Family processes and treatment outcome in the MTA: Negative/ineffective parenting practices in relation to multimodal treatment

To elucidate processes underlying therapeutic change in a large-scale rando mized clinical trial, we examined whether alterations in self-reported pare nting practices were associated with the effects of behavioral, medication, or combination treatments on teacher-reported outcomes (disruptive behavio r, social skills, internalizing symptoms) in children with attention-defici t hyperactivity disorder (ADHD). Participants were 579 children with Combin ed-type ADHD, aged 7-9.9 years, in the Multimodal Treatment Study of Childr en with ADHD (MTA). We uncovered 2 second-order factors of parenting practi ces, entitled Positive Involvement and Negative/ineffective Discipline. Alt hough Positive Involvement was not associated with amelioration of the scho ol-based outcome measures, reductions in Negative/Ineffective Discipline me diated improvement in children's social skills at school. For families show ing the greatest reductions in Negative/ineffective Discipline, effects of combined medication plus behavioral treatment were pronounced in relation t o regular community care. Furthermore, only in combination treatment (and n ot in behavioral treatment alone) was decreased Negative/Ineffective Discip line associated with reduction in children's disruptive behavior at school. Here, children in families receiving combination treatment who showed the greatest reductions in Negative/Ineffective Discipline had teacher-reported disruptive behavior that was essentially normalized. Overall, the success of combination treatment for important school-related outcomes appears rela ted to reductions in negative and ineffective parenting practices at home; we discuss problems in interpreting the temporal sequencing of such process -outcome linkages and the means by which multimodal treatment may be mediat ed by psychosocial processes related to parenting.