Chanakarn Tumthammarong, M.D., Chanvit Pornnoppadol, M.D., Wanlop Atsariyasing, M.D.
Division of Child and Adolescent Psychiatry, Department of Psychiatry, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.
ABSTRACT
Objective: To systematically evaluate the effectiveness of mindfulness-based parenting programs in reducing parenting stress in parents of children and adolescents with ADHD.
Materials and Methods: Studies published in English or Thai before February 2020 were identified through the PubMed, Embase, and Thai-Journal Citation Index databases. Studies were included if they used mindfulness-based parenting interventions for parents of children and adolescents with ADHD, and parenting stress was measured. The risk of bias was evaluated with the Cochrane risk-of-bias assessment tool for randomized trials, and with the ROBIN-I tool for non-randomized studies.
Results: Six studies were included. The 2 randomized controlled trials reported significant reductions in parenting stress in the intervention groups compared with the control groups at post-test, and this effect was maintained at the 8-week follow-up of one of the studies. However, the 4 pre-experimental studies reported conflicting results. Two reported significant reductions in parenting stress from pre- to post-intervention, with one of those studies reporting a further reduction in parental stress at the 6-week follow-up. In contrast, another study reported a significant reduction in parental stress from pre- to post-intervention for fathers but not mothers; this effect was maintained at the 8-week follow-up. The fourth study reported no significant changes in parental stress from pre- to post-intervention. A meta-analysis of 3 studies demonstrated no significant changes in parenting stress from pre- to post-intervention.
Conclusion: The effectiveness of mindfulness-based parenting programs in reducing parenting stress in parents of children and adolescents with ADHD is still inconclusive, although promising. Further studies are needed.
Keywords: Attention-deficit/hyperactivity disorder; mindfulness-based parenting program; parenting stress (Siriraj Med J 2022; 74: 371-380)
This research was presented in Virtual annual meeting American Academy of Child and Adolescent Psychiatry 2020 as new research posters. Therefore, the abstract was published in Journal of the American Academy of Child & Adolescent Psychiatry, 2020-10-01, Volume 59, Issue 10, Pages S152-S152, Copyright©2020.
Corresponding author: Wanlop Atsariyasing E-mail: wanlop.atr@mahidol.edu
All material is licensed under terms of the Creative Commons Attribution 4.0 International (CC-BY-NC-ND 4.0) license unless otherwise stated.
Tumthammarong et al.
INTRODUCTION
Attention-deficit/hyperactivity disorder (ADHD) is a common neuropsychiatric condition in children and adolescents, with a prevalence of 5% to 12% worldwide.1 ADHD is often comorbid with many psychiatric disorders, including oppositional defiant disorder2; conduct disorder3; mood disorders4,5; anxiety disorders6-8; learning disorders9; Tourette’s disorder10; and substance use disorder.11 ADHD negatively affects not only the patients but also their families. High levels of distress in the families-particularly inmothers12-of children with ADHD have been reported, and this can lead to difficulties in the caring for, and parenting of, the children. Effective parent management is a key component of behavioral management for children with ADHD. Previous studies found that parents under stress failed to demonstrate parenting skills despite their participation in a parent-training program, and they were likely to feel frustrated.13 This may be due to the parents lacking awareness of their own emotions when they are under stress.
Mindfulness is the awareness that arises through purposely and nonjudgmentally focusing on the present moment. There is strong evidence that mindfulness- based therapy is an effective treatment for a variety of psychological problems, and it is especially effective for reducing anxiety, depression, and stress.14 Mindful parenting is one of the modern approaches to child rearing which reduces parents’ reactivity to children’s behaviors.15 It also affects family functions through reducing parenting stress and focusing on the psychological pathology of parent-child.16,17 It exerts its effect via the following 5 processes: attentive listening, nonjudgmental acceptance of oneself and one’s children, awareness of emotions and self-regulation in childrearing relationships, and compassion toward oneself and one’s children.18 However, the results of studies on the effectiveness of mindfulness-based approaches to reducing parenting stress have been controversial.
The present review therefore aimed to systematically evaluate the effectiveness of mindfulness-based parenting programs in reducing parenting stress in the parents of children and adolescents with ADHD.
