Child Group Training Versus Pa

CHILD GROUP TRAINING VERSUS PARENT AND CHILD GROUP TRAINING
FOR YOUNG CHILDREN WITH ADHD
by
Elizabeth Gayle Corrin
A dissertation submitted in partial fulfillment of the
requirements for the degree of
Doctor o f Philosophy
Fairleigh Dickinson University
2003
Approved by
inda A Reddy, Ph.D.
Chairperson of Supervisor# Committee
Neil Massoth, Ph.D.
— >d«X-£L_
Gretchen Gibbs, Ph.D.
Robert McGrath, Ph.D.
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August 14, 2003
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Abstract
Child Group Training versus Parent and Child Group Training
For Young Children with ADHD
by Elizabeth Gayle Corrin
Chairperson o f the Supervisory Committee:
Professor Linda Reddy, University College
Parent training is an effective intervention for families with an Attention Deficit
Hyperactivity Disorder (ADHD) child, facilitating improvement on a range of child and
parent variables. Despite the extensive literature on treatment outcomes with ADHD
children, few studies have examined the effectiveness of parent group training with a
younger cohort that includes preschool-aged children. Fifty-five families with an ADHD
child were randomly assigned to either child group training (CT) or combined parent and
child group training (PCT) in an outpatient university-based clinic. Children ranged in
age from 4 Vz to 8 Vz years old and were primarily from middle class, Caucasian, and
intact families. Ten weekly sessions of group treatment were provided. The child group
training utilized behavioral, social learning, and child play therapy principles to address
three main areas: social skills, impulsivity, and anger management. Treatment techniques
included didactic instruction, modeling, role-playing, behavioral rehearsal, coaching, and
developmentally appropriate games. Parent group training was based on a modified
version ofBarkley’s (1997) parent training curriculum. Parents were taught how to
implement behavioral techniques, improve communication with their spouse and child,
and use effective anger and stress management techniques. It was hypothesized that both
treatment conditions would significantly improve in five clinical domains: child
externalizing behaviors, social skills, self-concept, parental stress, and parental efficacy.
It was also hypothesized that PCT would demonstrate significantly greater treatment
outcomes than CT, due to the parents’ increased ability to manage and shape their child’s
behavior in the home. Strong support was demonstrated for the first hypothesis.
Significant treatment responses were demonstrated in child externalizing behaviors,
parental stress, parental efficacy, and the cognitive competence domain of child self-
concept. Some support was found for the second hypothesis. PCT was significantly more
effective than CT in improving child problem behaviors and parental efficacy in the
domain of child management. Overall, the results support the use of PCT with a
preschool ADHD population.
TABLE OF CONTENTS
List of Tables iii
Acknowledgements iv
Chapter I: Introduction 1
Chapter II: Methods 58
Chapter III: Results 77
Chapter IV: Discussion 96
References 110
Appendix A: Study Consent Form 124
Appendix B: Child Treatment Curriculum 127
Appendix C: Parent Training Curriculum 138
Appendix D: Jacobson and Truax Tables 144
LIST OF TABLES
1. Child sample characteristics 62
2. Parent sample characteristics 63
3. Descriptive statistics of Cl 89
4. Descriptive statistics of C2 90
5. Repeated measures ANOVA 91
6. Analysis o f covariance 92
7. T-tests 93
8. Effect sizes 94
9. Clinically significant change 95
iii
ACKNOWLEDGEMENTS
My heartfelt thanks to Dr. Linda Reddy for all of her support and assistance with this
project. The clinical and research training that she has provided for me have greatly
enriched my professional development. I would also like to thank the members of my
Dissertation Committee, Dr. Gretchen Gibbs, Dr. Neil Massoth, and Dr. Robert McGrath,
for all o f their assistance.
iv
Chapter 1: Introduction
Attention-Deficit/Hyperactivity Disorder (ADHD) is a chronic developmental
disability affecting 3 to 5% of all school-aged children (American Psychiatric
Association, 1994). ADHD is believed to be the most common behavioral disorder
among preadolescent children (Rappaport, Omoy, & Tenenbaum, 1998). Children with
ADHD have difficulty regulating their impulses, and frequently display maladaptive and
socially inappropriate behaviors. The associated deficits occur in behavioral domains
that are central to social and academic functioning, such as sitting still, waiting one’s
turn, listening, and following directions. Functioning is frequently disrupted in school,
home, and peer settings. Symptoms tend to persist across setting and over time and, for
the majority o f cases, will last well into adolescence.
Diagnostic Criteria
The Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric
Association, 1994) organizes ADHD into three subcategories: Predominantly Inattentive
Type, Predominantly Hyperactive-Impulsive Type, and Combined Type, with associated
symptoms described for each. All symptoms must be maladaptive and inconsistent with
developmental level. These behaviors must have manifested themselves before the child
was 7 years old and they must be present in at least two settings. To receive a diagnosis
of Predominantly Inattentive Type, a child would have to meet six (or more) of nine
criteria for a period of at least 6 months. The criteria include: often has difficulty
sustaining attention in tasks or play activities, is often easily distracted by extraneous
stimuli, is often forgetful in daily activities, often has difficulty organizing tasks and
activities, and often loses things necessary for tasks or activities.
2
To receive a diagnosis of Predominantly Hyperactive-Impulsive Type, a child also
has to meet six (or more) of nine criteria for a period of at least 6 months. The criteria in
this case include: often fidgets with hands or feet or squirms in seat, often talks
excessively, often blurts out answers before questions have been completed, often has
difficulty awaiting turn, and often interrupts or intrudes on others. To receive a diagnosis
of Combined Type, a child would have to meet criteria for both the Inattentive Type and
the Hyperactive-Impulsive Type.
Etiology
The precise etiology of ADHD is unknown, although several risk factors have been
identified. The factor with the greatest empirical support is genetics; ADHD has been
found to be a highly heritable disorder (Barkley, 1990). From 10% to 35% of immediate
family members (and 32% of siblings) will also receive the diagnosis (Barkley, 1990).
Adoption research has supported these findings, noting that biological parents are more
similar to their children than adoptive parents are in levels of hyperactivity (Barkley,
1990). Large-scale twin studies are consistent with these conclusions. One twin study
(Stevenson, 1992) found that 50% of the variance in hyperactivity and inattention was
due to genetic factors, and 0 to 30% was environmental. The percentage of heritability
increased when only clinically significant levels of ADHD were studied, suggesting that
the more serious symptoms are the ones most affected by genetic factors. Another twin
study compared monozygotic and dizygotic twins and found an 81% concordance rate in
the former group compared to 29% in the latter (Gilger, Pennington & DeFries, 1992). A
large-scale treatment outcome study included a comparison of parent characteristics
between parents of children with ADHD and parents of control subjects (Epstein et al.,
3
2000). Using both self-ratings and the ratings of a spouse or a partner, a significant
difference was found between the treatment group and the control group on multiple
measures of ADHD symptomatology. Parents of ADHD children were significantly
higher on other-rated measures of hyperactivity, inattention, and impulsivity.
Surprisingly, no significant difference was found between the biological and non-
biological parents of ADHD children on levels of parental ADHD symptoms on self-
report measures. The authors speculated that the self-report measures may have been
affected by parental expectations, inflating the scores of non-biological parents, while the
other-reported scores reflected more objective perceptions. Additionally, they speculated
that the parents may have demonstrated a “response bias” from living with an ADHD
child, involving a heightened attention to possible ADHD symptoms in themselves.
Researchers have also investigated the role of environmental factors. Psychosocial
factors are not clearly implicated in the etiology of ADHD. Firstly, most relevant
psychosocial influences (such as parenting approaches, marital conflict or parental
psychopathology) have been shown to be the result of either the child’s ADHD or a
comorbid disorder. Secondly, these environmental factors may be the result of the
parent’s own ADHD, due to the highly heritable nature of the disorder. While social
factors may influence the expression of the disorder, researchers no longer consider them
a significant causal force (e.g., Anastppolous & Barkley, 1992; Anastopolous & Shaffer,
2001; Barkley, 1998). However, other types of environmental influences have been
studied and linked with ADHD. Elevated body lead has a statistically significant
relationship with ADHD symptoms, although the majority of lead-poisoned children do
not develop ADHD (Barkley, 1990). Prenatal exposure to alcohol and cigarette smoke is
also related to ADHD (Root & Resnick, 2003). It should be noted that methodological
flaws in the studies on both lead and prenatal influences limit the credibility of these
findings (Barkley, 1996).
Lastly, the symptoms of ADHD appear to be related to neurological impairment.
Children with ADHD display symptoms similar to those in individuals with brain lesions
or injuries in the frontal cortex, specifically in the prefrontal cortex. They are
consistently deficient on neuropsychological measures that assess frontal lobe functions,
such as persistence, inhibition, and planning. They have decreased blood flow to this
area of the brain and the pathways that connect it to the limbic system (Barkley, 1990).
Investigation is ongoing into the various differences in brain structures between ADHD
children and controls, but this area of research promises to hold many answers to the
disorder’s cause.
Associated Features
Social Skills
A host of concomitant deficits have been found to accompany the above criteria for
ADHD. ADHD children have been widely noted to display impaired social skills (e.g.,
Frederick & Olmi, 1994; Landau, Milich, & Diener, 1998; Landau & Moore, 1991).
Some researchers have even argued that this deficit is a defining characteristic of the
disorder (Landau & Moore, 1991). Children with ADHD are frequently intrusive,
obnoxious, inappropriate, disruptive and domineering. They experience significantly
more social rejection than normal children (Frederick & Olmi, 1994). High levels of
aggressive behavior, found in as many as half of hyperactive children, are a significant
correlate of peer rejection (Landau & Moore, 1991). In fact, social problems in the
ADHD population are predictive of negative long-term outcomes such as psychiatric
hospitalization, substance abuse, dropping out of school, criminal arrests and
incarceration, and job termination (e.g., Greene, Biederman, Faraone, Sienna, & Garcia-
Jetton, 1997; Landau et al., 1998; Landau & Moore, 1991).
Academic Functioning
Children with ADHD frequently display academic difficulties that may include
disruptive classroom behavior, sloppy or incomplete work, noncompliance, and defiance.
Between 19% and 26% of children with ADHD have been found to have a learning
disability, and 30% to 64% will demonstrate speech and language difficulties (Barkley,
1990). Nearly all children with ADHD exhibit significant academic underachievement
(Anastopoulos, Guevremont, Shelton, & DuPaul, 1992). In class, children with ADHD
have difficulty sitting still, focusing on structured tasks, and attending to and cooperating
with group activities (Anastopoulos & Shaffer, 2001). Because their behavior interferes
with classroom participation, they may miss out on skill and knowledge acquisition,
which creates increased risk for more serious academic difficulties later in their academic
career. Similarly, their frequent inability to complete assigned tasks interferes with skill
rehearsal opportunities. These problems may be less evident in younger children, for
whom the classroom demands are less stringent. Deficiencies in the amount of work they
produce signal the likelihood of problems to follow in the years to come.
Family Relationships
Children with ADHD typically have disrupted relationships with parents and siblings.
Their parents must frequently participate in interactions that are less rewarding, more
stressful, and provide less positive feedback than parents of normal children (Mash &
6
Johnston, 1983). Researchers have noted that parents of ADHD children tend to respond
more negatively to their children, express more criticism, and display fewer positive
behaviors toward them (Barkley, 1990). Difficulties in parent-child relations can lead to
escalation in problematic child behavior and an increasingly punitive response from the
parent. This “reciprocal interaction” (Newby, Fischer & Roman, 1991, p. 255) can
maintain a negative cycle and contribute to a further decrease in positive interactions
between parent and child.
Researchers have debated over the origin of these relational difficulties. Some have
proposed that the parents’ negativity is a reaction to their child’s poor behavior, while
others have suggested that the child’s symptoms are the product of parental
shortcomings. Medication research has suggested that the former explanation is the more
appropriate. When children were given stimulant medication and their noncompliant
behaviors decreased, parents reduced their negative and directive behaviors (e.g.,
Barkley, Cunningham, & Karlsson, 1983; Danforth, Barkley, & Stokes, 1991). These
changes in style suggest that the negative parenting style is a reaction to the child’s
behavior. Medication improves the hyperactive child’s behavioral control, which in turn
leads to improvements in the social responses of teachers and peers toward them
(DuPaul, Barkley, & McMurray, 1991).
It has been demonstrated that the parents of ADHD children experience significantly
greater stress than the parents of normal children (Anastopoulos et al., 1992).
Anastopoulos et al. attempted to explore the complex relationship between ADHD and
parental stress by studying 104 ADHD children, ranging in age from 4 to 12 years, and
their parents. The results indicated that, of the child variables, frequent aggressive
behavior, more severe ADHD symptoms, and a higher incidence of health problems were
significant predictors of parental stress, as measured by the Parenting Stress Index, and
together accounted for 43% of the variance in parental stress scores. O f the parent
variables, increased psychopathology and not working outside the home contributed to
parental stress.
Mash and Johnston (1983) investigated parental perceptions of child behavior and its
impact on parent functioning. They performed a correlational study with 91 families, 40
with a hyperactive child and 51 with normal children. They measured the parents’
perceptions of their child’s behavior, their self-esteem, and levels of stress in the mother-
child relationship. All three domains were significantly worse among the parents of the
hyperactive children. Maternal stress and self-esteem were also related to the parents’
perceptions of child behavior. The more significantly deviant the parent perceived her
child’s behavior to be, the greater her stress levels and the lower her self-esteem.
Parental stress was higher among the parents of hyperactive children on almost every
subscale; child characteristics were a particularly important predictor of stress. In
addition to stress, parents reported more isolation, depression, lack of attachment to their
child, and self-blame.
As noted above, parents of ADHD children have been found to have higher levels of
the disorder themselves, raising the possibility that parenting difficulties may stem from
their own symptoms and limited coping skills. In addition, researchers have identified
marital discord as playing a significant role in parental stress (Fischer, 1990), but whether
as a cause or an effect is unclear. Mothers of ADHD children reported significantly more
marital discord than control group mothers. Socioeconomic factors may also play a role.
Baldwin, Brown and Milan (1995) examined this question with 30 children with ADHD
and their parents. All o f the children were of low socioeconomic status and were
receiving stimulant medication for ADHD symptoms. The age range in the study was 5
to 14 years old. The authors found that financial issues accounted for the largest
percentage of the variance of parental stress (42%). The next largest percentage of the
variance was accounted for by the presence of ADHD symptoms (18%). The authors
concluded that their findings were consistent with previous research and indicated that
families from a lower socioeconomic background were particularly vulnerable to parental
stress. Conversely, Friedrich (1979) found that social supports, financial security and
physical health served as resistance factors against parental stress in mothers of
handicapped children.
Comorbiditv
Comorbidity with other disorders is high. It has been estimated that 44% of children
with ADHD have a comorbid disorder, nearly 33% have two comorbid disorders, and
10% have three comorbid disorders (Root & Resnick, 2003). The most common
comorbid diagnoses are Oppositional Defiant Disorder and Conduct Disorder. Among
clinic-referred children with ADHD, 35% to 60% will develop Oppositional Defiant
Disorder, 30% to 50% will be diagnosed with Conduct Disorder, and between 15% to
25% will eventually meet criteria for antisocial personality disorder (Barkley, 1990). The
figures for girls are about half those for boys. Children with ADHD are more likely to
engage in criminal activity, especially serious offenses. They are 4 to 5 times more likely
to be arrested and 25% more likely to be institutionalized because of delinquency than
other children (Young, 2000). Higher rates of depression and anxiety are found among
ADHD subjects than in comparison groups, occurring in about 25% o f ADHD children
(Root & Resnick). Individuals with ADHD achieve significantly poorer occupational
status and have more employment-related problems (Young).
Course
Researchers continue to investigate the course of the disorder into adolescence and
adulthood. While much remains to be understood about the developmental trajectory of
the disorder, it appears that symptoms do not follow a steady course. One study found
that 50% to 80% of clinic-referred children with the disorder continued to meet
diagnostic criteria for ADHD in adolescence (Barkley, Fischer, Edelbrock, & Smallish,
1990). The decline in numbers is at least in part accounted for by the reduction in the
symptoms of hyperactivity. Several studies have found that adolescents have fewer
symptoms of hyperactivity-impulsivity than pre-adolescents, who in turn have fewer
symptoms than children aged 5 to 10 years old (Anastopoulos & Shaffer, 2001). In
contrast, the symptoms of inattention appeared to remain relatively constant over time.
Even in adulthood, research suggests that approximately 30% of those with a diagnosis of
ADHD in childhood will continue to meet diagnostic criteria for the disorder (Barkley,
1996).
Gender Differences
ADHD is more commonly diagnosed in boys, although estimates of gender
differences vary widely. Boys are anywhere from two to nine times as likely to have the
disorder, and are found in much higher numbers than girls among clinic-referred children
(Root & Resnick, 2003). The gender difference may in part be explained by disparities in
symptom presentation. Boys frequently display disruptive and defiant behaviors, leading
10
more often to treatment referral and diagnosis. Girls, however, may become “overly
talkative and overly social” (Root & Resnick, 2003, p. 35). Genetic factors may also
account for part of the discrepancy, a topic of continued research and investigation. One
theory posits that females are less often afflicted with ADHD, a disorder caused by
multiple genetic and environmental factors, because they have a “higher threshold” and
require a greater confluence of negative variables in order to manifest the disorder.
Another theory suggests that different causal factors are involved for each gender, and
boys may be in particular risk because of unique aspects of their development (Rhee,
Waldman, Hay, & Levy, 1999). Further research is needed to resolve this debate more
conclusively.
Age Effects
Because of the severity and chronicity of ADHD symptoms, early intervention with
children with ADHD is important. Many researchers believe that young children present
a unique receptivity and responsiveness to treatment that older children lack: “As
children grow older, they may become less cooperative with adult therapists and less
likely to adjust their behavior to societal norms” (Weisz, Han, Granger, Weiss, &
Morton, 1995, p. 451). A large meta-analysis (Weisz, Weiss, Alicke, & Klotz, 1987)
reviewed 108 outcome studies evaluating psychotherapy with children and adolescents.
The subjects were aged 4 to 18, with a wide range of psychological problems. The
authors reported that the average child who received treatment was better adjusted than
79% of the untreated children. These effects persisted at follow-up, which occurred an
average of 168 days after termination of treatment. Behavioral treatments proved more
effective than non-behavioral treatments across age and diagnosis. Interestingly, they also
11
found that treatment was more effective for children under 12 than for adolescents,
supporting the notion that early intervention with young children is beneficial. However,
a later meta-analysis (Weisz et al., 1995) did not replicate this finding of an age effect.
Further research is needed to evaluate this relationship, particularly in regards to
differential response patterns within the 4 - 1 2 age group.
The need for early intervention was underscored by a longitudinal study by Lavigne
et al. (1998), who studied the diagnostic course of several hundred preschoolers. The
authors grouped children with ADHD, Oppositional Defiant Disorder and Conduct
Disorder together as “disruptive disorder,” and examined the stability of this condition
over four years. Stability of diagnosis for a disruptive disorder was high: Over 50% of
the children with a diagnosis at first examination retained that diagnosis 3 to 4 years later.
In fact, children with a disruptive disorder at age 2 through 5 were eight or nine times
more likely to have that disorder several years later than children with no initial
diagnostic status. Additionally, the majority of children with a disruptive disorder
developed a comorbid disorder when assessed 3 to 4 years later. Specific diagnoses were
not provided, but the majority of children acquired an emotional disorder, a category
comprised of anxiety and depressive disorders. The authors emphasized that treatment
interventions with this population should be initiated as early as possible. Their findings
contradicted an often-held belief that young children will “grow out” of their problems,
indicating instead that a substantial portion will in fact retain their psychiatric diagnosis
at follow-up. As McGoey, Eckert, and DuPaul (2002) concluded after conducting a
literature review of interventions with ADHD preschoolers:
Without early intervention in school and at home, many of the behavioral symptoms
12
continue to appear and often escalate once the demands of elementary school are
placed on the child....Typically, children designated as hyperactive while in preschool
continue to manifest problems with impulsive behaviors, aggression, and social
adjustment in elementary school. ...Given the relative stability o f problem behaviors,
interventions that ameliorate their symptoms and prepare a child for kindergarten are
strongly recommended for this population, (p. 15)
Treatment
Despite strong empirical support for early intervention, few studies have been
conducted with young children with ADHD. For the most part, therefore, clinicians must
look to studies with older children and attempt to generalize to their younger
counterparts. It still remains to be seen how relevant these findings are to the
developmental challenges of younger children. The remainder o f this chapter reviews the
research to date on treatment interventions for children with ADHD. Many treatments
have been evaluated with this population, including stimulant medication, cognitive-
behavioral treatment, parent training, and combination packages such as parent and child
training.
In order to provide a summary of recent treatment outcome research, a literature
search was conducted. Both PsycLit and Eric databases were searched, covering the
period of 1990 - 2003. The reference lists of published articles were also searched for
relevant studies. Studies were excluded that had a single subject, were school-based, or
did not fall into one of the aforementioned treatment categories. Where a particularly
interesting or notable study was discovered that pre- or post-dated the span of the
literature review, it was included. This review concludes with a summary and critique of
the outcome literature for children with ADHD.
Numerous treatments have been proposed specifically for use with ADHD children,
with a vast and often contradictory body of research to support them. To date, well-
controlled studies have not substantiated the putative results from biofeedback, vestibular
stimulation, or dietary changes (reviewed in Barkley, 1998). Traditional psychotherapy
and play therapy have also not been found effective treatments for ADHD (Barkley,
1998) and will not be discussed here. Programs that target cognitive change, such as self
monitoring or problem-solving techniques, have received extensive evaluation. These
techniques, often coupled with some type of behavioral reinforcement, have been utilized
successfully to improve classroom behaviors (e.g., Abramowitz & O’Leary, 1991;
Abramowitz, Eckstrand, O’Leary & Dulcan, 1992; Barkley et al., 2000; Robinson, Smith,
Miller, & Brownell, 1999). Classroom interventions typically utilize self-monitoring,
self-instruction, and/or self-reinforcement techniques, and are often implemented in an
individual format (Anastopoulos & Barkley, 1992). Self-monitoring programs teach a
child to keep track of his on-task and off-task behaviors, with rewards for classroom
compliance. Accurate self-evaluation is determined by matching teacher ratings. Self
monitoring approaches improve on-task behavior and academic productivity and are
typically provided in an individual format, providing a child with skills to remain at his
desk for independent study. Self-instruction, or self-statement modification, involves
teaching a child appropriate problem-solving skills by modeling the performance of a
task while stating planning strategies aloud. The child then performs the task and
engages in similar overt verbalizations. Self-reinforcement techniques teach children to
reinforce themselves with tangible and/or intangible rewards after completing a goal or a
14
step towards reaching a goal (Anastopoulos & Barkley).
However, the effectiveness of cognitive techniques has not been reliably
demonstrated by clinic-based treatments. Some success has been noted for specific
symptom reduction, but researchers have consistently failed to find generalization and
maintenance effects (Barkley, 1998). Treatment goals more relevant to the children, such
as peer acceptance or social skills, may generate more motivation and treatment success.
Treatment failures may also be due to the children’s lack of motivation to adhere to the
strict treatment regimens (Anastopolous & Barkley, 1992; Barkley, 1998). Perhaps
interventions that emphasize cognitive techniques are not intrinsically appealing and
motivating for young ADHD children, which can interfere with treatment success.
Medication
One of the most effective and well-researched treatments for the symptoms of ADHD
is stimulant medication. Many studies have substantiated its effectiveness in reducing the
symptoms of the disorder in the majority of ADHD children (Greenhill, Halperin, &
Abikoff, 1999; Rapport, Denney, DuPaul, & Gardner, 1994). It is believed that the
efficacy of stimulant medications is due to the neurochemical imbalances associated with
the disorder, but the exact nature of the mechanisms by which medication corrects them
is still unclear (Anastopolous & Shaffer, 2001). Four immediate-release stimulant
medications are currently available: methylphenidate, dextroamphetamine, Adderall, and
pemoline. Improvement has been demonstrated in 65% to 75% of patients administered
stimulant medication (Greenhill, Halperin, & Abikoff, 1999). Randomized controlled
trials of stimulants have demonstrated robust short-term effects in children with ADHD.
Improvements are commonly seen in compliance, on-task behaviors, fidgetiness,
interrupting, parent-child interactions, sustained attention, short-term memory and
impulsive responding on cognitive tasks (Greenhill et al., 1999). Because behavior and
attention improve in normal children as well as other clinical populations as a result of
stimulant medication, a positive response to medication cannot be used as a diagnostic
indicator for ADHD.
The effects of stimulant medication are short-term and children generally return to
baseline functioning when medication is terminated (Greenhill, Halperin, & Abikoff,
1999). In addition, while the effectiveness of medication has been well documented for
improving core ADHD symptoms of inattention and hyperactivity, it is less effective in
addressing related deficits in social skills and problem-solving (Hinshaw, Henker, &
Whalen, 1984). Medication does not appear to affect the poor prognosis associated with
ADHD, and as many as 30% of children with the disorder do not respond to stimulant
medication (Horn, Ialongo, Greenberg, Packard, & Smith-Winberry, 1990). It is evident
that, while medication presents a useful treatment tool for many children, additional
interventions are needed.
Horn et al. (1991) discussed the advantages of combining medication treatment with
psychosocial interventions. First, medication may enhance the child’s ability to benefit
from cognitive-behavioral interventions to improve social skills, self-control and
problem-solving. Second, parent training may enable parents to prompt and reinforce the
child’s improved behaviors in the home, thus increasing generalization and maintenance.
Third, the demonstrable improvements in parent-child interactions which result from
stimulant medications may allow parents to implement new parenting strategies
successfully. These successes will increase the likelihood that parents will continue with
16
the behavioral intervention. Fourth, lower medication doses may be possible if
adjunctive psychosocial treatments provide “an increment o f improvement” (p. 234).
Fifth, child and parent treatment programs may improve skills in areas for which
medication is less efficacious, such as academic and social skills. Thus, while medication
is likely to be an important and successful part of treatment for many children with
ADHD, it may be hypothesized that psychosocial interventions can provide an important
supplement for comprehensive and long-term improvement.
Parent Training
Parent training has been demonstrated to be an effective and empirically validated
treatment for ADHD children and their families. Barkley (1998) discussed the rationale
for utilizing parent training with ADHD children. The current research “increasingly
points to ADHD as being a developmental disorder of probably neurogenetic origins in
which some unique environmental factors play a role in expression of the disorder,
though a far smaller role than genetic ones do” (p. 69). Since neurological and genetic
factors contribute so heavily to the onset o f the disorder, it is unlikely that psychosocial
treatments could reverse these mechanisms. Barkley compared ADHD to learning
disabilities and mental retardation, conditions that cannot be cured through psychological
intervention. Therefore, treatment of ADHD must focus on management approaches
rather than curative ones. The factors in the child’s environment that may support or
reward negative behaviors can be changed. Support can be provided to parents for their
stress and lack of self-esteem in managing their child. Children can be taught techniques
to help them adapt to and compensate for their deficits.
Parent training can fulfill these functions by teaching parents to alter the
17
environmental responses to child behaviors. Most parent training treatments utilize
contingency management principles to affect change. This approach is based on social
learning theory, which emphasizes the effect o f reward and punishment in the
perpetuation of behaviors. Parents are taught to observe the antecedents (or “triggers”)
and consequences of their child’s behaviors. If a child is given parental attention
following misbehavior, for example, this may be experienced as rewarding and could
increase the likelihood that the behavior will be produced in the future. Parents are
taught to set realistic goals for their child, establish reasonable consequences for
misbehaviors, use extinction procedures, and follow through on all consequences. The
importance of positive reward is emphasized. This strategy can alter the negative pattern
of parent-child relationships and encourage future displays of appropriate behavior.
Parent training groups also provide a forum for parents to discuss the difficulty of raising
an ADHD child and can normalize the stress and confusion that often results. Parents can
find social support and compassion in these groups, which could be lacking from friends
and family who blame their child’s misbehaviors on their parenting skills.
A number of studies have evaluated the effectiveness of parent training with an
ADHD population. The evidence is promising, and researchers have concluded that
parent training is a viable and effective intervention for the ADHD population (e.g.,
Barkley, 1998; Pelham, Wheeler, & Chronis, 1998; Schaughency, Vannatta, & Maura,
1993). The following review of recent research on parent training examines the treatment
impact on the five clinical domains being evaluated in the present study: child
externalizing behavior, child social skills, child self-concept, parental stress, and parental
efficacy. Those studies that focus on a preschool population are reviewed in a separate
18
section.
Child Externalizing Behaviors. Most of the following studies on parent training for
ADHD children examined its impact on externalizing behaviors, although different
intervention approaches and techniques were used to effect change. Anastopolous,
Shelton, DuPaul and Guevremont (1993) evaluated the effectiveness of providing parent
training in individual treatment sessions. The mothers of 36 ADHD children between the
ages of 6 and 11 were included in the study. Sixteen of the children had a secondary
diagnosis (14 with Oppositional Defiant Disorder, 1 with an anxiety disorder and 1 with
enuresis). Treatment consisted of nine weekly treatment sessions based on Barkley’s
(1987, 1990) parent training program. Results were compared to a wait-list control
group. Externalizing behaviors were rated with the ADHD Rating Scale (DuPaul, 1991)
and the Home Situations Questionnaire-Revised. When subjects were assessed after
treatment, parents reported significant improvements on the Impulsivity-Hyperactivity
and Total ADHD scales of the ADHD Rating Scale. The post-treatment scores on the
Total ADHD scale were significantly better than the wait list control. These changes
remained stable two months after all clinical contact had been terminated.
Firestone, Kelly, Goodman and Davey (1981) evaluated the delivery of parent
training using a combination of individual and group sessions. Their program utilized
Patterson’s manual (1976) to guide the delivery of treatment. The parents of 43 children
with ADHD, aged 5 to 9, were randomly assigned to one of three groups: 1) parent
training plus Ritalin for the child, 2) parent training plus a placebo for the child, and 3)
Ritalin alone. Parents, clinicians, and assessors were blind to treatment condition.
Parents were given a book to read on child management and behavioral principles, and
19
participated in three individual parent training sessions. The parents then met as a group
for six additional sessions. The children’s behavior was measured with both the Teacher
and Parent versions of Conners Rating Scale, Hyperactivity Index. Baseline scores were
used as a covariate in the statistical analysis, which revealed significant change on both
Teacher and Parent measures for all three treatment conditions. The overall findings of
the study demonstrated that, while all three groups achieved significant improvement in
multiple clinical domains including conduct disorder and hyperactivity, there was no
evidence for a significant increase in improvement due to the addition of parent training.
In fact, the mean scores for the medication alone condition were either superior or nearly
identical to those for the parent training plus medication condition on all measures. The
lack of significant difference between the treatment conditions may be due to the
relatively small sample size (43 children). There could also be a ceiling effect from the
medication, which would prevent additional treatment from providing any incremental
improvement.
In Weinberg’s (1999) evaluation of parent training, 25 parents with ADHD children
participated in a 6-week group program. The children ranged in age from 4 to 12 years
and were predominantly (80%) male. The program used social learning principles to
teach contingency management techniques. Topics covered included an overview of
ADHD, related symptoms, comorbidity, and behavior management techniques. Parents
were taught how to reinforce appropriate behaviors consistently, implement time-out, and
set realistic goals with their child. The outcome measure used to evaluate changes in
externalizing behaviors was the Home Situations Questionnaire. A comparison between
pre- and post-treatment scores failed to find results on this measure, although a decrease
20
in mean problem scores was noted. Surprisingly, the severity index increased slightly
over time. The author speculated that this may have been due to a ceiling effect, since all
of the children in the study were on medication for its duration.
Social Skills. None of the parent training studies included outcome measures that
assessed children’s social skills. Programs that target social skills typically intervene
with the children directly, using both didactic instruction and rehearsal opportunities.
Child Self-Concept. Similarly, none of the parent training studies included child self-
concept as an outcome measure.
Parental Stress. Two of the recent studies on parent training for ADHD children
included a measure of parental stress. Anastopolous et al.’s (1993) study, discussed
above, evaluated Barkley’s (1987,1990) parent training program and measured changes
in parenting stress on the Child Domain, Parent Domain, and Total scores from the
Parenting Stress Index. Significant effects were found on all three scales, indicating both
a significant improvement over time and a significant improvement when compared to
the wait list control.
Weinberg’s (1999) study, discussed above, measured parental stress with a two-item
questionnaire, rating their level of stress and frustration on a 7-point scale. The
psychometric properties of this questionnaire were not reported. A significant mean
decrease in parental stress was found. No control group was included in this study,
however the symptoms of ADHD are not expected to remit spontaneously over time.
In Firestone et al.’s (1981) previously reviewed study, which examined the effects of
medication, parent training with medication, and parent training with a placebo, a
measure of “emotional adjustment” was included. While this is not an established index
of parent stress, it seems relevant to the overall distress reported by parents of ADHD
children. Their measure was a 3-point scale completed by an interviewer who rated the
parents on a scale from normal, to slightly disturbed, to severely disturbed. The assessor
was considered independent by the authors, although it is not clear if this indicates
blindness to treatment condition. Emotional adjustment improved significantly in all
three treatment groups, although it is unclear if the improvement in parental distress
resulted from parent training or changes in child behavior.
Parental Efficacy. One study targeted parental knowledge and parenting competence
as its primary treatment goals. Odom (1996) examined an educational intervention with
mothers of ADHD children based on an abbreviated version of Barkley’s (1987)
treatment manual. A master's level nurse provided the intervention. Ten mothers of
children aged 5 - 1 1 were randomly assigned to the group treatment condition or a wait
list control group. The educational intervention included five group sessions that
included information about ADHD, a review of social learning principles,
recommendations for improving the structure in the home, advice on positive
reinforcement and time-out procedures, and problem-solving strategies. Change was
measured on the Parenting Sense of Competence Scale (PSOCS), a measure of self
esteem, which provides satisfaction, efficacy, and total scores. While a significant effect
was found on the PSOCS total score for the treatment condition, the scores on the
efficacy scale actually decreased over time in both groups. Surprisingly, it appeared that
the treatment intervention did not reverse or even halt a worsening of parental efficacy
over time. Child behavior change was not assessed in this study, so it is unclear what the
relationship was between parental efficacy and possible changes in child behavior. The
22
author speculated that this finding was a result of the parents feeling overwhelmed by
their child’s recent diagnosis, given just before the start of the study. However,
recruitment was conducted by sending out letters to families, offering a free evaluation
for ADHD. Parents then called in to pursue this evaluation. This process suggests an
interest in learning about their child’s behavior and a desire to address their concerns,
characteristics that seem to contradict the author’s hypothesis. Given the limited
information provided in the article, it is difficult to interpret these unexpected findings.
Anastopolous et al. (1993) evaluated the effects of Barkley’s parent training manual
on parental competence. As in the Odom study, the measure used to evaluate change was
the PSOCS. However, the authors used only the total score on this scale. The treatment
group demonstrated significant improvements over the wait list control.
In conclusion, parent training has generally been found to be an effective treatment
for parents of ADHD children. Recent studies on parent training have evaluated its
impact on externalizing behaviors, parental stress, and parental efficacy. All three studies
that used externalizing behaviors as an outcome measure reported improvements
(Anastopolous et al., 1993; Firestone et al., 1981; Weinberg, 1999). Two studies found
significant improvements on measures of core ADHD symptoms; Weinberg, however,
reported a reduction in main problem scores that did not reach significance, perhaps
because all subjects were on medication and a ceiling of improvement had been reached.
In terms of parent training’s effect on parental stress, all three studies found a
significant improvement. One used the Barkley manual and evaluated change with three
subscales of the PSI, detecting significant improvements on all three scales when
compared to a wait list control (Anastopolous et al., 1993). Another study found a
23
significant decrease in stress as measured by a two-item questionnaire (Weinberg, 1999).
Lastly, significant improvement was found on a study measuring emotional adjustment
(Firestone et al., 1981).
Parental efficacy was evaluated in two studies, both using the PSOCS. Both studies
found a significant effect on parental competence as measured by the total score of this
scale. However, one study reported an unexpected decrease in self-reported efficacy. It
was unclear what led to this deterioration.
Parent and Child Training
Programs that provide both parent and child training have received substantial
research support, as reviewed below. Child training typically utilizes behavior
techniques to shape and reinforce appropriate behaviors, along with extensive
opportunities for in vivo rehearsal. Parent training often mirrors the child training, with
parents learning how to support and maintain their child’s behaviors in the home and
other settings.
Child Externalizing Behaviors. While a number of studies have been conducted
evaluating the impact of combined parent and child group training on externalizing
behaviors for an ADHD population, the randomized trial conducted by the Multimodal
Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder Cooperative
Group (MTA Cooperative Group, 1999) is the most rigorous and comprehensive
investigation to date. The study was commissioned by the National Institute of Mental
