Adverse Events Associated with Behavior Management Training for Families Experiencing Parent-ADHD Teen Conflict

Adolescents with ADHD pose significant management problems for their families as a consequence of their primary symptoms and self-regulatory or executive functioning deficits, particularly if they also manifest comorbid oppositional defiant disorder (ODD), as more than half of those referred to clinics are likely to do (Angold, Costello, & Erkanli, 1999; Barkley, Fischer, Edelbrock, & Smallish, 1990; Pliszka, 2015).

Even if youth with ADHD do not fully qualify for a diagnosis of ODD, 55-72% or more of them manifest significant symptoms of defiance, stubbornness, argumentativeness, and refusal to obey (Barkley et al., 1990). These and other negative behaviors can clearly increase conflicts with parents as well as other family members beyond simply that level associated with ADHD symptoms alone (Barkley, Fischer, Edelbrock, & Smallish, 1991).

Parent-teen conflict in such families is often triggered by the immediately preceding negative behavior of the teen or that of the parents and from there can escalate rapidly to greater levels of conflict, anger, and negativity generally in a tit-for-tat fashion (Fletcher, Fischer, Barkley, & Smallish, 1996) similar to the coercive family process described over a decade earlier by Patterson and colleagues (Patterson, 1982; Patterson, Dishion, & Reid, 1992).

Research on the parent-teen interactions of teens having ADHD and especially comorbid ODD finds that the teens emit significantly more negative behavior even during discussions of neutral topics. But both the teens and their parents escalate to more anger, conflict, and negative communication styles during discussions of topics around which they have previously reported conflict at home (Edwards, Barkley, Laneri, Fletcher, & Metevia, 2001).

These families also report using significantly more aggressive conflict tactics than is evident in typical families with teens (Edwards et al., 2001). Such conflict is especially evident with mothers (Barkley, Anastopoulos, Guevremont, & Fletcher, 1992) but has also been observed in interactions with fathers (Edwards et a!., 2001).

Besides the degree of teen ODD, the level of parental self-reported hostility (but not ADHD symptoms) makes additional contributions to the degree of parent-teen conflict evident in these families (Edwards et al., 2001). For more than a decade my colleagues and I studied the parent-teen interactions of teens with ADHD as well as those with comorbid ADHD and ODD. But our larger goal was to evaluate the extent to which two approaches to behavioral family training and their combination might reduce the substantial parent-teen conflicts had observed in these families. Those interventions were not designed specifically to reduce ADHD symptoms but to reduce family conflict.

The therapies included a revised version of my behavioral parent training program (BPT) in contingency management and other methods in tended for parents of children ages 4-12, described in the manual Defiant Children (Barkley, 2013), which was adapted for use with teens and their parents.

The second behavioral intervention was that developed by Robin and Foster (1989) known as problem-solving communication training (PSCT). We also studied the combination of these two approaches, as described in our clinical manual Defiant Teens (Barkley, Edwards, & Robin, 2013), in comparison to each program alone (Barkley, Edwards, Laneri, Fletcher, & Metevia, 2001; Barkley, Guevremont, Anastopoulos, & Fletcher, 1992). Each of these individual programs resulted in significant improvements at the group level of analysis beyond that achieved by a control condition (Barkley, Guevremont et al., 1992).

Others have reported similar success in such group-level comparisons of similar interventions with youth having ADHD (McCIeary & Ridley, 1999). Yet their combination in our study was not more effective than PSCT alone, except in improving family dropout rates from therapy where PSCT was more problematic in that regard (Barkley, Edwards et al., 2001). In contrast, at the individual level of analysis using indices of reliable change, only about 24-30% (or fewer) of families had improved significantly in any treatment arm (depending on the outcome measure). These results suggested that the reduction in family conflict found at the group level of analysis was driven by a minority of treated families (Barkley, Edwards et al., 2001; Barkley, Guevremont et al., 1992).

Just as sobering was our finding that between 3 and 17% of the families has shown reliable and significant deterioration in their family conflicts (depending on the measure), with such worsening being more evident in PSCT alone than in the combined form of therapy (Barkley, Edwards et al., 2001).

