TRAINING PARENTSOF ATTENTION DEFICIT HYPERACTIVITY

DISORDEREDCHILDREN: A SYSTEMATIC REPLICATION OF

RUSSELLBARKLEY'S DEFIANT CHILDREN MANUALIZED

PARENTTRAINING PROGRAM

IN A COMMUNITY SETTING

A Dissertation

Submittedto the
Facultyof ArgosyUniversity/Sarasota
In partial fulfillment of
The requirements for the degreeof
Doctorof Education

by

Troy LanceSchiedenhelm

ArgosyUniversity-Sarasota

Florida
Sarasota,

August2005

Dale.l*.Coovert,Ph.D.,Co-chair

DouglasG. Riedmiller,Psy.D.,Reader
 

Copyright 200 by
6FKLHGHQKHOP7UR\/DQFH

All rights reserved


2009
 TABLE OF CONTENTS

Page

Abstract . . . .. . . . . . v i

C o p y r i g hP
t a g e. .......,vii

Acknowledgements .........viii

ListofTables ..........ix

L i s to f A p p e n d i c e. s. . . . . . . . . . . . x.

C H A P T E RO N E : ......1

TheProblem.... ............1

W h a t i s A t t e n t i o nD e f i c i tH y p e r a c t i v i tDy i s o r d e r ? . . . . . ...........1

The DiagnosticDevelopment
andPerceptions
of ADHD .,......1

P a r e n t os f c h i l d r e nw i t h A D H D .........4

Efficacyof treatments...
.. .. .. . .. ..5

GeneralizabilityandExportabilityof ParentTraining . . ... . . . .. ..1

L i t e r a t u rRee v i e w .........10

Purposo
e f t h eS t u d y . . . . . . .1 3

Research
Questions ....14

Limitations ......15

Delimitations.... .....16

Definitions ........18

I m p o r t a n coef t h eS t u d y .....21

Summary .....22
CHAPTERTWO , , ..,.24

R e vi e wo f th eL i te ra tur e ...........24

C l i n i c aPl r e s e n t a t i o n . . . . . .........24

ADHD in Schools ........25

Socializations
in ADHD .. . . . ...26

T y p i c a lC o u r s eo f A D H D . . . . .. . . 2 8

C a u s eo
sf ADHD ....29

Comorbidities
with ADHD .....30

Parenting
StressandFamilialDiscord ... ....32

F a m i l yD y n a m i c s .........36

M a r i t a lD i s c o r d .....38

P a r e n t aMl a l a d j u s t m e n.t.s ........39

I d e n t i f y i n gA D H D i n C h i l d r e n .........40

Assessment...... ..........40

Diagnosis .....42

T r e a t m e not f A D H D .....43

BehavioralTherapy .. . ...41

Danforth'B
s MFC Procedure ...........48

Cognitive-Behavioral
Therapy .. . . . .. ..50

MedicatioT
n herapy .....52

School-Based
Interventions
. .. ...55

S o c i aS
l kills .......56
 Neurotherap
. .y.. ...........51

S u m m a t i oo
n f S i n g l eT r e a t m e nMt o d a l i t i e s .........58

M T A C o o p e r a t i vGer o u p .......59

P a r e nTt r a i n i n g ....64

Rationalefor ParentTrainins . ... . .....66

Supportfbr ParentTraining . . . ...67

A r g u m e n t as g a i n sPt a r e nTt r a i n i n g . . .. . . . . . . . 7 3

C l o s i n gt o t h eR e v i e wo f L i t e r a t u r e
..... .......'76

C H A P T E RT H R E E . . . . . .. . . 7 8

A Brief Review of the Study.

Research
Questions ... . . . .. ...78

Participants..... ........19

Instrumentation. .....81

ParentalStress

M a r i t a lo r P a r t n eD
r iscord .........83

ParentalDepression .... ..84

C h i l d B e h a v i o rD
a li s t u r b a n c e . , . . . ........85

A s s u m p t i o n. .s.. .......86

Procedures ...........87

S t e pO n e :W h y C h i l d r e nM i s b e h a v e
.. .........88

S t e pT w o : P a yA t t e n t i o n. . . ........89

StepThree:Increasing
ComplianceandIndependent
Play . ......89

lll
 StepFour:WhenPraiseIs Not Enough:PokerChipsandPoints......90

StepFive: Time Out! and OtherDisciplinaryMethods .. .. . . . ...90

S t e pS i x : E x t e n d i n T
g i m e O u t t o O t h e rB e h a v i o r . . . . . .. . . . 9 1

StepSeven:AnticipatingProblems:ManagingChildren
i n P u b l i cP l a c e s . . .. . . . 9 2

StepEight: ImprovingSchoolBehaviorfrom Home:

The Daily SchoolBehaviorReportCard . ......92

StepNine: HandlingFutureBehaviorProblems .....93

S t e pT e n :B o o s t e S
r essioa
n n dF o l l o w - U pM e e t i n g s. . . . ..........93

D a t aP r o c e s s i nagn dA n a l y s i s ......94

C H A P T E RF O U R ...........95

R e s t a t e m eonft t h eP u r p o s e . . . .. . . . . . 9 5

Statistical
Outcomesof Research
Questions ......99

P a r e n t aSl t r e s s ......99

Maritalor Relationship
Discord.. . . . .....101

ParentalDepression .......102

U n d e s i r a b lCeh i l dB e h a v i o r s ...103

Summary .. . . . . 1 0 5

C H A P T E RF I V E .........I07

Summary .......107

P a r t i c i p a n.t.s.. . .....108

Conclusions..... ........109

P a r e n t aSl t r e s s .......109

IV
 M a r i t ao
l r R e l a t i o n s hD
i pi s c o r d. . . . . ...110

ParentalDepression .. . . ...111

Undesirable
Child Behaviors .. ....112

G e n e r aD
l i s c u s s i oonf t h eP r o g r a ma n dF i n d i n g s. . . . . . . . . . .11 3

Recommendations . . . . .. . . .11 6

F u t u r eR e s e a r c h . . . . . . 11 6

ParticipantConsiderations.. .....116

InstrumentConsiderations.. ....118

OtherFutureResearchConsiderations. . ...119

R e c e nFt i n d i n e sR e l e v a ntto A D H D . . . .. . .. . . 1 2 0

Closing . . .. . . . . . 1 2 1

List of References .. . ....123

A p p e n d i c e. s. . . . . . . . . . . .1 6 5
 Abstractof DissertationPresented to the
GraduateSchoolof ArgosyUniversity/Sarasota
in PartialFulfillment of the Requirementsfor the
Degreeof Doctor of Education

TRAINING PARENTS OF ATTENTION DEFICIT HYPERACTTVITY

DISORDERED CHILDREN: A SYSTEMATIC REPLICATION OF
RUSELL BARKLEY'S DEFIANT CHILDREN MANU ALIZED
PARENT TRAINING PROGRAM
IN A COMMUNITY SETTING

by

Troy LanceSchiedenhelm

2005
Co-chair: Dale L. Coovert,Ph.D.
Co-chair: PaulaJ. Klanot,Psy.D.
Reader: DouglasG. Riedmiller,Psy.D.

Department: Schoolof Psychologyand BehavioralSciences

The dissertationexaminesthe exportabilityof R. A. Barkley's (1997c)Defiant

Childrenmanualizedparenttrainingprogram. The systematicreplicationstudywas

conductedin 2 non-universitysiteslocatednortheastof Charlotte,North Carolina.

Thirty one parentsor caregiversof childrendiagnosedwith ADHD between2 and

12 yearsparticipatedin the study. Data was analyzedfrom pretest-posttest

self-report

responses.Significantfindingswerefound on varioussubscales
of the ParentingStress

Index (Abidin, 1995)and the EybergChild BehaviorInventory(Eyberg& Pincus,1999)

instruments.Nonsignficantresultswerefound on the revisededitionof the Marital

SatisfactionInventory(Snyder,1991)and on the secondeditionof the Beck Depression

Inventory(Beck,Steer,& Brown, 1996). Finally, the necessityfor ongoingresearch

acrossprofessionaldisciplineswithin the ADHD populationis highlighted.

vi
Copyright2005by Troy LanceSchiedenhelm

vii
 Acknowledsements

to Dr. Dale Coovertand Dr. PaulaKlanot.

My gratitudeis greatlyexpressed

They supportedme and demonstratedpatiencewith me as I learnedas much aboutmyself

process.As co-chairson my dissertationcommittee,Drs.

as I did aboutthe dissertation

when criticism
Dale Coovertand PaulaKlanot providedguidanceand encouragement

was anticipated.I wish to extendmy thanksto Dr. Klanot for alsoservingas my guide

throughoutmy doctoraleducational.