Health and sought to address a broad range of questions regarding treatment
effectiveness. Five hundred and seventy-nine ADHD children between the ages of 7 and
9.9 years were randomized to one of four treatment conditions: 1) medication; 2)
24
behavior therapy for parent and child; 3) combination treatment, with both medication
and behavior therapy; and 4) community care, in which individuals were referred to
providers in the community. The majority of these children received medication
treatment.
The behavior therapy condition included 27 group parenting training sessions and 8
individual parenting sessions, using a program based on Barkley (1987) and Forehand
and McMahon’s (1980) models. Sessions were conducted weekly and were tapered off
in frequency over time. The child treatment was a highly intensive behavioral summer
program that consisted of 8 weeks of full time (45 hours/week) interyention. The program
utilized incentives and reinforcement for appropriate behaviors, social skills training,
time-out, and modeling. In addition, 10 to 16 sessions of teacher consultation was
provided to address classroom behavior management strategies, along with 12 weeks of a
part-time classroom aide to provide program implementation.
Child externalizing behaviors were measured on the inattention, hyperactivity-
impulsivity, and oppositional-aggressive subscales of the SNAP ratings (an acronym
based on the authors’ names). In addition, objective ratings were included of school-
based behaviors. Significant improvement was noted over time on externalizing
behaviors. On teacher ratings of hyperactivity-impulsivity, the medication condition
proved superior to behavioral treatment, but they were equivalent on other variables. The
combined treatment did not differ significantly from the medication condition on any
domain. Additionally, the combined medication and behavioral treatment condition was
found to be superior to the behavioral treatment in improving parent ratings of
hyperactivity-impulsivity and oppositional-aggressive behaviors. Therefore, while the
inclusion o f child and parent behavior therapy did not offer any significant increase in
outcome over medication, the inclusion of medication did offer a significant
improvement over the behavior therapy condition. One important contribution of
behavior therapy was in allowing significantly lower medication doses to achieve the
same effect as the medication condition alone. This finding supports the notion of ceiling
effects, demonstrating that behavior therapy contributes to outcome effects when there is
a lower medication dose and room for improvement remains. For parents who do not
wish to pursue medication for their child or in cases of a non-response to medication,
these findings support the equivalency of parent and child behavior therapy on nearly all
variables and offer a reliable alternative to medication treatment.
Fehlings, Robergs, Humphries and Dawe (1991) evaluated the effectiveness of a
parent and child treatment program delivered in individual treatment sessions. Twenty-
five ADHD children, aged 7 to 13, were randomized either to CBT or a “supportive
therapy” control group. In the CBT condition, child participants received twelve 1-hour
individual sessions in the clinic. Children were taught cognitive-behavioral strategies for
problem-solving through the use of modeling, role-playing, homework assignments, and
contingency reinforcement techniques. Parents received eight 2-hour individual sessions
in the home with a behavioral therapist. They were provided with information about
ADHD, instruction in CBT, and techniques for supporting and encouraging their child’s
new skills. The treatment manual was written by the researchers. The supportive therapy
control group received the same therapist exposure and tasks to perform, but did not
receive instruction in CBT strategies.
Child behavior change was measured on the Self Control Rating Scale (SCRS), a
measure of impulsivity, and the Modified Werry Weiss Activity Scale, a measure of
activity level in the home. In the initial analysis, SCRS measures of child impulsivity in
the home did not change significantly from treatment. However, the authors removed
four families from the analysis due to “family dysfunction.” (Three families were
undergoing a divorce and one primary caregiver met criteria for a major depression).
Performing the analysis without these four families did produce a significant effect on the
SCRS, favoring the CBT group over supportive therapy. A significant result was found
on the Werry Weiss Activity Scale, demonstrating that CBT had a positive effect on
reducing hyperactivity levels in the home and was significantly better than supportive
therapy. Treatment effects were maintained at a 5-month follow-up. The authors did not
include a child-only condition, so it is not possible to determine if the inclusion of the
parents in the intervention added an incremental effect.
Horn et al. (1990) examined the combination of behavioral parent group training with
child self-control group therapy. They recruited 42 ADHD children, aged 7 - 1 1 , and
their parents for the study. Twenty-two children had a comorbid diagnosis of Conduct
Disorder and 8 children had comorbid Oppositional Defiant Disorder. Subjects were
randomly assigned to one of three treatment groups: 1) child CBT, 2) parent training, or
3) a combination of child and parent treatment. All subjects received 12 weeks of group
treatment and three individual teacher consultations, which were tailored to the child’s
specific needs. The child group training utilized cognitive strategies such as self-
instruction and problem-solving to increase self-control. Parenting groups included
training in social learning principles and contingency management to improve their
child’s behavior. The parent training manual was derived from programs developed by
27
Patterson (1976), Forehand and McMahon (1981), and Barkley (1981). Child behavior
change was measured by three scales on the CBCL (Total Problems, Externalizing, and
Hyperactivity).
All three conditions demonstrated significant improvements on the CBCL Total
Problems and Externalizing scales, which were maintained at an 8-month follow-up.
Both the parent group training and the combined child and parent group training
conditions also demonstrated significant change on the CBCL Hyperactivity scale, but
this result was not demonstrated by the child-only condition. While the authors
hypothesized that the combination of parent and child group treatment would prove
superior to the other two conditions, this was not supported by the evidence. There was
some weak support for the superiority of the combination treatment, in that a significantly
larger proportion of children in that condition demonstrated clinically significant
improvement on the Externalizing scale on the parent-rated CBCL at follow-up.
However, the authors concluded that overall their study was consistent with previous
research debunking the additive-effect hypothesis.
In 1991, Horn et al. expanded this study to include a medication treatment condition.
Ninety-six ADHD children aged 7 - 1 1 were included. Twenty-five percent of subjects
had a comorbid disorder (8 had Conduct Disorder, 16 had Oppositional Defiant
Disorder). There were six treatment conditions: 1) medication placebo; 2) low dose
stimulant medication; 3) high dose stimulant medication; 4) medication placebo;
behavioral parent group training and child self-control group instruction; 5) low dose
stimulant medication plus behavioral parent group training and child self-control group
instruction; and 6) high dose stimulant medication plus behavioral parent group training
28
and child self-control group instruction. All the conditions containing both parent and
child group training also received three school consultation visits to aid the teacher in
implementing behavioral interventions in the classroom. As in the previous study, the
parent training curriculum was derived from three popular treatment manuals by Barkley
(1981), Forehand and McMahon (1981), and Patterson (1976).
Results were measured using the CBCL; SNAP Checklist (a parent-completed
measure of ADHD symptoms); and the Conners Parent Rating Scale (CPRS), a clinic-
based observation of motor activity and inattention to task. Specific subscales used were
not indicated. Parent measures, including the CBCL, SNAP, and CPRS, were analyzed
with a repeated measures MANOVA, which yielded a significant time effect. This
indicated improvement in all groups on core ADHD symptoms, although no differential
treatment effects between groups were detected. Analyses on each dependent variable by
group were not reported. In terms of observational data, neither of the three child and
parent treatment conditions showed improvement over time on observed motor activity
and attention to task.
The primary purpose of the study was to evaluate the hypothesis that the combination
of medication and behavioral intervention with ADHD children would prove more
effective than medication treatment alone. The evidence failed to support any significant
added benefit from the combination treatments over medication. However, the low dose
of medication plus parent and child group training proved somewhat more effective than
low dose alone, parent and child training plus placebo, and placebo alone. It proved
equally effective to high dose alone and high dose plus parent and child group training.
This result comes as good news to parents who wish to limit the medications their child is
29
taking and supports previous hypotheses about a treatment ceiling effect.
A 9-month follow-up was conducted (Ialongo et al., 1993) after treatment had ended
and medication had been withdrawn, at which time some support was found for the
superiority of the combined child and parent group treatment conditions over medication
in producing long-term improvement. The children in the medication alone condition
demonstrated either deterioration or no improvement. In contrast, the children in the
combination treatment group showed improvement from post-test to follow-up on parent
rated hyperactivity and problem behaviors. This study provides some evidence for the
long-term effectiveness of psychosocial treatments for ADHD, which are perhaps
facilitated by the inclusion of medication but which outlast the effects of medication.
Froelich, Doepfner, and Lehmkuhl (2002) evaluated cognitive behavioral treatment of
ADHD children and their parents in individual sessions. Eighteen children between the
age of 6 and 12 years received six one-hour sessions of treatment. Cognitive techniques
of self-instructional, self-monitoring, and problem-solving skills were taught, as well as
behavioral techniques to address social-conflict situations. Behavioral reinforcement was
provided by therapists to support the implementation of new skills. Following the six
weeks of child treatment, parents received six one-hour individual sessions of treatment
in which they learned behavioral strategies of contingency management. Child
externalizing behaviors were measured with German versions of the Yale Children’s
Inventory (Shaywitz, Schnell, Shaywitz, & Towle, 1986) and the Home Situations
Questionnaire. Significant improvement was noted on both measures at the conclusion of
each treatment phase, demonstrating the effectiveness of child and parent cognitive
behavioral treatment. The authors attribute this effectiveness, at least in part, to the
30
inclusion of parent training and the subsequent support and prompting of new child
behaviors by parents.
Pfiffher and McBumett (1997) compared child social skills group training to a
combination treatment that included both child and parent group training. They
conducted a controlled outcome study with 27 ADHD children aged 8 - 10. Comorbidity
was high: 19 of the children were also diagnosed with Oppositional Defiant Disorder, 3
with Conduct Disorder, and 11 with other anxiety and depressive disorders. Subjects
were randomly assigned to one of three treatment conditions: 1) a child social skills
training group, 2) parent group training plus child social skills training, and 3) a wait-list
control group. The child social skills group consisted of eight weekly sessions in which
didactic instruction, modeling, role playing and behavioral rehearsal were used to aid
learning. Positive reinforcement was used to increase motivation and reward success.
The parent training group mirrored the child group in that the parents were taught how to
encourage and reinforce the child’s new skills in other settings.
Child behavioral change was measured with the Aggression-Defiance and
Inattention-Overactivity subscales of the Conners, Loney, and Milich Rating Scale
(CLAM), the ADHD and ODD subscales of the SNAP-R, the Problem Behaviors scale of
the Social Skills Rating Scale (SSRS), and the Externalizing scale on the Child Behavior
Checklist (CBCL). The two treatment groups were significantly improved at post-test on
problem behaviors, which were analyzed as a composite. They also demonstrated
significant improvement when compared to the wait-list control, but did not differ from
each other significantly. The treated groups both maintained their gains at a 4-month
follow-up. These findings suggest that, while child problem behavior changes as a result
31
of direct intervention, the inclusion of parent training did not lead to a significant increase
in improvement.
Frankel, Myatt, Cantwell and Feinberg (1997) evaluated a treatment program that was
designed to improve the social skills of ADHD children. While its effects on social skills
will be discussed below, the authors also included measures of problem behavior,
specifically the Self-Control scale of the SSRS, and the Aggression and Hyperactivity
scales of the Pupil Evaluation Inventory, a teacher-completed measure. Approximately
70% o f the treatment group was comprised o f ADHD children, and half of these children
had comorbid Oppositional Defiant Disorder. All of the ADHD subjects were on
medication and required to remain on their medication for the duration of the study.
Forty-nine children received treatment, with 24 on the wait-list and 11 drop-outs. Child
age ranged from 6 to 12 years. Twelve weekly group sessions were held, with parent and
child training groups meeting simultaneously. The child group used skill-building
techniques o f instruction, role-play, rehearsal, praise and time-out. Children were taught
skills of group entry, peer praising, conversation techniques, tolerating rejection and
teasing, handling confrontations with adults and how to be a good host. The parent group
generally paralleled the child group. Parents were taught how to support and encourage
the skills being taught to their child, in addition to the techniques of verbal praise and
appropriate punishment.
The results indicated the intervention produced behavioral change. A large effect was
reported for the Aggression scale; the effect size for the Hyperactivity scale was not
reported, but was “not large.” This apparent lack of an effect on hyperactivity is not
surprising, since hyperactive behaviors were not targeted in this intervention.
32
Nonetheless, support was found for positive improvement on some of the problem
behaviors associated with ADHD.
Sheridan, Dee, Morgan, McCormick and Walker (1996) also tested a social skills
treatment with ADHD children. The subjects were five ADHD boys aged 8 to 10 and
their parents. The children were all Caucasian and from a middle to high socioeconomic
status. They met for 10 weekly sessions, with one booster session six weeks after
treatment termination, using a treatment manual developed by the first and second author.
All children were on medication for the duration of the study. The goals of the child
group training were to teach how to join a social group, problem-solving, and the ability
to maintain interactions. Teaching techniques included modeling, behavioral rehearsal,
and homework. A skill-based parent group was held simultaneously, and targeted four
goals for change: interacting with their child in a supportive way, assisting their child in
resolving social difficulties, helping their child establish social goals for themselves, and
helping them generalize the skills they learned in the child treatment group to real-life
situations. For the purposes of rating behaviors, children were observed pre- and post
treatment in both analogue (i.e., clinic-based) and naturalistic (i.e., school-based) settings.
The authors evaluated change in problem behaviors, as measured by the Conners
Parent Rating Scale. Two children demonstrated a positive change of at least two
standard deviations from pre-test, and one child demonstrated a negative change of at
least one standard deviation on the Conduct Problems scale of the Conners. On the
Impulsive-Hyperactive scale, four of the five children showed at least one standard
deviation of positive change, while two of these children showed two or more standard
deviations of change. On the Hyperactive Index, four of the five children showed at least
33
one standard deviation o f positive change, while three of these four children showed two
or more standard deviations of change. While this study has many limitations, including
small sample size and lack of significance testing, the results suggested positive
improvement on Impulsive-Hyperactive and Hyperactive indices of ADHD behaviors.
Social Skills. The MTA Cooperative Group (1999) study, discussed previously,
addressed the impact of treatment on parent-rated social skills. Parent and child behavior
therapy yielded improvement over time, and did not differ significantly from other
treatment conditions. This study did not include a comparison with child-only treatment,
but demonstrated that combined parent and child group treatment was as effective as
medication management in improving social skills in ADHD children.
Three of the studies discussed above were designed specifically to ameliorate social
skills deficits in ADHD children. Pfiffner and McBumett’s (1997) study compared the
effectiveness of two treatment conditions and a wait-list control in improving social
skills, hypothesizing that the inclusion of a parent training group along with child group
treatment would produce significantly greater improvements than in the child group
treatment condition alone. The group format and content was described previously.
Social skills were measured on the SSRS and Social Skills Scale (SSS; Swanson, 1992).
Significant effects were reported for both treatment groups over time on parent-rated
social skills, but no significant differences between groups were found. The authors
concluded that the addition of the parent group, intended as an aid to generalizing the
children’s behavior changes, does not add significant improvement over the child group
alone.
Frankel et al.’s (1997) study compared a parent and child combined treatment for
34
ADHD children and non-ADHD children to a wait-list control for ADHD children and
non-ADHD children. All children with ADHD were on stimulant medication for the
duration of the study. The treatment interventions are described above. The authors only
included the Assertion and Self-Control (a measure of appropriate responding to
provocation from others) subscales on the SSRS in the outcome analysis, as these are the
only measures “relevant to friendships” (p. 1059). However, the treatment interventions
targeted a range of social skills techniques, including regulating voice volume,
appropriate physical proximity, how to praise other people, how to join a game, and
handle rejections. For the comprehensive range of interventions on social skills that were
implemented, the outcome measures chosen do not seem sufficient. Both Assertion and
Self-Control scales demonstrated significant effects over time as a result of treatment.
The treatment group also demonstrated significant improvement over the wait-list control
on both measures.
In Sheridan et al.’s (1996) evaluation of a parent and child combination treatment,
improvement was measured on three child variables in the analogue setting: social entry
(joining a social group), maintaining interactions, and solving problems. All five
children showed improvements in mean scores in all three areas* although improvement
in solving problems was the smallest of the three variables. In the naturalistic setting (the
playground), virtually no social entry or problem-solving skills were noticed; however,
most children demonstrated small improvements in maintaining interactions.
Additionally, SSRS Total Skills Scores were reported pre- and post-treatment, and three
children demonstrated a positive change of at least one standard deviation over time.
While the sample size was far too small to draw strong conclusions, this study does raise
35
questions about the limited generalizability of treatment gains in home and school
settings. Nonetheless, some support was given for the effectiveness of improving social
skills in ADHD children with parent and child training.
Child Self-Concept. A few studies evaluating parent and child training examined its
impact on child self-concept. Horn et al. (1990) evaluated the effect of parent training,
child self-control instruction, and a combination of the two treatments on self-concept, as
measured by the Piers-Harris Self-Concept Scales. There was no significant change in
child self-concept over time. When Horn et al. (1991) conducted this study again, with
the additional inclusion of three medication levels along with three clinical intervention
levels, they found significant improvement in self-concept in only the low medication
and high medication conditions. The addition o f clinical intervention did not add
significant improvement in self-concept, nor did the medication groups differ from each
other significantly. These improvements were not maintained, however, at a 9-month
follow-up (Ialongo et al., 1993) once medication treatment had been terminated.
Fehlings et al.’s (1991) comparison of cognitive-behavioral group treatment for
children and parents with supportive therapy evaluated the effect of treatment on the
child’s self-concept. As described above, treatment focused on utilizing cognitive-
behavioral strategies for problem-solving, beginning with academic problems and then
addressing interpersonal situations. Parents were taught about the disorder and instructed
in the principles of CBT, so they could reinforce their child’s efforts to implement new
skills at home. Children in the combined child and parent group treatment condition
demonstrated a significant improvement in self-concept over time, as measured by the
Piers-Harris Self-Concept Scale. They also demonstrated a significantly greater
36
improvement on this measure than those in the supportive therapy condition.
Parental Stress and Efficacy. Surprisingly, none of the recent studies evaluating
combined parent and child treatment considered its impact on parental stress or feelings
of efficacy. This seems to neglect an important piece of child functioning, as high levels
of parental stress could be expected to reduce parenting effectiveness and worsen the
parent-child relationship. The effects of pervasive child misbehavior on parental stress
and feelings of efficacy remains an important topic of research, as does the effects of
reduced parental stress and improved efficacy on child behavioral change.
In summary, parent and child combined treatment has been shown to produce
significant change on a number of clinical variables. The effectiveness of combined
treatment on externalizing behaviors has been demonstrated through a number of
outcome studies, although the addition o f parent training has not been shown to provide a
significant increase in outcome over child only treatment. Similarly, significant
improvements in social skills have been demonstrated over time and when compared to a
wait-list control. Only one study compared a child group treatment to a combined parent
and child group treatment program (Pfiffner & McBumett, 1997), and it failed to
demonstrate a significant difference between treatment approaches. The results on child
self-concept are somewhat contradictory, with some evidence demonstrating a significant
improvement in response to CBT group treatment for parents and children (Fehlings et
al., 1991), and some evidence suggesting that medication, but not clinical treatment, is
effective (Horn et al., 1991).
Parent Training with Young Children with ADHD
None of the above studies evaluated the effectiveness of parent training with a
preschool population of ADHD children. With unique developmental needs and
treatment response patterns, studies conducted on children of elementary-age and older
may have limited applicability to this population. Preschool children offer a unique
opportunity for intervention. They are just entering structured task situations for the first
time in school. Their parents tend to demonstrate high levels of stress and distress. Their
symptoms are likely to persist over time and, for many of them, worsen. The following
review presents the available literature on parent treatment with an ADHD preschool
population. Several studies are included that target broader populations, such as those
with behavior disorders, as an important adjunct to the sparse literature on interventions
with this age group.
Child Externalizing Behaviors. All of the recent studies that have evaluated the
effectiveness of parent training with young ADHD children have measured changes in
externalizing behaviors. Sonuga-Barke, Daley, Thompson, Laver-Bradbury, and Weeks
(2001) compared two parent-based treatments with a wait-list control group, for 78
preschool-age children with ADHD. Diagnoses were based on a structured clinical
interview with the parents. Subjects were randomly assigned to three treatment
conditions: 1) parent training, 2) parent counseling and support, and 3) wait-list control.
The parent training condition consisted o f eight weekly sessions, conducted on a one-to-
one basis in the subject’s home. Treatment consisted o f psychoeducational interventions
in behavioral strategies. The parent counseling and support condition did not include any
behavioral strategies, and instead provided parents a forum to discuss their concerns and
their feelings about their child. Changes in child externalizing behaviors were measured
with the Parental Account of Childhood Symptoms (PACS, Taylor et al., 1991), the
38
ADHD Symptoms Clinical Interview, and direct observation of behavior. Significant
improvement in externalizing behaviors was demonstrated by PT over other treatment
conditions. Additionally, 53% of subjects in PT met the Jacobson and Truax (1991)
condition for recovery by the end of the trial, as compared to 38% in parent counseling
and support and 25% in the wait-list control condition. These effects were maintained at
a 15-week follow-up.
Pisterman et al. (1992b) evaluated the impact of parent group training on child
compliance behaviors. Forty-five parents of 3 - 6 year old children with ADHD
participated in the program, a twelve session parent training group described as similar to
the programs of Barkley (1987) and Forehand and McMahon (1981). ADHD diagnoses
were based on a parent or teacher-rated checklist that utilized DSM-III criteria, but these
diagnoses were not confirmed by an independent rater and comorbidity was not assessed.
Subjects were randomized to either the treatment group or a delayed-treatment control
group. Compliance training addressed techniques of appropriate reinforcement, time-out
for noncompliance, and shaping, using modeling, role-playing, and video-taped parent-
child interactions sessions with feedback. Behavioral change was measured by
evaluating change in percentage of child compliance behaviors and time to completed
assigned task. Both variables demonstrated significant improvement that was maintained
at follow-up, while no significant change was detected in the control group. In addition,
clinical improvement (as measured by 50% improvement from baseline) was
demonstrated by significantly more treatment families than by control families at post
treatment and at follow-up.
Strayhom and Weidman (1989) conducted an outcome study on parent group training
39
that was unique for several reasons. First, the therapists in their study were drawn from
the local community and reflected the racial, cultural, and economic make-up of that
population. Second, the intervention consisted of both parent group training and
observed parent-child play sessions with feedback in order to increase the generalizability
of the study and to ensure that parents could implement their new skills. Third, the length
of treatment was criterion-based rather than fixed. That is, parents terminated treatment
after they had achieved competence. Fourth, rather than select the most likely treatment
responders, the authors drew heavily from a parent population at high risk for drop-out
and low treatment responsiveness. The parents recruited were from a low socioeconomic
background, mostly from single-parent homes, with high rates of depression.
Ninety-eight parents of 2 - 5 year old children were randomized to treatment or
control conditions. The authors utilized a parent training manual geared toward
preschool age children but not specifically designed for an ADHD population. Inclusion
criteria stipulated that children needed to be at risk due to poor socioeconomic
circumstances and behavioral or emotional difficulties. Forty percent of the children had
at least 8 out o f 14 ADHD symptoms endorsed on a questionnaire. Thirty-four percent
had at least 5 out o f 9 symptoms of oppositional disorder endorsed. A high percentage of
the children had problems with aggressive behavior.
Treatment consisted of four to five parent group training sessions on contingency
management techniques with preschoolers and included didactic instruction and role-play
rehearsals. Parents were then observed at play with the children and given feedback on
any skill deficits. These monitored sessions continued until competence was reached, as
measured by scoring a 4 or 5 on a five-point scale on all relevant behaviors. Eighty-nine
40
people completed both pre- and post-intervention assessments; only 15 of the 45
treatment group members completed the entire treatment program to competence level.
Significant improvements were found on the Hyperactive subscale of the Behar
Preschool Behavior Questionnaire, on the number of DSM-III-R symptoms endorsed by
parents on an ADHD symptom checklist, and on the Child Behavior in Play with Parent
Scale, a rating scale for coding a child’s compliance behaviors with parents on a
videotape. The greatest improvement occurred among those children with the highest
initial scores on attention deficit symptoms. This study demonstrated the positive effect
of a parent training program geared toward behavior-disordered preschoolers from an
economically disadvantaged and socially at risk population.
Pisterman et al. (1989) evaluated a parent training program for the parents of young
children with ADHD, using a combination of group and individual sessions. Forty-eight
parents were randomized to either a treatment group or delayed-treatment control group.
Groups of approximately 10 families met weekly for 12 weeks, which included two
individual in-clinic sessions with their child. The treatment manual was a combination of
two popular parent training programs (Barkley, 1987; Forehand & McMahon, 1981),
focusing primarily on improving compliance behaviors in ADHD children. Parents were
taught behavior management principles, reinforcement techniques, how to issue
appropriate commands, and how to implement time-outs for noncompliance.
Significant improvements were demonstrated on both the percentage of compliance
behaviors and the frequency of noncompliance, favoring the treatment group over the
control condition. These positive results were maintained at a three-month follow-up.
The authors defined clinical improvement as the achievement of a 50% increase in
41
percentage of compliance to total commands, which was demonstrated by significantly
more treatment families than control at both post-treatment and follow-up.
Erhardt and Baker (1990) used a case study design to evaluate a parent training
program with hyperactive children. The parents of 2 children with ADHD were given
treatment in a 10-week parent training program based on social learning principles. The
treatment manual was a combination of several parent training programs (Baker, 1989;
Barkley, 1981; Forehand & McMahon, 1981; Patterson, 1976). Parents were taught to
observe their child’s behavior, identify areas of strength and weakness, develop a
program of behavior management, and reduce in appropriate parenting responses.
Treatment consisted of six group meetings and four individual consultations.
Behavioral change was measured using the Conners Abbreviated Symptom
Questionnaire, a modified version of the Werry-Weiss-Peters Activity Scale (a measure
of hyperactivity), the Child Behavior Checklist scores, Behavior Problem Data sheet, and
the Iowa Conners Rating Scale. While the case study design has limited power, some
support was indicated for improvements in targeted child behavior problems and parent
ratings of hyperactivity. Reductions in noncompliance were slight, however, and overall
levels remained high. Child Behavior Checklist Scores also demonstrated a failure to
generalize beyond hyperactivity and targeted behavior problems.
A few studies have evaluated the provision of parent training in individual treatment
sessions. Cunningham, Bremner, and Boyle (1995) conducted an interesting study,
comparing the effectiveness of a community-based parent group training to a clinic-based
individual parent training for children with behavior disorders. As an inclusion criterion,
scores of at least 1.5 standard deviations above the mean on the Home Situations
42
Questionnaire (HSQ) were required. Therefore, while the subjects’ diagnoses were not
identified by the authors, the sample included children with a large number of ADHD
symptoms. One hundred and fifty parents of kindergartners were randomly assigned to
one o f three treatment groups: 1) community-based group treatment, 2) clinic-based
individual treatment, or 3) a wait-list control. Both treatment groups received 1 1 - 1 2
weekly sessions.
The authors noted that many disadvantaged families, including low-income, single,
socially isolated or depressed parents, are much less likely to participate in or benefit
from traditional parent training programs, even though the children in these families are
at the greatest risk for disturbance. They therefore designed the community-based
program to accommodate large numbers in each group. Groups were held in community
centers that were more accessible to participants, in order to encourage utilization of
services. Treatment was based on the authors’ own manual and followed the same
structure and process in both conditions, emphasizing problem solving skills, mutual
support, and the development of child management strategies.
Changes in child externalizing behaviors were measured on the HSQ and the CBCL.
Both treatment groups demonstrated significant improvement on the HSQ and the CBCL
Externalizing Scale over time; in addition, at a 6-month follow-up the community-based
group demonstrated a significant improvement over the clinic-based group on the HSQ.
The authors speculated that parents may have benefited from group problem solving
sessions, which may have yielded more alternatives than individual clinic sessions could.
This hypothesis was supported by their finding that, at follow-up, only the community
group members were able to generate more problem-solving alternatives than the clinic
43
group members.
Barkley et al. (2000) evaluated a parent training group treatment program by
recruiting 158 preschool children with high levels of disruptive behaviors and randomly
assigning them to one of four treatment groups: 1) no-treatment control, 2) parent
training only (PT), 3) classroom-based intervention, and 4) parent training and
classroom-based intervention. Classroom-based interventions (groups three and four) are
outside the scope of this review and will not be covered here. Forty-two children were
assigned to the no-treatment control and thirty-nine children were in the PT condition.
Fifty-five percent of the control children had a diagnosis o f ADHD, based on a structured
parental psychiatric interview, and 68% o f the children in the PT condition had a
diagnosis of ADHD. Additionally, 57% of the no-treatment control children and 73% of
the PT children were diagnosed with Oppositional Defiant Disorder. The parent training
format was based on Barkley’s (1987) program. Child externalizing behaviors were
measured with the CBCL and the HSQ. The authors failed to find a significant treatment
effect on any of the scales on these measures. They speculated that the lack of an effect
may have been due to poor attendance. Out of 10 weekly sessions, the average number
of sessions attended was 3.3 and 35% of the subjects had parents who did not attend any
sessions. This low rate of attendance may have been due to the study’s recruitment
procedures, in which eligible subjects were offered services rather than including parents
who sought services on their own initiative. Low motivation and lack o f parental
readiness for change, therefore, may have limited the effectiveness o f treatment.
Sonuga-Barke, Daley, Thompson, Laver-Bradbury and Weeks (2001) compared two
different parent therapies for preschool children with ADHD. The parents of 78 3-year-
old children were randomly assigned either to 1) parent training, 2) parent counseling and
support, or 3) a wait-list control. Both treatment conditions received eight weekly
individual sessions, which were provided in the client’s home. The parent training
condition was geared toward the specific deficits of ADHD children, providing training
in behavioral strategies for managing difficult behavior and reducing defiance. The
parent counseling condition did not address specific ADHD-related issues or techniques
but instead provided clients with an opportunity to discuss their concerns about their
child and their feelings about his behavior.
Changes in child externalizing behavior were measured on the Parental Account of
Childhood Symptoms (PACS) ADHD/Hyperkinesis and Conduct scales. The parent
training condition demonstrated significant improvement over the counseling condition
and wait-list control in its impact on these two scales. The effect size for the ADHD
scale was large, though it was small for the Conduct scale. Fifty-three percent of the
children in the parent training group displayed clinically significant change as a result of
treatment. Additionally, the effects of treatment were maintained at a 15-week follow-
up.
Eisenstadt, Eyberg, McNeil, Newcomb and Funderburk (1993) evaluated H anf s two-
stage model o f family therapy, an individual treatment which typically involves a stage
called Child-Directed Interaction and a stage called Parent-Directed Interaction. The
authors evaluated the effectiveness of this program with behavior problem preschoolers,
and attempted to identify sequencing effects in the treatment program. In Child-Directed
Interaction (CDI), parents were instructed to praise appropriate behavior, mirror the
child’s actions, and participate in the child’s play. The purpose of this intervention was
45
to create a basis of positive interactions before structured interventions were taught to
address misbehavior. During Parent-Directed Interaction (PDI), parents were taught
techniques of behavior management, such as giving clear and simple commands, using
consistent and reasonable consequences, establishing behavioral goals and define house
rules.
Twenty-four families with a child between 2 years 6 months and 7 years were
randomized to CDI first or PDI first treatment. Fourteen 1-hour sessions were held in
total, seven in each treatment component. The child sample demonstrated a
heterogeneous group of behavior disorders; 17 children (70%) had ADHD, 9 of the 17
had comorbid Oppositional Defiant Disorder (37.5%) and 5 children (21%) had comorbid
Conduct Disorder. The authors measured changes in externalizing behaviors using the
Eyberg Child Behavior Inventory (ECBI), a measure of behavior problems; the CBCL;
the Werry-Weiss-Peters Activity Rating Scale; and the Dyadic Parent-Child Interaction
Coding System (DPICS), a scale used to measure deviant behavior and child compliance
in parent-child social interactions. Subjects were assessed at baseline, at mid-point after
the completion of the first stage, and at post-treatment when both treatment components
had been conducted.
While significant differences existed between the two treatment groups at mid
treatment, all favoring the PDI treatment condition, at post-treatment these differences
had largely vanished. The groups at post-treatment only differed significantly on the
ECBI Intensity scale, indicating that the PDI-first group had a greater improvement on
the parent-reported frequency of problem behaviors. Both treatment groups
demonstrated significant improvement on all measures of externalizing behavior.
Danforth (1998) also evaluated an individual parent training program with younger
ADHD children, aged 4 to 7. All the children had diagnoses of both ADHD and
Oppositional Defiant Disorder. The parent training program used was the Behavior
Management Flow Chart (BMFC) Program in which parents are taught a systematic
approach to behavior management steps to improve child noncompliance. The
components are visually depicted on a graph that parents could carry with them and each
component was taught in the order it would be used. Because the graph consisted of
decision trees, it could be adapted for any current situation. Danforth did not utilize a
between groups design. Because of the high degree of variability in individual treatment
responses to behavioral training programs, he argued that a between groups design misses
important information.
The parents of eight children with ADHD and ODD were included. All parents were
given eight individual 1-hour sessions of parent training with the BMFC. Child
externalizing behaviors were measured with direct observations of compliance behaviors
in parent-child interactions, the Parent Daily Report (a checklist of problem behaviors),
the Conduct Problems scale from the Conners Parent Rating Scale-R (CPRS-R), the
Externalizing scale of the CBCL, and the HSQ. Results indicated a significant increase
in the percentage of compliance behaviors, and a significant decrease in weekly Parent
Daily Report scores after baseline, CPRS-R Conduct Problems score, and number of
problem settings and severity of problems on the HSQ. Significant improvement was not
demonstrated on the CBCL Externalizing scale. A 6-month follow-up demonstrated the
stability of these findings. Results supported the use of this treatment to improve child
compliance and problem behaviors.
47
In summary, the research on parent training with a preschool population provides
strong support for its effectiveness for child externalizing behaviors. The above studies
demonstrate this effectiveness in both individual and group treatment contexts, clinic and
community settings, and with varied clinical approaches. However, only four of these
studies focus on an exclusively ADHD population (Erhardt & Baker, 1990; Pisterman et
al., 1989; Pisterman et al., 1992b; Sonuga-Barke et al., 2001), and none included direct
intervention with the child.
Child Social Skills. The effects of parent training on ADHD preschoolers’ social
skills have not been investigated to date. The studies of parent training with this
population have not included direct child intervention, and outcome measures have
focused on changes in parental behaviors and in the core symptoms of ADHD.
Child Self-Concept. Only one recent study has measured the impact of parent
training on behaviorally disordered preschoolers’ self-concept. In Eisenstadt et al.’s
(1993) evaluation o f Parent-Child Interaction Therapy, parents were coached through
interactions with their children using a bug-in-the-ear technique. They were instructed
both in positive non-directive play (CDI) and in child management techniques (PDI).
One treatment goal was to improve parent-child relationships and increase positive
interactions. Perhaps for this reason, even though direct intervention with the children
was not provided, a measure o f child self-concept change was included. Both treatment
groups combined demonstrated significant improvement on the Pictorial Scale of
Perceived Competence and Social Acceptance for Young Children. There was no
significant difference between the two groups (CDI-first or PDI-first) either at midpoint
or post-treatment.
Parental Stress. O f the three recent studies that evaluated the impact of parent
training on parental stress in a preschool population, only one targeted ADHD children
and their families. Pisterman and her colleagues (1992a) combined two samples from
previously published research (1989,1992b) discussed above, and examined the effect of
treatment on parenting stress and sense of competence. While the eligibility
requirements differed slightly between the two studies, both samples demonstrated high
levels of noncompliance and hyperactivity. Ninety-one children between 3 and 6 were
randomly assigned to group treatment or wait-list control. Twelve weeks of parent group
training was provided, using a group format of five families each. The treatment program
utilized components from a number of treatment approaches, including Barkley (1981),
Forehand and McMahon (1981), and Hanf (1969), and emphasized behavioral