MATERIALS AND METHODS
A literature search was conducted via the PubMed, Embase, and Thai-Journal Citation Index databases from inception to February 9, 2020. The keywords used for the search were (mindfulness OR meditation) AND (parent OR parenting) for PubMed; and (mindfulness OR mindfulness-based stress reduction OR mindfulness-based
therapy OR meditation) AND (parent OR parenting) for Embase. As to the Thai-Journal Citation Index database, the keywords were (mindful AND parent AND ADHD). In addition, the reference lists of eligible articles were scanned, and a Google search was used for relevant articles. The process of article selection is illustrated in Fig 1.
To be eligible for inclusion in the meta-analysis, a study needed to meet all of the following criteria.
The study investigated the efficacies of mindfulness- based, parent-training interventions for the parents of children and adolescents with ADHD. The interventions included mindfulness-based stress reduction, mindfulness training for parents, and mindfulness-based cognitive therapy. The interventions had to be delivered by qualified leaders for at least 1 hour per week over a minimum of six weeks.
The study participants were the parents of children up to 18 years of age with ADHD. The ADHD diagnoses were based on either the Diagnostic and Statistical Manual of Mental Disorders criteria for Attention Deficit Hyperactivity Disorder, or the Strengths and Weakness of Attention Deficit Hyperactivity Disorder Symptoms and Normal Behavior Scale (SWAN).19-22
The study was designed as a randomized controlled trial, a case-control study, or an uncontrolled trial.
Parenting stress was measured and compared using at least one of the following instruments: the Parenting Stress Index–Short Form (PSI-SF)23; PSI-2524; and the Stress Index for Parents of Adolescents (SIPA).25 The assessments were made at pre-intervention, post-intervention, and follow-up, with or without a control group.
The study had been published in English or Thai.
One of the authors identified the included studies, and 2 authors independently extracted data from each paper. The data were the participants’ characteristics, youth age and gender, study design, intervention characteristics, the instrument used to measure parenting stress, and the points-of-time of parenting-stress assessments (Table 1). The qualities of the included studies were independently assessed by 2 authors. For the randomized controlled studies, the Cochrane Collaboration’s tool for assessing risk of bias in randomized trials was used.26 In the case of non-randomized controlled studies, the authors utilized ROBINS-I.27 Disagreements about the qualities of the studies were resolved by consultation with the third
author.
Fig 1. PRISMA (2009) flow diagram.
Cohen’s d effect size was used to estimate the effect of the mindfulness-based, parent-training intervention between the pre- and post-intervention time-points for each study. Three studies were subsequently included in a meta-analysis, using Cohen’s d effect size to estimate the overall effect of the mindfulness-based, parent-training intervention between pre- and post-intervention.
RESULTS
As shown in Fig 1, the database search identified 876 articles. One study was added from another resource. After duplicates were removed, 653 remained. Through the title and abstract screening process, 644 studies were considered non-eligible for inclusion in the systematic review. The full text of 9 studies was examined. Three studies did not meet the selection criteria for at least one of the following reasons: (a) the outcome measures reported stressful life events rather than parenting stress;
(b) the intervention was not a parenting program but psychoeducation; or (c) the outcome measurement was
in the form of a descriptive report. The 6 studies that met the selection criteria were included in the systematic review.
Table 1 details the main characteristics of the 6 included studies. Four studies used a single-group design (pre-post intervention), whereas the remaining two were randomized controlled trials. The majority of the participants in each study were mothers and male children. Four studies reported no changes in medication during the study period. As to the other two, all the children in both groups received either risperidone or Ritalin in one study, while the other did not mention any medications.
In addition, two studies reported comorbid disorders in the children: learning disability, depressive disorder, anxiety disorder, speech disorder, developmental delay, genetic disorder, and Tourette’s syndrome. The interventions for the parents were mindfulness-based cognitive therapy and mindfulness-based stress reduction. Five studies had an intervention for children and adolescents. All studies were published in English.
Tumthammarong et al.
TABLE 1. Details of included studies.