I wish to thankJosephStegman,M.D. and the Developmental& Behavioral

Pediatricsof the Carolinasphysiciansfor providingreferralsto the dissertationstudy.

Further,my gratitudeis expressedin permitting the use of the facility and the support

receivedfrom all staff members.I alsowish to thankAnn Davis,ARNP for her referrals

to the study.

I wish to expressmy gratitudeto PatriciaLyerly, LCSW for allowing me to

utilize her facility for the dissertationstudyand supportingmy goals. Mrs. Lyerly

continuedto providesupportto my privatepracticewithin her facility as I completedthe

process.The Lyerly CounselingServices,LLC staff memberswere alsovery

dissertation

supportive.

to my wife and daughterfor their sacrificesand

My deepestgratitudeis expressed

for alwaysbeing therefor me when I neededthem. My thanksare especiallygiven to my

parents,my sister,and my brotherfor their supportsincemy dreamsvanishedin 1987.

is becauseof you.
My renaissance

vlll
 List of Tables

Table l. Participant
Reportof Age Ranges ......98

T a b l e2 . P a r e n t i nSgt r e s s .........100

T a b l e3 . M a r i t a lo r R e l a t i o n s h iDpi s c o r d. . . . . ........102

T a b l e4 . P a r e not r C a r e g i v e r D e p r e s s.i.o. .n. .........103

Table5. Undesirable
Child Behavior ....104

ix
 List of Appendices

AppendixA: A D H D B r o c h u r e ......166

AppendixB: A D H D F l y e r. . . . . .. . . .1 6 9

AppendixC: ParentStressIndex(PSI)Screening
Instrument. .......111

AppendixD: Marital SatisfactionInventory- Revised(MSI-R) Screening

Instrument ...175

Inventory- II (BDI-ID .. . .
AppendixE: Beck Depression . ....178

AppendixF: EybergChild BehaviorInventory(ECBI) ScreeningInstrument ...181

AppendixG: Participant
Demographic
Form ..185

AppendixH: Consentto Participate

in Research
Form .. . . . . . .. 189

AppendixI: Authorization
to Consentto Release
InformationForm ....... 196

AppendixJ: HumanSubjectReviewCommittee/Institutional
Review Board Forms... 199

AppendixK: Participant
Follow-upLetter ......203
 CHAPTER ONE

The Problem

What is Attention Deficit HyperactivityDisorder?

The AmericanPsychiatricAssociationDiagnosticand StatisticalManual for

Mental Disorders(APA, 2000)fourth edition-textrevisionidentify the diagnosticcriteria

for Attention-DeficitHyperactivityDisorder(ADHD). ADHD is a psychiatricdisorder

evidencedby a developmentally
inappropriate
presentation
of inattention,hyperactivity,

and impulsivity. The diagnosticcriteriaindicateevidenceof thesesymptomsbefore7

years. A child must demonstrate

functionalimpairmentin two or more socialsettingsto

fulfill the diagnosticcriteriafor attentiondeficit hyperactivitydisorder(APA, 2000). The

prevalencerateof ADHD is 3Vo-'/Vo

(APA, 2000).

According to Barkley (2000),most children are identified with ADHD as they are

beingevaluatedto enterthe first grade. The childrenwith ADHD are often retainedin

kindergartenbecauseof demonstrated
emotionalimmaturityor slow academic

achievement.Parentsor othersmust attendto the children'sbehavioraldisturbances.

Persistent
child disturbances
impactthe parentand the parent-childinteractionsin a

negativemanner(Barkley,1997c).A child diagnosedwith ADHD displayssignificant

behavioralor emotionaldisturbanceat school,at home,or in othersocialsettings.

The Diagnostic Developmentand Perceptionsof ADHD

The nosologyof ADHD evolvedover time. The originalterm utilized in the

classificationof subtleneurologicalproblemswasminimal brain dysfunction(Newby,

1996). The developmentof a psychiatricdiagnosticclassificationsystemensuedin the

1960s.The DSM-ll (APA, 1968)secondeditionusedthe diagnosisHyperkinetic

Reactionin Childhoodor Adolescence.The DSM-III (APA, 1980)third editionprovides

evidencefor a focuson inattentionas a centralclinical featureof the disorder.The

diagnosticlabelsof attentiondeficit disorderwith hyperactivityand attentiondeficit

disorderwithout hyperactivitywerethenutilized.

The DSM-lll-R (APA, 1987)third edition,revisedfirst utilized the diagnostic

term attentiondeficit hyperactivitydisorder.The nosologyis slightly modified in the

manual'sDSM-IV (APA, 1994)fourth edition. The DSM-ly-fR (APA, 2000) text

revisionis currentlyin use. The currentdiagnosticclassificationis AttentionDeficit

HyperactivityDisorder(ADHD) with four clinical specifiersto depictprevailing

symptomaticpresentation.The clinical specifiersarethe PredominantlyInattentive

Type,the PredominantlyHyperactivity-Impulsivity
Type, the CombinedType, andNot

OtherwiseSpecified(APA, 2000). The diagnosticcriteriafor attentiondeficit

hyperactivitydisorderarenotedin the Definitionssectionof this chapter.

Childrenwith ADHD tendto strugglein the socialcontext. This unfortunate

characteristicof ADHD setsthe stasefor a host of disturbancesfor the child. Children

with ADHD tendto impactsocietyin a negativemanneras they grow older. Children

with ADHD aremore likely thanthosewithout ADHD to be expelledfrom schoolor

drop out of school. They are alsomore likely to performat a lower gradepoint average,

to haveseveredriving accidents,to drive with a suspended

or revokeddriver'slicense,to

experiencesignificantproblemsin the work setting,and are at an increasedprevalence

for antisocialbehaviors(RussellA. Barkley,personalcommunication,March 19,2004).

Selectindividualsfrom the generalpopulationdisplaya quality of resistancein

acceptingADHD as a valid diagnosis.Their resistance

may be relatedto an actualor
perceivedthreatof inadequacyas a parentor a humanbeing. This threatis combined

with the parents'guilt that he or shemay havegiven their child the disorderthrough

genetictransmission.The parents'experienceof helplessness

and the generalized

suchas "He'sall boy" or "She'llgrow out of

folklore relatingto behavioraldisturbances

it" addsto this resistance.Thesevehementlyheld perspective

placesthe child at risk for

not receivingthe treatmentthat may possiblyreducebehavioralor socialproblems.

Therefore,this resistance
impedesthe child'spotentialfor succeedingin academicsand in

varioussocialsettinss.

Attentiondeficit hyperactivitydisorderis a complexdisorderthat remainsa topic

ongoingsocialdebate.Individualperceptionsand selectreligiousgroupspersistin

problem. Therefore,theseselect
arguingthat ADHD is not an authenticdiagnosable

individualsor groupsinsistany form of medical,pharmaceutical,

sociological,or

psychologicalinterventionis not warranted.Conversely,theseselectindividualsor

groupsmaintainthat a punishment-based
parentingstyleeliminatesbehavioralproblems

in children. Scientificevidencearguesotherwise.The standardfor identifyinga valid

disorderincludes2 criteriafor harmful dysfunction(Wakefield,,1992,1999). ADHD is

comprisedof a seriousdeficit or failure in adaptationand it producesharm to the

individual. The 2 criteriaaremet. Therefore,ADHD is identifiedas a valid and

diagnosable
disorder.

to reducethe psychosocialimpactson childrendiagnosedwith ADHD

Strategies

continuethroughthe pursuitof identifyingsociallyvalid protocols.Parenttrainingis an

identifiedempiricallysoundtreatmentfor behavioraldisturbances
often seenin ADHD

(Barkley,1997c).When parenttrainingis administered

early in a child'slife it provides
parentswith a proactiveinterventionto addresssignificantbehavioraldisturbances.

Thus,abehavioralparenttrainingprogrampotentiallyenhances
the child'squalityof life

throughoutthe developmental
stages.Further,parenttrainingmay indirectlyprovidea

potentialpreventativevaluefor society.

Parentsof children with ADHD

Barkley (1998)reportschildrenwith ADHD frequentlydemonstrate

poor

academicperformanceand experienceotherschool-related
problems. Additionally,they

haveemotionaldifficulties,low self-esteem, (Newby, Fischer,&

and socialawkwardness

Roman,1991). Childrenwith ADHD are at an increasedrisk for experiencing

relationshipconflicts. Theserisks areenhancedwhen environmentalor parentaldemands

exceedtheir capacityto cope(Barkley,1998). Intra-familialstresstriggersa parental

adoptionof a more negativeparentingstyle(Barkley,1998;Cunningham& Barkley,

1919). Parentsof childrenwith ADHD tendto view their abilitiesto parentas less

positive(Anastopoulos,
Guevremont,Shelton,& DuPaul,1992;Fischer,1990;Mash &

Johnston,1990). Also, theseparentsare at an increasedrisk of experiencingdepression.

anxiety,andmaritaldiscord(Cunningham,
Benness,
& Siegel,1988;Laheyet al., 1988).

