In this issue...

ADHD and mothers' feelings of psychological distress: The importance of child behavior and mothers' feelings of control

Effects of Interactive Metronome rhthymicity training of children with ADHD: Preliminary study of a new treatment approach

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Researchers studying the impact on parents of raising a child with ADHD have emphasized that increased caretaking demands exist for parents throughout childhood and adolescence.  These increased demands can have an adverse impact on parents and increase the parenting related stress that they experience.  In fact, several studies have documented that, on average, parents of children with ADHD experience more parenting stress than parents of other children, including parents of children with disorders other than ADHD.  These findings have encouraged additional research on how children with ADHD affect parents so that interventions to alleviate distress in parents can be developed.

What factors are associated with the psychological stress experienced by parents of ADHD children?  The severity of a child's symptoms would be one important factor, with more severe symptoms linked to greater parental distress.  Several researchers have suggested, however, that how parents' interpret their child's behavior, and whether they believe they have control over their child's behavior, are also important factors to consider.

How people explain the behavior they observe in themselves or others are referred to as "attributions".  In regards to parenting, it has been demonstrated that parents' attributions for their child's behavior (i.e. why they think their child did what he/she did) play an important role in determining parents' behavioral and emotional response.

A simple example will help illustrate this.  If a parent sees their knock over a favorite vase they are more likely to become punitive and angry if they believe it was done intentionally rather than by accident.  Similarly, if a child is behaving inappropriately in a public setting - something that is not uncommon for children with ADHD - parents will become more upset if they believe their child's behavior reflects willful disobedience rather than difficulty their child has managing his/her behavior when overstimulated.  The latter attribution could promote a non-punitive effort to help the child regain control over his/her behavior, while the former would be more likely to promote a punitive response.

Researchers have suggested that parents who consistently regard the behavior problems of their ADHD child as under their child's control, as opposed to recognizing how ADHD often contributes to non-compliance, are prone to feelings of anger and discouragement.  Some researchers have speculated that when this occurs, parents can withdraw from their child in an attempt to avoid further failure experiences that they view as reflecting their own incompetence as parents.

What about parents' perceptions of their own ability to control their child's behavior?  Parents vary substantially in the degree of control they believe they have over their child's behavior.   Parents who believe they can control the behavior of their ADHD child may feel less distressed because, despite any behavior problems their child displays, they retain the sense of being in command and able to direct their child's actions.  Alternatively, a strong belief that one can control the behavior of a child who consistently shows behavior difficulties could lead to feelings of discouragement and distress.  This is because such a belief would be increasingly difficult to reconcile with the child's behavior.

The relationships between parents' attributions and beliefs about the controllability of children's behavior, and parents' psychological distress is an important and developing research area in the field of ADHD.  These relationships were examined more closely in a recently published study (Harrison, C., & Sofrofoff, K. (2002). ADHD and parent psychological distress: Role of demographics, child behavioral characteristics, and parental cognitions. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 703-711.)  These researchers hypothesized that parents distress would be predicted by: 1) the severity of children's behavioral disturbance; 2) parents' knowledge of ADHD; 3) parents' tendency to believe the child's misbehavior was under the child's control, and, 4) the degree to which parents believed they could control their child's behavior.

Participants in this study were 100 mothers of 4-12 year-old children who had a confirmed diagnosis of ADHD.  As noted above, the researchers were interested in: 1) how much control mothers believed they had had over their child's ADHD related behaviors; 2) how much control they believed their child had over these same behaviors; 3) mothers' opinions about what causes these behaviors in their child (i.e. their attributions); and, 4) the severity of the child's symptoms.

Beliefs about controllability were measured by having mothers rate each symptom of ADHD (for a list of specific ADHD symptoms click here), as well as 8 symptoms of oppositional defiant disorder (ODD) on a 1 "not all controllable" to 6 "completely controllable" scale.  These ratings were completed two times for each of the 22 symptoms: once to reflect the control mothers believed they had over their child's symptoms and a second time to assess mothers' perceptions of their child's control over the symptoms.