Author | Country | Study design | Sample size | Youth age | Instrument | Points-of- | ||
(parent's | years | Intervention characteristics | used to | time for | ||||
gender) | (mean) | measure | assessment | |||||
(child’s | Intervention Intervention | Sessions | parental | |||||
gender) | program groups | stress | ||||||
Herman | Hong Kong | 2-armed RCT: | n = 100 | 5–7 (6.25) | 1.MP adapted from MP: Parent group | MP: 6 weeks x 1.5 h; | PSI-SF | T1 – baseline |
H.M.Lo et. al.28 | 1.MP | Bögels and Restifo., and separate child | total 9 h | (36 items) | T2 – after | |||
2.wait list | (96% | (83% boys) | 2014 and Coatsworth mindfulness | (for parent group) | intervention | |||
control | mothers) | et al., 2010 group | 8 weeks x 1 h (for | |||||
2.control: nil (offered Control: Nil | child group) | |||||||
MP after waitlist) | ||||||||
Dexing Zhang | Hong Kong | Uncontrolled | n = 10 | 8–12 (9.5) | MP adapted from Parent group and | MP: 8 weeks x 1.5 h; | PSI-SF | T1 – baseline |
et.al.29 | trial: | mindfulness-based separate child | total 12 h (for both | (36 items) | T2 – after | |||
1.MP | (64% | (73% boys) | intervention (MYmind) mindfulness | parent and child | intervention | |||
mothers) | of van de Weijer- group | groups) | ||||||
Bergsma et al., 2012 | ||||||||
and van de Oord et al., | ||||||||
2012 | ||||||||
Mahdiyeh | Iran | 2-armed RCT: | n = 56 | 7–12 | 1.MP (Bögels and MP: Parent group | MP: 8 weeks x 1.5 h; | PSI-SF | T1 – baseline |
Behbahani | 1.MP | Restifo, 2014) Control: | total 12 h for parent | (36 items) | T2 – after | |||
et.al.30 | 2.wait list | (100% | (66% boys) | 2.control: nil Parent group | group | intervention | ||
control | mothers) | T3 – 8 weeks follow up | ||||||
Van de Oord | The | Uncontrolled | n = 22 | 8–12 (9.55) | MP adapted for Parent group and | MP: 8 weeks x 1.5 h; | PSI-SF | T1 – waitlist |
et.al.31 | Nether- | trial: | parents of children separate child | total 12 h (for both | (25 items) | T2 – pretest | ||
lands | 1.MP | (95% | (73% boys) | with ADHD from mindfulness group | parent and child | T3 – posttest | ||
mothers) | Bögels et al., 2008 | groups) | T4 – 8 weeks | |||||
and Bögels et al., | follow up | |||||||
2010 |
TABLE 1. Details of included studies. (Continue)
Author | Country | Study design | Sample size | Youth age | Instrument | Points-of- | ||
(parent's | years | Intervention characteristics | used to | time for | ||||
gender) | (mean) | measure | assessment | |||||
(child’s | Intervention Intervention | Sessions | parental | |||||
gender) | program groups | stress | ||||||
Haydicky | Canada | Uncontrolled | n = 17 | 13–18 | MP adapted from Parent group and | MP: 8 weeks x 1.5 h | SIPA | T1 – waitlist |
et.al.32 | trial: | (15.5) | Bögels et al., 2008 separate child | ; total 12 h (for both | (4 weeks | |||
1.MP | (94% | mindfulness | parent and child | pre- | ||||
mothers) | (72% boys) | group | groups) | intervention) | ||||
T2 – pretest | ||||||||
T3 – posttest | ||||||||
T4 – 6 weeks follow up | ||||||||
Van de | The | Uncontrolled | n = 11 | 11–15 | MP (Bögels et al., Parent group and | MP: 8 weeks x 1.5 h; | PSI-SF | T1 – baseline |
Weijer- | Nether- | trial: | (13.4) | 2008 and Bögels separate child | total 12 h (for both | (25 items) | T2 – after | |
Bergsma | lands | 1.MP | (55% | et al., 2010) mindfulness group | parent andchild groups) | intervention | ||
et.al.33 | mothers) | (50% boys) | + 1xjointparent and | T3 – 8 weeks | ||||
adolescent booster at | follow up | |||||||
8 weeks post-completion | T4 – 16 weeks follow up |
Abbreviations: MP; mindfulness-based parenting program, PSI-SF; Parenting Stress Index–Short Form, SIPA; Stress Index for Parents of Adolescents
The results of the 6 studies (summarized in Table 2) indicated that the mindfulness-based parenting programs tended to reduce parenting stress. The 2 randomized controlled trials reported significant reductions in parenting stress, with nearly a small effect size (d = 0.19; p = 0.009) in the intervention group compared with the control group at post-test. This effect was maintained until the 8-week follow-up of one of those 2 studies. The 4 pre- experimental studies reported conflicting results. Van de Oord et al. and Haydicky et al. reported significant reductions in parenting stress from baseline to the 8-week follow up with a medium effect size (d = 0.57), and from post-intervention to the 6-week follow up with a large effect size (d = 0.81), respectively. By contrast, Van de Weijer-Bergsma and colleagues reported a significant reduction in parenting stress from pre- to post-intervention for the fathers, but not for the mothers; this effect was maintained at the 8-week follow-up. On the other hand, Dexing Zhang et al. reported no significant changes in parenting stress between the pre- and post-intervention time-points.