management techniques. The second study also included techniques to improve
attentional control and duration.
Significant improvement was demonstrated for the treatment group both at post
treatment and at follow-up, as measured by the Child Domain Scale of the Parenting
Stress Index. Surprisingly, the control group’s levels of stress, as they pertain to child
behaviors, also decreased but the changes occurred more slowly and only reached
significance at the 3-month follow-up. On the Parent Domain Scale, however, significant
improvement was noted in the treatment group at post-treatment and at follow-up,
whereas virtually no change was detected on this scale in the control group.
Three further studies have evaluated the impact of parent training on parental stress in
a mixed preschool population. Eisenstadt et al.’s (1993) evaluation of Parent-Child
Interaction Therapy with behaviorally disordered children, described above,
49
demonstrated significant reductions in parental stress, as measured by the Total Score on
the PSI. The groups did not differ from each other significantly at post-treatment, nor did
they different significantly at mid-point when only one stage of the treatment had been
completed. However there was a trend at mid-point favoring the parent-directed
intervention, which stresses behavior management skills, over the child-directed
intervention, which addresses the quality of the parent-child relationship and attempts to
increase positive interactions. Overall, the results suggest that both components of
treatment are necessary, although some weak support was found to support the
effectiveness of PDI treatment alone.
Danforth’s (1998) study of the Behavior Management Flow Chart technique with
children diagnosed with both ADHD and ODD demonstrated significant decreases in
parental stress on the Total Score and Parent Domain scales of the PSI. A trend toward
decreased stress on the Child Domain scores was also reported.
Barkley et al. (2000) evaluated changes in parental stress as a result of a 10-week
parent training group treatment, described above. Sixty-eight percent of subjects were
diagnosed with ADHD and 73% were diagnosed with Oppositional Defiant Disorder,
using a structured parental interview. Surprisingly, the authors failed to find a significant
improvement on the Parenting Stress Index, which appeared to be related to poor
attendance and low motivation for compliance.
Overall, these studies provide preliminary support for the reduction of parenting
stress as a result of parent training in a preschool population. There is evidence to
suggest that child management techniques are the most relevant component of treatment,
but benefit was also demonstrated by improvements in the quality of the parent-child
50
relationship. None of these studies included direct intervention with children, so it is
unclear if reductions in parental stress were related to improvements in child behavior.
These positive results suggest that continued research into this intervention is warranted.
Parental Efficacy. Pisterman et al. (1992a) also examined the effect of parent training
on the sense of competence in parents of ADHD children. In this study, as described
above, the parents of 91 children were randomly assigned to a treatment or a wait-list
control condition. Competence was measured with an older version of the PSOCS (Mash
& Johnston, 1983), a measure which produces two subscales. The Skills subscale
measures parents’ sense of skill and knowledge of parenting functions. The Valuing
subscale measures feelings of appreciation for and satisfaction with parenting. This
instrument is not a measure of parental efficacy per se, but since later versions of the
measure include an efficacy scale, there appears to be a conceptual overlap between these
two constructs. As the results were consistent across the two studies, results were
reported based on analyses of the combined sample.
The results indicated significant improvements on both the Skills and Valuing
subscales on the PSOCS in the treatment condition, which were maintained at a 3-month
follow-up. These changes represented, on average, an improvement of one standard
deviation as a result of treatment. Significant improvement was also noted on the Sense
of Competence subscale on the PSI at post-treatment and at follow-up, an effect which
was not found in the control group. While the control group evidenced no significant
change on the Skills subscale, there was a significant improvement on the Valuing
subscale despite receiving no treatment during this time.
Sonuga-Barke et al.’s (2001) outcome study, described above, also evaluated parent
training’s effectiveness in improving parental efficacy among parents of ADHD
preschoolers. The authors measured change with the Parental PSOCS (Johnston & Mash,
1989) Parenting Satisfaction and Parenting Efficacy subscales. A comparison of pre
treatment scores with those of non-ADHD controls indicated that parents of ADHD
children possessed a significantly lower sense of parenting competence than controls. A
medium effect size was reported at post-treatment for efficacy, after controlling for
differences between groups at pre-treatment.
In summary, strong support has been demonstrated for parent group training with a
younger population. A number of studies have demonstrated its effect on child
externalizing behaviors, using both individual and group treatment formats. O f the
studies which focused on an ADHD population (Erhardt & Baker, 1990; Pisterman et al,
1989; Pisterman et a l, 1992b; Sonuga-Barke et al., 2001), most evaluated behavioral
change with narrowly defined measures of compliance, such as percentage ratios of
compliance behaviors. It is unclear therefore how parent training affects the wide range
of child externalizing behaviors, including impulsivity, hyperactivity, and problem social
behaviors. None o f the above studies addressed child social skills and only one evaluated
change in child self-concept (Eisenstadt et al., 1993), which produced significant
improvement among children with behavior problems. Parental stress was significantly
reduced in three studies ofbehaviorally disordered and ADHD children (Danforth, 1998;
Eisenstadt et al., 1993; Pisterman et al., 1992a), and one study of parental efficacy
(Pisterman et al., 1992a) demonstrated a medium effect size in favor of parent training.
This intervention shows great promise as a means to treat the wide range of difficulties
demonstrated by young ADHD children and their parents.
52
Summary
A number of treatment approaches for ADHD children have been evaluated.
Stimulant medication has consistently been found effective with approximately 70% of
children with ADHD. Medication effectively improves compliance, sustained attention,
on-task behaviors, parent-child interactions, impulsivity, and fidgetiness. However, it
does not appear to ameliorate deficits in problem-solving and social skills substantially.
In addition, improvements due to medication are short-lived and dissipate once the
medication is terminated. Parents often express concern about placing their child on
medication for long periods of time. For these reasons, psychosocial treatments are
frequently incorporated into a treatment plan.
Parent training has received the most empirical support as a psychosocial treatment
for use with an ADHD population. Numerous studies have substantiated the
effectiveness of parent training for improving child compliance and externalizing
behaviors, child social skills, parental stress, parental efficacy, and child self-concept.
Similar findings have been reported in studies that included a preschool and/or early
elementary school age population. Many variations of parent training have been
evaluated. Only a few studies have evaluated the effectiveness o f the Barkley (1987,
1997) parent training manual, some in combination with other parent training approaches,
but the initial evidence supports its effectiveness with a school-age population. The
Barkley parent training program (1997) has not yet been evaluated on its own on younger
ADHD children.
Cognitive-behavioral group treatment for ADHD children has received some
empirical support, although there is some evidence that the inclusion of parent training
53
leads to better outcomes. However, CBT group training has not been evaluated with a
younger population of ADHD children. It is unclear whether this population would
demonstrate a different pattern of treatment responsiveness than is found in older
children. A CBT program that has been tailored to the developmental needs of young
ADHD children may be more engaging and effective.
The Present Study
The present study is unique in several ways. It is the first study to evaluate the
effectiveness o f Barkley’s (1997) parent training manual with a young ADHD population
that includes preschool-age children. Similarly, it is the first study to combine parent
training with child group training for a younger population of ADHD children. The child
group treatment has been adapted for this age group to include activities and games that
are more likely to engage the children’s attention. Therapeutic techniques like
developmentally appropriate games (DAGs) that are potent, relevant, and enjoyable to
young children may increase motivation and skill development (Reddy, Spencer, Hall, &
Rubel, 2001; Reddy et al., in press). As Barkley (1998) recommended, treatment should
focus on “the performance o f particular behaviors at the points o f performance in the
natural environment where and when such behaviors should be performed” (p. 65). That
is, treatment is most likely to be effective when skills are taught in contexts in which
children work and play.
Group-based DAGs are an effective way to capture ADHD children’s interest and
motivation while teaching them important skills in natural settings such as the school,
home, and playground. DAGs provide children the opportunity to interact naturally with
peers and learn appropriate behaviors in the context in which they will be used. DAGs
54
can produce valuable information on when and how social problems occur among
children. Treating children in a natural play setting also increases the likelihood of
maintaining and generalizing treatment gains over time (Hoag & Burlingame, 1997).
DAGs are gross motor activities that are based on three principles: 1) each child has
the opportunity to participate at his/her own ability level, 2 ) as each child plays the game,
opportunities to participate increase, and 3) children who vary in ability can interact
positively with each other (Torbert, 1994). DAGs can build children’s sense of
accomplishment, creativity, and positive regard for themselves and others, while teaching
them important life skills for work and play (Torbert & Schneider, 1993). Children who
participate in group games share an affiliation through which they can encourage other's
growth through positive social interactions (Torbert, 1994). DAGs also present
challenges to children that encourage them to persist and try alternative solutions
(Bunker, 1991).
The present study will address an important gap in the literature by investigating the
effectiveness of combined child group training and parent group training in comparison
to child-only group training for young ADHD children. Consistent with previous
research, it is hypothesized that both treatment groups will be effective in improving
impulsivity, social skills, and anger management. It is also hypothesized that the addition
of parent treatment will provide a significant incremental effect.
Hypotheses
Five hypotheses are proposed:
H i: Children with ADHD exhibit elevated levels of problematic externalizing
behaviors (Barkley, 1990). Behavioral child treatment has been found successful
55
with elementary-age and adolescent children with ADHD (e.g., Pfiffher &
McBumett, 1997; Zaragoza, Vaughn, & McIntosh, 1991). It is hypothesized that
4 - 8 year-old children with ADHD will demonstrate significantly (both
statistically and clinically) reduced levels of problematic behaviors from Time 1
to Time 2 within groups, as measured by the Externalizing composite score and
the Aggression scale on the CBCL, the Hyperactivity and Oppositional subscales
of the CPRS-R, the Problem Behaviors subscale on the SSRS - Parent Form, and
difficulty in compliance situations (Factor 1 ) and difficulty in leisure situations
(Factor 2) on the HSQ. It is also hypothesized that a significant effect will be
found between groups, indicating a greater improvement in behavior problems in
children whose parents received parent training.
H2 : Social skills deficits have been called the “hallmark” characteristic of the disorder
(Whalen & Henker, 1991). Children with ADHD experience significantly
disrupted and delayed social development. Numerous studies have targeted these
deficits, but findings have been mixed (Landau & Moore, 1991). However,
research in this area has primarily focused on elementary-age and adolescent
children. It is hypothesized that preschool children’s social skills will significantly
(both statistically and clinically) improve from Time 1 to Time 2 within groups,
as measured by the Social Skills scale on the SSRS - Parent Form, the Social
Problems subscale on the CBCL, and the Social Problems subscale on the CPRS-
R. It is also hypothesized that a significant effect will be found between groups,
indicating a greater improvement in social skills in children whose parents
received parent training.
56
H3 : There is evidence that self-concept in ADHD children is poorer than in normal
children (Treating & Hinshaw, 2001), and cognitive-behavioral parent and child
treatment interventions have been effective in improving self-concept in ADHD
children (Eisenstadt et al., 1993; Fehlings et al., 1991). It is hypothesized that a
significant improvement (both statistically and clinically) will be found as a result
of treatment on the Cognitive Competence, Peer Acceptance, Physical
Competence, and Maternal Acceptance scales on the Pictorial Scale of Perceived
Competence and Social Acceptance for Young Children. It is also hypothesized
that a significant effect will be found between groups, indicating a greater
improvement in self-esteem in children whose parents received parent training.
H4: Previous research has found elevated levels of stress among parents of ADHD
children (e.g., Barkley, 1996). It is hypothesized that a significant improvement
(both statistically and clinically) in parental stress will occur from Time 1 to Time
2 within groups, as measured by the Child Domain, Parent Domain, and Total
scores on the PSI - III. It is also hypothesized that a significant effect will be
found between groups indicating a greater reduction in stress among parents who
also received the parent treatment.
H5 : Parents o f children with ADHD exhibit a decreased sense of parenting
competence and efficacy, due in part to their children’s behavioral, social, and
educational difficulties (e.g., Barkley, 1996; Cantwell, 1996; Scheel &
Rieckmann, 1998). Several studies have demonstrated that parent training results
in an increase in perceived efficacy among parents of children with ADHD (e.g.,
Erhardt & Baker, 1990; Odom, 1996). Additionally, medication studies suggest
that when child behavior improves, parent functioning improves as well (Barkley,
Cunningham & Karlsson, 1983). It is hypothesized that a significant improvement
in parental efficacy will occur from Time 1 to Time 2 within groups, as measured
by the Child Total, Family Total, and Total on the Family Efficacy Scale. It is
also hypothesized that significant improvement (both statistically and clinically)
will be found between groups, indicating a greater improvement in parental
efficacy among parents who received parent treatment.
Chapter 2: Method
Participants
Children
Five criteria were used for determining children’s eligibility for the program.
Selection criteria included: 1) a primary diagnosis of ADHD by a licensed psychiatrist,
psychologist and/or a pediatric neurologist, 2) child age of 8 years and 8 months or
younger, 3) child enrolled in a part-time or full-time preschool or elementary school
program, 4) clinically elevated scale scores (1.5 standard deviations above the mean) on
several standardized child assessment instruments (discussed below), and 5) parent scores
in the 85th percentile or above on the Child Domain Scale of the Parenting Stress Index-
HI.
Exclusionary criteria included parents currently separated or in the process of divorce,
children who had been sexually and/or physically abused within the past 18 months, and
children who had experienced other significant losses in the past 12 months of their fives.
Fifty-five children who met these criteria were randomly assigned to one of two
treatment conditions: 1) child group training, or 2) parent and child group training. The
groups took place over six consecutive semesters in 1998,1999, and 2000, beginning in
the spring of 1998. In the child training condition (Condition 1), 10 children received
group treatment in the fall of 1998, 9 received group treatment in the spring of 1999, and
8 more in the fall o f 2000. In the parent and child group training condition (Condition 2),
8 children received group treatment in the spring of 1998, 9 received group treatment in
the fall of 1999, 6 in the spring of 2000, and 5 more in the fall of 2000. In total, 27
children were in Condition 1 and 28 were in Condition 2.
59
Child sample characteristics by treatment condition are presented in Table 1. The
mean age of the children in Condition 1 was 78.19 months, or 6 years 6 months (SD =
14.98 months) and the mean age for Condition 2 was 80.54 months, or 6 years 8 months
(SD = 16.68 months). The combined mean age for the child participants was 79.38
months or 6 years 7 months. The minimum age was 51 months (4 years 3 months) and
the maximum age was 104 months (8 years 8 months). Thirty-one (56%) o f the children
in the study were the biological offspring o f their parents, seven (13%) were adopted, and
data were not available for the remaining seventeen subjects (31%). Thirty-nine out of
the 55 children were male (71%) and 16 were female (29%). Forty-seven o f the children
were Caucasian (85%), two were African-American (4%), one was Asian (2%), two were
Hispanic (4%), and three were other/did not wish to answer (6%).
All of the participants had received primary diagnoses of ADHD from an independent
evaluator (a psychiatrist, psychologist, and/or pediatric neurologist). Comorbidity was
assessed using a structured interview, the ADHD Clinic Parent Interview (Barkley,
1991), which included checklists of diagnostic criteria for relevant childhood disorders. It
should be noted that the structured interview provides a measure of ADHD and other
disorder-specific symptomotology, but is not a sufficient source of information to render
a diagnosis. It relies exclusively on parental report, rather than using multiple informants
reporting on behaviors across settings. Therefore, symptom profiles from the Interview
are provided solely to provide a rough indicator of behavioral dysfunction in the sample,
but these categories do not serve as diagnoses. Using the ADHD checklist, 91% of
children had eight or more symptoms of ADHD, thereby meeting or exceeding the DSM-
IV cut-off for the diagnosis. Thirty-two children (58%) met criteria on this measure for
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Oppositional Defiant Disorder, nineteen (35%) met criteria for Dysthymic Disorder, ten
(18%) met criteria for Separation Anxiety Disorder, nine (16%) for Conduct Disorder,
and eight (15%) for Overanxious Disorder. Eight subjects (15%) were reported to have a
speech abnormality and fifteen subjects (27%) demonstrated abnormal social behavior.
Groups differed significantly on only one variable, with higher levels of Conduct
Disorder found in Condition 1.
Parents
Parent sample characteristics by treatment condition are presented in Table 2. Sixty-
three percent of the parents whose children received the child group training (Condition
1) reported an annual income of $61,000 or more. One family (4%) had an income
between $16,000-30,000, three (11%) between $31,000-45,000, one (4%) between
$46,000-60,000, five (19%) between $61,000-80,000, three (11%) between $81,000-
100,000, three (11%) between $110,000-125,000, and six (22%) reported an income
greater than $126,000. The level of mothers’ education ranged from a high school
diploma (4%), to some college (22%), to a BA or BS (37%), to a graduate degree (37%).
Seventy-four percent of mothers had completed college. The level of fathers’ education
ranged from less than high school (7%), to a high school diploma (19%), to some college
(15%), to a BA or BS (33%), to a graduate degree (26%). Fifty-nine percent of the fathers
had completed college. Twenty of the parents (74%) were still married, for lengths
ranging from 7 to 28 years and with a mean marriage length of 13 years.
Fifty-six percent of the parents who received child and parent group training
(Condition 2) reported an annual income of $61,000 or more. One family (4%) had an
income less than $15,000, one family (4%) had an income between $16,000-30,000, one
(4%) between $31,000-45,000, three (11%) between $46,000-60,000, three (11%)
between $61,000-80,000, five (18%) between $81,000-100,000, two (7%) between
$110,000-125,000, and five (18%) reported an income greater than $126,000. The level
of the mothers’ education ranged from less than high school (4%), to some college
(26%), to a BA or BS (33%), to a graduate degree (8%). Forty-one percent of mothers
had completed college. The level of fathers’ education ranged from a high school
diploma (7%), to some college (15%), to a BA or BS (41%), to a graduate degree (8%).
Forty-eight percent o f fathers had completed college. Twenty-one parents (75%) were
still married, for lengths ranging from 4 to 22 years and a mean marriage length of 12
years. Parents differed significantly on only one variable, with higher numbers of
children in the home of parents in Condition 2.
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Table 1
Child sample characteristics
Treatment group
Child Only (Cl) Parent and Child (C2)
N % N %
Total N 27 28
Age
Mean age in months 78.19 80.54
Standard deviation 14.98 16.68
Minimum age 51 51
Maximum age 102 104
Gender
Male 17 63 22 79
Female 10 37 6 21
Ethnicity
White 23 85 24 86
Black 1 4 1 4
Asian 1 4 0 0
Hispanic 1 4 1 4
Other/No answer 1 4 2 7
Grade level
Preschool 4 15 4 14
Kindergarten 5 19 4 14
1st 9 33 8 29
2nd 6 22 9 32
3rd 3 11 3 11
Adopted?
No 15 56 16 57
Yes 2 7 5 18
No answer 10 37 7 25
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Table 2
Parent sample characteristics
Treatment group
Child Only Parent and Child
N % N %
Mother’s education
No information 0 0 8 29
Less than high school 0 0 1 4
High school diploma 1 4 0 0
Some college 6 22 7 25
BA or BS 10 37 10 36
Masters 10 37 1 4
MD, JD, PhD 0 0 1 4
Father’s education
Less than high school 1 4 0 0
High school diploma 5 19 2 7
Some college 4 15 4 14
BA or BS 10 37 11 39
Masters 4 15 1 4
MD, JD, PhD 3 11 1 4
Income range
<$15,000 0 0 1 4
$16,000-30,000 1 4 1 4
$31,000-45,000 2 7 1 4
$46,000-60,000 1 4 4 14
$61,000-80,000 5 19 3 11
$81,000-100,000 3 11 5 18
$101,000-125,000 3 11 2 7
$126,000+ 6 22 5 18
Marital status
Married 20 74 21 75
Divorced 2 7 4 14
Separated 2 7 1 4
Never married 2 7 1 4
Widowed 0 0 1 4
No Answer 1 4 0 0
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Measures
All families were asked to complete the following measures for the baseline (Time 1)
assessment before randomization: the ADHD Clinic Parent Interview (Barkley, 1991),
the Family Screening Form (Reddy, 2000), the Family Efficacy Scale (FES; Reddy,
2000), the Home Situations Questionnaire - Revised (HSQ-R; DuPaul & Barkley, 1992),
the Conners’ Parent Rating Scale - Revised (CPRS; Conners, 1997), the Child Behavior
Checklist (CBCL; Achenbach, 1991), Social Skills Rating System - Parent Form (SSRS;
Gresham & Elliot, 1990), Parenting Stress Index-HI (PSI-III; Abidin, 1995), and the
Pictorial Scale o f Perceived Competence and Social Acceptance for Young Children
(Harter & Pike, 1984). For the post-treatment assessment (Time 2), the FES, HSQ-R,
CPRS, CBCL, SSRS, PSI-III, and the Pictorial Scale of Perceived Competence and
Social Acceptance for Young Children were re-administered.
The ADHD Clinic Parent Interview (Barkley, 1991) is composed of 88 structured
questions about the child’s developmental (i.e., prenatal, perinatal, postnatal,
developmental milestones), medical, treatment, school, and social histories, as well as
current behavioral concerns. In addition, questions keyed to DSM-IV criteria for several
disorders (i.e., ADHD, Oppositional Defiant Disorder, Conduct Disorder, Separation
Anxiety Disorder, Overanxious Disorder, Dysthymia) are included. For the purposes of
this study, the measure was used to identify possible comorbid disorders. Both parents
and/or primary caretakers were encouraged to attend the interview. The interviewers
were all advanced psychology doctoral students who were trained by a licensed
psychologist. The psychometric qualities of the ADHD Clinic Parent Interview have not
been evaluated (R.A. Barkley, personal communication, November 28, 2001).
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The Family Screening Form (Reddy, 2000) is composed of 39 structured questions
that address demographic information about the child and the family. A five-point Likert
scale is used to assess the availability of social support, levels of family connectedness,
and routines in the home. The psychometric qualities of the Family Screening Form have
not been evaluated (L.A. Reddy, personal communication, July 15,2003).
The Family Efficacy Scale (FES; Reddy, 2000) uses a 5-point Likert scale to evaluate
the parents’ sense of personal efficacy in effecting positive change in the child and
family, on a rating scale from (1) impossible to (5) easy. The FES includes 18 items that
represent a Total Score and two subscales. The Child-Focused scale consists often items
that pertain to the parents’ perceived ability to produce a positive change in a range of
child behaviors. The Family-Focused Scale consists of eight items that assess the
parents’ perceived ability to produce change in family interactions. The FES has been
shown to have good internal consistency and construct and predictive validity
(Braunstein et al., 2001; Reddy et al., 2002).
The Home Situations Questionnaire-Revised (HSQ-R; DuPaul & Barkley, 1992) is
designed to assess parents’ perceptions of their child’s attention and behavior problems in
a number o f social contexts. Parents rate their child’s behavior on 14 items that are
arranged in a nine-point Likert scale ranging from (1) mild to (9) severe. The Factor I
scale, a measure of difficulty in compliance situations, and the Factor n scale, a measure
of difficulty in leisure situations, are calculated by dividing the sum of scores on the
relevant items by the number of items. The HSQ-R possesses adequate internal
consistency, test-retest reliability, and construct validity. The internal consistency is .93.
The test-retest reliability across a four-week period is .91, although the test-retest
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reliability for the mean severity score is .77. The HSQ-R significantly correlated with
other parent and teacher ADHD measures (DuPaul & Barkley, 1992).
The Conners’ Parent Rating Scale - Revised (Conners, 1997) is a parent-completed
rating scale that assesses parental perceptions of ADHD-related behaviors. The CPRS is
an 80 item measure that produces 14 scales: Oppositional, Cognitive Problems,
Hyperactivity, Anxious/Shy, Perfectionism, Social Problems, Psychosomatic, ADHD
Index, Global Index: Restless-Impulsive, Global Index: Emotional Lability, Global
Index: Total, DSM-IV Inattentive, DSM-IV Hyperactive-Impulsive, and DSM-IV Total.
Parents rate each item on a Likert scale, ranging from (0) not true at all or never to (3)
very much true or very often. The scale scores are then converted into T-scores, based on
same-age peers. The CPRS has excellent internal reliability, with coefficient alphas for
the ten scales ranging from .75 to .94. The test-retest correlations range from .42 to .78.
The validity o f the CPRS has also been adequately demonstrated. The sensitivity is
92.3%, specificity is 94.5%, and the overall correct classification rate is 93.4% (Conners,
Sitarenios, Parker, & Epstein, 1998).
The Child Behavior Checklist (CBCL; Achenbach, 1991) is a behavior rating scale
that allows parents to rate their child’s level of psychopathology on multiple domains.
The CBCL produces three composite scales (Total, Internalizing, and Externalizing) and
eight subscales (Withdrawn, Somatic Complaints, Anxious/Depressed, Social Problems,
Thought Problems, Attention Problems, Delinquent Behavior, and Aggressive Behavior).
The measure is composed of 113 items that rate the child on a three-point Likert scale
ranging from (0) not true to (2) very true, regarding the child’s behavior within the past
six months. Norms were obtained using two groups (normal and clinically referred) of
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1,300 four to sixteen year-old children. The measure has demonstrated high inter-rater
reliability, high internal consistency, and high test-retest reliability (stability coefficients
range from .65 to .87) for as long as two years. Furthermore, the CBCL has been shown
to have acceptable discriminant, concurrent, predictive, and construct validity
(Achenbach, 1991).
The Social Skills Rating System (SSRS; Gresham & Elliot, 1990) is a rating scale
that assesses parents’ perceptions of their children’s social skills and behavioral
difficulties. There were two forms of the SSRS utilized in this study, the Preschool Level
for the participants in preschool and the Elementary Level for the participants in
kindergarten through third grade. There is a total of 48 (49 on the preschool form) items
that are rated by the parent on a three-point Likert scale, ranging from (0) never to (2)
very often. The measure is divided into two composites. The Social Skills scale consists
of items related to the child’s level of cooperation, responsibility, self-control, and
assertion (high scores indicate more positive social skills). The Problem Behavior scale
consists of items related to externalizing behavior and internalizing behavior problems
(high scores indicate more behavior problems). The SSRS was normed on a large and
diverse national sample. The authors reported good reliability of domain scores (alpha
coefficients greater than .87) and the ability to discriminate between non-clinical and
referred children (Gresham & Elliot, 1990). The test-retest reliability is high for both
Social Skills and Problem Behaviors (.87 and .65 respectively). The SSRS has high
convergent and discriminant validity and high internal consistency. The median
Coefficient alpha for the Social Skills Scale is .90 and is .84 for the Problem Behavior
Scale (Gresham & Elliot, 1990).
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The Parenting Stress Index III (PSI-III; Abidin, 1995) is a parent rating scale
designed to assess parents’ personal level o f stress and their stress related to parenting
their children. The PSI-IH provides a Total Scale and 13 subscale scores divided into two
domains: the Child Domain (i.e., Adaptability, Acceptability, Demandingness, Mood,
Distractability/Hyperactivity, Reinforces Parent) and the Parent Domain (i.e., Depression,
Attachment, Role Restriction, Competence, Isolation, Health, Spouse). The measure is
composed of 100 items that rate the parents’ perceptions on a five-point Likert scale
ranging from (1) strongly agree to (5) strongly disagree. The stability of this measure is
supported by the test-retest reliability coefficients obtained from four separate studies
(Abidin, 1983; Burke, 1978; Hamilton, 1980; Zakreski, 1983). The range of correlation
coefficients between the first and second set of scores obtained for the Child Domain was
.55 to .82, and for the Parent Domain was .69 to .91. A high degree o f internal
consistency is indicated for this measure. Coefficient alpha reliability coefficients based
on the normative sample (2,633 mothers) were calculated for the subscales of both
domains. For the Child Domain the coefficients ranged from .70 to .83 and for the Parent
Domain the coefficients ranged from .70 to .83. Several studies have demonstrated the
PSI-IH’s construct and predictive validity (e.g., Cameron & Orr, 1989; Frey, Greenberg,
& Fewell, 1989; Hart, 1985; Webster-Stratton, 1988; Zakreski, 1983).
The Pictorial Scale o f Perceived Competence and Social Acceptance for Young
Children (Harter & Pike, 1984) is a pictorial scale that measures perceived competence
and social acceptance via four domains of a child’s self-concept: cognitive competence,
physical competence, peer acceptance, and maternal acceptance. Each subscale contains
six items. There are two versions of the scale, one designed for preschoolers and
69
kindergarteners and another for first and second graders. There are separate versions for
boys and girls, allowing the child to respond to pictures of a same-sex child. For each
item, the subject is shown two pictures of a child engaging in a task, one doing the task
poorly and the other doing it successfully. The child is asked which girl/boy s/he is most
like. Then the child is asked to refine this answer further, for example: “Are you pretty
good at skipping or really good?” Each item is scored on a four-point scale. The scale has
demonstrated adequate psychometrics. The reliability of the total scale is in the mid- to
high .80s. Subscale reliabilities range from .50 to .85. The authors (1984) reported good
convergent, discriminant, and predictive validity.
Procedure
All applicants who contacted the ADHD Clinic at Fairleigh Dickinson for treatment
were screened for eligibility for the study. Parents learned of the program from their
child’s physician, from ads placed in local papers, from an Internet web page, or from
word of mouth. After calling the clinic and providing basic demographic information,
subjects’ parents were contacted by the Clinic Coordinator, an advanced doctoral student
who explained the program further. Parents were told that the children’s treatment
program has three targeted goals: anger management, impulse control, and social skills.
Additionally, they were told the general format of the program (a 10-week program
meeting weekly in the evenings) and the cost. The Clinic Coordinator then informed the
parents that a representative from the Clinic would contact them to set up an interview at
their mutual convenience.
A screening interview was conducted with the subject’s parent(s) to assess the child’s
appropriateness for the program. Documentation from a pediatric neurologist, board
certified child and adolescent psychiatrist, and/or developmental psychologist was
required, attesting that each child had a diagnosis of Attention-Deficit/Hyperactivity
Disorder. Parents signed consent forms (included in Appendix A), agreeing to participate
in clinical treatment as well as a research outcome study. The ADHD Clinic Parent
Interview was administered, which included diagnostic checklists and collected extensive
information regarding pre-natal, post-natal, and current functioning. The Family
Screening Form and the Family Efficacy Scale were also administered to collect further
demographic information, to assess family routines and resources, and to evaluate the
family’s perceived sense of efficacy. After the screening was completed, the parents
were given an assessment packet to complete at home and mail into the Clinic containing
the HSQ-R, CBCL, SSRS, and PSI. The parents were asked to bring their child in on a
separate occasion to complete the Pictorial Scale of Perceived Competence and Social
Acceptance for Young Children.
Once the assessment measures had been reviewed, parents were notified regarding
their acceptance into the program. If the child was on stimulant medication, participating
parents were advised not to change medication for the duration of the program and to
consider giving their child an extra dose (with their doctor’s consent) before each group
so s/he could maximally benefit from the children’s group training. Parents filled out a
questionnaire at the conclusion of treatment stating if their child was medicated at the
start o f treatment, the type of medication, dosage at Time 1, whether the medication type
or dosage changed over the course of treatment, and dosage at Time 2. Of the 34 subjects
for whom data are available, 17 were on stimulant medication at the start of treatment.
Ten of the medicated subjects were in Condition 1 and 7 were in Condition 2. There
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were five reported medication changes at post-treatment. In Condition 1, 1 subject
switched to a different stimulant medication, 1 reported an increase in dosage, 1 reported
a decrease in dosage, and 1 stopped taking medication. In Condition 2, there was one
reported increase in dosage. There were no significant differences between groups in the
numbers of subjects on medication or the dosage at Time 1 or Time 2.
Therapist Training
Therapists were trained by a licensed psychologist. The Director of the ADHD Clinic
provided intensive training and supervision to several advanced graduate students on the
family eligibility screening, child group treatment, and parent group treatment. Training
for the family eligibility screenings consisted of a two hour review of: 1) the objectives
of the program, 2) procedures for ensuring confidentiality, and 3) procedures for
administering and scoring the parent interview and several parent and child standardized
measures. The graduate students then observed an experienced interviewer administer a
screening and s/he was asked to complete a second screening protocol independently
while observing the experienced interviewer. Both protocols were then compared and
inter-rater reliability was computed, yielding 100% overall agreement for all therapists.
Training for the child group training included a full day seminar in the techniques of
behavior modification, on the specifics of ADHD, and on the procedures utilized by the
ADHD Clinic. All techniques were discussed, modeled, and role-played with the child
group therapists. The Director o f the Clinic provided supervision 30 minutes prior to the
start of each child group session. Therapists were given a copy of each session’s
curriculum to review, and relevant interventions were modeled and rehearsed. After the
session was completed, the Director provided supervision on the implementation of the
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curriculum. One of the group therapists monitored adherence to the curriculum in each
session by checking off on a form each item as it was addressed. High levels of
compliance were demonstrated in all groups.
Training to administer the parent group training included weekly meetings in which
the next session’s content was carefully reviewed. The Director of the Clinic discussed
the new skills to be taught each week, and answered any questions about how to
implement them. Each treatment session was audio-taped and reviewed by the Director
of the Clinic, to ensure consistency between groups and adherence to the curriculum.
Treatment Program
Child Group Training
The child group training was designed to address three main areas (i.e., social skills,
impulsivity, and anger management), which are common concerns reported for young
children with ADHD. The Director of the Clinic developed the child group training
based on behavioral, social learning, and child play therapy principles (Reddy et al.,
2001). Children were taught problem-solving skills through didactic instruction,
symbolic and in vivo modeling, role-playing, behavioral rehearsal, coaching, and
developmentally appropriate games (DAGs). DAGs were based on the following
principles: 1) each child had the opportunity to choose to participate at his/her own
ability level, 2) there were increased opportunities for each child to participate, and 3)
children who varied in ability could interact successfully with each other (Torbert, 1994).
The child group training was held in a large room with enough floor space for 15
people to sit comfortably. In every group, the ratio of child to therapist was 2:1. The
child group training included a token economy system to encourage children to master
new skills and promote their self-confidence. Children were able to earn a sticker for
each of three group goals they achieved during each session: following directions, using
words appropriately, and keeping hands and feet to themselves. Topics addressed in the
group included sharing with others, managing anger and stress, and problem-solving in
social contexts. A Time Out protocol was implemented, to promote self-control and self
regulation. Time Out was presented as a positive step to take when feeling “restless” or
“antsy,” and children were praised for utilizing this technique. Children were encouraged
to self-initiate Time Out, but were required to raise their hand, request a Time Out, and
take the Time Out pass with them to the chair. After a few minutes of Time Out, a .
therapist would go over to the child, validate him/her for taking the Time Out, and assess
with the child if s/he was ready to return to the group. Three levels of Time Out were
used, one in the room, one in the hallway outside the child training room, and the third in
a nearby seclusion room. A group therapist accompanied a child to a level 2 or 3 Time
Out. In addition to the Time Out pass, a bathroom pass was utilized, and children raised
their hands to request this as well.
Skill sequences were taught through three methods: 1) modeling, 2) role-play, and 3)
corrective feedback. The steps were visually presented on a large easel in front of the
group, and were each read aloud and discussed. First, all skill sequences were modeled
by two group therapists. Next, a therapist and a child performed the skill sequence for the
group. Last, two children, assisted by a group therapist, role-played the skill sequence for
the group. Role-plays were set in home, peer, and school contexts to enhance
generalization. During the role-plays, the therapists stopped at each step, reviewing with
the group if the role-players demonstrated the skill sequence correctly.
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At the conclusion of each group, children filled out a therapeutic workbook called
“About Me,” in which they were asked to depict pictorially their hobbies, likes, dislikes,
and other personal information. After completing their drawings, children presented and
explained them to the group. The mles and structures of the group were reviewed at the
beginning of each session. Details of the curriculum taught in the child group training are
presented in Appendix B.
Parent Group Training
A modified version of Barkley’s (1997) parent training curriculum was used. The
parent group training was designed to provide parents with support and information about
their child's disability. In addition, the group was geared to teach families techniques for
managing their child's educational, social, and behavioral needs. The five primary
objectives were: (1) to increase the parents’ knowledge of ADHD, (2) to heighten their
awareness of their child’s strengths and weaknesses, (3) to introduce and systematically
maintain the use of behavioral techniques at home and public places, (4) to improve
communication patterns between parents and between parent and child, and (5) to help
parents with anger and stress management.
The parent group was held for 10 consecutive weeks, concurrently with the children’s
group training. The group was located in a conference room that allowed all the parents
to sit comfortably around a large table. Group instruction included both lecture and
discussion components, and handouts with synopses of the session’s content were
frequently provided. Parents were encouraged to take notes, and weekly assignments
were given to aid the parents in implementing and improving the new skills being taught.
Homework was reviewed at the start of each group, before new skills were taught. At the
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conclusion of each group, a brief summary of the skills taught during the child session
was provided. Details o f the parent group training curriculum are included in Appendix
C.
Analytical Methods
First, descriptive statistics were computed to determine the means and standard
deviations on each measure for each treatment condition.
Second, an analysis of covariance (ANCOVA) was performed on each o f the 20
variables that fell in the five clinical domains being studied: externalizing problems,
social skills, child self-concept, parental stress, and parental efficacy. Baseline scores on
each measure were covaried out of the analysis, providing a conservative measure of the
differential effects o f treatment.
Third, a repeated measures analysis of variance (ANOVAs) was performed on each
variable, with 1 between (i.e., group assignment) and 1 within (i.e., time) subject factor.
Fourth, pre- planned comparisons (i.e., paired t-tests) were performed on each
variable by treatment group to determine the time contrasts between baseline (Tl) and
program completion (T2).
Fifth, between group effect sizes (Glass, McGraw, & Smith, 1981) were calculated to
provide a standardized measure of the magnitude of change (i.e., from Tl to T2) of each
one o f the two treatment conditions. The gain score between group effect size formula is
as follows:
(_E -post " _ E -p re) " (_C -post " _C -pre)