Mothers' attributions for their child's behavior were measured by asking mothers why their child displayed each of the symptoms they had just rated.  Responses such as "to get attention", "laziness", "to get his way", "its just his nature" were coded as reflecting "internal" attributions (i.e. the behavior was understood as occurring because of something about the child).  Responses such as "the medication makes him act this way", "the teacher doesn't know how to manage him", "we don't provide him with sufficient structure" were coded as "external" (i.e. the causes of behavior were seen as outside the child).  A single attribution score was then calculated by subtracting the number of external attributions from the number of internal attributions.  Higher scores thus reflected a stronger belief that the cause of the behavior resided within the child and was intentional.

In addition to assessing mothers' beliefs about the controllability and reasons for their child's behavior, they were asked to rate the severity of their child's behavioral disturbance using standardized behavior rating scales.  This included ratings of behaviors specific to ADHD as well as ratings of other behavioral and emotional problems.  Mothers' knowledge of ADHD along with demographic information on mothers (e.g. years of education) was also obtained.

Finally, mothers' rated the amount of parenting stress they were experiencing as well as their current level of depressive symptoms.
 

RESULTS

What predicts the level of parenting stress and depression in mothers of children with ADHD?

For parenting stress, children's behavior problems and the severity of their ADHD symptoms predicted greater stress.  It was noteworthy, however, that total behavior problems were a stronger predictor of mothers' stress than ADHD symptom severity.

Even after taking the severity of children's behavior problems into account, however, mothers' beliefs about their ability to control their child's behavior predicted their stress.  Specifically, the more mothers believed they were in control, the less stress they experienced.

Parenting stress was not related to mothers' attributions for children's behavior, whether mothers believed children could control their behavior, or mothers' knowledge of ADHD.  In addition, neither children's gender, age, nor medication status (i.e. taking medication vs. not) predicted mothers' stress.

For maternal depression, similar results were obtained.  Once again, higher maternal depression was predicted by higher child behavior problem scores.  In contrast, mothers who believed they could control their child's behavior reported fewer depressive symptoms.

Interestingly, maternal depression was not related to the severity of children's ADHD symptoms.  Maternal depression was also not related to mothers' attributions for their child's behavior, whether mothers believed children could control their behavior, or mothers' knowledge of ADHD.  As before, child age, gender, and medication status were also not significant predictors.
 

SUMMARY AND IMPLICATIONS

Results from this study suggest that children's behavior problems, and mothers' beliefs about being able to control their child's behavior, contribute to parenting stress and depression in mothers of children with ADHD.

Not surprisingly, mothers whose child displayed greater behavior problems reported higher levels of stress and depression.  What is noteworthy, however, is that maternal distress was more strongly predicted by overall child behavior problems than by the severity of ADHD symptoms specifically, that predicted maternal distress.

This suggests that when other behavioral and emotional problems do not accompany children's ADHD symptoms, the impact on mothers' psychological well-being will be diminished.  Thus, preventing emotional and behavioral problems from developing in children with ADHD may not only result in better outcomes for children, but for their mothers as well.

As previously noted, maternal distress was predicted not only by the severity of children's behavior problems, but also by mothers' beliefs about being able to control their child's behavior.  Essentially, this means that for children displaying comparable behavior difficulty, mothers who felt less able to control their child's behavior experienced more stress and depression.

As with any study, there are limitations to this report that should be considered.  First, all of the data - including information about children's behavior - was provided by mothers' themselves.  Collecting independent information about the severity of children's behavior problems would enable one to have greater confidence in these results.

Second, it is important to note that outcome measures (i.e. maternal stress and depression) were collected at the same time as the predictor variables (e.g. controllability beliefs, attributions for children's behavior).  Ideally, these findings would be re-examined in the context of a longitudinal study in which maternal beliefs about being able to control their child's behavior at one point in time were used to predict mothers' stress and depression in the future.  Finding this predictive relationship would provide stronger evidence that mothers' beliefs have a direct impact on their distress level.

Finally, it would be interesting to replicate this study with fathers.  Based on the current work, in which fathers were excluded, the applicability of these results to fathers of children with ADHD remains unknown.

In summary, this study suggests that children's behavior problems, and mothers' beliefs about being able to control their child's behavior, contribute independently to stress and depression in mothers of ADHD children.  This is an interesting finding but the meaning remains a bit unclear.