Parentaldemandsdirectedat a child with ADHD sometimesresultin a

noncompliantresponse.Associationsarereportedbetweenthe disruptivebehaviors

exhibitedby childrenand parentalstress(Anastopoulos

et al., 1992;Eyberg,Boggs,&

Rodriguez, 1992). A stressfulparent-childrelationshipadverselyeffectsparental

functioning(Anastopoulos,
Shelton,DuPaul,& Guevremont,1993). Additionally,

parentsof childrenwith ADHD areoften involvedin addressing

their children'svarious
school,peer,and sibling difficulties. Significantparentalinvolvementtendsto endure

throughoutchildhoodand into adolescence

(Anastopoulos
& Farley,2003).

EJJicacyof treatments

Greenhill,Halperin,and Abikoff (1999)reportstimulantmedicationtherapiesare

consideredby far the most commontreatmentfor childrenwith ADHD. However,they

noteat least10-307oof thosewho takethe medicationsdo not show clinically significant

improvementsin the primaryADHD symptoms.Even when positiveresultsare

associated
with pharmaceutical
interventions,
somechildrenexperiencenegativeside

effects. Medication relatedside effectsmay be significantenoughin frequencyor

severitythat medicationtherapyis discontinued.Further,someparentsmake a conscious

decisionnot to utilize medicationas a meansof treatingtheir child'sADHD symptoms

(Anastopoulos
& Farley,2003). In practice,parentsof childrenwith ADHD often report

their frustrationwith the child's medicationregimen. Parentcomplaintsrelatingto

medicationtherapyincludefrequentchangesin dosagesor medicationsand child

complaintsof sideeffects. Parentsreportthey observesideeffectsin their children.

Parentsalsonote a significantfinancialcostto maintainthe prescriptions,

and yet,

behavioralproblemspersistevenwith medicationcompliance.Despitemedication

therapy'seffectiveness
in reducingthe core symptomsof ADHD, medicationsmay not

effectivelyaddressfunctionalimpairments(Greenhillet al., 1999).

AnastopoulosandFarley(2003)noteparenttrainingis an effectiveintervention

with childrentaking stimulanttherapies.Physiciansoftenprescribemedicationsfor

periodsof the day when the greatestpharmaceutical

effectis needed,most notablyduring

schoolhours. Regardless,
parentsmust contendwith the child'sbehavioraldisruptionsrn
the eveningsand on weekendswithout the assistance
of positivemedicationeffects.

Someresearchers
assertaddinga behavioralparenttrainingprogramto the child's

medicationtherapymay reducemedicationdosagesnecessary
for treatmenteffectiveness

(Froelich,Doepfner,& Lehmkuhl, 2002).

Alizadehand Andries(2002)assertparentingstyleis a pervasiveand crucial

factorthat plays a role in children'spsychologicaldevelopment.Theseresearchers

also

notethat thereis a considerable

lack of researchaboutthe relationshipbetweenparenting

stylesand child psychopathology.A changein the parentingstyle inducesa changein

the parent-childinteractions.A constructiveparentingstylemay enhanceparentalself-

esteemasthey functionin theparentingrole (Mash& Johnston

,l99};Pisterman et al.,

1992). Parenttrainingreinforcesa cooperativeparentingstyle. Parenttrainingmay also

facilitatespousalsupportand consistencywhen functioningin the parentingrole (Harvey,

2000).

AnastopoulosandFarley(2003)reportthat parenttrainingis consideredto be one

of the more commonly employedinterventionsfor ADHD. Mothers report they

experiencereductionsin stressand increases

in self-esteem
aftercompletinga behavioral

parenttrainingprogram(Pistermanet al., 1992).Parentsalsoreportimprovementsin the

overallseverityof their child'sADHD symptoms(Anastopoulos

et al., 1993).

Weinberg(1999)reportsparenttrainingprogramsincreaseparentalknowledge

andunderstanding
aboutADHD and behavioralmanagement
skills. Theseparentsalso

reporta mild decrease

in parentalstress.However,Weinbergalsostatesthat no

improvementsin the children'sbehaviorswere found at the end-pointof the parent

trainingprogram. Weinbergreportsparenttrainingdoesprovidean educationaldynamic

for parents.The extentto which the parenttrainingprogramaidsin generalizing

continuouspositivetreatmenteffectsto othersettingsis not determined(Weinberg,

1e99).

Generalizabilitvand Exportability of Parent Training

Wilson (1996)notesempiricallyprovenmanualizedtreatmentprogramsare

usefulto assessthe functionalutility of an interventionoutsideof a controlledtreatment

setting. However,concernsrelevantto the generalization

and exportabilityof

psychosocialtreatmentfor ADHD populationsare seenin the literature(e.g.,Whalenand

Henker,1991). Generalizabilityis an issueof lessconcernformedicationtherapiesdue

to its treatmenteffectscarriedacrosssocial settings. The exportability of behavioral

interventionsin the treatmentof ADHD is a recognizedbut understudiedaspectof

behavioraltreatmentsfor ADHD (Hoagwood,Hibbs,Brent, & Jensen,1995:Weisz,

Donenberg,Han, & Weiss, 1995). The useof a manualizedprotocolincreases

the

probabilityof a reliabledeliveryof the interventions.The findingsfrom a community-

basedstudymay providevaluableinformationregardingthe exportabilityof a

manualizedintervention.

A major sourceof influenceupon the child is the parentor the primary caregiver.

Parentsor caregiversusingbehavioraltools to facilitateprosocialbehaviorsprovidean

arenafor the child to constructivelyprogressin variousacademic,familial, and social

settings.The newly learnedbehavioralmanagement

strategiesare availableto the parent

at timeswhen the positiveeffectsof the medicationtherapyare not present.Medication

therapiesmay not be usedin the evenings,on the weekends,or throughoutthe summer.

 Barkley (1990)reportsincreasinga parent'sknowledgeaboutADHD and

behaviormanagementstrategiesfor ADHD arejustifiable areasfor treatmentand

disruptivebehaviorsoften seenin
research.Parenttrainingconstructivelyaddresses

childrenwith ADHD. Behavioralparenttrainingis an interventionto be consideredas

part of a multimodal approachin treatingADHD (MTA CooperativeGroup, 2OO4a).

to provethe efficacyof parenttraining

Othersreportthat additionalresearchis necessary

Weller, & Koning, 1998). The identifiableresearch

(van der Krol, Oosterbaan,

conductedon parenttrainingwith childrendiagnosedwith ADHD is limited to controlled

environmentstypically seenin universityhospitalsettings(viz., Anastopouloset al.,

1993;Erhardt,& Baker, 1990;MTA CooperativeGroup, 1999;Pistermanet a1.,1992;

Pisterman,McGrath,Firestone,& Goodman,1989;Pollard,Ward, & Barkley, 1983)'

The questionof socialvalidity is posedas to whethera cliniciancan conducta

manualizedparenttrainingprogramwith parentsof an ADHD child in a privatepractice

settingand obtain comparableresults. In fact, researchersannouncethe needfor such

studiesrelatingto the exportabilityof behavioralprogramsthat includea parenttraining

component(Hoagwoodet al., 1995;Pelham,Wheeler,& Chronis,1998;Weiszet al.,

I995).

RussellBarkley's(1997c)manualizedparenttrainingprogramfor defiantchildren

hasgainedrecognitionas the modelfor behavioralparenttraining. Supportfor a

therapeuticinterventiongainsscientificrigor throughthe replicationof the intervention.

in the literatureas
However,Barkley'sparenttrainingprogramis not well represented

part of an exportabilitystudy. Universitybasedstudiesreportparenttrainingyields

et al., i993; Pistermanet a1.,1992;van

positiveeffectson parentalstress(Anastopoulos
der Krol et al., 1998),maritaldiscord(Anastopoulos
et al., 1993;Lavee,Sharlin,&Katz,

1996),and contributesto the reductionof ADHD relatedsymptoms(Anastopoulos&

Farley,20O3;
Klein & Abikoff,1997: Pisterman
et al., 1989a;Smith& Barrett,2000).