ESbetw een —
^S C-post S C-pre " 2r(C-post,C-pre)(SDc-pre)(SDc-post)
"E" indicates child and parent group data and "C" indicates child only group data. In this
76
equation, r is the test-retest reliability coefficient for the outcome measure.
Sixth, within group effect sizes (Smith & Glass, 1977) were computed to compare the
change found from Time 1 to Time 2 between groups, to determine if the combined
treatment condition improved more than the child training group. The within group
effect size formula is as follows:

^treatment _ ^pre-treatment
E Sw ithin —
S D p r e -treatment
Seventh, the Jacobson and Truax method (1991) was computed to determine
clinically significant change among participants. This method was devised as an
alternative or supplement to traditional statistical analyses. As Jacobson and Truax
argue, a statistically significant treatment effect does not necessarily produce change with
clinical significance, which requires a demonstration o f positive impact on functioning
and in quality of life. Therefore, rather than looking at mean changes in a sample over
time, Jacobson and Truax focus on how far an individual’s test score has moved from
within the range of a dysfunctional population to within the range of a normal population.
Additionally, by evaluating change for each individual, it is possible to examine the
variability of responses within the sample. The Jacobson and Truax method uses a
Reliable Change Index (RCI), which indicates if the degree of change for each individual
is one that is unlikely to occur by chance. Four categories are produced from the RCI
procedure: no change, minimal change, reliable change, and reliable change with
recovery.
Chapter 3: Results
Descriptive Statistics
Means and standard deviations are presented in Table 3 for the two conditions (Cl and
C2) at both Time 1 (pre-treatment) and Time 2 (post-treatment). Because SYSTAT tests
for significance using a 2 -tailed test, significance values on all subsequent analyses were
adjusted to reflect the hypotheses, which were 1-tailed. Where outliers were detected,
analyses were conducted with these outliers removed and no change in results was found.
Therefore, all reported analyses were based on the full set of data that included outliers.
Hypothesis 1: Externalizing Behaviors
It was hypothesized that the child participants would demonstrate significantly
reduced levels of problematic behaviors from Time 1 to Time 2 within groups, as
measured by the Externalizing composite score and the Aggressive scale on the CBCL,
the Oppositional and the Hyperactivity subscales of the CPRS, the Problem Behaviors
subscale on the SSRS-Parent Form, and Factor 1 (compliance situations) and Factor 2
(leisure situations) on the HSQ. It was also hypothesized that the within group change
would be significantly greater in the combined child and parent group treatment
condition.
Seven repeated measure ANOVAs were conducted with one between (treatment
group) and one within (time) subject factor to evaluate the effects of treatment group and
time on externalizing behaviors. Table 5 presents these results. The Time x Group
interaction effects were nonsignificant for all seven scales. The Time main effect was
significant for all seven scales: Externalizing scale, F (1,44) = 11.13, p < .01, Aggressive
scale, F (1,44) - 10.04, p < .01, Oppositional scale, F (1,36) = 12.65, p < .01, Hyperactive
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scale, F (1,36) = 4.84, p = .02, Problem Behavior scale, F (1,45) = 8.19,2 < -01, Factor 1
(compliance situations), F (1,45) = 35.71,2 < .01, Factor 2 (leisure situations), F (1,45) =
21.57,2 < .01. This finding demonstrates that both treatment groups combined exhibited
a significant improvement on all seven of the scales measuring externalizing behavior.
Seven ANCOVAs were conducted in order to compare statistically each group’s post
treatment scores, while controlling for differences in pre-treatment scores. Table 6
presents these results. A significant effect was noted on the SSRS Problem Behavior
scale, F (1,45) = 3.08, p = .04, and a trend that approached significance on the CBCL
Aggressive scale, F (1,43) = 2.18, p = .07, both favoring C2 over Cl.
Pre-planned comparisons were computed to determine within group effects on each
dependent variable. As Table 7 indicates, significant effects for Cl were noted on the
Externalizing scale o f the CBCL, t (20) = 1.80, p = .04, the Oppositional Scale of the
CPRS-R, t (21) = 2.13, p = .02, Factor 1, t (22) = 5.27, p < .01, and Factor 2, t (22) =
4.16, p < .01. A trend that approached significance was observed on the Cl CBCL
Aggressive scale, t (20) = 1.51, p = .07, and the CPRS-R Hyperactive Scale, t (21) = 1.47,
2 = .08. All seven scales were significant for C2: Externalizing scale, t (24) = 3.22, p <
.01, Aggressive scale, t (24) = 3.36, p < .01, Oppositional scale, t (15) = 4.36, p < .01,
Hyperactive scale, t (15) = 4.35, p < .01, the Problem Behavior scale, t (24) = 3.56, p <
.01, Factor 1, t (23) = 3.43, p < .01, and Factor 2, t (23) = 2.58, p = .01.
Within group effect sizes were calculated to provide a standardized measure of the
clinical magnitude of change from Time 1 to Time 2 within each of the treatment
conditions. Effect sizes were interpreted in accordance to Cohen’s (1988) classification
system, in which values of .20, .50, and .80 represent small, medium, and large changes
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on a dependent variable. Effect sizes can have either positive or negative values,
indicating the direction of change. A large positive within group ES indicates a
significant improvement over time as a result of treatment, while a large negative ES
indicates that deterioration or worsening has taken place during treatment. As presented
on Table 8 , a positive effect was seen on all seven scales for both groups. Cl
demonstrated small positive effects on five scales: the CBCL Externalizing and
Aggressive scales, the CPRS Oppositional and Hyperactive scales, and the SSRS
Problem Behavior scale. A large effect was found on the HSQ Factor 1 (compliance
situations) scale and a medium effect on the Factor 2 (leisure situations) scale. C2
demonstrated medium positive effects on six scales, Externalizing, Aggression,
Oppositional, Hyperactive, Problem Behavior, and HSQ Factor 1 (compliance situations),
and a small effect on Factor 2 (leisure situations).
Between group effect sizes were computed to determine the clinical magnitude of
change that occurred from Time 1 to Time 2 between the two treatment groups. A large
positive between group effect sizes indicates that, consistent with hypotheses, the
combined parent and child group treatment has demonstrated a larger positive result than
the child treatment group. Table 8 presents these results. Small positive effects were
found on the CBCL Aggressive scale and the SSRS Problem Behavior Scale. Contrary to
expectations, a medium negative effect was found on the HSQ Factor 2 (leisure
situations) scale and a small negative effect was found on the HSQ Factor 1 (compliance
situations) scale, indicating a greater improvement in Cl than in C2 on these measures.
Hypothesis 2: Social Skills
It was hypothesized that the child subjects would demonstrate significantly improved
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social skills from Time 1 to Time 2 within groups, as measured by the Social Skills scale
on the SSRS, the Social Problems scale on the CBCL, and the Social Problems scale on
the CPRS. It was also hypothesized that the within group change would be significantly
greater in the combined child and parent group treatment condition.
Three repeated measure ANOVAs were conducted with one between (treatment
time on social skills. Table 5 presents these results. The Time x Group interaction effects
were nonsignificant for all three scales, although a trend toward significance favoring Cl
over C2 was noted on the CPRS Social Problems Scale, F (1,36) = 2.08, p = .08. The
Time main effect was also nonsignificant for the three social skills scales. This finding
demonstrates that the treatment groups combined did not demonstrate a significant
improvement in social skills as measured by these three scales.
Three ANCOVAs were conducted in order to compare statistically each group’s post
presents these results. The between group effects were nonsignificant for all three scales,
although a trend approaching significance favoring C2 over Cl was noted on the CBCL
Social Problems scale, F (1,43) = 1.97, p = .08.
dependent variable. As Table 7 indicates, none of the three social skills scales were
significant for either group, although a trend approaching significance was noted on the
CPRS Social Problems scale for C2, t (15) = -1.45, p = .08.
Within group effect sizes were calculated to assess the clinical magnitude of change
from Time 1 to Time 2 within each of the treatment conditions. As presented on Table 8 ,
there were no positive effects on the three social skills scales for C l, but there was a
small positive effect on the SSRS Social Skills scale for C2.
change that occurred from Time 1 to Time 2 between the two treatment groups. It was
hypothesized that C2 would have greater improvements than C l. The results were largely
consistent with this hypothesis; medium effects were found on both the SSRS Social
Skills and CBCL Social Problems scales.
Hypothesis 3: Child Self-Concept
It was hypothesized that the child subjects would demonstrate significant
improvement in self-concept from Time 1 to Time 2 within groups, as measured by the
Cognitive Competence, Peer Acceptance, Physical Competence, and Maternal
Acceptance scales o f the Pictorial Scale of Perceived Competence and Social Acceptance
for Young Children. It was also hypothesized that the within group change would be
significantly greater in the combined child and parent group treatment condition. Data
were available for the majority of subjects on the younger version o f the measure (39
subjects at Time 1, 37 subjects at Time 2), so analyses were conducted using these data.
Four repeated measure ANOVAs were conducted with one between (treatment group)
and one within (time) subject factor to evaluate the effects of treatment group and time on
externalizing behaviors. Table 5 presents these results. The Time x Group interaction
effects were nonsignificant for all four scales. The Time main effect was significant for
the Cognitive Competence scale, F (1,34) = 9.80, g < .01. This finding demonstrates that
both treatment groups combined exhibited a significant improvement on Cognitive
Competence.
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Two ANCOVAs were conducted in order to compare statistically each group’s post
treatment scores, while controlling for differences in pre-treatment scores. The between
group effects were nonsignificant for all scales measuring child self-concept.
dependent variable. As Table 7 indicates, the Cognitive Competence scale was
significant for C l, t (22) = -2.55, p = .01, and C2, t (12) = -2.04, g = .03.
a positive effect was seen on two scales for C l. The child group treatment demonstrated
a medium positive effect on the Cognitive Competence scale and a small positive effect
on the Physical Competence scale. C2 demonstrated a medium positive effect on
Cognitive Competence, and a small positive effect on Peer Acceptance, Physical
Competence, and Maternal Acceptance.
change that occurred from Time 1 to Time 2 between the two treatment groups. It was
hypothesized that C2 would have greater improvements than C l. As presented on Table
8 , a medium effect was found on the Maternal Acceptance Scale and small effect was
found on the Peer Acceptance scale. These results are consistent with the study
hypotheses, favoring C2 over C l.
Hypothesis 4: Parental Stress
It was hypothesized that a significant improvement in parental stress would occur
from Time 1 to Time 2 within all groups, as measured by the Child Domain, Parent
Domain, and Total Scores on the PSI-III. It was also hypothesized that the within group
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change would be significantly greater in the combined child and parent group treatment
condition.
Repeated measure analyses of variance (ANOVAs) were conducted on all three
variables with one between (treatment group) and one within (time) subject factor to
evaluate the effects o f treatment group (Cl or C2) and time (pre-treatment and post
treatment) on parent ratings of stress. Table 5 presents these results. The Time x Group
interaction effects were nonsignificant for all three subscales o f the PSI-ffl. The Time
main effect was significant for all three scales: the Child Domain, F (1,43) = 13.60, g <
.01, the Parent Domain, F (1,43) = 4.19, g = .02, and the Total Score, F (1,43) = 9.27, g <
.01. This finding demonstrates that both treatment groups combined exhibited a
significant improvement on the Child Domain, Parent Domain, and the Total Score
subscales over time.
Analyses of covariance (ANCOVAs) were conducted in order to compare statistically
each group’s post-treatment scores, while controlling for differences in pre-treatment
scores. Table 6 presents these results. None of the three subscales measuring parenting
stress demonstrated significance.
Pre-planned comparisons (i.e., paired t-tests) were computed to determine within
group effects on each dependent variable. As Table 7 indicates, Cl yielded significant
results for the Child Domain, 1(21) = 1.79, g = .04, and the Total Score subscale, t (21) =
1.68, g = .05. C2 yielded significant results for all three scales: the Child Domain, t (22)
= 3.77, g < .01, Parent Domain, t (22) = 1.77, g = .05, and for the Total Score, t (22) =
2.95, g < . 01.
Next, effect sizes (ES) were computed to generate a standardized measure of change
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between and within groups. As Table 8 demonstrates, Cl demonstrated small positive
effects on the Child Domain, Parent Domain, and Total Score scales. C2 demonstrated a
medium positive effect on the Child Domain and a small positive effect on the Total
Score.
Between group effect sizes were conducted to assess the clinical magnitude of change
from pre-treatment to post-treatment between the two treatment conditions. It was
hypothesized that C2 would have greater improvements than Cl. As presented on Table
8 , the results did not support the hypotheses. One small negative effect was found on the
Total Score subscale, indicating that Cl showed a slightly greater improvement on this
scale than C2.
Hypothesis 5: Parenting Efficacy
It was hypothesized that a significant improvement in parental efficacy will occur
from Time 1 to Time 2 within all groups, as measured by the Child Total, Family Total,
and Total Score on the Family Efficacy Scale. It was also hypothesized that the within
group change would be significantly greater in the combined child and parent group
treatment condition.
Three repeated measure ANOVAs were conducted with one between (treatment
time on parent ratings o f efficacy. Table 5 presents these results. The Time x Group
interaction effects were nonsignificant for all three subscales of the FES. The Time main
effect was significant for the Child Domain, F (1,37) = 7.35, p = .01, and the Total Score,
F (1,37) = 5.82, p = .01. A trend was also observed on the Family Domain that
approached significance, F (1,37) = 2.51, p = .06. This finding demonstrates that both
85
treatment groups combined exhibited a significant improvement on the Child Domain
and Total Score subscales of the FES over time, and exhibited changes on the Family
Domain that approached significance.
Three ANCOVAs were conducted in order to compare statistically each group’s post
presents these results. The between group effects were significant for the Child Domain
scale in favor of C2 over Cl, F (1,37) = 2.74, g - .05.
dependent variable. As Table 7 indicates, Cl yielded significant results on the FES Total
Score scale, t (21) = -1.67, p = .05, and a trend that approached significance was noted on
the Child Domain scale, t (21) = -1.37, g = .09, and on the Family Domain scale, t (21) -
-1.40, g = .09. C2 yielded significant results for the Child Domain, t (16) = -2.44, g =
.01, and the Total Score, t (16) = -1.93, g = .04.
a positive effect was seen on all three scales for both groups. C l demonstrated small
positive effects on the Child Domain and Total Score scales, and a medium positive
effect on the Family Domain. C2 demonstrated a medium positive effect on the Child
Domain and Total Score scales, and a small positive effect on the Family Domain.
change that occurred from Time 1 to Time 2 between the two treatment groups. Since the
test-retest reliability has not been determined for the FES, a conservative estimate of .7
was used. Table 8 presents these results. A small positive effect was found on the Child
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Domain, indicating that C2 had a greater improvement on this measure than C l. Contrary
to expectations, a small negative effect was found on the Family Domain scale, indicating
that C l had greater improvement than C2 on this scale.
Clinical Significance Based on the Jacobson and Truax Method
Jacobson and Truax’s (1991) method of calculating clinically significant change was
used. All measures on which statistically significant change, or a trend approaching
significance, were detected were included in the analysis. The difference between post
treatment and pre-treatment scores for each individual was divided by the standard error
of difference between the two test scores. The standard error of difference (Sdiff) was
calculated by taking the square root of two times the standard error of measurement (Se)
squared. The Se was, in turn, calculated by multiplying the standard deviation of the
normative sample by the square root of 1 minus the test-retest reliability. Where the
normative data was not available, the standard deviation from the study sample was used.
Four categories o f reliable change are possible. On scales that measure degrees of
maladaptive behavior, such as the CBCL Externalizing Scale, “no change” indicates that
the Reliable Change (RC) score is greater than or equal to zero. A “minimal change”
score is between 0 and -1.96, two standard deviations from the mean. A “reliable
change” score is less than or equal to -1.96, indicating a 95% likelihood that the post-test
score reflects true change. The sign of these cut-off scores is reversed if the test scores
are expected to increase with treatment, as on the Family Efficacy Scale and the Pictorial
Scale of Perceived Competence and Social Acceptance for Young Children. On these
scales, “no change” indicates that the Reliable Change (RC) score is less than or equal to
zero. A “minimal change” score is between 0 and 1.96, and a “reliable change” score is
87
greater than or equal to 1.96.
To achieve “reliable change with recovery,” three criteria must be met. The RC score
has to fall in the “reliable change” range, the subject’s baseline score has to fall in the
clinically deviant range, and the post-treatment score has to fall within the normal range.
The cut-off scores for the normal range were drawn from the manuals for each measure.
On the CBCL, the author’s cut-off score was a T-score of 60, so scores of 59 and below
were considered in the normal range. On the Conners Parent Rating Scale-Revised, the
author’s cut-off of 65 was used, and on the SSRS, the author’s cut-off score was 115. On
the PSI-III, the author established the 85th percentile as the cut-off score for the deviant
population. Using this standard, the cut-off for the Child Domain scale was a score of
116, a score of 148 on the Parent Domain, and a score of 258 on the Total Score. On the
HSQ-R, using the guidelines in the manual, the cut-off score was based on the age- and
gender-specific means and standard deviations of the normative sample in the manual.
For each age and gender, a cut-off score was determined that was 1.5 standard deviations
from the mean of the normal sample. Recovery was not calculated on scales that measure
positive traits (i.e., child self-concept and parental efficacy), since they are not measures
of pathology.
The results of the clinically significant analysis for each measure are reported in
Appendix D. Table 9 presents the percentages of subjects that fall within each category,
by treatment condition. Visual inspection of Table 9 indicates that a larger percentage of
subjects in the combined parent and child group training “recovered” than in the child
group training condition on eight of the twelve measures on which recovery was
evaluated, supporting the superiority of the combined treatment condition. On aggressive
behavior, oppositional behavior, problem behavior, social problems, difficulty in leisure
situations, and two scales measuring parental stress, the combined treatment resulted in
more subjects returning to a normal range of functioning. Cl indicated superiority to C2
on four measures, the Parent Domain of the PSI, the Externalizing scale of the CBCL, the
Hyperactive scale on the CPRS, and the Factor 1 scale on the HSQ. Looking at both
groups combined, a substantial percentage of subjects (60%) recovered on the HSQ
Factor 1 scale (difficulty in compliance situations), SSRS Problem Behavior scale (43%),
PSI Total Score (31%), and difficulty in leisure situations (38%).
89
Table 3
Means and Standard Deviations for Child Group Training (C l) at Times 1 and 2
M easure Time 1 Time 2
M SD N M SD N
Parent - completed
Externalizing Problems
CBCL Externalizing 65.89 9.27 26 62.00 8.30 22
CBCL Aggressive 6 8 .0 0 12.28 26 63.41 8.97 22
CPRS-R Hyperactive 75.89 17.59 27 69.73 11.36 22
CPRS-R Oppositional 71.85 13.87 27 65.91 12.52 22
SSRS Problem Behavior 125.89 11.34 27 121.82 14.10 22
HSQ Factor 1 52.22 18.34 27 35.26 18.13 23