Three studies with the same outcome measures were included in the meta-analysis. In all, there were 166 participants. The meta-analysis did not reveal any significant changes in parental stress between pre- and post-intervention (Fig 2).
Fig 3 illustrates the risk-of-bias assessments of the 2 randomized controlled studies. Both studies were judged to have a high risk of bias for blinding of outcome assessment. Table 3 shows the risk of bias assessment for the 4 non-randomized studies using the ROBIN-I quality assessment tool; their overall risk of bias was moderate.
DISCUSSION
The main results of this study were that the 2 randomized controlled trials reported significant reductions in parenting stress in the intervention groups compared with the
Fig 3. Risk-of-bias assessment for the included randomized controlled studies.
control group at post-test, while the 4 pre-experimental studies reported conflicting results. A meta-analysis of 3 studies demonstrated no significant changes in parental stress from pre- to post-intervention.
To our knowledge, this is the first systematic review on this topic, which means that there are no previous studies to compare with. However, there are some factors that may influence the differences in the main outcome- parenting stress-of each study. Only 2 studies mentioned comorbid disorders (speech disorders, developmental delay, genetic disease, Tourette’s syndrome, learning disability, depressive disorder, and anxiety disorder), and only one study mentioned the severity of ADHD. It is reasonable to assume that both comorbidity and severity can affect the effectiveness of mindfulness-based parenting programs aimed at relieving parenting stress. For example, parents of children with more comorbid disorders or the more severe symptoms of ADHD are likely to experience more stress and more challenges in
Fig 2. Meta-analysis of 3 studies
TABLE 2. Results of mindfulness-based parenting programs for parenting stress.
Study Instrument Intervention group Control group P-value Cohen's d | |||||||||||||
used to | Pre-test | Post-test | Follow-up | Pre-test | Post-test | Follow-up | T1-T2 | T2-T3 | T1-T3 | T1-T2 | T2-T3 | T1-T3 | |
measure | (T1) | (T2) | (T3) | (T1) | (T2) | (T3) | |||||||
parental stress | Mean | Mean | Mean | Mean | Mean | Mean | |||||||
(S.D.) | (S.D.) | (S.D.) | (S.D.) | (S.D.) | (S.D.) | ||||||||
Herman H.M.Lo | PSI-SF | 117.82 | 112.36 | – | 110.02 | 111.28 | – | 0.009 | – | – | 0.19 | – | – |
et al., 2017 | (36 items) | (27.29) | (29.51) | (24.95) | (25.17) | ||||||||
Dexing Zhang | PSI-SF | 113.1 | 116.3 | – | – | – | – | 0.01 | – | – | -0.18 | – | – |
et al., 2017 | (36 items) | (18.2) | (17.9) | ||||||||||
Behbahani | PSI-SF | 130.8 | 110.4 | 109.4 | 132.4 | 128.0 | 130.3 | ||||||
et.al., 2018 | (36 items) | (14.1) | (18.5) | (18.9) | (11.6) | (17.6) | (18.0) | ||||||
van de Oord | PSI-SF | 70.68 | 65.41 | 58.18 | – | – | – | >0.05 | – | <0.01 | – | – | 0.57 |
et al., 2012 | (25 items) | (-1.73) | (-3.64) | (8 weeks) | (8 weeks) | ||||||||
Haydicky | SIPA | 58.82 | 55.78 | 51.36 | – | – | – | – | 0.010 | – | – | 0.81 | – |
et al., 2015 | (9.50) | (8.50) | (6.40) | (6 weeks) | (6 weeks) | ||||||||
van de | PSI-SF | 64.1 | 73.1 | 67.4 | – | – | – | >0.05 | – | >0.05 | 0.5 | – | 0.2 |
Weijer- Bergsma et al., 2012 | (25 items) | (17.4) Mother 73.8 | (20.6) Mother 54.1 | (19.4) Mother 46.1 | – | – | – | <0.01 | – | (8 week) <0.01 | 0.7 | – | (8 weeks) 1.1 |
(27.8) Father | (28.7) Father | (24.0) Father | (8 weeks) | (8 weeks) | |||||||||
Abbreviations: PSI-SF; Parenting Stress Index–Short Form, SIPA; Stress Index for Parents of Adolescents
