliminate some of the worst behaviors but doctors should also provide the adjunct behavioral or cognitive behavioral therapies that could help ADHD parents learn parenting skills and achieve their full potential as parents.
 

REFERENCES
Chronis-Tuscano, A., K. E. Seymour, et al. (2008). “Efficacy of osmotic-release oral system (OROS) methylphenidate for mothers with attention-deficit/hyperactivity disorder (ADHD): preliminary report of effects on ADHD symptoms and parenting.” J Clin Psychiatry 69(12): 1938-1947.
Waxmonsky, J. G., D. A. Waschbusch, et al. (2014). “Does pharmacological treatment of ADHD in adults enhance parenting performance? Results of a double-blind randomized trial.” CNS Drugs 28(7): 665-677.

Mark Stein, PhD, ADHD in AdultsIt has been known for many years that ADHD runs in families. Twin, family, and adoption studies indicate that ADHD is common in first-degree relatives of children with ADHD, including many parents. In contrast to children with ADHD whose difficulties in school or at home lead to an ADHD evaluation, parental ADHD is much less likely to be detected if it has been missed previously. ADHD in adults can be easily misdiagnosed as another problem, sometimes the result of longstanding, untreated ADHD, such as substance use and demoralization. The problem of recognition compounded as there is much less awareness of ADHD among health and mental health providers who treat adults, since for years ADHD was viewed primarily as a pediatric condition. Until recently, there have been few studies to guide treatment of ADHD in parents, although it is also been established that parental ADHD can have a negative impact on behavioral parent training, a frequent first line treatment fort ADHD in children.

Andrea Chronis-Tuscano and I began a series of studies investigating the effects of treating mothers with ADHD about 10 years ago. We first studied the effects of long-acting stimulant medications on maternal ADHD, and observed improvements in mothers’ ADHD symptoms and some improvements in parenting (e.g. there were fewer reports of corporal punishments at higher doses) (Chronis-Tuscano et al., 2008) (Chronis-Tuscano & Stein, 2012).

More recently, a large multisite study examined the impact of treating maternal ADHD with either 12 weeks of multimodal treatment consisting of methylphenidate and group psychotherapy or 12 weeks of clinical management (i.e., less intensive supportive counselling) prior to receiving 12 weeks of parent-child training (Jans et al., 2015). Multimodal treatment of mothers was associated with improvements in maternal ADHD and mental health in general, however children whose mothers were treated with 12 weeks of supportive counseling displayed the same level of improvement in behavior as children whose mothers received multimodal treatment that included maternal stimulant medication. In this study, three-quarters of the child participants were already receiving stimulant medication, which may have reduced the potential for detecting effects of treating ADHD mothers on children who were already being treated (Stein, 2015).

Several years ago, we began a study of mothers with ADHD who have young children at risk for ADHD due to genetics and environment, with ADHD symptoms, who have not yet started treatment. This study, Mothers First, is testing whether treating mothers with ADHD first, with either stimulant medication or parent training, not only helps mothers, but also improves parenting and reduced or delays the need for medication in the child (Chronis-Tuscano, Wang, Strickland, Almirall, & Stein, in press). We are in the last year of the study at Seattle Children’s hospital, which is aimed at mothers with suspected ADHD who have 3-7 year olds with ADHD symptoms who are not taking ADHD medications. As part of the study, mothers and children are evaluated for ADHD and receive study treatments and monitoring. In addition, we are now beginning an extension study with fathers with ADHD, Father too. In this study, fathers will be treated with 8 weeks of stimulant medication or behavioral parent training. In this our first study with fathers, we look forward to comparing our experience with mothers to ADHD treatment and measuring the impact on parenting and on young children with ADHD.

We know now that ADHD is common in parents, and that treatment can make a difference in terms of reducing parents’ ADHD symptoms. We also know that pediatric and mental health providers seldom identify ADHD in parents, and that there is a paucity of adult provides trained in ADHD management. Consequently, it is often challenging to find providers who can treat parents with ADHD. Through our research, we hope to increase awareness of parental ADHD and learn how best to sequence treatment and differences between ADHD in a mother and father and how that relates to treatment of the child with ADHD. Eventually, ADHD will be recognized as a family disorder that is not focused exclusively on the child or childhood years.