Further,parenttraining may reducethe presenceof maternaldepressionoften reportedby

mothersof childrenwith externalizingdisorders(Barkley, 1997c Forehand& McMahon,

1981). A limitationof any exportabilitystudyis the dynamicthe clinicianbringsto the

program'spresentation.Group facilitatorrelatedvariablesmay influencethe program's

and socialvalidity findings(Kendall,Chu, Gifford, Hayes,& Nauta, 1998).

effectiveness

The identifiableresearchon parenttrainingis limited to a controlledenvironment

often seenin university settings. Someassertthat more researchon the exportability of

behavioraltreatmentand their effectivenessin real world settinssneedsto be conducted

(Pelham,Wheeler,and Chronis,1998). The issueof efficacyversuseffectiveness,

relatingto the exportabilityof empiricalstudiestypicallyconductedin university-based

hospitalsandclinics(Hoagwoodet al., 1995;Weiszet a1.,1995),

remainsrelatively

unexaminedin the literature.The exportabilityof a parenttrainingprogramprovidesa

treatmenttool for cliniciansin privatepracticeor othercommunitybasedsettings.This

treatmentis would thenthen availableto servechildrennot accessible

to a university

study. The evaluationof socialvalidity is obtainedby systematically

replicatingthe

secondeditionof Barkley's (1997c)manualizedprogram,Defiant Children:A Clinician's

Manualfor Assessment
and Parent Training. The replicationof this manualized

behaviorparenttrainingprogramis conductedin a licensedcounselor'sprivatepractice

and in a non-universitydevelopmental
and behavioralpediatricoffice. The participants

areparentsor caregiverswith a child diagnosedwith ADHD.

 LiteratureReview

The Multimodal TreatmentStudyof Childrenwith Attention-

Deficit/HyperactivityDisorderCooperativeGroup (MTA CooperativeGroup, 1999)is a

l4-month studyconductedby the NationalInstituteof Mental Health. The study

examinesevidence-based
treatmentsfor ADHD at 6 university-based
sitesin the United

States(MTA CooperativeGroup, 1999). The participantsof the MTA Cooperative

Group studyare randomlyassignedto 1 of 4 groups. The study'streatmentgroups

includethe administrationof methylphenidate

hydrochloride(Ritalin) alone,the

implementationof comprehensive
behavioralinterventionstrategies,
the combinationof

stimulanttherapyand behavioralinterventions,
and a communitycaregroup. The initial

resultsof the MTA CooperativeGroup study revealedthe superiorityof the medication

only and the combinedtreatmentgroupsover the behavioralinterventionsaloneand the

communitycaregroups(MTA CooperativeGroup, 1999). However,criticismsaremade

relatingto the study'smethodology(Breggin,2001; Klein, 2001).

424-month follow up (MTA CooperativeGroup, 2004a)on 540 of the original

579 childrenreportson the effectsizesof the medicationalgorithm(medicationonly and

medicationplus behavioralinterventionsgroups)versusbehavioralinterventionsonly

and communitycaregroups. The medicationonly groupand the combinedmedication

plus behavioralinterventionsgroupremainedsuperiorover the behavioralintervention

only and the communitycaregroups. However,the findingsreveala reductionin effect

size by half at 24 months (MTA CooperativeGroup, 2004a).

Jensenet al (2002)announcethe major finding of the MTA CooperativeGroup

studyis the lossof initial benefitseenat 14 months. Somearguethat the MTA

l0
CooperativeGroup study actuallyprovidedlittle utilizableinformationbeyondthe realm

of medicationin the treatmentof ADHD (Greene& Ablon, 2001). Most notablyargued

is the early fadingout of behavioralinterventionsduringthe study'sinitial l4-month

period(MTA CooperativeGroup, 2004a).The discontinuance

of eitherbehavioral

interventionsor medicationyieldsa returnto baselinemeasures(MTA Cooperative

Group,2004a). The findingshighlightthe short-termeffectiveness

limits of medication

and behavioralinterventionsin the treatmentof ADHD. The oositionthat the treatment

and sustainedover time is supported(Chroniset al.,

for ADHD must be comprehensive

2001).

The MTA CooperativeGroup (2004a)findings offer arguablesupportfor the

incorporationof a parent-trainingprogramin the multimodal treatmentapproachfor

childrenwith ADHD. Uniqueparentingstylesare neededwith childrendiagnosedwith

ADHD comparedto childrennot diagnosedwith ADHD. Parentalstressaffectsthe

parent'sability to functionin the home. A child'sexposureto parentalstressexacerbates

his or her emotionaland behavioralresponses.The child respondswith increased

aggressive
or disruptivebehaviors.The parentthen respondsto the child from an

increasedlevel of parentalstress.Parentsnot utilizing behavioral-social

learning

approaches
in their parentingstyleoften experiencean increasedlevel of stress(Barkley,

1997c).

The literaturepointstowardsa needfor empiricallysupportedpsychosocial

interventionsfor childrendiagnosedwith ADHD. Ample evidenceexistsin the realmof

stimulanttherapy(e.g.,Biederman,Lopez,Boellner,& Chandler,2002)and

reuptakeinhibitormedicationtherapy(e.g.,Kratochvilet al., 2002). It is

norepinephrine

ll
anticipatedthat pharmaceutically
basedresearchin the treatmentof ADHD will continue

to develop. The effectsof medicationare shownto be greaterthan behavioral

interventions.However,this advantage
is limited to when eithermedicationtherapyor

behavioralinterventionsarestopped(MTA CooperativeGroup,2004b). Although

behavioraltreatmenteffectstendto be smallerthanmedications,the effectsof behavioral

treatmentsare maintainedand possibly generalized(MTA CooperativeGroup, 2004b).

Loeber(1990)and Patterson(1982)reportthat poor or inconsistentchild and

familial behaviormanagement
practicesby parentsarecentralto defiantbehaviorsin

children. Noncomplianceand sociallyaggressive

behaviorsare facilitatedby attention

seekingor learnedescapetactics. Attentionseekingor escapemotivatedstrategiesare

frequentlyutilizedby childrenwith behavioraldisturbances.The behavioraldisruptions

may diminishby a parent'sconstructiveuseof behavioralinterventionsthat limit the

reinforcementof attentionseekingor escapestrategies(Barkley, 1997c). Further,the

behavioraldisturbances
seenin childrendiagnosedwith ADHD tend to producene.gative

peerinteractions.As a result,the child experiences

difficulty in obtainingand keeping

positivepeerrelations(Sheridanet al., 1996). The probablenegativesocialimpactyields

precipitatingfactorsfor variousconcurrentinternalizingand externalizingdisorders.

Barkley (1991a)reportsthat behavioralinterventionsareeffectivewith children

diagnosedwith ADHD when deliveredat the point of performance.His assertions

exemplifythe necessityto train parentsin behavioralmanagement

principles. Ancillary

benefitsfor parentsreceivingparenttrainingarereportedin the reductionof parental

stress,marital discord,and externahzingbehavioraldisturbancesof the child (Barkley,

the potentialfor the child

1997c).Additionally,behavioralparenttrainingincreases

t2
diagnosedwith ADHD to displayprosocialbehaviorswithin and outsidethe home. The

resultis a potentialdecrease
in peerand adultrelationalproblemsacrosssocialsettings.

Further,a potentialpositiveimpactis a decrease

in experiencingbehavioral,financial,

interpersonal,
and legalconsequences
as he or shedevelopsthroughoutthe life span.

Purposeof the Study

The purposeof the studyis centeredon examiningthe exportabilityof a

manualizedparenttrainingprogram(viz., Barkley, 7997c)when appliedto the ADHD

population.The studyexploresthe program'sability to contributeto parentor caregiver

reductionsof parentalstress,maritaldiscord,and depression.An additionalfocusof the

studyis to determineif parentsor caregiversreportimprovedbehaviorsin their children

with ADHD aftercompletingthe program.

A constructiveand competentparentalpresencein the child's life increaseshis or

her potentialto succeedin academicor othersocialsettings.Use of an empiricallyvalid

interventionmay contributeto a parentor caregiver'sability to manageundesirablechild

behaviors.Increasedconfidenceandcomposure,while functioningin the parentingrole,

affordsthe opportunityfor the parentsor caregiversto consistentlymeetand

constructivelyaddressthe needsof the child. Parenttrainingof behavioralintervention

is proposedin the literatureas a valid, if not a critical,aspectin the treatmentof

strategies

ADHD.

The goalsof the studyrelateto the socialvalidity of the secondeditionof

Barkley's(1991c)DeJ'iantChildren:A Clinician'sManualfor Assessment

and Parent

Trainingprogramwhen appliedto the ADHD population.Specifically,the studyplansto

examineparentand caregiverself-reportsin a pretest-posttest

format. Participantself-

13
reportsof their parentalstress,maritalor partnershipdiscord,depressiveexperiences,
and

their children'sbehavioralpresentation
areanalyzed.