HSQ Factor 2 30.48 13.92 27 20.09 10.97 23
Social Skills
SSRS Social Skills 78.52 18.50 27 76.08 18.38 24
CBCL Social Prob. 66.39 8.97 26 67.82 9.45 22
CPRS-R Social Prob. 69.70 13.92 27 68.73 13.66 22
Parental Stress
PSI-m Child Domain 145.89 23.75 27 135.05 21.72 22
PSI-m Parent Domain 138.48 27.08 27 131.32 20.85 22
PSI-m Total Score 284.59 44.37 27 266.36 33.36 22
Parental Efficacy
FES Child Domain 32.44 5.84 27 33.71 4.09 22
FES Family Domain 29.04 5.40 27 32.09 10.09 22
FES Total Score 61.48 10.43 27 65.80 12.49 22
Child - completed
Child Self-Concept
Cognitive Competence 3.40 .56 24 3.76 .62 23
Peer Acceptance 3.19 .61 24 3.17 .92 23
Physical Competence 3.33 .54 24 3.45 .52 23
Maternal Acceptance 2.97 .6 6 24 2.89 .84 23
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Table 4
Means and Standard Deviations for Parent & Child Group Training (C 2 ) at Times 1 and 2
Measure Time 1 Time 2
M SD N M SD N
Parent - completed
CBCL Externalizing 63.18 7.27 28 58.88 6.40 25
CBCL Aggressive 64.18 8.97 28 58.36 8.36 25
CPRS-R Hyperactive 67.58 9.61 19 60.53 8.32 17
CPRS-R Oppositional 74.47 9.59 19 68.59 8.78 17
SSRS Problem Behavior 122.36 10.30 28 114.79 9.43 24
HSQ Factor 1 48.22 18.43 27 34.64 16.87 25
HSQ Factor 2 27.59 14.75 27 20.56 14.49 25
Social Skills
SSRS Social Skills 78.22 12.94 27 81.12 14.32 26
CBCL Social Prob. 63.32 9.21 28 62.36 9.30 25
CPRS-R Social Prob. 65.58 14.68 19 65.88 16.32 17
Parental Stress
PSI-HI Child Domain 138.89 19.04 27 127.13 22.43 24
PSI-m Parent Domain 119.44 27.11 27 114.58 25.67 24
PSI-HI Total Score 258.33 39.93 27 243.33 41.69 24
Parental Efficacy
FES Child Domain 32.75 5.23 20 35.88 3.97 17
FES Family Domain 32.63 4.04 19 33.94 3.23 17
FES Total Score 63.75 9.55 20 69.82 6.28 17
Child - completed
Child Self-Concept
Cognitive Competence 3.28 .59 15 3.71 .41 14
Peer Acceptance 3.07 .73 15 3.25 .6 6 14
Physical Competence 3.31 .50 15 3.48 .35 14
Maternal Acceptance 2.79 .82 15 3.01 .76 14
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Table 5
Repeated measures analysis o f variance for parent- and child-completed outcome
measures from Time 1 to 2
Measure Time Time x Group
F , N F N
Parent - completed
CBCL Externalizing 1113*** 46 .03 46
CBCL Aggressive 1 0 04*** 46 .29 46
CPRS-R Oppositional 1265*** 38 .04 38
CPRS-R Hyperactive 4.84** 38 .06 38
SSRS Problem Behavior 8.19*** 47 .95 47
HSQ Factor 1 35.71*** 47 .54 47
HSQ Factor 2 21.57*** 47 .53 47
Social Skills
SSRS Social Skills .0 2 49 .50 49
CBCL Social Problems .0 0 46 .44 46
CPRS-R Social Problems .07 38 2.08* 38
Parental Stress
PSI-m Child Domain 13.60*** 45 .60 45
PSI-HI Parent Domain 4 jg** 45 .0 0 45
PSI-m Total Score 9 27*** 45 .24 45
Parental Efficacy
FES Child Domain 7.35*** 39 .76 39
FES Family Domain 2.51* 39 .48 39
FES Total Score 5.82** 39 .0 1 39
Child - completed
Child Self-Concept
Cognitive Competence 9.80*** 36 .0 0 36
Peer Acceptance .09 36 .58 36
Physical Competence .91 36 .15 36
Maternal Acceptance .03 36 1.65 36
Note. *2 ^-10, **p <05, *** p <01.
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Table 6
Analysis o f Covariance for parent- and child-completed outcome measures from Time 1
to 2
M easure Between Group
F N
Parent - completed
CBCL Externalizing 0.82 46
CBCL Aggressive 2.18* 46
CPRS-R Oppositional 0.97 38
CPRS-R Hyperactive 0 .0 0 38
SSRS Problem Behavior 3.08** 47
HSQ Factor 1 0 .2 1 47
HSQ Factor 2 0.27 47
Social Skills
SSRS Social Skills 0.92 49
CBCL Social Problems 1.97* 46
CPRS-R Social Problems 0.95 38
Parental Stress
P SI-III Child Domain 1.38 45
PSI-III Parent Domain 1.55 45
PSI-m Total Score 1.50 45
Parental Efficacy
FES Child Domain 2.74** 39
FES Family Domain 0 .0 0 39
FES Total Score 0.51 39
Child - completed
Child Self-Concept
Cognitive Competence 0.04 36
Peer Acceptance 0.51 36
Physical Competence 0.04 36
Maternal Acceptance 1.44 36
Note. *g < 10, **p <05, *** g < .01.
93
Table 7
T-tests for parent- and child-completed outcome measures from Time 1 to 2
Measure Cl C2
t df t df
Parent - completed
CBCL Externalizing 1.80** 2 0 3.22*** 24
CBCL Aggressive 1.51* 2 0 3.36*** 24
CPRS-R Oppositional 2.13** 21 4.36*** 15
CPRS-R Hyperactive 1.47* 21 4.35*** 15
SSRS Problem Behavior 1.09 21 3.56*** 23
HSQ Factor 1 5.27*** 22 3.43*** 23
HSQ Factor 2 4.16*** 22 2.58*** 23
Social Skills
SSRS Social Skills .47 23 -.59 24
CBCL Social Problems -.42 20 .53 24
CPRS-R Social Problems .80 21 -1.45 15
Parental Stress
PSI-III Child Domain 2 79 ** 21 2 77 *** 22
PSI-HI Parent Domain 1.24 21 1.77** 22
PSI-III Total Score 1 .6 8 ** 21 2 95*** 22
Parental Efficacy
FES Child Domain -1.37* 21 -2.44*** 16
FES Family Domain -1.40* 21 -1.05 16
FES Total Score -1.67** 21 -1.93** 16
Child - completed
Child Self-Concept
Cognitive Competence -2.55*** 22 -2.04** 12
Peer Acceptance .33 22 -1 .1 2 12
Physical Competence -1.04 22 -.41 12
Maternal Acceptance .98 22 -.82 12
Note. *p < 1 0 , **2 <.05, *** p < .01.
Table 8
Effect sizes (ESI for parent and child-completed outcome measures for C l and C2 from
Time 1 to 2
Measure Within group Between group
Cl ES C2 ES C1-C2 ES
Parent - completed
CBCL Externalizing .42 small .59 medium .1 2
CBCL Aggressive .37 small .65 medium .2 2 small

CPRS-R Oppositional .43 small .73 medium .09
CPRS-R Hyperactive .35 small .61 medium -0.03
SSRS Problem Behavior .36 small .73 medium .29 small
HSQ Factor 1 .92 large .74 medium -0.44 small
HSQ Factor 2 .75 medium .48 small -0.56 medium
Social Skills
SSRS Social Skills -0.13 .2 2 small .57 medium
CBCL Social Problems -0.16 .1 0 .51 medium
CPRS-R Social Problems 0.07 -0 . 0 2 -0.15
Parental Stress
PSI-m Child Domain .46 small .62 medium .05
PSI-HI Parent Domain .26 small .18 .0 2
PSI-III Total Score .41 small .38 small -0.03
Parental Efficacy
FES Child Domain .2 2 small .60 medium .45 small
FES Family Domain .57 medium .32 small -0.24 small
FES Total Score .41 small .64 medium .19
Child - completed
Child Self-Concept
Cognitive Competence .64 medium .73 medium .08
Peer Acceptance -.03 .25 small .30 small
Physical Competence .2 2 small .34 small .1 2
Maternal Acceptance -.1 2 .27 small .50 medium
Note. ES values of .20, .50, and .80 signify small, medium, and large changes. A positive
value indicates that the outcome was in the hypothesized direction; a negative value
indicates that the outcome worsened.
95
Table 9 - Percentages of Subjects Showing Clinically Significant Change at Post-test
Dependent Measure Group Clinical Significance

No change/ Minimal Reliable Reliable change
deterioration change change with recovery
Parent - completed
PSI-III Child Domain Cl 32 50 14 5

C2 17 70 0 13
PSI-III Parent Domain Cl 36 41 14 9
C2 30 57 9 4
PSI-ni Total Score Cl 36 14 36 14
C2 22 30 30 17
FES Child Domain Cl 50 41 9
C2 24 59 18
FES Family Domain Cl 50 41 9
C2 41 53 6
FES Total Score Cl 41 50 9

C2 35 59 6
CBCL Externalizing Cl 33 43 14 10
C2 20 64 8 8
CBCL Aggressive Cl 38 38 14 10
C2 16 52 16 16
CPRS-R Oppositional Cl 27 45 23 5
C2 6 63 6 25
CPRS-R Hyperactive Cl 32 9 32 27
C2 19 31 50 0
SSRS Problem Behavior Cl 50 23 14 14