Chronis-Tuscano, A., Seymour, K. E., Stein, M. A., Jones, H. A., Jiles, C. D., Rooney, M. E., . . . Robb, A. S. (2008). Efficacy of osmotic-release oral system (OROS) methylphenidate for mothers with attention-deficit/hyperactivity disorder (ADHD): preliminary report of effects on ADHD symptoms and parenting. The Journal of clinical psychiatry, 69(12), 1938-1947. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/19192455
Chronis-Tuscano, A., & Stein, M. A. (2012). Pharmacotherapy for parents with attention-deficit hyperactivity disorder (ADHD): impact on maternal ADHD and parenting. CNS drugs, 26(9), 725-732. doi:10.2165/11633910-000000000-00000
Chronis-Tuscano, A., Wang, C. H., Strickland, J., Almirall, D., & Stein, M. (in press). Personalized Treatment of Mothers with ADHD and Their Young At-Risk Children: A SMART Pilot. Journal of Clincal Child and Adolescent Psychology.
Jans, T., Jacob, C., Warnke, A., Zwanzger, U., Gross-Lesch, S., Matthies, S., . . . Philipsen, A. (2015). Does intensive multimodal treatment for maternal ADHD improve the efficacy of parent training for children with ADHD? A randomized controlled multicenter trial. Journal of child psychology and psychiatry, and allied disciplines. doi:10.1111/jcpp.12443
Stein, M. A. (2015). Does helping mothers with ADHD in multiplex families help children? Reflections on Jans et al Journal of Child PSychology and Psychiatry, 56, 1314-1315.

key words: adult ADHD, parents with ADHD, pharmacotherapy

Anthony_Rostain_AIA_15_Bzb6ml.png.jpgJournal of Clinical Child and Adolescent Psychology. 2014. DOI: 10.1080/15374416.2014.963858

“The Role of Parental ADHD in Sustaining the Effects of a Family-School Intervention for ADHD”

Dawson, A.E., Wymbs, B.T., Marshall, S.A., Mautone, J.A., Power, T.J.

This paper reports on the extent to which parental ADHD impacts child and parent functional outcomes of a multimodal family-school intervention designed to boost academic performance of 139 school-aged children with ADHD.   The initial results of this randomized controlled trial (N = 199) comparing an experimental intervention, the Family School Success Program (FSS) to an active-control condition, Coping with ADHD through Relationships and Education (CARE), revealed that participants in each group showed gains in the primary targeted outcomes.  For children, these included rates of completing homework, academic productivity, and symptoms of ADHD and oppositional defiant disorder (ODD) as measured by the Swanson, Nolan and Pelham Questionnaire (SNAP).  Parental outcomes included parents’ view of their efficacy as their child’s educator, quality of the parent-teacher relationship, and quality of the parent-child relationship.  While both groups showed improvements, there were modest treatment effect sizes seen in the FSS group as compared to the CARE group in ratings of homework performance, self-reported parenting practices, and overall quality of school-family relationships (Power et al, 2012).   The last two outcomes were also better in the FSS group at a follow-up assessment conducted by the researchers three months after the conclusion of the study.  

Given growing concern regarding the role that parental ADHD may play in moderating the effectiveness of treatments for children with ADHD (a topic that is thoroughly reviewed in the introduction section of this paper), these investigators went on to examine the impact of parental ADHD symptoms on the study’s outcomes.  Parental ADHD was determined by administering a self-report scale, the Conners’ Adult ADHD Rating Scale (CAARS) to 139 of the parent participants in the study.  Both dimensional and dichotomous ADHD variables were created but only the latter was used in the analysis because of the small size of the ADHD group (N = 23, or roughly 16% of the total).    Results showed that parental ADHD did not affect treatment outcome for either the experimental (FSS) or the control (CARE) condition at the end of the study period.  However, at the three month follow-up assessment, parental ADHD was associated with declines in treatment gains only in the FSS group, particularly in the quality of parent-teacher relationship and the child’s homework performance.  This finding surprised the investigators who hypothesized that ADHD parents in both groups would show declines in outcomes as compared to non-ADHD parents.   They concluded that the control condition may have provided ADHD parents with greater opportunities to develop strategies and to practice problem-solving skills on their own, whereas ADHD parents in the experimental condition might have become overly dependent on study clinicians to implement the parenting practices that were the focus of the intervention.  

This study illustrates the importance of modifying parent-focused treatment interventions to the specific characteristics of the patient and family.  In particular, when parents of ADHD children also exhibit the symptoms of ADHD, it may be helpful to provide additional opportunities for them to develop strategies, cultivate resources, and practice parenting skills aimed at helping their ADHD children succeed at school.

CAARS = Conners’ Adult ADHD Rating Scale

CARE = Coping with ADHD through Relationships and Education

FSS = Family School Success Program

 

Power, T.J., Mautone, J.A., Soffer, S.L. Clarke, A.T., et al (2012). “A family-school intervention for children with ADHD: Results of a randomized clinical trial.” Journal of Clinical Child and Adolescent Psychology. 80: 611-623 DOI: 10.1037/a0028188.