On the one hand, it certainly makes sense that mothers who believe they cannot control their child's behavior would feel stressed and discouraged.

On the other hand, it is not clear why mothers who believe they can control her child's behavior, but whose children display significant behavior problems, would feel better.  In this instance, the mothers' belief and the reality of their child's behavior seem inconsistent, and how such inconsistency would result in less maternal distress is hard to understand.

Perhaps, however, the belief of being in control, even when this is not the case, results in more hopefulness and less discouragement.  This would be an interesting issue to consider in subsequent research.  In the meantime, working with mothers to provide them with the skills and knowledge to maintain better control over their child's behavior, in addition to simply focusing on their beliefs, would seem be an important component of comprehensive treatment for ADHD.

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Could learning to keep the beat with a metronome be a helpful adjunctive treatment for children with ADHD?  This question addressed in a study published last year in the American Journal of Occupational Therapy (Shaffer, R.J. et al., (2001). Effect of interactive metronome rhythmicity training on children with ADHD. American Journal of Occupational Therapy, 55, 155-162).

As you are probably aware, a metronome is a simple device that emits a sound at regular and adjustable intervals. It is used to help developing musicians learn to "keep the beat".  The Interactive Metronome (IM)is a variant of this device that uses a computer to produces a rhythmic beat that individuals listen to through headphones. As the participant listens, he/she must anticipate the beat and perform various hand and foot exercises for a high number of repetitions.  Regular auditory feedback is provided through headphones indicating whether one's response was on time, early, or late. The difference between the participants' response and the actual beat is measured in milliseconds and indicates the size of the discrepancy between the beat of the metronome and the person's response. Over repeated practice sessions, many individuals who initially have trouble coordinating their behavior with the beat of the metronome gradually become more successful at "keeping the beat".  This improvement in IM performance is thought to reflect meaningful gains in motor planning and sequencing ability.  For additional information about the Interactive Metronome, visit www.interactivemetronome.com.

What does this have to do with helping children with ADHD?  The rational for using the interactive metronome as an adjunctive treatment for ADHD is evidence that motor planning and sequencing, rhythmicity, and timing are all relevant to attention problems.  Difficulty regulating the sequence and timing of motor patterns are related to problems with behavioral inhibition (i.e. being able to stop or inhibit oneself from executing a behavioral response) and executive functioning (i.e. higher level cognitive abilities such as goal setting and planning), that some experts believe are critical to the understanding of ADHD.  In addition, there is evidence of considerable overlap between attention deficits and motor clumsiness and between the severity of inattentive symptoms and motor clumsiness in boys with ADHD.  Finally, substantial overlap in brain areas thought to be involved in ADHD and those involved in the regulation of timing and motor planning have also been reported.  Collectively, these findings suggest that technologies aimed at strengthening motor planning, sequencing, timing, and rythmicity may have an important role in improving the capacity to learn and attend.

In the study reference above, 56 6 to 12 year old boys with a confirmed diagnosis of ADHD were recruited to participate in an investigation of the Interactive Metronome.  Boys were matched on ADHD severity, age, and medication dosage, and then randomly assigned to one of three different experimental conditions: IM Training, Video game training, and a no training control group.

IM training consisted of 15 one-hour training sessions administered over a 3-week period.  The goal was to help participants selectively attend - without interruption by internal thoughts or external distraction - for extended periods of time.  This was done as explained above - i.e. by having participants execute various patterns of hand and foot motions in keeping with the beat of the Interactive Metronome for increasingly longer periods.  The IM training device provided boys with immediate feedback about how accurately they were "keeping the beat", and all boys showed improvement over the 15 training sessions.

Boys in the video game training group received instruction in 5 commonly available PC-based non-violent video using an identical training schedule - i.e. 15 one-hour sessions over a 3-week period.  The games involved hand-eye coordination skills, advanced mental planning, and multiple task sequencing.  In each game, the difficulty increased as boys became more skillful. Video game training was included so the researchers could determine whether benefits of IM training exceeded those that may result from concentrated video game play, an activity that also provides practice in focus and concentration skills).