ResearchQuestions

1. Do parentsor caregiversof childrendiagnosedwith ADHD reporta

statisticallysignificantreductionof parentalstressas measuredby pretest-posttest

on the ParentingStressIndex (Abidin, 1995)aftercompletingRussell

responses

Barkley'sDefiant Child (1997c)manualizedparenttrainingprogramin a privatepractice

or pediatricoffice setting?

2. Do parentsor caregiversof childrendiagnosedwith ADHD reporta

statisticallysignificantreductionof marital or partnershipdiscord as measuredby pretest-

posttestresponses (Snyder,1997)after
on the Marital SatisfactionInventory-Revised

completingRussellBarkley'sDefiantChild (1997c)manualizedparenttrainingprogram

in a privatepracticeor pediatricoffice setting?

3. Do mothersor femalecaregiversof childrendiagnosedwith ADHD reporta

statisticallysignificantreductionin their depressive

mood experiences
as measuredby

pretest-posttest on the Beck DepressionInventory(Beck,Steer,& Brown,

responses

1991)aftercompletingRussellBarkley'sDefiantChild (1997c)manualizedparent

trainingprogramin a privatepracticeor pediatricoffice setting?

4. Do fathersor malecaregiversof childrendiagnosedwith ADHD reporta

statisticallysignificantreductionin their depressive

mood experiences
as measuredby

pretest-posttest on the Beck DepressionInventory(Beck,Steer,& Brown,

responses

1991)aftercompletingRussellBarkley'sDefiantChild (1991c)manualizedparent

trainingprogramin a privatepracticeor pediatricoffice setting?

l4
 5. Do parentsor caregiversof childrendiagnosedwith ADHD reporta

child behaviorsas measuredby pretest-

statisticallysignificantreductionin undesirable

on the EybergChild BehaviorInventory(Eyberg& Pincus,1999)after

posttestresponses

completingRussellBarkley'sDefiantChild (1997c)manualizedparenttrainingprogram

in a privatepracticeor pediatricoffice setting?

Limitations

designin a private practiceand pediatric office setting

The study'spretest-posttest

presentsthe fbllowing limitations. Datacollectionis limited to participantself-reports.

Participantsarenot screenedfor their own psychopathology.This may effect raterbias

or error. Additionally,participantcompliancewith the treatmentprotocolmay be

influencedby his or her psychopathology.

study designusesself-reportson parentalstress,parental

The pretest-posttest

maritalor partnerdiscord,andbehavioralchangein the child. A pretestmay

depression,

influencethe participant'sresponses
at posttest.

Participantsmay drop out of the studydue to personalor environmentalvariables.

A commitmentfrom the participantsto attend9 weekly sessionsand a 1-monthfollow-up

sessionmay be difficult to sustain.Despitethe fact that the sessionsare at no financial

costto the participants,a weeklycommitmentfrom them may be difficult. Thus,

participantattritioneffectsmay be present.

Other aspectsmay exist that cannotbe controlled. Theseaspectsmay include the

in therapyfor themselvesor their children.

participants'historicalexperiences

Additionalchild or participantactivitiesbeforeand duringtreatmentdeliverymay effect

or treatmentcompliance.Also, individualdifferencesplacea
programattendance

l5
potentialthreatupon internalvalidity. Specifically,the study'sprincipleinvestigatoris

influencedfrom a different cultural perspective.An unfortunatebut realistic potentialfor

biasof the participantsexists. Finally,the capacityof the principleinvestigatorto

effectivelydisseminate
the manualizedparenttrainingprogrammaterialscontributesas a

limitationto the studv.

Delimitations

The parentsor caregiversof childrendiagnosedwith ADHD are the participants

in the study. A pediatrician,family physician,psychiatrist,or nursepractitionermakes

the ADHD diagnosisin the childrenandthen refersthe parentsor caregiversto the study.

The parentsor caregiverscompletethe pretest-posttest

instruments.Thus,thereexists

neithera randomselectionof subjectsnor a controlgroup.

The samplesizeis not pre-determined.A goal of at least34 participantsis

anticipated.Thirty four subjectsprovidea minimum yield of an alphaof .05, a powerof

.90, and an effect sizeof .50 for a CaseI one-tailedsignificancetest (Shavelson,1988).

More than one groupof participantsis necessary

to acquirethe desiredstatisticalpower

for analysis.The sizeof eachparenttraininggroupis limited to 20 participantsper

group.

The sampleincludesparentsor caregiversof childrenages2 to 12 yearswho have

beendiagnosedwith ADHD. The specifiertype of ADHD is not an exclusioncriterion.

The childrenarediagnosedwith ADHD by a licensedphysicianor nursepractitioner.

The methodsusedby the physicianor nursepractitionerto makethe ADHD diagnosisare

not known.

l6
 A child's comorbiddiagnosismay excludea participantfrom the study. The

comorbidexclusioncriteriaincludeTourette'sSyndrome,a major neurologicalor

medicalconditionthat would inhibit the benefitsfrom a behavioralintervention,ongoing

or unreportedabuse,suicidalor homicidalideations,and moderateto profoundmental

retardation.Theseexclusioncriteriaare similarto thoseusedin similar studies(e.g.,

MTA CooperativeGroup, 1999). Any exclusionarycriteriaarefirst identifiedby the

referringclinicianand arepresentedto the principleinvestigator.The principle

investigatormakesthe final determinationwhetheror not to excludethe potential

participantfrom the study. The exclusionarycriteriafor the study'sparticipantsare

equivalentto thoseof the child. A participantdiagnosisof ADHD is not an exclusionary

criteriondue to the disorder'spresumedbiologicalor geneticfoundation.Any participant

mentalconditionsthat may influencethe studyarediscussedin Chapter5.

self-reported

The study'sanalysisis basedon self-reportsof parentsor caregiverswith children

diagnosedwith ADHD. Due to the geneticallyor biologicallybasedaspectsof the

disorder,a parentparticipatingin the studymay or may not possessthis diagnosisas

may play a potentialhindranceto generalizingthe

well. Participantpsychopathology

findingsof the study.

A notabledelimitation is the time of the school year that the parent-training

and child-teacherrelationsat
programis conducted.This is due to participant-teacher

differenttimesduring the schoolyear. Constructiveteacherinvolvementis an important

componentof the programunderstudy.

A final delimitationrelatesto geographyand the selectionprocess.The studyis

conductedin a rural and a suburbanareanortheastof Charlotte,North Carolina.

t7
Generalizabilityis limited to race,gender,and socioeconomic
statusof the participants

within the geographicregionof the United Stateswho arereferredto and participatein

the study.

Definitions

1. AttentionDeficit HyperactivityDisorder(ADHD). The DSM-Iy-fR (APA,

2000) text revision reportsthe significantfeaturesof ADHD as a developmentally

inappropriate
persistentpatternof inattentionor hyperactivity-impulsivity.Thesecore

featuresof inattentionand hyperactivity-impulsivity

may alsobe presentedin

combination.A clinical presentation

of impairmentmust be evidentwithin the child's

first 7 years. The ADHD diagnosticsymptomsmust causeimpairmentin 2 or more

socialsettings.Diagnosticsymptomsmust inducea negativeeffectupon

developmentally
appropriateacademic,familial, or socialfunctioning. The ADHD

symptomsmust not occur only during the courseof or better accountedfor by another

mentaldisorder(APA, 2000).

The DSM-ly-ZR (APA, 2000)text revisionliststhe diagnosticcriteriaof ADHD.

Eitherat least6 symptomsof inattentionor at least6 symptomsof hyperactivity-

impulsivitymust be presenta minimum of 6 months. The ADHD-Predominantly

InattentiveType diagnosticcriteriainclude,

(a) often fails to give close attentionto detailsor makescarelessmistakesin

schoolwork,work, or otheractivities,(b) often hasdifficulty sustainingattention

in tasksor play activities,(c) oftendoesnot seemto listenwhen spokento

directly,(d) often doesnot follow throughon instructionsand fails to finish

schoolwork,chores,or dutiesin the workplace(not due to oppositionalbehavior

l8
 or failureto understandinstructions),(e) often hasdifficulty organizingtasksand

activities,(0 often avoids,dislikes,or is reluctantto engagein tasksthat require

sustainedmentaleffort (suchas schoolworkor homework),(g) often losesthings

necessaryfor tasksor activities(e.9.,toys,schoolassignments,

pencils,books,or

tools),(h) is ofteneasilydistractedby extraneousstimuli, and (i) is often forgetful

in daily activities.(p.92)

The DSM-ly-fR (APA, 2000) text revision lists the diagnosticcriteria for ADHD

hyperactivity-impulsive
type. At least6 of the following criteriamust be evidentto meet

the diagnosticcriteria. The ADHD-PredominantlyHyperactive-Impulsive

Type

diagnosticcriteriainclude,

(a) often fidgetswith handsor feet or squirmsin seat,(b) often leavesseatin

classroomor in othersituationsin which remainingseatedis expected,(c) often

runs aboutor climbs excessivelyin situationsin which it is inappropriate,

(d)

often hasdifficulty playingor engagingin leisureactivitiesquietly,(e) is often

"on the go" or often actsas if "drivenby a motor", (f) often talks excessively,(g)

often blurts out answersbeforequestionshavebeencompleted,(h) often has

difficulty awaitingturn, and (i) ofteninterruptsor intrudeson others(e.g.,butts

or games).(p.92)
into conversations

The predominantlyinattentivetype,the predominantlyhyperactive-impulsive

type,the combinedtype, and the not otherwisespecifiedtype arethe four identified

clinical specifiersassociated
with the ADHD (APA, 2000).