What other work has been done with psychosocial treatment with teens with ADHD has largely been teen focused, and did not target parent-teen interaction conflicts as the principle focus of therapy. And so I am aware of no other research that has even examined for deleterious effects of family training for such youth with ADHD, much less even studied such therapies any further. Langberg’s work on organization training reported in the February issue has been mainly teen focused, with some advice given to parents on implementing the strategies. The Challenging Horizons program for youth with ADHD is implemented in the middle and high school settings by paraprofessionals and includes a few sessions of par ent training in behavior management methods as part of its various treatment components. Yet no mention seems to have been made in research reports of any deleterious effects of that training, or of the treatment package generally (Evans, Schultz, DeMars, & Davis, 2011).

Margaret Sibley and colleagues have more recently worked with teens and their parents on improving teen organization, time management, and contingency contracting for privileges, but again the majority of work in therapy is focused on the teen, with some collaborative assistance from parents (Sibley et al., 2013; Sibley, et al., 2016). This program is not focusing on family conflicts per se other than those related to organization and time management. And none of these reports mentions any risk of deterioration from therapy or other adverse effects, although Sibley and colleagues (2016) have noted that the initial beneficial effects of treatment on ADHD symptoms and time management did not persist to the 6-month follow-up.

Likewise, the extension of parent training to reduce parent-teen conflict via Internet delivery, while feasible, has not yet reported on its effectiveness and certainly not on any detrimental effects (Carpenter, Frankel, Marina, Ehian, & Smalley, 2004). I have been well aware for quite some time of the deleterious effects that BPT can have on a subset of families of children with defiant behavior since first learning to implement such training in 1976-1977 under the tutelage of my internship supervisor, Constance Hanf, Ph.D.

Hanf had developed one of the first such programs for defiant behavior, and it formed the core of my own variation of that program. Defiant Children, in 1987. Any clinician implementing such a program with more than a few families would certainly have noted some detrimental effects occurring from setting limits on oppositional children. Another article in the February issue, by Carla Allan and Anil Chacko, addressed the side effects of BPT for children with ADHD, so I will not review those in detail here. Clearly, there is some overlap between the adverse events reported there and here. Suffice to say that going into our later work with teens with ADHD and their parents, we were well aware that training parents to both (a) withdraw their attention to (ignore) disruptive child behavior and (b) set limits on disruptive children—violations of which would lead to punishment (time out, response cost, etc.)—could ignite increases in child temper outbursts, defiance, destructiveness, anger, and even counter-aggression in some cases. For most, such reactions were relatively temporary, only spanning the next few weeks of therapy after parents implemented that method. However, a few children also engaged in more passive-aggressive behavior in response to time out, such as breath-holding until turning blue, urinating openly, defecating, or vomiting; these are just a few of the conflict tactics I noted during my training of hundreds of families in the time-out component of BPT in my 40-year career. In contrast to children, teens have an increasingly longer time period over which the potential for training in family coercive processes exists (Patterson, 1982), as well as greater physical size, strength, and independence. So we certainly knew that both these factors could produce adverse events that might be even worse when dealing with disruptive and emotionally dysregulated teens than with children in response to our behavioral approaches to family training.

Moreover, Dishion and Patterson’s earlier work (1992) also noted that improvements due to family behavioral training may decrease with age, while dropout rates can significantly increase with age, particularly after 7 years of age. But this was the first set of studies in which we intentionally examined for the extent of deterioration at the individual level of analysis using reliable change indices. And even those analyses did not reflect the more varied and specific adverse reactions that were evident in our work with teens having ADHD (and ODD in most cases) in response to our adapted BPT and PSCT formats.

It is regrettable that we did not systematically keep track of the types of adverse reactions or the percentage of cases manifesting each type, just as one would routinely do in research on medications for ADHD. But those actions happened nonetheless. In hopes of encouraging others to examine for these effects, and even to develop a rating scale of adverse reactions, much as I did for side effects of stimulant medication (Barkley & Murphy, 2006), here is an incomplete list of the side effects we observed during our research on these methods:

Impact on Parent-Teen Interactions

• Predictably, increased teen and parent arguing, anger, and verbal hostility during problem-solving discussions of conflict-laden topics in therapy sessions. These reactions occurred in a majority of families. Even though they may not have risen to a level greater than that reported previously by parents during conflict discussions at home, these reactions were nonetheless provoked by the therapy procedures.
• In fewer cases, a continuation of such conflict behavior into the clinic lobby and parking lot following therapy sessions.
• Predictably, increased teen and parent arguing, anger, and hostility during problem-solving discussions of conflict-laden topics in the home during the next week as precipitated by the homework assignments for the PSCT format or as a consequence of parent implementation of rules, limit-setting, and punishment as part of the BPT format.
• Threats of harmful behavior toward the confronting family member during sessions, in clinical areas, and at home (on rare occasions, such threats were directed toward the therapist who was leading the problem-solving discussion).
• Physical aggression between family members during problem-solving discussions in the clinic session, clinical areas, and at home the following week. In rare cases, assault with injury to a family member occurred.
• Physical confrontations, especially between fathers and teens, in the clinical hallways and waiting areas following a therapy session.

Impact on Treatment Delivery

• Teen refusal to attend subsequent training sessions.
• Family dropout from therapy before completion (18% for BMT combined with PSCT and 38% for PSCT alone; Barkley, Edwards et al., 2001).

Impact on Therapists and Clinical Staff

• Theft of personal possessions of clinic staff by the ADHD youth.
• Destruction of clinic property both in and outside the therapy room following therapy sessions; destruction of property at home during problem-solving conflict discussions with parents as part of PSCT homework assignments or in response to behavioral tactics recommended to parents, such as time out, grounding, and response cost (usually loss of privileges) for rule violations.
• Declining therapist morale.

While this list is not exhaustive, it spells out the kind of side effects noted in some families undergoing these forms of psychosocial treatment. It also provides some reasons for the noted deterioration in some families in their family problem-solving and relationships.

In the February issue, Allan and Chacko provided a useful means of parsing such adverse events from BPT into those that may be due to inappropriate use of a therapy for a disorder, inappropriate implementation of that therapy by a clinician, and factors related to the characteristics of both the teens and their parents. That categorization, particularly the latter one, could apply to our observations as well. We do not think that inappropriate application of the therapy applies so much to our experience as that these therapies were targeted specifically for family conflict and families had been more thoroughly evaluated for this project than is often the case in clinical practice.

Nor was inappropriate application by the therapist a likely commonplace factor, as steps were taken to monitor treatment fidelity across all sessions of therapist involvement with families. My goal here was not to provide a detailed discussion of adverse events associated with these therapies and how to address them, but was simply to make others aware of their existence, even if only in a minority or rare number of families. And surely the comorbidity of youth ODD and even conduct disorder greatly increased the likelihood of such adverse reactions. We are not the first to notice such adverse events when conducting family training with youth having disruptive behavior disorders, such as conduct disordered or delinquent youth and their families (Patterson, 1982; Patterson et al., 1992). But we had not seen them reported previously in research articles on these therapies when applied to youth with ADHD specifically, much less being systematically recorded and analyzed.

Two additional points should be made in closing. First, any one of these reactions, had they occurred in response to a psychiatric medication for ADHD, would have resulted in it being listed on the drug package insert as a potential adverse reaction or even as a black box warning.

Second, as noted above, my colleagues and I found that these various adverse reactions had become so emotionally burdensome and draining to the therapists working with these families on the project that staff morale declined over time. This reached such a low point that staff requested that I not seek a renewal of the federal grants that had supported this decadelong investigation of the merits of psychosocial family training for youth with ADHD. They were so essentially “burned out” on studying family psychosocial treatment for disruptive youth that I didn’t seek grant renewal, leaving this area of research to others.

Banks and colleagues (1991) noted a similar problem of emotional burden on therapists in their earlier work on behavioral family therapies similar to those used here when applied to chronic delinquent youth. Few, if any, investigators have ventured into using these methods with ADHD youth since we left this field of research. Nonetheless, 1 encourage future researchers to watch for and systematically document and even statistically analyze these (and other) side effects. Doing so can serve to expand scientific findings beyond these clinical observations of individual and family reactions to family training with teens having ADHD and suggest better ways to address them.

Acknowledgments: I deeply appreciate the review and comments of Joshua Langberg, Ph.D., on an earlier draft of this article. Dr. Barkley is Editor of The ADHD Report and Clinical Professor of Psychiatry at the Virginia Treatment Center for Children of the Virginia Commonwealth University Medical Center in Richmond. He can be contacted via e-mail at: drbarkley@russeltbarkley.org.

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