Boys in the IM and video game training groups received the same level of adult supervision, encouragement, and support. The adults supervising both types of training were college students without advanced degrees, who had no formal therapy or teaching experience.  Administrators were trained in IM and video game training protocols, and supervised the training for boys in both groups.  This assured that there were no systematic differences between adults working with boys in each group.

Boys in the control group received neither IM training nor video game training during the 3-week period.

Before any training began, extensive information was collected on the functioning of all boys.  This included assessments of: 1) attention and concentration using a computerized test of sustained attention; 2) intellectual ability using a standardized IQ test; 3) clinical functioning using parent and teacher standardized behavior rating scales; 4) academic and cognitive skills using standardized academic achievement and language processing tests. These measures were administered a second time after training ended - approximately 4-5 weeks after the pretest.  When available, a different version of the test was administered at pre- and post-test, and boys were pre-and post-tested at the same time of day to control for medication schedules. Examiners who administered the tests did not know which boys had received IM training, which had received video game training, and which were in the control group.
 

RESULTS

From these measures noted above, 58 separate scale scores were computed for each boy based on pre and post-test results. Preliminary analysis of pre-test data indicated that boys in each group were essentially equal prior to training.

To examine the impact of IM and video game training, post-test scores were subtracted from pre-test scores on all measures.  A positive result was obtained when post-test scores exceeded pre-test scores, thus indicating improved performance.

Boys in the control group had 28 scores improve and 30 scores decline. This is consistent with what would be expected by chance, and indicates that neither prior experience with the test, nor simply the passage of 4-5 weeks time, was sufficient to produce consistent improvement in the different measures.

Boys in the video game training group showed improvement in 40 of the 58 variables assessed.  This pattern of improved scores is unlikely to have occurred by chance, and demonstrates that video game training under adult supervision was associated with better outcomes on many variables.

Boys who received IM training showed even greater gains - i.e. they improved on 53 of the 58 different scales.  The number of scales on which higher post test scores were found significantly exceeded results for the video game training, suggesting that IM training produced significant additional benefits above and beyond those resulting from video game training.

The authors next compared outcomes for the 3 groups of boys to determine where IM training had yielded significantly better results.  Compared to boys in the other 2 groups, boys who received IM training showed greater declines in parent rated aggression, and greater improvements on reading achievement, motor control, and computerized tests of attention.  Because the pre and post-treatment means on these variables was not provided in the article, the actual magnitude of these differences is not known.
 

SUMMARY AND IMPLICATIONS

Results from this study provide initial evidence that IM training directed towards improving rhythmcity, motor planning, and sequencing may be a beneficial adjunctive treatment for boys with ADHD.  As predicted, boys with ADHD who received IM training showed improvement in a wide range of areas, and their gains exceeded those associated with supervised training in a task that also requires sustained concentration and focus in order to improve (i.e. boys who received video game training).  These results are consistent with the theory behind IM training - namely that motor planning and sequencing ability influence a broad array of adaptive functions, including attention.

While this was a carefully conducted study in which necessary experimental controls were incorporated and promising results were obtained, it is important to recognize the limitations of this research.  First, all boys were already receiving medication treatment for ADHD, so the effectiveness of IM training for ADHD in the absence of medication treatment is not known. One cannot assume that IM training alone would result in effective symptom management and/or functional improvement for children with ADHD who were not taking medication.  This would be an important question to pursue in future research.  It is worth noting, however, that because children were presumably already benefiting from medication treatment, the fact that IM training resulted in additional gains to those provided by medication is certainly encouraging.

Second, outcomes in this study were assessed immediately following treatment and no additional follow up was conducted.  Whether the benefits found for IM training would persist over a sustained period is thus unknown.  Because this study was limited to boys with ADHD, the potential benefits of this treatment for girls with ADHD is also unclear.  Finally, because actual pre- and post-treatment scores were not included with the results, the actual magnitude of the gains found for IM training could not be examined.

In conclusion, results of this study provide promising indications that IM training may play a useful role in the treatment of ADHD.  Additional research in which the limitations noted above are addressed will provide important information about the utility of IM training as an adjunctive or perhaps even a primary treatment for ADHD, and allow better informed decisions about the use of this treatment to be made.