2.The MTA CooperativeGroup. The Multimodal TreatmentStudy of Attention

Deficit HyperactiveDisorder(MTA CooperativeGroup, 1999)is a six-site14-month

t9
studyof evidencebasedinterventionsfor the treatmentof ADHD. This study is

conductedby the NationalInstituteof Mental Health. The six sitesfor the MTA

CooperativeGroup studyincludethe Universityof Californiaat Berkley and San

Francisco,Duke University,the Universityof Californiaat Irvine and Los Angeles,the

Long IslandJewishMedicalCenter,the New York StatePsychiatricInstitute,Columbia

Universityand Mount Sinai MedicalCenterof New York, and the Universityof

Pittsburgh.The principlecollaborators
arePeterS. Jensen,L. EugeneArnold, JohnE.

Richters,JoanneB. Severe,DonaldVereen,BenedettoVitiello, and Ellen Schiller.

Five hundredseventynine childrendiagnosedwith ADHD-CombinedType were

randomly assignedto one of 4 groups. The first group is the 3-tractbehavioraltreatment

only group. The behaviorinterventionsin this grouparea parenttrainingprogram,a

summertreatmentprogram,and a school-based
treatmentprogram. The parenttraining

programis basedon Barkley (1987)and Forehandand McMahon (1980)manualized

parenttrainingprogramswith a,fadedbi-weeklyteacherconsultation.Additionally,the

behavioraltreatmentgroupparticipatesin a summertreatmentprogram(Pelham& Hoza,

1996). The behavioraltreatmentgroup also incorporatesa school-basedtreatment

program(Pelhamet al., 1998)with a modified l0-16 week biweeklyteacherconsultation

focusingon classroombehavioralmanagement
strategies.A modified versionof a

behavioralclassroomprogram(viz., Swanson,1992)utilizesa part-timeparaprofessional

in the classroomworking directlywith the child. The secondgroup is the medication

grouputilizing methylphenidate
management hydrochloride(Ritalin). The third groupis

the combineddeliveryof behavioralinterventionsand medicationmanagementtherapy.

The fourth group is a community carecomparisongroup. Members of this group were

referredout with a list of community mental healthcareresourcesand then monitoredby

the researchers.

The rationalefor the MTA CooperativeGroup study(1999)is to conductthe first

multimodalcollaborativestudyon currentlyavailableevidence-based
interventionsfor

the treatmentof ADHD. The behavioraltherapycomponentof the MTA Cooperative

Group studyusesan adaptationfrom the first editionof the manualizedparenttraining

programunderstudyin this dissertation.

3. Point of Performance.Barkley (1997a)argueschildrendiagnosedwith ADHD

arenot limited in knowledgeor skill. However,childrenwith ADHD are limited in

performingthe appropriateskills necessary

to meetthe expectations
of the situation.

Behavioralinterventionsare most effective when utilized in the natural settinewhere

thesebehavioraldisturbances
occur. This settinsor situationwherebehavior

disturbances
occur and wherebehavioralinterventionsaredeliveredis calledthe point of

performance.

4. Reciprocity.Barkley (1997c)utilizesthe term reciprocityto describethe

complexparent-childinteractions.The child's negativeor positiveemotionsand

behaviorsarepartiallya functionof the child's responseto parentalinteractionswith the

the parent'semotionaland behavioralresponseis partiallya

child. Simultaneously,

functionof a child's behaviortowardsthe parent.

Importanceof the Study

Findingswill providepotentialevidenceon the exportabilityof a manualized

parenttrainingprogramwhen appliedto the ADHD population.The currentliterature

relatedto the efficacy of suchprogramsis sparse.An exportablemanualizedtreatment

2l
programprovidesan opportunityto betterservea populationthat possesses
a

demonstrated
needfor interventionin orderto succeedacrosssocialsettings.

A sociallyvalid parenttrainingprogramfor the ADHD populationmay assist

parentsin managingthe functionalsymptomsof his or her child's chronicdisorder.The

untreatedor under-treated
child diagnosedwith ADHD predisposes
all family members

to a hostof psychosocialstressors.The impactof an untreatedor under-treated

child

with ADHD impedeseachperson'sphysicaland emotionalavailability. The utilization

and possiblegeneralization
of learnedbehaviorsconsistentlymeetingparentaland

societalexpectations
afford the child diagnosedwith ADHD the opportunityto adaptand

overcomepsychosocialhurdles.Benefitsmay be realizedfor the child throughouthis or

her developmental
life span. Improvementsin the child's,the family members',andthe

parents'quality of life are alsopotentialresults.The exportabilityof a manualized

parent-training
programmay encourageparentsand teachersto reconsidertheir growing

relianceon medicationtherapyto addressADHD relatedsymptoms.Finally, the results

of this studymay spawnnew researchin the deliveryof currentor yet to be created

psychosocialservices,treatmentprotocols,or clinical pathwaysto optimally address

ADHD symptoms.

Summary

The diagnosticterm ADHD is relativelynew. A vast amountof

information remainsunknown aboutthe disorderand its treatment. Researchon the

diagnosisand treatmentof ADHD continueswithin severalprofessionaldisciplines.

ADHD is deemeda complexdisorderwith biologicalor geneticties to its clinical

predisposition.The precipitatingenvironmentalfactorscontributeto the

22
multidimensionalcomplexityand chronicityof the disorder.Debatecontinueson the

efficacy of different treatmentdisciplines. Valuableprogressis being accomplishedin

of the disorder'setiology,prevalence,
researchtowardsa more informedunderstanding

course,and treatment.

Parentsor caregiversexperiencean internalnegative,and perhapsa defensive,

responsewhen informedtheir child is diagnosedwith ADHD. Hopesand dreamsfor

their child's prospectspotentiallyassumea new path of daily survivalversusa future

orientationof thriving in life. The chronicityof the disordermay inadvertentlyreinforce

frustration,or pessimism.
the parents'or the caregivers'feelingsof helplessness,

tools to effectivelymanage
Providingparentsor caregiverswith behavioralmanagement

and
their children'sexternalizingbehaviors,may alsoimprovetheir self-perception

in the parentingrole. Anotherresultmay includeinterpersonal

experiences

improvementsas a spouseor a partner.Further,any improvementsin the child and the

parent-childrelationshippromotelong-termbenefitsin our societyat large. An

providesparentswith behavioralinterventions
programthat.effectively
empirically-based

outsideof a controlledsettingis not definitivelyidentified. A systematicreplicationof a

setting
parenttrainingprogram(e.g.,Barkley,1997c)within a non-university
manualized

contributesto the eventualidentificationof such a program.

ZJ
 CHAPTER TWO

Review of Literature

Clinical Presentation

AttentionDeficit HyperactivityDisorder(ADHD) is a neurologically-based

disorder.ChildrenexperienceADHD-relatedsymptomsat an early age. ADHD also

and adults. The diagnosticfeaturesof ADHD are generallyseen

affectsadolescents

within the normaldevelopmental

spectrum.However,clinical significanceis considered

when the observablebehaviorsexceeda normalizeddevelopmental

presentation.

Diagnosticrelevanceis consideredwhen the behaviorsappearbeyondthe children's

ability to inhibit them and a failureof socialadaptationis evident(Pelham& Gnagy,

1999). The ADHD diagnosisis describedwith the clinical specifiersof predominantly

inattentivetype,predominantlyhyperactive-impulsive
type,combinedtype, and not

otherwisespecified.