C2 29 8 33 29
HSQ Factor 1 Cl 17 39 4 39
C2 17 46 17 21
HSQ Factor 2 Cl 22 30 30 17
C2 29 29 21 21
CBCL Social Problems Cl 57 5 29 10
C2 64 0 20 16
CPRS-R Social Problems Cl 57 5 29 10
C2 - 64 0 24 12
Child - completed
Cognitive Competence Cl 43 43 13
C2 31 62 8
Note. The four categories of clinical significance are mutually exclusive. Percentages were
rounded up to the nearest whole number.
Chapter 4: Discussion
The purpose of the present investigation was to evaluate the effectiveness of group
treatment for young ADHD children and their parents. Two treatment approaches were
compared, the first a group treatment program for children, and the second a combined
package of child group training and parent group training. It was hypothesized that both
groups would show improvement on five clinical domains: child externalizing problems,
social skills, child self-concept, parental stress, and parental efficacy. Further, it was
hypothesized that the combined package of child and parent group training would
demonstrate greater improvement on these five domains than the child treatment alone.
Since the parents in the second condition had been provided with techniques to shape and
maintain appropriate behavior in their child, it was expected that both the children and
parents in this condition would benefit more from treatment. The results strongly support
the first hypothesis in most of the clinical domains. Some support was demonstrated for
the second hypothesis, with the results largely favoring the combined treatment
condition.
This study was unique for several reasons. The target population was one that has
received little research attention. Preschool age children, while in need of early
intervention, have been overlooked in most treatment outcome studies on ADHD. The
inclusion of developmentally appropriate games provides a more compelling and
motivating treatment approach for young children. The broad scope of the interventions
addressed both the core symptoms of ADHD as well as the associated features of the
disorder (e.g., social skills and peer relationships), by including training in tasks such as
joining a social group, saying no, and working cooperatively with peers. The current
97
study is also unique in its evaluation o f the Barkley (1997) manual with a younger
population, a treatment application that has received little empirical study. Additionally,
while several studies have evaluated the effectiveness of parent training with a preschool
ADHD population, no published study to date has examined a clinic-based child training
program with this population, nor has a comparison been conducted between child
training and the combined package of parent and child treatment. The results have
important implications for future interventions with this population.
Externalizing Behaviors
Externalizing behaviors comprise some of the core symptoms of ADHD, including
hyperactive, oppositional, aggressive, compliance, and problem behaviors. Previous
research has supported the effectiveness of parent training in alleviating these symptoms,
demonstrating significant improvement over time and in comparison to wait list controls.
This effect has been demonstrated for elementary-school-aged children in group-based
(e.g., Frankel et al., 1997; Horn et al., 1990; Pfiffher & McBumett, 1997; Sheridan et ah,
1996) and individual (e.g., Anastopolous et ah, 1993; Fehlings et ah, 1991) child and
parent training formats, and for preschool aged children in group-based (e.g.,
Cunningham et ah, 1995; Pisterman et ah, 1992b; Strayhom & Weidman, 1989) and
individual parent training sessions (Cunningham et ah, Sonuga-Barke et ah, 2001).
However, the benefits of combining parent training with child psychosocial treatment
have not been clearly established, with most studies failing to demonstrate a significant
and reliable increase in effectiveness from combined treatments (e.g., Pfiffher &
McBumett, 1997), and had not yet been evaluated in a younger ADHD population.
The results strongly supported the effectiveness of combined parent and child
treatment in improving symptoms of externalizing, aggressive, oppositional, hyperactive,
and problem behaviors. Significant improvement was demonstrated on all measures of
externalizing behaviors in the combined treatment condition. In contrast, the child group
training condition demonstrated significant change on only four o f seven variables, with
trends in the hypothesized direction on two additional variables, suggesting a superior
effect by the combined treatment group. This differential treatment effect reached
significance on a measure of problem behaviors, and a positive trend favoring the
combined treatment approached the significance level on aggressive behaviors. The
combined treatment condition also demonstrated medium effect sizes on six of the seven
outcome variables, while in contrast, the child treatment condition had small effect sizes
on five out of the seven variables.
These findings lend some support to the additive hypothesis, suggesting that the
combined treatment is a more effective treatment for a broader range of externalizing
behaviors. As expected, the inclusion of parent training appears to facilitate the
behavioral change that the child treatment group instigates, most likely by continuing to
provide a contingency management program in the home that rewards and shapes
appropriate behaviors.
It is noteworthy that, while the child-only treatment did not produce change on as
many variables as the combined treatment, significant effects were noted on several
measures including externalizing, oppositional, and compliance behaviors. Previous
research on cognitive-behavioral child-only treatments with ADHD children has not
produced reliable improvements (Barkley, 1998). However, as Kendall (1993) has
observed, the lack of uniformity of treatment approaches may explain these mixed
99
findings. For example, some evaluations of cognitive-behavioral techniques have not
included the full behavioral program of contingent reinforcement procedures. It may be
that the consistent and structured use of behavioral techniques in the current child
treatment program was responsible for facilitating the greater part of behavior change.
The effectiveness of child treatment may also be explained by the unique
characteristics of the younger age group. The behavioral patterns of school-age and older
children have become more established over time and may be more resistant to change.
School-age children also have more experience with structured group settings and are
likely to have already endured multiple attempts to correct their behavior. The younger
children, on the other hand, may experience a greater novelty effect in the structured
setting, and perhaps have more flexibility in selecting alternative behaviors, since all of
the rules of social engagement are relatively new to them. Particularly in comparison to
pre-adolescent and adolescent children, younger children tend to present a willing
dependence on adults for direction and may therefore demonstrate a unique receptivity to
treatment effects. These characteristics may enable them to profit from treatment more
than their older peers.
Social Skills
Treatment effects on social skills have previously been evaluated in targeted social
skills programs, which focused on relevant peer interaction and problem solving skills for
the duration o f treatment. Those recent studies that have evaluated social skills training
programs with ADHD children have supported its use. However, only one study
(Pfiffher & McBumett, 1997) examined whether the inclusion of parent training with
child social skills group treatment adds a significant increase in effectiveness, but failed
100
to support the additive effect.
The results o f the current study do not provide support for either hypothesis regarding
the effectiveness of treatment or the superiority of the combined treatment approach.
Neither group demonstrated a significant improvement in parent-rated social skills. In
fact, the child group condition’s mean scores worsened slightly on two scales, Social
Skills and Social Problems. The parent and child group training condition’s mean scores
worsened on one scale, Social Problems.
The lack o f improvement may be due to the broad nature of treatment goals that
included social skills as only one of several targets for change, whereas improvement has
previously resulted from focused social skills programs. It is possible that a more intense
approach to social skills training is necessary to affect significant change. Another factor
may be the developmental level of the subjects, whose ability to perceive and understand
complex rules o f social engagement is considerably less advanced than elementary
school-age children. Where age may have served as an advantage in the ability to
decrease disruptive behaviors, it may function to limit young children’s responsiveness to
change in this domain. The social arena may present less of a motivational pull for
younger children, who are just beginning to develop peer relationships and perceive their
role within a social collective. When Harter and Pike (1984) investigated children’s
methods of achieving social acceptance, they found that younger children were much
more likely to generate naive solutions and to lack an understanding o f how their
behaviors influence others. They posit that, in contrast to elementary school children
who are aware of the relationship between their social skills and peer acceptance,
“[young] children have not yet acquired the knowledge concerning this relationship in the
101
social domain” (p. 1980). Future research on the social skills of young children with
ADHD could implement a similarly targeted social skills program as used by Pfiffher and
McBumett (1997) to determine if young children can benefit and improve in this area.
Another possible explanation for the lack of a treatment effect is the reliance on
parental report for the evaluation of child social skills. Parents may not have the
opportunity to observe peer interactions with the frequency that they have for child
externalizing behaviors, and therefore may not be aware of changes that have taken place.
Therefore, using teacher ratings or observational ratings may reflect more accurately the
effect of treatment on child social skills.
Parenting Stress
The results o f this study demonstrate strong support for the effectiveness of parent
training in alleviating parental stress. Both treatment groups made significant
improvements as a result of treatment, a finding which is consistent with previous
research. The Barkley manual has been found effective in reducing parental stress with a
school-age population in an individual treatment format (Anastopoulos et al., 1993), and
a group program derived from the Barkley manual (along with several other sources) was
effective with a preschool population (Pisterman et al., 1992a). This is the first study,
however, to demonstrate the effectiveness of the Barkley group treatment approach with
a younger age cohort.
There was evidence for the superiority of the combined parent and child training
condition over the child training group. The combined treatment condition demonstrated
significant improvement on all three components o f parental stress, the child domain,
parent domain, and the total score. In contrast, significant improvement was noted in the
102
child training group condition on only two of the three scales, the child domain and the
total score. Notably, the child-only treatment condition did not improve significantly on
the parent domain scale, which focuses on the variables specific to parent functioning and
interpersonal relationships. Therefore, while the untreated parents reported significant
improvement in their child’s behavior and their levels of stress related to these behaviors,
they did not demonstrate significant improvement in the areas of social isolation,
depression, spouse relationship, and attachment to child.
This finding is consistent with expectations, since the treated parents learned multiple
techniques for handling stress, dealing with anger, addressing conflicts with spouse, and
fostering positive relations with their child in the parent group training. In addition, they
experienced supportive interactions with the other parents, who frequently offered each
other suggestions, encouragement, and commiseration. While the differences between
the two groups did not reach significance, the effectiveness of parent group training in
multiple domains of functioning has important clinical implications.
Parental Efficacy
A few studies (e.g., Anastopolous et al., 1993; Pisterman et al., 1992a; Sonuga-Barke
et al., 2001) have demonstrated the effects of parent and child treatment on parental
competence by using the Parenting Sense of Competence Scale, a measure that includes
efficacy as a subscale. Only one author (Odom, 1996), however, reported the treatment
effects on the efficacy scale itself and in that study efficacy actually decreased as a result
of treatment. The current study contradicts Odom’s finding. A significant improvement
was demonstrated over time in the child domain and on the total efficacy score, while
improvement in the family domain showed a trend toward significant improvement. A
103
few group differences were noted. The combined parent and child group training
condition demonstrated significant improvement on two subscales, the child domain and
total score. The child-only condition significantly improved on only the total score,
while trends toward significant improvement were found on the other two scales. There
was a significant differential treatment effect on the child domain subscale, favoring the
combined child and parent group training condition. The parents who received the parent
group training reported a significantly greater sense of parenting efficacy regarding their
child’s behaviors. This finding is consistent with expectations, since the treated parents
received extensive training in techniques for child management and behavioral training.
While Odom’s treatment program used the Barkley parent training program, the
difference in effectiveness can perhaps be explained by differences in program structure
and clinical population. Odom’s intervention only included 5 treatment sessions, where
the current study provided 10 sessions. Additionally, her program targeted mothers from
low socioeconomic status, a category which has been demonstrated to have poorer
outcomes with parent training, have a slower treatment response, and drop out of
treatment more often (Holden, Lavigne, & Cameron, 1990). Her sample was comprised
primarily o f single, African American women in the lowest two tiers on a socioeconomic
measure. The present study included a largely middle class, Caucasian population, which
has been shown to demonstrate a more successful and more rapid treatment response to
parent training (Holden et al., 1990). It is possible that Odom’s sample could have
achieved significant improvement if given sufficient time and treatment exposure.
Child Self-Concept
Few studies have evaluated the impact of parent training on the self-concept of
children with ADHD and the findings are somewhat mixed. One study (Horn et al., 1991)
failed to find a significant benefit from psychosocial treatment either with parents or
children and only detected improvement as a result of low or high doses of stimulant
medication. However, some support for its effectiveness has been demonstrated (e.g.,
Eisenstadt et al., 1993; Fehlings et al., 1991). Eisenstadt et al. (1993) evaluated
improvement in self-concept in preschool ADHD children as a result of a parent training
program that included both non-directive play and child management techniques, and
significant improvement was noted. It was hypothesized that the current treatment would
produce significant improvement in both treatment conditions in child self-concept and
that the combined parent and child group training would demonstrate a greater treatment
effect than the child-only treatment.
These hypotheses were largely unsupported. A significant treatment effect was
demonstrated in both groups on only one of the four scales of child self-concept,
cognitive competence. No significant difference between groups was noted. The lack of
a treatment effect on the other three scales may be due to the high baseline scores in both
conditions. When the study subjects’ means are compared to the means and standard
deviations from a normal population with a similar socioeconomic make-up (Harter &
Pike, 1984), the sample pre-treatment means are equal to or above the means of a normal
population on nearly every scale except for cognitive competence. On cognitive
competence, the study subjects’ pre-treatment means were more than two standard
deviations below the means of the normal population. Therefore, a treatment effect was
not detected on the three scales that were already within the normal range at baseline on
this measure.
105
This finding may be due to a “positive illusory bias” in ADHD children’s self
perceptions. While the evidence is somewhat contradictory, some research has
demonstrated that ADHD children report more positive self-evaluations than are
warranted, given their severe and chronic behavioral, academic, and social impairments
(e.g., Hoza, Pelham, Dobbs, Owens, & Pillow, 2002). This reporting bias may explain,
for example, baseline scores on the Peer Acceptance subscale within the normal range for
children whose scores on a social skills measure fall nearly two standard deviations
outside of the normal range. It has been speculated that this bias in self-perception may
serve a defensive and self-protective role, enabling children with ADHD to cope despite
frequent negative experiences (Hoza et al., 2002).
The lack of accurate self-evaluation may also be due to the developmental level of the
subjects. The authors of the measure (Harter & Pike, 1984) caution that young children
are not yet capable of making stable assessments of their worth or deriving a sense of
their capacities through social comparisons. It is possible that the capacity for self-
evaluation develops unevenly for different domains of functioning, allowing the children
to make more accurate judgments in some areas more than others. Thus, these limitations
may significantly affect their perceptions of their social skills, for example, an area that
requires subjective and comparative appraisals, more than their academic skills, on which
children are typically given extensive and objective feedback.
It is noteworthy that a significant improvement was noted on the Cognitive
Competence domain, as the child treatment program includes many cognitive techniques
to assist children in making accurate appraisals, problem solve difficulties, and utilize
proactive coping strategies. This scale is likely to be the most relevant measure of
106
treatment effects of the four, and the study demonstrates having a successful impact as a
result of these intensive clinical interventions.
Limitations o f study
A few limitations of this study should be noted. The absence of objective verification
of client-reported improvements, in the form of observable behavior change, renders the
current results susceptible to expectancy effects. It is possible that the hopefulness
produced by treatment participation led subjects to inflate post-treatment responses, due
to an expectation that improvement was likely. In the area of child behavioral
improvement, the treated parents may have perceived a greater degree of child behavioral
improvement as a result of their own increased knowledge and skill. Experiencing
themselves as better informed and better prepared to intervene may have generated an
inflated perception of their child’s improvement. In addition to the parents’ increased
management skills, they may also have gained a better appreciation for the limitations of
an ADHD child and may have developed more realistic and lowered expectations for his
behavioral control. The inclusion of blind ratings of child behaviors and parent - child
interactions would allow more definitive statements regarding true change. However, the
possibility of post-treatment score inflation is somewhat undermined by the lack o f any
significant treatment effect on social skills measures, a clinical domain that seems as
likely to respond to expectancy effects as the measures that did demonstrate
improvement, such as externalizing behaviors.
The lack of any follow-up evaluation in the study also prevents any conclusions on
maintenance o f effects. In addition to evaluating initial treatment outcome, it would be
useful to know if subjects maintained their gains once the intervention was withdrawn,
107
and whether or not the two treatment conditions differ in these maintenance effects.
There is evidence that a combined parent and child treatment will produce a greater
treatment effect at follow-up (Horn et al., 1990), compared to either child-only or parent-
only treatments. This effect suggests, as one might expect, that the continued structure
and reinforcement that the parents provide is an important component in maintaining
long-term change. It remains to be determined if this effect applies to the younger
ADHD children as well.
While this study aimed to expand the research base on treatment outcomes into the
preschool population, it was not possible to achieve adequate sample size and limit the
eligibility criteria to preschool children only. The groups therefore included children
from 4 to 8 years old, a span which perhaps incorporates different levels or types of
treatment responders. Further narrowing of the subject pool to examine treatment effects
in an exclusively preschool population would supplement these findings and better
capture the response patterns of this age group.
Lastly, the issue of a control group should be addressed. The superiority of parent
and child treatments over wait-list controls have been well established (e.g.,
Anastopoulos et al., 1993; Frankel et al., 1997; Pfiffher & McBumett, 1997), and given
the chronicity of the disorder, the spontaneous remission of symptoms is not expected
and need not be controlled for. Additionally, it was not felt to be ethically appropriate to
delay treatment for children and families with severe behavioral and emotional
difficulties. Therefore, a wait-list condition was not included in this study.
Directions for Future Research
All subjects in this study were asked not to change their medication status for the
duration of treatment. The effects of medication were kept constant therefore over time,
but it raises the question of ceiling effects among some of the subjects. It would be
useful to explore possible additive effects from medication and psychosocial
interventions in a preschool population. Future research could include medication
treatment as an additional study variable, randomizing subjects to child-only, parent-and-
child, child-and-medication, or parent-and-child-and-medication groups. Alternatively, a
comparison could be made between parent-and-child treatment with parent-and-child-
and-medication treatment. The demonstration of equivalency of effects between
medicated and non-medicated subjects receiving treatment would be important
information for parents who wish to delay medicating their preschool age children.
Anther important area of further exploration is the possibility of differential treatment
effects among the subtypes of ADHD. Given the high baseline hyperactivity scores, the
present sample is likely composed of Combined Type and Predominantly Hyperactive
Type children. The presence of varying degrees of inattention symptoms among the
children may have hindered some subjects’ ability to profit fully from treatment. Future
studies could isolate the subtypes and assess whether adaptations in treatment are
appropriate for the different needs of each group.
Lastly, as noted above, the inclusion of long-term follow-up is another important area
for future research. While positive treatment response is beneficial, this finding is only
meaningful if it leads to sustained behavioral improvement. One useful technique to
supplement treatment gains would be to provide booster sessions, allowing parents and
children to return periodically for a review. In addition to reminding subjects of
behavioral techniques and strategies, helping parents preserve an appropriate long-term
109
perspective can lower their frustration and keep their focus on structured contingency
management programs in order to maintain child behavioral change.
Summary of Findings
The current study has demonstrated the effectiveness of both child group training and
parent and child group training on multiple clinical domains. Significant treatment
responses were demonstrated in child externalizing behaviors, parental stress, parental
efficacy, and the cognitive competence domain of child self-concept. The combined
parent and child group training demonstrated improvements over child-only treatment in
several domains. The combined treatment was significantly more effective in improving
child problem behaviors and parental efficacy in the domain of child management. There
were trends that approached significance favoring the combined treatment group on child
aggression and social problems. The one domain where the treatment did not demonstrate
significant improvement was in the area o f social skills, where group means actually
worsened slightly on three scales. Overall, strong support was found for the effectiveness
of both treatment conditions and some indicators suggested the superiority of the
combined parent and child group training.
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Appendix A
Study Consent Form
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ADHD CLINIC
131 Temple Avenue
Hackensack, New Jersey 07601
201-692-2645 Telephone
201-692-2164 Fax
CHILD AND PARENT ADHD SPECIALITY GROUP PROGRAM
INFORMED CONSENT STATEMENT
understand that the Child and

Adolescent ADHD Clinic is both a treatment and research program. The data collected in
the program will add to scientific knowledge about children with ADHD. All information
will be kept strictly confidential.
The initial screening process will consist of the following:
1. An interview on my child’s developmental history and past, and current learning

and behavior problems at home and school. I will be asked questions about my
approach to parenting and my family’s educational and medical history. The
interview will last approximately 90 minutes.
2. I will be asked to complete measures designed to assess my child’s social skills,

concentration, and behavior at home. I will also be asked to complete instruments
on myself.
3. My child’s teacher will be asked to complete measures designed to assess my

child’s social skills, concentration, and behavior at school.
The information collected will be used to determine my eligibility into the program.
If my child and I are selected to participate in the program, I understand:
1. I will be asked to complete the above mentioned measures (#2) again in January.
FDU will pay me $10 for completing the measures on these dates.
2. My child’s teacher will be asked to complete the above mentioned measures (#2)
in January. FDU will pay my child’s teacher $10 for completing the measures.
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3. I understand that my child and I may be dropped from the program if we fail to:
1) complete the required measures and 2) attend all treatment sessions.
4. All treatment sessions will be audiotaped for procedural checks by program staff.
No other use of these tapes will be made without my written consent. These tapes
will be erased promptly after use.
Potential Benefits
1. The treatment interventions and services may improve my child’s behavior in

home and school.
2. The treatment interventions and services may improve my family’s interactions

and decrease my stress level.
Potential Risks
1. There is risk that my child may experience some distress when participating in the
child training group and/or when I practice my child management skills at home.
2. Although the treatment procedures are likely to help my child and family, the
success of the treatment cannot be guaranteed.
I also understand that my child or I may withdraw from the study at any time. I
understand if I have any questions about the treatment and/or evaluation, I can contact:
Dr. Linda A. Reddy, Director o f the Child and Adolescent ADHD Clinic
Fairleigh Dickinson University’s Center for Psychological Services
131 Temple Avenue, Hackensack, NJ 07601
(201)692-2645
Date Parent’s name
Parent’s signature
Appendix B
Child Group Training Curriculum
Copyright © Linda A. Reddy, Ph.D. at Fairleigh Dickinson University
All rights of reproduction in any form reserved.
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S e ssio n O ne. At the start of each group session, children were welcomed to the
group, and taught the rules o f the program: follow directions, use my words, and keep
hands to myself or my side. Next, the group’s Time Out procedures were explained and
then demonstrated by a group therapist.
After the rules were explained, the group played games to learn everyone’s names
and to create a fun atmosphere. The children then colored in two pages of a coloring
book called the All About Me book, in which they were asked to provide information
about themselves and their family. They each took turns sharing their pictures to the rest
of the group. After this was completed, the “sticker ceremony” takes place. All the
children sat on the floor in front of the sticker chart. One by one, each child stood in
front of the group with a group therapist and reviewed how s/he performed on each group
goal. A star was placed on the chart for each goal s/he attained. The child then met with
another therapist and was allowed to choose a corresponding number o f stickers to place
in a sticker book that he took home with him at the end o f the program. Once each child
received his stickers, snack was handed out and the therapists helped the children prepare
for parent pick-up.
S essio n Tw o. Group rules and structures were reviewed again, including the group
goals and Time Out procedures. The games Clap Your Hands and Swedish Meetball
were reviewed. Next, they were taught an activity called Using Nice Talk. The steps for
Using Nice Talk are: 1) A p p ro a c h th e p e r s o n in a fr ie n d ly w ay, 2) U se a fr ie n d ly look,
a n d 3) U se a fr ie n d ly voice. These steps were operationalized in clear behavioral terms
and demonstrated by group members. Three role-plays, as described above, were
performed to demonstrate the skill sequence.
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After the role-plays, the group played Monkey in the Blanket, a game designed to
enhance impulse control, attention, recall, and collaboration among team members. The
group was divided into two teams, and one team covered their eyes while the other team
chose a member to hide under the blanket. The guessing team then had to discuss who is
missing. Before giving an answer, the team had to reach a group consensus and choose a
member who will present their guess. Each team took a few turns hiding and then
guessing.
Next, the group returned to its circle and another skill sequence was introduced,
Following Directions. The steps are: 1) L o o k a t w h o is a s k in g y o u to fo llo w directions,
2) A s k w h en to sto p d o in g th e a c tiv ity (e.g., p la y in g ), 3) R e p e a t th e d irec tio n s, a n d 4) D p
it! F o llo w th e d irectio n s. Three role-plays were performed, which show a child both
following and not following directions so the consequences of each could be
demonstrated. Again, the therapists stopped the role-plays to point out each step in the
skill sequence and had the group decide if the role-players followed the steps
appropriately. The children then filled out 2 more pages in the All About Me book, the
sticker ceremony was performed, and snack was handed out.
S essio n Three. Children were welcomed to the group, and group rules and structures
were reviewed. The steps for Following Directions were reviewed and role-played. A
game called The Freeze Game was used to enhance the children’s self-control,
impulsivity, auditory acuity, and ability to follow directions. The children were then
presented an activity for identifying and coping with scared and sad feelings. They were
asked to describe situations that make people scared, and to describe the specific
behaviors exhibited by people with these feelings. The children gave examples of times
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when they were scared, and then drew a picture of this situation. After sharing their
drawings, the children then drew a picture of what then happened to help them feel less
sad. A discussion was introduced on handling scared feelings and the children can
successfully cope with these situations. Next, the group discussed things that make
people sad. The children gave examples of sad situations and described the specific
behaviors of a sad person. They shared examples of when they have been sad, and they
drew these situations. After sharing their pictures with the group, each child drew what
happened to help him/her feel less sad and shared it with the group. The group discussed
ways to handle sad feelings, and the therapists emphasized the skills of using their words
to express their feelings and asking for help.
The children were directed to complete 2 more pages in their All About Me book, the
sticker ceremony is performed, and snack is distributed.
S essio n F o u r. Children were welcomed to the group, and group rules and structures
were reviewed. The topic of sad feelings was revisited, and the group again discussed
what makes people sad. As in session three, the children drew a sad situation as well as
what happened to help them feel less sad. They shared both drawings, and the group
discussed techniques to deal with sad feelings. The Cotton Ball Game was then
introduced to the group. The Cotton Ball Game was designed to teach children the
influence their bodies have on their environment. The group was directed to stand close
to a long rectangular table. Each child was given a straw. Two group therapists
demonstrated controlled breathing by blowing a cotton ball with a straw across the table
to each other. The children were then given the opportunity to blow the cotton ball
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across the table to each other, working their way down the table and back. Anyone who
exhibited uncontrolled breathing had to leave the game.
An activity for identifying and coping with angry feelings was introduced. The
children gave examples of situations that make people angry, and described how an angry
person looks. They shared a time when they have felt angry, and then they drew a picture
of this. After sharing their drawings to the group, the children were asked to think of
things people can do to make themselves less angry. The therapists encouraged the
children to think about catching their angry early and taking steps to calm themselves
down. A strategy for coping with anger, the Turtle, was taught to the children, which
involves relaxation techniques and an incompatible response approach. Children were
taught to engage in a focused, calming physical activity that interferes with other less
appropriate actions they make take when upset. They practiced doing “The Turtle,”
which involves squatting on one’s heels, squeezing one’s knees tight into the chest, and
taking three deep breaths. The steps for the Turtle are; 1) S to p a n d th in k - w h a t is
m a k in g m e m a d ? , 2) D o th e T u rtle III, 3) R e la x - ta k e 3 d e e p breaths, 4) D o a fu n
a ctivity.
The group then completed another 2 pages of the All About Me book, received their
stickers, and ate snack.
S e ssio n F ive. Children were welcomed to the group, and group rules and structures
were reviewed. The group reviewed the activity Identifying and Coping with Anger.
The Turtle technique was also reviewed. The group was then introduced to another
technique for anger management, the Pillow Squeeze. The Pillow Squeeze also utilizes
an incompatible response approach. The children were taught to squeeze a pillow and
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take three deep breaths when frustrated. Other techniques for dealing with anger were
discussed, such as reading a book, coloring, playing with a pet, taking a time out. Role-
plays, as described above, were performed to model and rehearse these skills.
After the role-plays, two more pages of the All About Me book are colored in and the
sticker ceremony is performed.
S e ssio n Six. Children were welcomed to the group, and group rules and structures
were reviewed. Anger management strategies were reviewed again with the group. Two
children demonstrated the steps in the Turtle technique, and two children demonstrated
the steps in the Pillow Squeeze technique. The therapists encouraged the children to use
these strategies outside of the group when they become angry or frustrated. Additionally,
other techniques (such as asking for help, writing down one’s feelings, taking a walk) for
managing anger were discussed. The group then applied these concepts and skills to
situations in which another person is upset. A skill sequence called Dealing with Another
Person's Angry Feelings is presented. The steps are: 1) L is te n to w h a t th e p e r s o n h as to
sa y, 2) T h in k a b o u t w h a t to do. P ic k one: a). K e e p listening, b) A s k w h y th e p e r s o n is
a n g ry, c) G ive th e p e rs o n a n id e a to f i x th e p r o b le m , d) W a lk a w a y. 3) D o it. This activity
helps decrease impulsivity and reactivity in conflict situations. The children then
practiced this skill in three role-plays, in which a parent, a friend, and then a sibling was
angry.
A developmentally appropriate game, Islands, was presented to the children. This
game is designed to improve self-control and cooperation. Towels and carpet squares
were used to represent the islands, and the rest of the floor was the surrounding water.
The children were told a story about hungry piranhas who live in this water, and are
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lulled to sleep by music. Whenever music is playing, the piranhas sleep and the water is
safe for the islanders to swim in. When the music stops, however, the piranhas wake up
and look for their next meal. All of the islanders need to return to the safety of the
islands, with careful and controlled movements, and must assist their fellow islanders in
making it to safety as well. After the game, the children discussed how it felt when the
music was playing, and how it felt when it stopped and they had to secure safe footing on
the island. The group reviewed what each member did when they felt scared of the
piranhas. Two more pages of the All About Me book were completed, and stickers were
awarded for meeting group goals. The children had snack and prepared for parent pick
up.
S e ssio n S even. Children were welcomed to the group, and group rules and structures
were reviewed. Dealing With Another Person’s Angry Feelings was reviewed. Children
described how that makes them feel, and the skill sequence for coping with another’s
angry feelings was reviewed. Volunteers from the group performed three role-plays to
practice this skill. Next, the topic of self-control is introduced. The group discussed
what it means to be out of control and in control, and examples of each were explored.
They were taught a skill sequence to use when they feel out of control, which involved
attending to their physiological arousal with relaxation techniques. The steps are: 1)
S to p a n d c o u n t to 10, 2) T h in k o f h o w y o u r b o d y fe e ls , 3) D o s o m e th in g r e la x in g a n d fu n ,
4) T a lk w ith so m e o n e . The children performed role-plays in three contexts to practice this
skill.
The group then engaged in a controlled physical activity, I Am a Balloon, in which
they pretended to be a balloon that is alternately filling up with and emptying of air.
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Through this activity, they were taught to attend to their physiological state, and note
when their body was tense, and when it was limp and calm. The therapists went around
the group and ensured that each child was a “limp noodle,” with totally relaxed arms and
legs. After this activity, the group completed and shared another two pages of the All
About Me book. Each child was then presented with his stickers for reaching group
goals, and snack was distributed.
S e ssio n E ig h t. Children were welcomed to the group, and group rules and structures
were reviewed. The group reviewed relaxation again, reintroducing the “limp noodle”
test for a relaxed body. The children shared ways that they relax when they feel jumpy.
The therapists introduced a skill sequence that prompts them to assess their physical state,
take slow deep breaths, and tighten and relax each part o f their body in turn. The steps
are: 1) D e c id e i f y o u n e e d to relax, 2) T ake 2 slow , d e ep b rea th s, 3) T ig h ten o n e p a r t o f
y o u r body, c o u n t to 3, a n d relax, 4) C o n tin u e th is f o r ea ch p a r t o f y o u r body, 5) A s k
y o u r s e lf h o w y o u fe e l. The children then role-played this sequence in three different
contexts. The ZZZZ Game was introduced next, in which the children pretended to be
falling asleep to a pretend story. The therapists prompted them to think about how their
body felt and attend to their relaxed condition. Next, a pretend alarm went off, and
everyone “woke up.” This cycle was repeated a few times, to help the children
distinguish between a relaxed and a tense body.
The skill sequence Dealing with Boredom was presented next. This skill required the
children assess their mood and determine if they are bored. They were then encouraged
to problem solve through this situation, brain storming various activities they could
engage in and choosing one. They were also encouraged to reward themselves at the end
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o f this process, for handling their boredom productively. This skill was role-played in
three different contexts. Everyone then engaged in a group stretch, to again encourage
attention to their body and to teach ways of relaxing themselves. The group completed
and shared another two pages of their book and received stickers for reaching group
goals.
S essio n N in e. Children were welcomed to the group, and group mles and structures
were reviewed. The group was reminded that only two sessions remained, and the
process of the graduation ceremony was explained. They were congratulated for all of
their hard work in the program. The skill sequence Dealing with Boredom was practiced
again, with the children reviewing the steps and acting out one or two role-plays to
demonstrate this technique. The skill sequence Using Brave Talk was presented next.
The skill has two parts, Saying No and Accepting No. Beginning with Saying No, the
children reviewed the steps involved: 1) D e c id e w h e th e r o r n o t y o u w a n t y o u d o w h a t is
b e in g asked, 2) T h in k a b o u t w h y y o u d o n 't w a n t to d o this, 3) T e ll th e p e r s o n "N O " in a
fr ie n d ly w ay, 4) G ive y o u r rea so n . The group discussed and practiced how to say no in a
friendly way. The children then performed three role-plays practicing this skill, which
involves problem-solving through a difficult situation in which someone attempts to
entice them with inappropriate behavior. These skills were then applied to situations in
which the children have to Accept No. The steps involved are: 1) D e c id e w h y y o u w ere
to ld no, 2) T h in k a b o u t y o u r ch o ice s: a) D o so m e th in g else, b) S a y h o w y o u f e e l in a
fr ie n d ly w ay, c) W rite a b o u t h o w y o u fe e l; 3 )D o it! Attention was paid to the careful
review of options, and to thoughtfully selecting the best course of action.
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A new skill sequence, Not Interrupting Others, was then presented to the group. The
children were taught to assess the importance of their question before interrupting and
then, if it is necessary to interrupt, polite ways of doing so. The steps for this skill
sequence are: 1) D e c id e i f y o u n e e d to, 2) W a lk to th e p e rs o n , 3) W a it w ith o u t ta lk in g
u n til th e p e rs o n lo o k s a t yo u , 4) S a y "E xcuse m e ." (T hen a s k w h a t y o u n e e d to ask). This
technique was role-played in three different contexts, to encourage generalizability.
Next, the children played a controlled physical activity, the Pop Up Game, which
strengthens their ability to control their impulses and attention. They were divided into
two teams, each with a stuffed animal as a mascot. First the stuffed animals were shown
in turn, while the therapist called out the team names, and the children on that team
jumped up from their seats. Next, the team names were called out without a visual aid.
Next, the therapist showed the stuffed animal without a verbal aid. Lastly, the therapist
called out clues that could identify each animal. After this activity, the children complete
two more pages in the All About Me book and receive their stickers for meeting the
group goals.
S essio n Ten. Children were welcomed to the group, and group rules and structures
were reviewed. In this last session, children were validated for all of their hard work in
the program. The process of the graduation ceremony was reviewed again, and they were
asked for their feedback on the group. The skill sequence of Not Interrupting Others was
reviewed, and the group practiced this skill again in one or two role-plays. Next, the
group learned a new skill sequence, Joining In. The steps are: 1) D e c id e i f y o u w a n t to
jo in in, 2) D e c id e w h a t to say, 3) C h o o se a g o o d tim e, 4) S a y it in a fr ie n d ly w ay. The
therapists emphasized carefully evaluating a situation before joining in, and choosing an
137
optimal time to inquire about participation. After this skill sequence was reviewed and
demonstrated, the group discussed the skill sequence Being a Good Sport. The children
gave examples ofbeing a good or bad sport, and the group discussed how to act
appropriately in this situation. The steps rehearsed are: 1) D e c id e h o w y o u a n d th e o th e r
p e r s o n p la y e d th e g a m e, 2 ) T h in k o f w h a t y o u can te ll th e o th e r p e r s o n : a)
C o n g ra tu la tio n s! b) You p la y e d a g o o d g a m e ! c) Y o u 're g e ttin g a lo t b e tte r a t this g a m e !
3) A c t o u t y o u r b e st ch o ice, 4) H e lp th e o th e r p e r s o n p u t e q u ip m e n t o r m a te ria ls aw ay.
They practiced these new skills by doing three role-plays in different contexts. Lastly,
the group was taught the skill sequence Dealing With Being Left Out. The children
talked about how it feels to be left out and reviewed appropriate ways to handle it. The
steps for the skill sequence were reviewed. They are: 1) D e c id e w h a t h a s h a p p e n e d to
c a u se y o u f e e l le ft out, 2) T h in k a b o u t y o u r ch o ices: a) A s k to jo in in, b) C h o o se so m e o n e
e lse to p la y w ith, c) D o a n a c tiv ity y o u e n jo y; 3) A c t o u t y o u r b e st ch o ice. The group
reviewed these steps and practiced them in three role-plays. Children were given their
stickers for reaching group goals, and snack is distributed.1
1 From The ADHD Child Group Training Manual, by L.A. Reddy, 1997. Unpublished
manuscript, Fairleigh Dickinson University. Adapted with permission.
Appendix C
Parent Group Training Curriculum
139
S e ssio n O ne: In the first session, the parents were welcomed to the program and
praised for their efforts in seeking out services for their children. The importance and
value o f early intervention was stressed. Basic information about their child’s disability
was discussed. Specifically, the parents were informed that this is a chronic and long
term disorder, and the treatment approach is one of management rather than cure. The
deficits involved in ADHD were discussed, and the parents were advised to remember
that their child is functioning at a lower developmental level than their peers. Risk
factors, comorbidity, and prognosis were briefly reviewed. The rules and structures of
the Child Group were reviewed, including the group goals and the time out procedure.
Parents were encouraged to review their children’s performance in the group at the end of
each session by examining the group sticker chart. For homework, parents are asked to
fill in a Family Schedule and to list the Family Rules.
S e ssio n Tw o. The Family Schedules were brought out and assessed, in the context of
a discussion of the factors that affect symptom severity. Family Rules were reviewed,
and parents were encouraged to make these as behaviorally specific as possible and to be
consistent in their implementation. Parents were taught How to Give Effective
Commands and a handout was provided to remind them of the skill components. For
homework, they were asked to practice this 1 - 2 times a day. They were reminded to
lower their expectations in terms of what a child with ADHD will realistically be able to
do. When giving a direction, parents should state it as a command and not as a question,
and to give few instructions at any one time.
S e ssio n Three. The homework of Giving Effective Commands was reviewed and any
questions about this procedure were addressed. Next, the parents were instructed to make
up Game Cards for an activity that their child has difficulty with, such as their morning
routine. They were to write the steps for this activity out on index cards, and show their
child these cards one by one and monitor their performance on each step. After this was
clarified, the parents were taught some key concepts in child management, i.e., that
consequences need to be immediate, specific, and consistent. These concepts were
reviewed in detail and discussed as they pertain to a variety of contexts and behaviors.
Parents were encouraged to follow through on consequences they give their child, and to
only make realistic threats. Additionally, they were encouraged to use incentives before
punishment. Parents were next asked to write down the qualities of their best and worst
bosses, and after sharing these, were asked to consider where their child would place
them on this continuum. Lastly, the parents were taught the Positive Attention technique.
They are asked to spend child-directed positive time with their child for ten minutes,
twice a day, for homework.
S e ssio n F o u r. Homework was reviewed, and questions and concerns were addressed.
The parents are taught Teaching Your Child Not to Interrupt You. This is a shaping
technique, and the parent is required to engage the child in an interesting task and clearly
direct them NOT to bother them. The parents leave the room or area for a brief period of
time (e.g., 45 seconds), and return quickly in order to praise the child for remaining on
task and for following directions. This is repeated over the ten to fifteen minute period.
The parents were asked to identify two behaviors they want to improve in their child, and
were instructed to explain these behaviors in specific terms. Next, the group began to
discuss the token economy system. Research on the effectiveness of this technique and
the philosophy behind the intervention were reviewed. Parents were told how the token
141
economy will operate, and were asked to write a list of privileges their child could earn
and how many points each one would equal. A total of four points can be earned a day,
and children are able to trade in their points for privileges. Time Out was introduced as a
positive technique for promoting self-control, and how to implement it in the home was
discussed. Parents were told that Time Out should be implemented before the child
escalates out of control, and should instead be used when he or she is just beginning to
act restless and keyed up. Parents were encouraged to take time outs as well, and to view
the technique as a positive means of slowing down when feeling stressed or chaotic.
Parents practiced the Teaching Your Child Not to Interrupt You exercise for homework.
S e ssio n F ive. Homework was reviewed. This session was spent reviewing the
procedures to design and implement a token economy. The therapist helped each parent
to identify and define in behavioral terms two behaviors they wish to improve in their
child. Parents were also asked to list simple privileges their child could earn in the home.
Questions about Time Out are also addressed. For homework, parents were asked to
continue to implement the techniques already taught and to begin the token economy.
S essio n Six. Session six focused on the token economy and questions and/or concerns
that have come up during implementation. Goals, privileges and points are reviewed and
improved upon, if necessary. Parents were assisted in designing and implementing a
token economy. Advantages and disadvantages of stimulant medication were briefly
discussed. For homework, parents were asked to revise their privilege and point sheets
and post them.
S essio n Seven. Homework was reviewed. The advantages of using Time Outs as a
family intervention were discussed. The token economy was also reviewed and the
142
technique of graphing was introduced. Parents were encouraged to graph with their
children their daily points earned. This was done to provide a visual representation of the
child’s progress over time. Next, parents were taught a technique to manage behavior in
public places. The focus of this technique is on planning ahead, setting specific rules for
behavior in addition to their goals for their token economies, and implementing
additional incentives for appropriate behavior during the outing. In addition, parents
were encouraged to bring small treats (such as cookies or crackers) to reward their child
with at random intervals during the outing. Parents were told to provide frequent and
consistent positive reinforcement during public outings, in order to help the child work
toward his/her goals. For homework, parents were asked to practice managing their
child’s behavior in public places.
S e ssio n E ig h t. After reviewing homework, techniques for managing parent stress
were presented. Parents were reminded that the child behavioral interventions presented
in the program help improve their children’s behaviors, as well as reduce their parent’s
stress. However, additional strategies were presented on managing parental stress and
building family relationships, such as keeping a disability perspective, scheduling time
for exercise and social events, using shared parenting, and expanding social supports.
The importance of planful stress reduction was emphasized. Parents were asked to
implement two stress management techniques during the week for homework.
S e ssio n N in e. After reviewing homework, the topic of anger management was
introduced and discussed. Parents were reminded that they serve as models for their
child’s own anger management techniques. Appropriate means o f handling anger were
discussed, such as taking Time Outs, talking to a friend, and exercise. Parents described
143
the situations that most easily angered them, as a step to proactively identifying problem
areas and planning for them. The topic of spousal relationships and sharing of child-
rearing responsibilities was also discussed. The group then discussed their child’s peer
relationships, and parents were encouraged to become actively involved in setting up and
structuring peer interactions. As homework, parents were asked to set up a structured
play date for their child.
S e ssio n Ten. After reviewing homework, termination was discussed. Parents were
reminded that their children will experience loss when the group ends and were informed
that this can take many behavioral forms. Ways to help their children cope were
addressed. Issues dealing with school relationships were introduced, and parents were
encouraged to proactively build connections with faculty members and involve
themselves in their child’s education. The lines between the school’s responsibility and
the parents’ responsibility were clarified. Special education laws and parental rights were
reviewed.2
2 From Defiant Children. Second Edition: A Clinician’s Manual for Assessment and
Parent Training, by R.A. Barkley, 1997, New York: Guilford Press. Copyright 1997 by
Guilford Press. Adapted with permission.
Appendix D
Jacobson and Truax Tables
145
Jacobson and Truax Method for CBCL Externalizing Scale
Group ID# Time 1 Time 2 Se Sdiff RC Category*