TABLE 3. Risk-of-bias assessments of included non-randomized studies, using ROBIN-I quality assessment tool.
Studies | Confounding | Selection of participants | Classification of interventions | Deviation from intended intervention | Missing data | Measurement of outcomes | Selection of reported results | Overall quality |
Dexing Zhang et al., 2017 | – | – | – | – | / | / | – | Moderate |
van de Oord et al., 2012 | – | – | – | – | – | / | – | Moderate |
Haydicky et al., 2015 | – | – | – | – | – | / | – | Moderate |
van de Weijer- Bergsma et al., 2012 | – | – | – | – | – | / | – | Moderate |
+ critical; x serious; / moderate; –low; ? no information
practicing mindfulness in parenting. Moreover, parents’ continuous practicing of mindfulness and the parenting skills they learned from a program are other factors that can affect the outcomes. Nevertheless, no studies mentioned those factors. Moreover, with limited data on comorbidities, the severity of ADHD, and the parents’ understanding and practicing of mindful parenting skills, these possible confounding factors could not be controlled. This could have affected the outcomes of each of the 6 studies and the meta-analysis, as well as the generalizability of the results of the meta-analysis. There were several limitations of this review. Firstly,
the studies recruited in this review were published in Thai or English from 3 databases, so some relevant studies might not have been included in this review. In addition, all of the studies had small sample sizes. Moreover, there was heterogeneity in the outcome measures, the interventions, and the designs of the studies. All of those factors could affect the accuracy and generalizability of the meta-analysis results.
The findings from this study may have an important implication for the treatment of children with ADHD. Our experience in conducting a parent training program with parents of young patients with ADHD found that parenting stress hindered the effectiveness of their parenting skills they have gained. Therefore, a mindfulness-based
parenting program, which may be able to reduce parenting stress, could be an effective parent training program for parents of children with ADHD, leading to a better treatment outcome in this patient population.
To conclude, the effectiveness of mindfulness-based parenting programs in reducing the parenting stress in parents of children and adolescents with ADHD is still inconclusive, although promising. More studies on this topic are needed.
ACKNOWLEDGEMENTS
The authors are grateful to Patompong Ungprasert,
M.D. (currently working at the Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, Ohio, USA) for his assistance with the article’s review and statistical analyses. Another one, Keerati Patanasaree,
M.D. (currently working at the Department of Psychiatry, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand) for her guidance about systematic review and meta-analysis.
Financial disclosure: None
Funding: This review did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Declaration of competing interests: The authors declare that there are no conflicts of interest related to this study.
Ethics approval: Ethics approval was obtained from the Siriraj Institutional Review Board. The study was conducted in accordance with the principles for medical research involving human subjects as defined by the Declaration of Helsinki, the Belmont Report, CIOMS guidelines, and the International Conference on Harmonization in Good Clinical Practice (ICH-GCP).
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