Palfrey,Levine,Walker, and Sullivan(1985)identify the peakonsetof ADHD

symptomsat 3 to 4 yearsof age. Diagnosticreliability improvesas the child enters

formal schoolingat approximately5 to 6 yearsof age(Campbell,Breaux,Ewing, &

Szumnowski,1986;Campbell,Endman,& Bernfeld, 1977;Schleiferet al., 1975).The

disorderis more prevalentin malesthan females.The disordereffectsfrom 3Vato'/ Voof

children(APA, 2000). Someresearchers

school-aged reportADHD affects5Voto l7o of

the total childhoodpopulation(Johnson,Franklin,Hall, & Prieto,2000). Childrenand

Adults with AttentionDeficit/HyperactivityDisorderreportin 1993that 3.5 million

children,plus 2 to 5 million adults,experiencesomeform of ADHD (Mathes& Bender,

t991).
 Barkley (1998)reportsthat the youngerthe child the more likely he or shewill be

diagnosedwith the predominatelyhyperactive-impulsive

specifier.The inattentivetype

and adulthood(Resnick,
is more evidentas thesechildrenprogressinto adolescence

2000). The assessment

and diagnosisof ADHD is subjectivein nature. Therefore,

practitionersand researchers
shouldbe cognizantof and sensitiveto culturaland ethnic

factorswhen making an ADHD diagnosis(Root & Resnick,2003).

ADHD in Schools.

Barkley (2000)notesthdt as many as 30Voof all ADHD childrenhaveat leastone

type of learningdisorder. Virtually all childrenwith ADHD displaysignificantacademic

(Barkley,DuPaul,& McMurray, 1990). Public schoolsprovide

underachievement

significantfunctionalimpairmentwith specialservices(Barkley,
childrendemonstrating

1990;Reid,Maag,Vasa,& Wright, 1994). Dyslexiaor othertypesof learning

disabilitiesis evidentin as many as 30Voof childrenwith ADHD (Barkley,DuPaul,&

McMurray, 1990). NumerousschoolsareprogressingtowardsservingADHD children

in mainstreamclassrooms(Mathes& Bender,1997). Academicperformanceis

significantlylower comparedto their estimatedpotential(Barkley,1990). General

educationteachersmodify the environmentand the deliveryof educationalmaterialsto

meetthe needsof all students,as requiredby Section504 of the RehabilitationAct of

1973(Reid& Katsiyannis,
1995;Reidet al,1994).

Routh and Schroeder(1976)notethat ADHD-relatedbehavioraldisturbances

occurin play settings.Significantpeersocializationproblemsmay occur for the child

activity (Canoll, Durkin,

when he or sheis on schoolgroundsor during a school-related

Hattie,& Houghton,799l; Pelham& Bender,1982). However,most behavioral

25
 occur when the academicor socialsituationdemandssustainedattentionto
disturbances

situationsthat providelimited feedback

dull, boring,repetitivetasks,and in unstructured

(Barkley,1977;Douglas,
1983;Luk, 1985;Milich,Loney,& Landau,1982).

Socializationsin ADH D.

CunninghamandSiegel( 1987)reportchildrenwith ADHD displayan inabilityto

controltheir behaviorin socialsituations.The persistentexhibitionof negativebehaviors

frequentlyalienatestheir peers. Children with ADHD are more frequently nominatedby

their peersas "liked least"comparedto normalcontrols(Lahey,Schaughency,

Strauss,&

childrenwith ADHD as obnoxious,impulsive,or

Frame,1984). Peerscharacterize

(Frankel,Myatt, Cantwell,& Feinberg,1996;Landau& Moore, 1991).

inconsiderate

Suchbehavioral,academic,and socialproblemspredispose
childrenwith ADHD for an

low frustrationtolerance,symptomsof depressionand anxiety,

onsetof low self-esteem,

and otheremotionalchallenges(Barkley,1998;Margalit & Arieli, 1984).

Newby et al (1991)reportchildrendiagnosedwith ADHD exhibit significant

socialawkwardness.Childrenwith ADHD alsoexperiencesignificantlymore conflicts

with peersand siblings(Mash & Johnston,1990).Childrenwith ADHD tend to not know

activities(Pelhamet al., 1990).

or adhereto the rulesfollowed by othersin sports-related

of
Socialskills limitationsrelatingto sportingactivitiescontributefurtherto experiences

(Pelham& Bender,1982). Conflictscreatedby

socialrejectionand low self-esteem

children with ADHD and the amountadult attentionrequiredto addressthe problem

behaviorsadd to their socialadaptationdifficulties(Dixon, 1995). Group settingsare

more problematicthan individualone-to-onesettingsfor childrenwith ADHD,

presumablydue to the increaseddemandsfor behavioralself-regulation.

26
 Zentall (1985) assertsADHD is not an all-or-nothingphenomenon.Zentall

reportsADHD is a disorderwith the primary symptomsshowingsignificantfluctuations

in responseto differentsituationaldemands.Someproposethat understanding

the social

problemsof childrenwith ADHD may be centralto understanding

the psychopathology

of thesechildren(Erhardt& Hinshaw,1994).They tend to havefew, if any,friends.

Friendsthey do haveareconsideredto be intrusive,boisterous,and annoyingplaymates

(Landau,Milich, & Diener, 1998;Pelham& Bender,1982).Childrenwith ADHD who

(Hinshaw,1987 Loney & Milich, 1982),or social

haveearly difficultieswith aggression

relationsproblems(Barkley,1990;Milich & Landau, 1982;Parker& Asher, 1987),tend

to experiencemore seriousclinical problemsin adolescence.

Lochman,White, andWayland(1991) reporton a 3-yearfollow up with

adolescents
diagnosedwith ADHD that aggressive
boyswho receivedangercontrol

trainingreportself-esteem
levelswithin normallimits and engagedin lesssubstance

abusethan untreatedindividuals.Anger management

groupsspecificallydesignedfor

childrenwith ADHD are available(e.g.,Hinshaw& Erhardt,1991). The simultaneous

incorporationof a parenttrainingprogram(e.g.,Barkley, 7987, 1997c)with an anger

control(e.g,,Hinshaw& Erhardt,1991)or othersocialskills(e.g.,Sheridan,1995)

programis encouraged
to build a breadthof clinical benefitsto the treatmentfor children

with ADHD (Landau,et al., 1998).

Barkley (1997b)reportsthat behavioraldisinhibitionappearsto be a central

featureof ADHD in children. ADHD appearsto be a disorderof performanceratherthan

a deficit of skills awareness.ADHD is a disorderof self-controlor self-regulation

(Barkley,1991a).Notwithstandingthe currentperspective
that ADHD is a

21
neurologically-based
disorder,findingsrevealthat psychosocialfactorscorrelate

significantlywith childhoodinhibitiondifficulties(Carton& Carton,1998). An

authoritativeparentingstylecan reduceself-controlproblems(Pettit,Dodge,& Brown,

1988;Hart, DeWolf, Wozniak,& Burts, 1992).

Typical Courseof ADHD

Barkley(1997c,1998)reportsADHD significantlyimpactschildren'semotional,

family, school,and socialfunctioning. Childrenwith ADHD are at risk for a variety

externalizedbehaviorproblemsas they grow (Barkley,1998). Barkley alsoreportsthat

by adolesce
nce,20Voto 5OVoof the hyperactivechildrenwill carry a conductdisorder

diagnosis.Additionally,25Voof the hyperactivechildrenwill progressinto antisocial

personalitydisorderby youngadulthood.Delinquencyand conductdisorderseenin

placethe personat risk for futuresubstance

adolescence abuseproblems(Crowley,

Mikulich,MacDonald,Young,&Zerbe,1998). Delinquencyandconductdisorderis

with high risk behaviorsrelatingto HIV inflection(Canterbury,Clavet,

alsoassociated

McGarvey,& Koopman,1999). Moreover,childrendiagnosedwith ADHD-

PredominantlyHyperactive-Impulsive
type may be more likely to be diagnosedwith an

affectivedisorderin adulthood(Barkley,1998).

Childrenaretypically first diagnosedduringthe elementaryschoolyears.

However,the disorderis not outgrownas the child developsinto adulthood.Children

diagnosedwith ADHD areconsideredat the highestdegreeof risk for negativesocial

and adulthood(Hinshaw,1994;Lynam,1996). The

outcomesin adolescence

psychosocialimpairmentsaffectingsocialrelationships,
academicperformance,or

and into adulthood(Barkley,

organizedsportscontinuethroughadolescence
Anastopoulos,
Guevremont,& Fletcher,l99l; McCleary& Ridley, 1999;Szatmari,

Offord,& Boyle, 1989;Weiss& Hechtman,1986).

The negativeimpactfrom ADHD is evidentin adulthood.The diagnostic

symptomsmay be exhibitedwith a lesserdegreeof impairment.Adults with ADHD

vocational,and cognitivedomains(Biederman,
displayimpairmentin the interpersonal,

Faraone,Keenan,& Munir, 1990;Dinn, Robbins,& Harris,2001;Murphy & Barkley,

1996S
; c h w e i t z e r e t a l . , 2 0 0 0O
) .n c e t h o u g h t t o b e o u t g r o w n . b y l a t e a d o l e s c e n c e , i t i s

clearthat childrenwith ADHD will continueto haveproblemsattributableto ADHD in

adulthood(Root & Resnick,2003).ADHD is considereda chronicdisorderand will

requiretreatmentthroughoutthe lifespan(Resnick,2000).