Cl 10 55 55 3.40 4.81 0.00 NC/D
13 - 63 2.54 3.59 . -
25 71 68 3.40 4.81 -0.62 MC

26 62 52 2.54 3.59 -2.78 RCR
27 58 57 2.54 3.59 -0.28 MC
28 52 68 3.40 4.81 3.33 NC/D
29 69 71 2.54 3.59 0.56 NC/D
30 65 66 3.40 4.81 0.21 NC/D
31 85 - 3.40 4.81 - -
41 64 63 3.40 4.81 -0.21 MC

69 66 - 3.40 4.81 - -
70 65 - 3.40 4.81 . -
72 60 62 3.40 4.81 0.42 NC/D

74 65 62 2.54 3.59 -0.84 MC
75 62 - 3.40 4.81 - -
77 62 57 2.54 3.59 -1.39 MC

83 80 68 2.54 3.59 -3.34 RC
85 56 50 2.54 3.59 -1.67 MC
87 64 - 2.54 3.59 - -
127 76 75 3.40 4.81 -0.21 MC

134 55 41 3.40 4.81 -2.91 RC
135 66 60 3.40 4.81 -1.25 MC
136 84 68 3.40 4.81 -3.33 RC
137 75 75 3.40 4.81 0.00 NC/D
138 74 65 3.40 4.81 -1.87 MC
140 72 54 2.54 3.59 -5.01 RCR
141 50 64 3.40 4.81 2.91 NC/D
C2 1 68 68 3.40 4.81 0.00 NC/D
2 58 52 3.40 4.81 -1.25 MC
3 59 60 3.40 4.81 0.21 NC/D
4 58 47 3.40 4.81 -2.29 RC
5 67 56 2.54 3.59 -3.06 RCR
6 59 53 2.54 3.59 -1.67 MC
7 62 53 3.40 4.81 -1.87 MC
8 55 56 3.40 4.81 0.21 NC/D
100 68 58 3.40 4.81 -2.08 RCR
101 64 62 3.40 4.81 -0.42 MC
102 60 58 2.54 3.59 -0.56 MC
103 53 50 3.40 4.81 -0.62 MC
104 65 - 2.54 3.59 _ -
105 60 57 2.54 3.59 -0.84 MC

106 55 69 3.40 4.81 2.91 NC/D
107 69 65 3.40 4.81 -0.83 MC
108 63 60 3.40 4.81 -0.62 MC
111 80 69 3.40 4.81 -2.29 RC
112 52 59 3.40 4.81 1.46 NC/D
113 63 54 3.40 4.81 -1.87 MC
114 70 68 2.54 3.59 -0.56 MC
121 69 65 3.40 4.81 -0.83 MC
123 62 - 3.40 4.81 - -
128 77 - 3.40 4.81 - -
129 68 62 3.40 4.81 -1.25 MC

130 54 52 3.40 4.81 -0.42 MC
132 75 66 3.40 4.81 -1.87 MC
133 56 53 3.40 4.81 -0.62 MC
Note. a: NC/D = no change/deterioration; MC = minimal change; RC = reliable change; RCR = reliable

change with recovery.
146
Jacobson and Truax Method for CBCL Aggressive Scale
Group ID# Time 1 Time 2 Se Sdiff RC Category2

Cl 10 57 58 2.65 3.75 0.27 NC/D
13 - 62 2.59 3.66 . -
25 70 69 2.65 3.75 -0.27 MC

26 64 53 2.59 3.66 -3.00 RCR
27 57 55 2.59 3.66 -0.55 MC
28 55 69 2.65 3.75 3.74 NC/D
29 69 72 2.59 3.66 0.82 NC/D
30 67 68 2.65 3.75 0.27 NC/D
31 100 - 2.65 3.75 - -
41 65 65 2.65 3.75 0.00 NC/D

69 68 - 2.65 3.75 - -
70 68 - 2.65 3.75 - -
72 60 63 2.65 3.75 0.80 NC/D

74 64 59 2.59 3.66 -1.37 MC
75 64 - 2.65 3.75 . .
77 61 57 2.59 3.66 -1.09 MC

83 87 67 2.59 3.66 -5.46 RC
85 52 50 2.59 3.66 -0.55 MC
87 64 - 2.59 3.66 - -
127 87 85 2.65 3.75 -0.53 MC

134 56 50 2.65 3.75 -1.60 MC
135 65 63 2.65 3.75 -0.53 MC
136 92 65 2.65 3.75 -7.20 RC
137 75 82 2.65 3.75 1.87 ■ NC/D
138 75 63 2.65 3.75 -3.20 RC
140 75 55 2.59 3.66 -5.46 RCR
141 51 65 2.65 3.75 3.74 NC/D
C2 1 67 70 2.65 3.75 0.80 NC/D
2 60 51 2.65 3.75 -2.40 RCR
3 62 58 2.65 3.75 -1.07 MC
4 58 50 2.65 3.75 -2.13 RC
5 65 53 2.59 3.66 -3.28 RCR
6 58 53 2.59 3.66 -1.37 MC
7 60 53 2.65 3.75 -1.87 MC
8 56 57 2.65 3.75 0.27 NC/D
100 65 56 2.65 3.75 -2.40 RCR
101 64 60 2.65 3.75 -1.07 MC
102 61 58 2.59 3.66 -0.82 MC
103 53 34 2.65 3.75 -5.07 RC
104 67 - 2.59 3.66 - -
105 57 55 2.59 3.66 -0.55 MC

106 55 68 2.65 3.75 3.47 NC/D
107 75 68 2.65 3.75 -1.87 MC
108 64 63 2.65 3.75 -0.27 MC
111 83 72 2.65 3.75 -2.94 RC
112 51 62 2.65 3.75 2.94 NC/D
113 65 55 2.65 3.75 -2.67 RCR
114 72 69 2.59 3.66 -0.82 MC
121 72 67 2.65 3.75 -1.33 MC
123 65 - 2.65 3.75 - -
128 87 - 2.65 3.75 - -
129 64 57 2.65 3.75 -1.87 MC

130 53 50 2.65 3.75 -0.80 MC
132 80 64 2.65 3.75 -4.27 RC
133 58 56 2.65 3.75 -0.53 MC

147
Jacobson and Truax Method for Conners Oppositional Scale

Cl 10 69 63 3.38 4.78 -1.26 MC
13 58 62 3.20 4.52 0.88 NC/D
25 88 80 3.38 4.78 -1.68 MC
26 87 68 2.85 4.04 -4.71 RC
27 58 46 3.20 4.52 -2.65 RC
28 52 80 3.62 5.12 5.46 NC/D
29 71 67 3.20 4.52 -0.88 MC
30 69 61 3.62 5.12 -1.56 MC
31 92 - 3.62 5.12 - -
41 65 58 3.62 5.12 -1.37 MC

69 77 - 3.62 5.12 - -
70 72 - 3.62 5.12 - -
72 56 54 3.62 5.12 -0.39 MC

74 60 48 3.20 4.52 -2.65 RC
75 65 - 3.38 4.78 - -
77 71 75 2.85 4.04 0.99 NC/D

83 87 73 3.20 4.52 -3.10 RC
85 58 50 3.20 4.52 -1.77 MC
87 58 - 2.85 4.04 - -
127 90 88 3.38 4.78 -0.42 MC

134 47 49 3.62 5.12 0.39 NC/D
135 63 69 3.62 5.12 1.17 NC/D
136 90 65 3.62 5.12 -4.88 RC
137 90 83 3.38 4.78 -1.47 MC
138 85 78 3.62 5.12 -1.37 MC
140 90 54 3.20 4.52 -7.96 RCR
141 72 79 3.62 5.12 1.37 NC/D
C2 1 . - 3.38 4.78 _ .
2 - - 3.38 4.78 - -
3 - . 3.62 5.12 - -
4 - - 3.62 5.12 - -
5 - - 2.85 4.04 - -
6 - - 2.85 4.04 - .
7 - - 3.38 4.78 - -
8 - - 3.38 4.78 - .
100 61 53 3.38 4.78 -1.68 MC

101 65 54 3.62 5.12 -2.15 RCR
102 66 62 2.85 4.04 -0.99 MC
103 50 49 3.62 5.12 -0.20 MC
104 60 - 3.20 4.52 - -
105 69 60 2.85 4.04 -2.23 RCR

106 70 63 3.62 5.12 -1.37 MC
107 72 65 3.62 5.12 -1.37 MC
108 65 59 3.62 5.12 -1.17 MC
111 72 56 3.62 5.12 -3.12 RCR
112 56 54 3.62 5.12 -0.39 MC
113 59 65 3.62 5.12 1.17 NC/D
114 81 79 3.20 4.52 -0.44 MC
121 - 65 3.62 5.12 - -
123 71 - 3.38 4.78 - -
128 87 - 3.62 5.12 - -
129 65 59 3.62 5.12 -1.17 MC

130 63 62 3.62 5.12 -0.20 MC
132 87 76 3.62 5.12 -2.15 RC
133 65 48 3.62 5.12 -3.32 RCR

148
Jacobson and Truax Method for Conners Hyperactive Scale

Cl 10 68 61 2.29 3.23 -2.16 RCR
13 84 84 1.85 2.61 0.00 NCD
25 56 55 2.29 3.23 -0.31 MC
26 91 71 1.64 2.32 -8.63 RC
27 98 69 1.85 2.61 -11.11 RC
28 68 55 2.09 2.96 -4.40 RCR
29 90 77 1.85 2.61 -4.98 RC
30 91 85 2.09 2.96 -2.03 RC
31 85 - 2.09 2.96 - -
41 73 59 2.09 2.96 -4.74 RCR

69 73 - 2.09 2.96 - -
70 90 . 2.09 2.96 - -
72 77 79 2.09 2.96 0.68 NC/D

74 88 67 1.85 2.61 -8.05 RC
75 66 2.29 3.23 - -
77 64 69 1.64 2.32 2.16 NCD

83 81 84 1.85 2.61 1.15 NCD
85 88 77 1.85 2.61 -4.22 RC
87 73 - 1.64 2.32 - -
127 75 61 2.29 3.23 -4.33 RCR

134 61 53 2.09 2.96 -2.71 RC
135 6 70 2.09 2.96 21.65 NCD
136 83 57 2.09 2.96 -8.80 RCR
137 90 90 2.29 3.23 0.00 NCD
138 83 79 2.09 2.96 -1.35 MC
140 77 56 1.85 2.61 -8.05 RCR
141 70 76 2.09 2.96 2.03 NCD
C2 1 . 2.29 3.23 _
2 - - 2.29 3.23 - -
3 - . 2.09 2.96 _ -
4 - - 2.09 2.96 - -
5 - - 1.64 2.32 - -
6 - - 1.64 2.32 - -
7 - - 2.29 3.23 - -
8 - - 2.29 3.23 - -
100 68 63 2.29 3.23 -1.55 MC

101 57 57 2.09 2.96 0.00 NCD
102 76 67 1.64 2.32 -3.89 RC
103 76 66 2.09 2.96 -3.38 RC
104 69 - 1.85 2.61 - -
105 67 69 1.64 2.32 0.86 NCD

106 77 76 2.09 2.96 -0.34 MC
107 66 64 2.09 2.96 -0.68 MC
108 85 77 2.09 2.96 -2.71 RC
111 64 53 2.09 2.96 -3.72 RC
112 59 61 2.09 2.96 0.68 NCD
113 81 72 2.09 2.96 -3.04 RC
114 86 79 1.85 2.61 -2.68 RC
121 - 57 2.09 2.96 - -
123 73 - 2.29 3.23 . -
128 90 - 2.09 2.96 - -
129 74 68 2.09 2.96 ‘-2.03 RC

130 77 75 2.09 2.96 -0.68 MC
132 81 79 2.09 2.96 -0.68 MC
133 89 83 2.09 2.96 -2.03 RC

149
Jacobson and Truax Method for SSRS Problem Behavior Scale

Cl 10 133 102 1.24 1.75 -17.68 RCR
13 114 121 2.00 2.83 2.47 NC/D
25 131 135 1.24 1.75 2.28 NC/D
26 130 130 1.16 1.64 0.00 NC/D
27 110 112 2.56 3.62 0.55 NC/D
28 102 135 2.44 3.45 9.56 NC/D
29 121 128 2.56 3.62 1.93 NC/D
30 131 131 2.52 3.56 0.00 NC/D
31 142 - 2.44 3.45 - -
41 130 120 2.44 3.45 -2.90 RC

69 122 - 2.20 3.11 - -
70 133 - 2.52 3.56 - -
72 118 120 2.20 3.11 0.64 NC/D

74 112 107 2.00 2.83 -1.77 MC
75 116 - 2.20 3.11 - -
77 132 130 1.16 1.64 -1.22 MC

83 130 114 1.80 2.55 -6.29 RCR
85 133 79 2.00 2.83 -19.09 RCR
87 123 - 2.56 3.62 - -
127 140 134 2.20 3.11 -1.93 MC

134 112 120 2.52 3.56 2.24 NC/D
135 133 122 2.52 3.56 -3.09 RC
136 140 135 2.00 2.83 -1.77 MC
137 140 141 2.52 3.56 0.28 NC/D
138 138 133 2.52 3.56 -1.40 MC
140 128 121 2.32 3.28 -2.13 RC
141 105 110 2.00 2.83 1.77 NC/D
C2 1 140 110 2.20 3.11 -9.64 RCR
2 112 100 2.20 3.11 -3.86 RC
3 131 122 2.44 3.45 -2.61 RC
4 112 115 2.44 3.45 0.87 NC/D
5 130 121 2.56 3.62 -2.49 RC
6 128 110 1.80 2.55 -7.07 RCR
7 118 108 2.20 3.11 -3.21 RCR
8 110 130 1.24 1.75 11.40 NC/D
100 120 110 2.20 3.11 -3.21 RCR
101 108 92 2.00 2.83 -5.66 RC
102 128 110 1.80 2.55 -7.07 RCR
103 105 108 2.44 3.45 0.87 NC/D
104 126 - 2.00 2.83 - -
105 123 117 2.56 3.62 -1.66 MC

106 130 133 2.52 3.56 0.84 NC/D
107 125 120 2.00 2.83 -1.77 MC
108 127 118 2.52 3.56 -2.53 RC
111 107 - 2.52 3.56 - -
112 110 118 2.44 3.45 2.32 NC/D

113 125 125 2.52 3.56 0.00 NC/D
114 135 123 2.56 3.62 -3.31 RC
121 108 110 2.00 2.83 0.71 NC/D
123 116 - 1.24 1.75 - -
128 138 - 2.44 3.45 - -
129 120 105 2.44 3.45 -4.35 RCR

130 125 108 2.44 3.45 -4.93 RCR
132 134 120 2.52 3.56 -3.93 RC
133 135 122 2.44 3.45 -3.77 RC

150
Jacobson and Truax Method for HSO Factor 1 Scale

Cl 10 24 12 5.38 7.61 -1.58 MC
13 52 42 5.02 7.10 -1.41 MC
25 20 6 5.38 7.61 -1.84 MC
26 44 17 4.51 6.37 -4.24 RCR
27 59 31 4.51 6.37 -4.39 RCR
28 20 6 6.30 8.91 -1.57 MC
29 55 44 4.51 6.37 -1.73 MC
30 70 28 6.30 8.91 -4.71 RCR
31 54 - 6.30 8.91 - -
41 67 39 6.30 8.91 -3.14 RCR

69 53 27 5.38 7.61 -3.42 RCR
70 61 - 5.38 7.61 - -
72 84 79 5.38 7.61 -0.66 MC

74 56 47 5.02 7.10 -1.27 MC
75 68 - 5.38 7.61 - -
77 20 26 4.51 6.37 0.94 NC/D

83 66 49 4.51 6.37 -2.67 RC
85 26 26 5.02 7.10 0.00 NC/D
87 47 - 4.51 6.37 - -
127 73 64 5.38 7.61 -1.18 MC

134 35 32 5.38 7.61 -0.39 MC
135 56 60 5.38 7.61 0.53 NC/D
136 59 25 6.29 8.90 -3.82 RCR
137 80 37 5.38 7.61 -5.65 RCR
138 68 41 5.38 7.61 -3.55 RCR
140 42 50 4.88 6.91 1.16 NC/D
141 51 23 6.29 8.90 -3.15 RCR
C2 1 72 62 5.38 7.61 -1.31 MC
2 38 27 5.38 7.61 -1.45 MC
3 34 17 6.30 8.91 -1.91 MC
4 51 12 6.30 8.91 -4.38 RCR
5 60 37 4.51 6.37 -3.61 RC
6 30 24 4.51 6.37 -0.94 MC
7 22 21 5.38 7.61 -0.13 MC
8 66 66 5.38 7.61 0.00 NC/D
100 69 40 5.38 7.61 -3.81 RCR
101 29 12 6.29 8.90 -1.91 MC
102 42 26 4.51 6.37 -2.51 RCR
103 65 18 6.30 8.91 -5.28 RCR
104 66 - 5.02 7.10 - -
105 22 56 4.51 6.37 5.34 NC/D

106 51 45 5.38 7.61 -0.79 MC
107 38 24 6.29 8.90 -1.57 MC
108 46 53 5.38 7.61 0.92 NC/D
111 33 12 6.30 8.91 -2.36 RC
112 16 36 6.29 8.90 2.25 NC/D
113 60 56 5.38 7.61 -0.53 MC
114 65 40 5.02 7.10 -3.52 RC
121 . 22 6.29 8.90 - -
123 15 - 5.38 7.61 . -
128 76 - 6.29 8.90 - -
129 47 29 6.29 8.90 -2.02 RC

130 63 25 6.29 8.90 -4.27 RCR
132 61 58 5.38 7.61 -0.39 MC
133 65 48 6.29 8.90 -1.91 MC

151
Jacobson and Truax Method for HSO Factor 2 Scale
Group ID# Time 1 Time 2 Se Sdifif RC Category*

Cl 10 11 5 4.02 5.69 -1.05 MC
13 17 24 2.96 4.18 1.67 NC/D
25 9 5 4.02 5.69 -0.70 MC
26 26 7 2.76 3.90 -4.87 RC
27 16 12 2.76 3.90 -1.03 MC
28 3 5 4.37 6.19 0.32 NC/D
29 32 22 2.76 3.90 -2.56 RC
30 36 16 4.37 6.19 -3.23 RCR
31 37 - 4.37 6.19 - -
41 40 22 4.37 6.19 -2.91 RC

69 49 33 4.02 5.69 -2.81 RC
70 36 - 4.02 5.69 - -
72 49 45 4.02 5.69 -0.70 MC

74 30 3 2.96 4.18 -6.45 RCR
75 29 - 4.02 5.69 - -
77 14 22 2.76 3.90 2.05 NC/D

83 51 34 2.76 3.90 -4.36 RC
85 15 20 2.96 4.18 1.20 NC/D
87 28 - 2.76 3.90 - -
127 40 30 4.02 5.69 -1.76 MC

134 30 22 4.02 5.69 -1.41 MC
135 36 32 4.02 5.69 -0.70 MC
136 41 16 4.64 6.55 -3.81 RCR
137 50 24 4.02 5.69 -4.57 RC
138 52 23 4.02 5.69 -5.10 RC
140 20 28 3.29 4.65 1.72 NC/D
141 26 12 4.64 6.55 -2.14 RCR
C2 1 41 41 4.02 5.69 0.00 NC/D
2 27 20 4.02 5.69 -1.23 MC
3 18 17 4.37 6.19 -0.16 MC
4 16 0 4.37 6.19 -2.59 RC
5 45 29 2.76 3.90 -4.10 RC
6 16 12 2.76 3.90 -1.03 MC
7 2 6 4.02 5.69 0.70 NC/D
8 39 61 4.02 5.69 3.87 NC/D
100 49 26 4.02 5.69 -4.04 RCR
101 0 0 4.64 6.55 0.00 NC/D
102 16 9 2.76 3.90 -1.80 MC
103 30 6 4.37 6.19 -3.88 RCR
104 44 - 2.96 4.18 - -
105 7 33 2.76 3.90 6.67 NC/D

106 41 27 4.02 5.69 -2.46 RCR
107 25 5 4.64 6.55 -3.05 RC
108 43 24 4.02 5.69 -3.34 RCR
111 20 8 4.37 6.19 -1.94 MC
112 14 27 4.64 6.55 1.98 NC/D
113 26 26 4.02 5.69 0.00 NC/D
114 31 15 2.96 4.18 -3.82 RC
121 - 20 4.64 6.55 - -
123 7 - 4.02 5.69 - -
128 24 - 4.64 6.55 - -
129 32 20 4.64 6.55 -1.83 MC

130 40 9 4.64 6.55 -4.73 RCR
132 45 32 4.02 5.69 -2.28 RC
133 47 41 4.64 6.55 -0.92 MC
Note. *: NC/D = no change/deterioration; MC = minimal change; RC = reliable change; RCR = reliable

152
Jacobson and Truax Method for CBCL Social Problems Scale

Cl 10 66 0.45 0.63 - NC/D
13 66 50 0.45 0.63 -25.41 -
25 62 66 0.45 0.63 6.35 RC

26 70 73 0.45 0.63 4.76 RCR
27 57 52 0.45 0.63 -7.94 NC/D
28 76 62 0.45 0.63 -22.23 NC/D
29 62 66 0.45 0.63 6.35 NC/D
30 73 73 0.45 0.63 0.00 NC/D
31 57 - 0.45 0.63 - -
41 82 73 0.45 0.63 -14.29 MC

