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Objective: Parental attention-deficit/hyperactivity disorder (ADHD) is associated with suboptimal parenting and reduces the effectiveness of child ADHD treatments. We conducted a Pilot Sequential, Multiple Assignment, Randomized Trial (SMART Pilot) to evaluate the feasibility and acceptability of sequencing medication and behavioral treatments for mothers with ADHD to target outcomes, including maternal ADHD, parenting, and child ADHD symptoms/impairment in multiplex ADHD families. Methods: Thirty-five mothers with ADHD and their 5- to 8-year-old child with ADHD symptoms were enrolled. Mothers were randomized to 8 weeks of individually titrated stimulant medication (MSM) or behavioral parent training (BPT), followed by rerandomization to 8 weeks of continued first-line treatment (with as-needed modifications) or combined treatment, leading to four treatment sequences (MSM-MSM, MSM-BPT, BPT-MSM, and BPT-BPT). Results: Recruitment of multiplex ADHD families came primarily from child providers. Mothers were adherent to medication and had high therapy session attendance. Mothers and clinicians found both treatments to be acceptable and preferred combination treatment, especially receiving medication before BPT. Monotherapy treatment visits were viewed as more burdensome (MSM-MSM, BPT-BPT). Conclusions: Maternal stimulant medication and BPT are acceptable and feasible interventions for families in which both the mother and child have ADHD symptoms. Mothers with concerns about their children's ADHD symptoms are receptive to receiving treatment themselves as an initial strategy for improving their children's health and functioning. Fully powered SMART designs show promise in evaluating the sequencing of interventions and helping clinicians develop algorithms for treating multiplex families in real-world practice settings.

Experiencing the death of a parent during childhood is associated with a variety of difficulties, including lower academic achievement, that have implications for functioning in childhood and adulthood. This study examines effects of the Family Bereavement Program (FBP), a preventive intervention for parentally-bereaved youth and their caregivers, on grade point averages (GPA), educational expectations and job aspirations of youths 6 years after the intervention. A total of 244 bereaved youths ages 8-16 and their caregivers were randomized to either the FBP or a comparison group that received books about bereavement. Assessments occurred at pretest, post-test, and 11-month and 6-year follow-ups. Direct program effects on educational outcomes and job aspirations 6 years later were non-significant, although the program improved educational expectations for children with fewer behavior problems at program entry, and GPA for younger children. Mediational pathways for program effects on educational outcomes were also tested. Program-induced improvements in effective parenting at 11-month follow-up were associated with higher GPAs at 6-year follow-up for youth who were younger or for whom more time had passed since the loss. Program-induced improvements in parenting and teacher-rated youth mental health problems at the 6-year follow-up mediated program effects on youths' educational expectations for those with fewer behavior problems at program entry. The implications of these findings for understanding processes related to academic and educational outcomes following the death of a parent and for prevention efforts to help bereaved and other high-risk children succeed in school are discussed.

This article reviews findings from 46 randomized experimental trials of preventive parenting interventions. The findings of these trials provide evidence of effects to prevent a wide range of problem outcomes and to promote competencies from one to 20 years later. However, there is a paucity of evidence concerning the processes that account for program effects. Three alternative pathways are proposed as a framework for future research on the long-term effects of preventive parenting programs: (a) through program effects on parenting skills, perceptions of parental efficacy, and reduction in barriers to effective parenting; (b) through program-induced reductions in short-term problems of youth that persist over time, improvements in youth adaptation to stress, and improvements in youth belief systems concerning the self and their relationships with others; and (c) through effects on contexts in which youth become involved and on youth-environment transactions.