69 76 76 0.45 0.63 0.00 -
70 52 62 0.45 0.63 15.88 -
72 50 52 0.45 0.63 3.18 NC/D

74 73 . 0.45 0.63 - RC
75 66 70 0.45 0.63 6.35 -
77 76 79 0.45 0.63 4.76 RC

83 50 64 0.38 0.54 25.90 NC/D
85 73 70 0.38 0.54 -5.55 NC/D
87 50 70 0.38 0.54 37.00 -
127 56 60 0.38 0.54 7.40 RC

134 64 . 0.38 0.54 - NC/D
135 70 68 0.38 0.54 -3.70 RCR
136 68 - 0.38 0.54 - RC
137 73 - 0.38 0.54 - NC/D
138 70 83 0.38 0.54 24.05 NC/D
140 56 - 0.38 0.54 - RC
141 83 80 0.38 0.54 -5.55 NC/D
C2 1 60 68 0.38 0.54 14.80 RC
2 60 50 0.38 0.54 -18.50 NC/D
3 77 73 0.38 0.54 -7.40 RC
4 68 68 0.38 0.54 0.00 RCR
5 70 70 0.38 0.54 0.00 NC/D
6 73 87 0.38 0.54 25.90 NC/D
7 80 68 0.38 0.54 -22.20 NC/D
8 50 52 0.38 0.54 3.70 NC/D
100 80 73 0.38 0.54 -12.95 RC
101 60 56 0.38 0.54 -7.40 NC/D
102 56 60 0.38 0.54 7.40 NC/D
103 52 64 0.38 0.54 22.20 RC
104 70 64 0.38 0.54 -11.10 -
105 70 70 0.38 0.54 0.00 NC/D

106 52 42 0.38 0.54 -18.50 NC/D
107 64 64 0.38 0.54 0.00 NC/D
108 64 73 0.38 0.54 16.65 NC/D
111 56 64 0.38 0.54 14.80 RCR
112 64 56 0.38 0.54 -14.80 NC/D
113 56 68 0.38 0.54 22.20 NC/D
114 64 64 0.38 0.54 0.00 NC/D
121 50 50 0.38 0.54 0.00 NC/D
123 60 - 0.38 0.54 - -
128 60 - 0.38 0.54 - -
129 70 60 0.38 0.54 -18.50 RC

130 68 52 0.38 0.54 -29.60 RCR
132 64 50 0.38 0.54 -25.90 RCR
133 70 70 0.38 0.54 0.00 NC/D

153
Jacobson and Truax Method for Conners Social Problems Scale

Cl 10 50 64 0.72 1.02 13.74 NC/D
13 - 66 0.73 1.03 - -
25 73 70 0.72 1.02 -2.94 RC

26 66 50 0.67 0.95 -16.92 RCR
27 62 66 0.73 1.03 3.90 NC/D
28 50 70 0.90 1.28 15.67 NC/D
29 70 73 0.73 1.03 2.92 NC/D
30 56 60 0.90 1.28 3.13 NC/D
31 64 - 0.90 1.28 - -
41 70 68 0.90 1.28 -1.57 MC

69 68 - 0.90 1.28 - -
70 73 - 0.90 1.28 - -
72 70 83 0.90 1.28 10.19 NC/D

74 57 52 0.73 1.03 -4.87 RC
75 56 . 0.72 1.02 - -
77 76 62 0.67 0.95 -14.81 RCR

83 62 66 0.73 1.03 3.90 NC/D
85 73 73 0.73 1.03 0.00 NC/D
87 57 - 0.67 0.95 - -
127 83 80 0.72 1.02 -2.94 RC

134 60 68 0.90 1.28 6.27 NC/D
135 60 50 0.90 1.28 -7.84 RC
136 77 73 0.90 1.28 -3.13 RC
137 68 68 0.72 1.02 0.00 NC/D
138 70 70 0.90 1.28 0.00 NC/D
140 82 73 0.73 1.03 -8.77 RC
141 73 87 0.90 1.28 10.97 NC/D
C2 1 80 68 0.72 1.02 -11.78 RC
2 50 52 0.72 1.02 1.96 NC/D
3 80 73 0.90 1.28 -5.49 RC
4 60 56 0.90 1.28 -3.13 RC
5 76 76 0.67 0.95 0.00 NC/D
6 52 62 0.67 0.95 10.58 NC/D
7 56 60 0.72 1.02 3.93 NC/D
8 52 64 0.72 1.02 11.78 NC/D
100 70 64 0.72 1.02 -5.89 RCR
101 70 70 0.90 1.28 0.00 NC/D
102 50 52 0.67 0.95 2.12 NC/D
103 52 42 0.90 1.28 -7.84 RC
104 73 - 0.73 1.03 - -
105 66 70 0.67 0.95 4.23 NC/D

106 64 64 0.90 1.28 0.00 NC/D
107 64 73 0.90 1.28 7.05 NC/D
108 56 64 0.90 1.28 6.27 NC/D
111 64 56 0.90 1.28 -6.27 RC
112 56 68 0.90 1.28 9.40 NC/D
113 64 64 0.90 1.28 0.00 NC/D
114 76 79 0.73 1.03 2.92 NC/D
121 50 50 0.90 1.28 0.00 NC/D
123 60 - 0.72 1.02 - -
128 60 - 0.90 1.28 - -
129 70 60 0.90 1.28 -7.84 RCR

130 68 52 0.90 1.28 -12.54 RCR
132 64 50 0.90 1.28 -10.97 RC
133 70 70 0.90 1.28 0.00 NC/D

154
Jacobson and Truax Method for PSI Child Domain Scale

Cl 10 121 102 11.56 16.34 -1.16 MC
13 123 114 11.56 16.34 -0.55 MC
25 181 182 11.56 16.34 0.06 NC/D
26 163 129 11.56 16.34 -2.08 RC
27 144 104 12.17 17.20 -2.32 RCR
28 121 182 11.56 16.34 3.73 NC/D
29 136 128 12.17 17.20 -0.46 MC
30 125 140 11.56 16.34 0.92 NC/D
31 179 - 11.56 16.34 - -
41 149 135 11.56 16.34 -0.86 MC

69 157 - 12.17 17.20 - -
70 180 - 12.17 17.20 - -
72 146 147 12.17 17.20 0.06 NC/D

74 124 121 11.56 16.34 -0.18 MC
75 126 9.73 13.76 - -
77 141 128 11.56 16.34 -0.80 MC

83 148 134 12.17 17.20 -0.81 MC
85 149 133 11.56 16.34 -0.98 MC
87 144 - 9.73 13.76 - -
127 173 166 9.73 13.76 -0.51 MC

134 109 111 12.17 17.20 0.12 NC/D
135 121 122 12.17 17.20 0.06 NC/D
136 184 142 10.95 15.48 -2.71 RC
137 154 142 9.73 13.76 -0.87 MC
138 186 152 12.17 17.20 -1.98 RC
140 150 141 10.95 15.48 -0.58 MC
141 105 116 10.95 15.48 0.71 NC/D
C2 1 176 147 11.56 16.34 -1.77 MC
2 95 92 11.56 16.34 -0.18 MC
3 126 114 11.56 16.34 -0.73 MC
4 113 95 11.56 16.34 -1.10 MC
5 160 139 11.56 16.34 -1.28 MC
6 149 115 9.73 13.76 -2.47 RCR
7 148 151 9.73 13.76 0.22 NC/D
8 144 139 11.56 16.34 -0.31 MC
100 130 110 9.73 13.76 -1.45 MC
101 111 94 10.95 15.48 -1.10 MC
102 144 113 9.73 13.76 -2.25 RCR
103 109 82 11.56 16.34 -1.65 MC
104 133 - 11.56 16.34 - -
105 138 153 9.73 13.76 1.09 NC/D

106 146 164 12.17 17.20 1.05 NC/D
107 154 140 10.95 15.48 -0.90 MC
108 148 136 12.17 17.20 -0.70 MC
111 151 106 11.56 16.34 -2.75 RCR
112 113 130 10.95 15.48 1.10 NC/D
113 145 140 12.17 17.20 -0.29 MC
114 150 131 11.56 16.34 -1.16 MC
121 - 153 10.95 15.48 - -
123 134 - 11.56 16.34 - -
128 159 - 10.95 15.48 - -
129 135 - 10.95 15.48 - -
130 131 127 10.95 15.48 -0.26 MC

132 170 150 12.17 17.20 -1.16 MC
133 138 130 10.95 15.48 -0.52 MC

155
Jacobson and Truax Method PSI Parent Domain Scale

Cl 10 127 112 7.80 11.03 -1.36 MC
13 125 145 7.50 10.61 1.89 NC/D
25 148 134 7.80 11.03 -1.27 MC
26 124 101 7.80 11.03 -2.09 RC
27 184 134 6.30 8.91 -5.61 RCR
28 99 134 7.50 10.61 3.30 NC/D
29 108 117 6.30 8.91 1.01 NC/D
30 115 116 7.50 10.61 0.09 NC/D
31 172 - 7.50 10.61 - -
41 167 157 7.50 10.61 -0.94 MC

69 159 - 6.30 8.91 - -
70 138 - 6.30 8.91 - -
72 135 125 6.30 8.91 -1.12 MC

74 113 116 7.50 10.61 0.28 NC/D
75 133 - 8.10 11.46 - -
77 139 124 7.80 11.03 -1.36 MC

83 185 165 6.30 8.91 -2.24 RC
85 101 89 7.50 10.61 -1.13 MC
87 127 - 8.10 11.46 - -
127 151 169 8.10 11.46 1.57 NC/D

134 129 139 6.30 8.91 1.12 NC/D
135 163 155 6.30 8.91 -0.90 MC
136 171 157 6.60 9.33 -1.50 MC
137 147 118 8.10 11.46 -2.53 RC
138 158 134 6.30 8.91 -2.69 RCR
140 147 136 6.60 9.33 -1.18 MC
141 74 112 6.60 9.33 4.07 NC/D
C2 1 178 153 7.80 11.03 -2.27 RC
2 112 101 7.80 11.03 -1.00 MC
3 73 64 7.50 10.61 -0.85 MC
4 92 92 7.50 10.61 0.00 NC/D
5 140 140 7.80 11.03 0.00 NC/D
6 122 102 8.10 11.46 -1.75 MC
7 135 129 8.10 11.46 -0.52 MC
8 103 82 7.80 11.03 -1.90 MC
100 160 131 8.10 11.46 -2.53 RCR
101 128 115 6.60 9.33 -1.39 MC
102 108 100 8.10 11.46 -0.70 MC
103 83 69 7.50 10.61 -1.32 MC
104 115 - 7.50 10.61 - -
105 104 117 8.10 11.46 1.13 NC/D

106 108 105 6.30 8.91 -0.34 MC
107 136 128 6.60 9.33 -0.86 MC
108 127 114 6.30 8.91 -1.46 MC
111 110 127 7.50 10.61 1.60 NC/D
112 98 125 6.60 9.33 2.89 NC/D
113 87 104 6.30 8.91 1.91 NC/D
114 113 126 7.50 10.61 1.23 NC/D
121 - 107 6.60 9.33 - -
123 112 - 7.80 11.03 - -
128 89 - 6.60 9.33 - -
129 138 - 6.60 9.33 - .
130 139 110 6.60 9.33 -3.11 RC

132 186 184 6.30 8.91 -0.22 MC
133 129 125 6.60 9.33 -0.43 MC
Note. a: NC/D = no change/deterioration; MC = minimal change; RC = reliable change.; RCR = reliable

156
Jacobson and Truax Method PSI Total Score Scale

Cl 10 248 214 8.00 11.31 -3.01 RC
13 248 259 8.00 11.31 0.97 NC/D
25 329 316 8.00 11.31 -1.15 MC
26 289 230 8.00 11.31 -5.21 RCR
27 328 238 7.40 10.47 -8.60 RCR
28 220 316 8.00 11.31 8.49 NCD
29 244 245 7.40 10.47 0.10 NCD
30 240 256 8.00 11.31 1.41 NCD
31 351 - 8.00 11.31 - -
41 316 292 8.00 11.31 -2.12 RC

69 316 - 7.40 10.47 - -
70 318 - 7.40 10.47 . -
72 281 272 7.40 10.47 -0.86 MC

74 237 237 8.00 11.31 0.00 NC/D
75 259 6.00 8.49 - -
77 280 252 8.00 11.31 -2.47 RCR

83 333 299 7.40 10.47 -3.25 RC
85 250 222 8.00 11.31 -2.47 RC
87 271 - 6.00 8.49 - -
127 324 335 6.00 8.49 1.30 NCD

134 235 250 7.40 10.47 1.43 NCD
135 284 277 7.40 10.47 -0.67 MC
136 355 299 6.40 9.05 -6.19 RC
137 301 260 6.00 8.49 -4.83 RC
138 344 286 7.40 10.47 -5.54 RC
140 297 277 6.40 9.05 -2.21 RC
141 186 228 6.40 9.05 4.64 NCD
C2 1 354 300 8.00 11.31 -4.77 RC
2 207 193 8.00 11.31 -1.24 MC
3 199 178 8.00 11.31 -1.86 MC
4 205 187 8.00 11.31 -1.59 MC
5 300 279 8.00 11.31 -1.86 MC
6 271 217 6.00 8.49 -6.36 RCR
7 283 280 6.00 8.49 -0.35 MC
8 247 221 8.00 11.31 -2.30 RC
100 290 241 6.00 8.49 -5.77 RCR
101 239 209 6.40 9.05 -3.31 RC
102 252 213 6.00 8.49 -4.60 RC
103 192 151 8.00 11.31 -3.62 RC
104 248 — 8.00 11.31 - -
105 242 270 6.00 8.49 3.30 NCD

106 254 269 7.40 10.47 1.43 NCD
107 290 268 6.40 9.05 -2.43 RC
108 275 250 7.40 10.47 -2.39 RCR
111 261 283 8.00 11.31 1.94 NCD
112 211 255 6.40 9.05 4.86 NCD
113 232 244 7.40 10.47 1.15 NCD
114 263 257 8.00 11.31 -0.53 MC
121 - 249 6.40 9.05 - -
123 246 - 8.00 11.31 - .
128 248 - 6.40 9.05 - -
129 273 - 6.40 9.05 - -
130 270 237 6.40 9.05 -3.65 RCR

132 356 334 7.40 10.47 -2.10 RC
133 267 255 6.40 9.05 -1.33 MC

157
Jacobson and Truax Method FES Child Domain Scale
Group ID# Time 1 Time 2 Se Sdiff RC Category®

Cl 10 39 34.5 3.20 4.52 -0.99 NC/D
13 32 32 3.20 4.52 0.00 NC/D
25 31 31 3.20 4.52 0.00 NC/D
26 39 35 3.20 4.52 -0.88 NC/D
27 38 40 3.20 4.52 0.44 MC
28 36 31 3.20 4.52 -1.11 NC/D
29 35 34 3.20 4.52 -0.22 NC/D
30 35 35 3.20 4.52 0.00 NC/D
31 31 - 3.20 4.52 - -
41 28 37 3.20 4.52 1.99 RC

69 35 - 3.20 4.52 - -
70 28 - 3.20 4.52 - -
72 33 30 3.20 4.52 -0.66 NC/D

74 28 34 3.20 4.52 1.33 MC
75 40 - 3.20 4.52 - -
77 33 37 3.20 4.52 0.88 MC

83 27 35 3.20 4.52 1.77 MC
85 38 40 3.20 4.52 0.44 MC
87 35 - 3.20 4.52 - -
127 20 22 3.20 4.52 0.44 MC

134 34 33 3.20 4.52 -0.22 NC/D
135 30 27 3.20 4.52 -0.66 NC/D
136 32 37 3.20 4.52 1.11 MC
137 26 31 3.20 4.52 1.11 MC
138 18 34 3.20 4.52 3.54 RC
140 31 35 3.20 4.52 0.88 MC
141 44 37 3.20 4.52 -1.55 NC/D
C2 1 _ . 2.86 4.05 _ .
2 - - 2.86 4.05 - -
3 _ - 2.86 4.05 - -
4 - - 2.86 4.05 - -
5 - - 2.86 4.05 - -
6 - - 2.86 4.05 - -
7 - - 2.86 4.05 - -
8 - - 2.86 4.05 - -
100 33 36 2.86 4.05 0.74 MC

101 38 46 2.86 4.05 1.97 RC
102 40 37 2.86 4.05 -0.74 NC/D
103 31 37 2.86 4.05 1.48 MC
104 30 - 2.86 4.05 - -
105 35 41 2.86 4.05 1.48 MC

106 36 37 2.86 4.05 0.25 MC
107 27 34 2.86 4.05 1.73 MC
108 30 39 2.86 4.05 2.22 RC
111 41 31 2.86 4.05 -2.47 NC/D
112 34 40 2.86 4.05 1.48 MC
113 35 34 2.86 4.05 -0.25 NC/D
114 32 33 2.86 4.05 0.25 MC
121 30 32 2.86 4.05 0.49 MC
123 41 - 2.86 4.05 - -
128 26 - 2.86 4.05 - -
129 35 33 2.86 4.05 -0.49 NC/D

130 33 36 2.86 4.05 0.74 MC
132 27 32 2.86 4.05 1.23 MC
133 21 32 2.86 4.05 2.72 RC
Note. a: NC/D = no change/deterioration; MC = minimal change; RC = reliable change. Recovery was not
calculated for this scale, as it is not a measure of deviancy.
158
Jacobson and Truax Method FES Family Domain Scale

Cl 10 38 36 2.96 4.18 -0.48 NC/D
13 24 27 2.96 4.18 0.72 MC
25 26 32 2.96 4.18 1.43 MC
26 32 32 2.96 4.18 0.00 NC/D
27 32 29 2.96 4.18 -0.72 NC/D
28 28 32 2.96 4.18 0.96 MC
29 33 31 2.96 4.18 -0.48 NC/D
30 32 33 2.96 4.18 0.24 MC
31 17 - 2.96 4.18 - -
41 30 32 2.96 4.18 0.48 MC

69 32 - 2.96 4.18 - -
70 24 - 2.96 4.18 - -
72 29 26 2.96 4.18 -0.72 NC/D

74 30 27 2.96 4.18 -0.72 NC/D
75 35 - 2.96 4.18 - -
77 30 36 2.96 4.18 1.43 MC

83 30 28 2.96 4.18 -0.48 NC/D
85 35 37 2.96 4.18 0.48 MC
87 33 - 2.96 4.18 - -
127 26 19 2.96 4.18 -1.67 NC/D

134 24 21 2.96 4.18 -0.72 NC/D
135 24 30 2.96 4.18 1.43 MC
136 32 72 2.96 4.18 9.56 RC
137 26 25 2.96 4.18 -0.24 NC/D
138 16 32 2.96 4.18 3.83 RC
140 28 32 2.96 4.18 0.96 MC
141 38 37 2.96 4.18 -0.24 NC/D
C2 1 . . 2.21 3.13 _ .
2 - - 2.21 3.13 . -
3 - - 2.21 3.13 - -
4 - - 2.21 3.13 - -
5 - - 2.21 3.13 - -
6 - - 2.21 3.13 - -
7 - - 2.21 3.13 - -
8 - - 2.21 3.13 - -
100 31 32 2.21 3.13 0.32 MC

101 36 38 2.21 3.13 0.64 MC
102 35 36 2.21 3.13 0.32 MC
103 35 40 2.21 3.13 1.60 MC
104 30 - 2.21 3.13 - -
105 33 33 2.21 3.13 0.00 NC/D

106 31 29 2.21 3.13 -0.64 NC/D
107 28 34 2.21 3.13 1.92 MC
108 37 40 2.21 3.13 0.96 MC
111 40 30 2.21 3.13 -3.20 NC/D
112 32 35 2.21 3.13 0.96 MC
113 35 35 2.21 3.13 0.00 NC/D
114 34 35 2.21 3.13 0.32 MC
121 26 30 2.21 3.13 1.28 MC
123 - - 2.21 3.13 - -
128 32 - 2.21 3.13 - -
129 33 33 2.21 3.13 0.00 NC/D

130 32 32 2.21 3.13 0.00 NC/D
132 37 32 2.21 3.13 -1.60 NC/D
133 23 33 2.21 3.13 3.20 RC
159
Jacobson and Truax Method FES Total Scale

Cl 10 77 70.5 5.71 8.08 -0.80 NC/D
13 56 59 5.71 8.08 0.37 MC
25 57 63 5.71 8.08 0.74 MC
26 71 67 5.71 8.08 -0.50 NC/D
27 70 69 5.71 8.08 -0.12 NC/D
28 64 63 5.71 8.08 -0.12 NC/D
29 68 65 5.71 8.08 -0.37 NC/D
30 67 68 5.71 8.08 0.12 MC
31 48 - 5.71 8.08 - -
41 58 69 5.71 8.08 1.36 MC

69 67 . 5.71 8.08 - -
70 52 . 5.71 8.08 - -
72 62 56 5.71 8.08 -0.74 NC/D

74 58 61 5.71 8.08 0.37 MC
75 75 - 5.71 8.08 - -
77 63 73 5.71 8.08 1.24 MC

83 57 63 5.71 8.08 0.74 MC
85 73 77 5.71 8.08 0.50 MC
87 68 - 5.71 8.08 - -
127 46 41 5.71 8.08' -0.62 NC/D

134 58 54 5.71 8.08 -0.50 NC/D
135 54 57 5.71 8.08 0.37 MC
136 64 109 5.71 8.08 5.57 RC
137 52 56 5.71 8.08 0.50 MC
138 34 66 5.71 8.08 3.96 RC
140 59 67 5.71 8.08 0.99 MC
141 82 74 5.71 8.08 -0.99 NC/D
C2 1 - - 5.23 7.40 . -
2 - - 5.23 7.40 - -
3 - - 5.23 7.40 - -
4 - - 5.23 7.40 - -
5 - - 5.23 7.40 - -
6 . - 5.23 7.40 - -
7 - 5.23 7.40 - -
8 - - 5.23 7.40 - -
100 64 68 5.23 7.40 0.54 MC

101 74 84 5.23 7.40 1.35 MC
102 75 73 5.23 7.40 -0.27 NC/D
103 66 77 5.23 7.40 1.49 MC
104 60 - 5.23 7.40 - -
105 68 74 5.23 7.40 0.81 MC

106 67 66 5.23 7.40 -0.14 NC/D
107 55 68 5.23 7.40 1.76 MC
108 67 79 5.23 7.40 1.62 MC
111 81 61 5.23 7.40 -2.70 NC/D
112 66 75 5.23 7.40 1.22 MC
113 70 69 5.23 7.40 -0.14 NC/D
114 66 68 5.23 7.40 0.27 MC
121 56 62 5.23 7.40 0.81 MC
123 41 - 5.23 7.40 - -
128 58 - 5.23 7.40 - -
129 68 66 5.23 7.40 -0.27 NC/D

130 65 68 5.23 7.40 0.41 MC
132 64 64 5.23 7.40 0.00 NC/D
133 44 65 5.23 7.40 2.84 RC
160
Jacobson and Truax Method for Harter’s Cognitive Competence Scale

Cl 10 3.33 4.00 0.31 0.43 1.54 MC
13 3.33 3.00 0.31 0.43 -0.76 NC/D
25 3.50 3.67 0.31 0.43 0.39 MC
26 4.00 3.83 0.31 0.43 -0.39 NC/D
27 3.83 4.00 0.31 0.43 0.39 MC
28 3.33 4.00 0.31 0.43 1.54 MC
29 3.70 4.00 0.31 0.43 0.69 MC
30 3.30 3.83 0.31 0.43 1.22 MC
31 4.00 3.83 0.31 0.43 -0.39 NC/D
41 3.00 3.17 0.31 0.43 0.39 MC
69 4.00 4.00 0.31 0.43 0.00 NC/D
70 3.50 3.50 0.31 0.43 0.00 NC/D
72 3.67 3.50 0.31 0.43 -0.39 NC/D
74 4.00 3.83 0.31 0.43 -0.39 NC/D
75 3.83 3.83 0.31 0.43 0.00 NC/D
77 3.67 3.50 0.31 0.43 -0.39 NC/D
83 3.80 4.00 0.31 0.43 0.46 MC
85 2.83 4.00 0.31 0.43 2.70 RC
87 2.16 - 0.31 0.43 - -
127 3.33 3.33 0.31 0.43 0.00 NC/D

134 4.00 6.00 0.31 0.43 4.61 RC
135 2.50 2.66 0.31 0.43 0.37 MC
136 - - 0.31 0.43 - -
137 2.33 3.83 0.31 0.43 3.46 RC

138 2.60 3.16 0.31 0.43 1.29 MC
140 - - 0.31 0.43 - -
141 - _ 0.31 0.43 - -
C2 1 - - 0.32 0.46 . _
2 - - 0.32 0.46 - -
3 - - 0.32 0.46 . -
4 - - 0.32 0.46 - -
5 - - 0.32 0.46 - -
6 - - 0.32 0.46 - -
7 - - 0.32 0.46 - -
8 - - 0.32 0.46 - -
100 3.83 4.00 0.32 0.46 0.37 MC

101 - - 0.32 0.46 - -
102 4.00 4.00 0.32 0.46 0.00 NC/D

103 3.16 3.83 0.32 0.46 1.47 MC
104 - 4.00 0.32 0.46 . _
105 4.00 3.83 0.32 0.46 -0.37 NC/D

106 4.00 4.00 0.32 0.46 0.00 NC/D
107 - - 0.32 0.46 . _
108 2.80 3.33 0.32 0.46 1.16 MC

111 3.80 4.00 0.32 0.46 0.44 MC
112 2.50 - 0.32 0.46 - -
113 2.20 3.66 0.32 0.46 3.19 RC

114 3.50 4.00 0.32 0.46 1.09 MC
121 - - 0.32 0.46 - -
123 2.80 - 0.32 0.46 - -
128 2.66 3.33 0.32 0.46 1.47 MC

129 3.33 4.00 0.32 0.46 1.47 MC
130 3.16 3.33 0.32 0.46 0.37 MC
132 3.50 2.66 0.32 0.46 -1.84 NC/D
133 - - 0.32 0.46 - -
calculated. Recovery was not calculated for this scale, as it is not a measure o f deviancy.

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CHILD GROUP TRAINING VERSUS PARENT AND CHILD GROUP TRAINING

FOR YOUNG CHILDREN WITH ADHD

Elizabeth Gayle Corrin

A dissertation submitted in partial fulfillment of the

requirements for the degree of

Fairleigh Dickinson University

Neil Massoth, Ph.D.

Robert McGrath, Ph.D.

College Authorized to Offer Degree:

University College: Arts • Sciences • Professional Studies

August 14, 2003

All rights reserved.

ProQuest Information and Learning Company

Elizabeth Gayle Corrin

Requests for copying or reproduction of this dissertation may be referred to University

(b) printed copies of the manuscript made from microform.”

Child Group Training versus Parent and Child Group Training

For Young Children with ADHD

by Elizabeth Gayle Corrin

Chairperson o f the Supervisory Committee:

Professor Linda Reddy, University College

Parent training is an effective intervention for families with an Attention Deficit

Hyperactivity Disorder (ADHD) child, facilitating improvement on a range of child and

child group training (PCT) in an outpatient university-based clinic. Children ranged in

included didactic instruction, modeling, role-playing, behavioral rehearsal, coaching, and

developmentally appropriate games. Parent group training was based on a modified

treatment conditions would significantly improve in five clinical domains: child

Significant treatment responses were demonstrated in child externalizing behaviors,

preschool ADHD population.

List of Tables iii

Chapter II: Methods 58

Chapter III: Results 77

Chapter IV: Discussion 96

Appendix A: Study Consent Form 124

Appendix B: Child Treatment Curriculum 127

Appendix C: Parent Training Curriculum 138

Appendix D: Jacobson and Truax Tables 144

1. Child sample characteristics 62

2. Parent sample characteristics 63

5. Repeated measures ANOVA 91

9. Clinically significant change 95

enriched my professional development. I would also like to thank the members of my

for all o f their assistance.

Attention-Deficit/Hyperactivity Disorder (ADHD) is a chronic developmental

disability affecting 3 to 5% of all school-aged children (American Psychiatric

Association, 1994). ADHD is believed to be the most common behavioral disorder

socially inappropriate behaviors. The associated deficits occur in behavioral domains

turn, listening, and following directions. Functioning is frequently disrupted in school,

the majority o f cases, will last well into adolescence.

The Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric

Association, 1994) organizes ADHD into three subcategories: Predominantly Inattentive

Type, Predominantly Hyperactive-Impulsive Type, and Combined Type, with associated

sustaining attention in tasks or play activities, is often easily distracted by extraneous

activities, and often loses things necessary for tasks or activities.

To receive a diagnosis of Predominantly Hyperactive-Impulsive Type, a child also

the Hyperactive-Impulsive Type.

large-scale treatment outcome study included a comparison of parent characteristics

measures of ADHD symptomatology. Parents of ADHD children were significantly

compliance. Accurate self-evaluation is determined by matching teacher ratings. Self