Causesof ADHD

The core featuresof attentiondeficit hyperactivitydisorderare inattention,

hyperactivity,and impulsivity. A biologicalor neurologicalfoundationis consideredto

explainthe etiologyof thesecorefeatures.No known geneticanomalyis associated

with

ADHD. However, stronggeneticinfluencesare recognizedwith the core featuresof

ADHD (Barkley, 1997a).Neuro-imagingstudiesutilizing the quantitativeEEG, the

MRI, the/MRI, and the PET scanreveala common clinical pathwayfor ADHD related

circuitsin the brain (Barkley,7997a).The neurochemical

to the fronto-striatal-cerebellar

deficitsrangefrom dopamineand norepinephrine

dysregulationto the ineffective

in selectareasof the brain (RussellA. Barkley,personal

distributionof neurotransmitters

communication,March 19,2004). Barkleycontinuesby identifyingthe DRD4-7+ repeat,

the DATI-480bp, the DBH-Taql, and the 16p13regionas geneticmarkersfor ADHD.

29
High amplitudein thetabrainwavesis considereda biologicalmarkerfor ADHD-

Predominantly type(Malone,Kershner,& Swanson

Inattentive ,lg94).

The DSM-Iy-fR (APA, 2000) notesenvironmentalinfluencesare identified as

contributionsto the ADHD child'sfunctionalimpairments.However,the influencesof

environmentalfactorsor food-relatedproductsin the etiologyof ADHD are generally

dismissed(Barkley,personalcommunication,
March 19,2OO4).Regardlessof the actual

or hypothesized
etiologicalcontributionsto ADHD onset,the resultingpsychosocial

impactsand the significantfunctionalimpairmentscan not be dismissed.

Comorbidities w ith AD HD

Hinshaw( 1987)identifiesthe existenceof a comorbidpresenceof externalizing

behaviorswithin ADHD more than l8 yearsago. Oppositionaldefiantdisorderis seenin

407oof preschooland elementaryschoolagedchildrenwith ADHD (Jensenet al., 1997).

Almost 30Voof thesechildrenwill eventuallymeetcriteriafor conductdisorder

(Anastopoulos
& Farley,2003). Othersreportapproximately50Voof all childrenwith

ADHD developoppositionaldefiantdisorderand approximately50Voof this groupwill

eventuallydevelopconductdisorder(Barkley,1998). A 50Voto 75Vocomorbidity

overlapis evidentwith the disruptivebehaviordisorderspectrumand the ADHD

diagnosisin children(Pelhamet al., 1998). Still othersreportthe comorbidclinical

presentation
is likely to includemood disorders,anxietydisorders,plus otherdisorders

suchas mentalretardation,Tourette'ssyndrome,and borderlinepersonalitydisorder

(Biederman,Newcorn,& Sprich,1991). Sincethe 1990s,the presenceof comorbid

internalizingbehaviorsis increasinglybeingidentified(Jensenet al., 2002).

30
 Loeber,Keenan,Lahey,Green,andThomas(1993)hypothesizea

developmentally-based
relationshipbetweenADHD and oppositionaldefiantdisorderor

conductdisorder. Loeberand colleaguesidentify from their developmental

psychopathology
reportsa possibledevelopmental
pathwayoriginatingfrom ADHD to

thesenotedcomorbidconditions.The importanceof early interventionwith ADHD to

attemptto inhibit comorbidconditionpotentialsare supported(Anastopoulos& Farley,

2003). Further,childrenwith ADHD areat substantialrisk for developingpoor social

(Barkley,1990;Frederick& Olmi, 1994;Pelham& Bender,1982;Pope,

relationships

Bierman,& Mumma, 1989;Teeter,1991;Whalen& Henker,1985). The existenceof a

comorbidclinical presentation the child'slevel of psychosocialimpairment.

eixacerbates

A historyof poor psychosocialfunctioningmakesthe individual'sprognosisless

favorable(Anastopoulos& Farley,2003).

Cunninghamand Barkley (1979)andMash and Johnston(1982)reportchildren

diagnosedwith ADHD exhibit higherthan averageratesof non-compliance.These

childrenare at risk for developingcomorbiddisruptivebehaviorproblems(Barkleyet al.,

1990). Factorsrelatedto externalizingbehaviorsin the ADHD populationinclude

dissimilaritiesin parentingvalues,beliefs,andpractices.When the parental

interpersonal

similaritiesexist fewer behavioralproblemsarereportedamongchildrenin general

(Block,Block, & Morrison,1981).

Barkley (1998)notesthat childrenwith ADHD are at increasedrisk to experience

relationshipconflicts. Conflict ariseswhen environmentaldemandsexceedtheir capacity

to cope. The resultingfamilial stresstendsto triggera parentaladoptionof a more

parentingstyle (Cunningham& Barkley, 1919). Parentsof

negativeor punishment-based

3l
childrenwith ADHD tend to view their abilitiesas parentsas lesspositive(Mash &

J o h n s t o n1. 9 9 0 ) .

A concurrentpsychiatricdisorderalongwith ADHD addsto the challengefor

obtaininga normalizedlevel of functioning.The variousinfluencesfrom the child's

environment(e.g.,parent-childinteraction,poor peersocializations,
familial dysfunction,

and maritaldiscordin the home)contributeto the child'sexternalizingbehavioral

problems.Internalizingdisordersare alsopossiblecomorbiddysfunctions.Reducingthe

significantcoexistingpsychosocialimpairmentsaffordsthe opportunityfor childrenand

their familiesto enjoy a more satisfyinglife experience.

Parenting S/ressand Familial Discord

Baker (1994)reportsparentingstressis associated

with child behavioral

problems.Parentsof childrenwith ADHD reportexperiencingconsiderablestressin

their parentingroles(Anastopoulos
et al., 1992;Fischer,1990;Mash & Johnston,1990).

Parentsof childrenwith ADHD often seethemselvesas lessskilled and knowledgeable

parents,and derivelessvalueand comfortfrom their parentingefforts(Mash & Johnston,

1983a,1990).

Anastopouloset al (1992) report on a study conductedat a university mental

healthclinic. They reportcorrelationalevidenceis foundbetweenchild-parentrelational

characteristics
and higherlevelsof parentingstressamongthe ADHD population.

Parentinga child with significantbehavioralproblemsthat stretchacrosssocialsettings

canbe stressful.Assessingthe severityof the child'sADHD symptoms,comorbid

presentations,
and parentalpsychopathology,
may contributeto a betterunderstanding
of

the causalfactorsrelatedto parentalstress.

JZ
 Parentinga child with ADHD posesa significantand uniquechallengeas the

parentsengagein the parentingrole. Parentsof childrenwith ADHD experiencemore

stressand familial strainthanparentsof childrennot diagnosedwith ADHD

(Anastopoulos
et al., 1992;Barkley,1989,1990;Breen& Barkley,1988;Mash &

Johnson,1983a).Stressreportedby parentsof childrenwith ADHD is notedto be much

greaterthan amongfamiliesof normalcontrols(Breen& Barkley, 1988;Mash &

Johnston,1983a).Anastopoulosand colleaguesstate,"Whetherthis stressemanates

directlyfrom the child'sADHD is unclearat present.Clinical experiencewould suggest

that it probablydoes,at leastto somedegree,given the increasedcaretakingdemandsthat

childrenwith ADHD imposeupon their parents."(p. 50a)

Barkley (1990)notesparentsof childrenwith ADHD describetheir parenting

experiences
with a learnedhelplessness
quality. Parents'subjectiveview of their

efficacyin the parentingrole is found to be lower in parentsof childrenwith ADHD

(Breen& Barkley, 1988;Mash & Johnson,1983a).Parentingprogramsexist that are

to meetthe uniqueparenting
designedto increaseknowledgeand skills necessary

demands.Theseprogramsaddressthe parents'feelingsof inadequacyand incompetency

in the parentingrole (Barkley,1990).

Harvey (2000)reportsa,similarityin generalparentingand disciplinestyles

betweenparentsare associated
with fewer disruptivebehaviorproblems. Fatherself-

reportsrevealthat parentingallianceand disciplinesimilarityare associated

with a lower

maternalstress(Harvey2000). Further,greaterdisciplinesimilarityis associated

with

greaterparentingalliance(Harvey,2000).

aa
JJ
 Barkley ( 1998)reportsthe psychologicalstructureof a child with ADHD

significantlyaffectsthe psychosocial
functioningof the parentsand siblings. Parentsof

childrenwith ADHD oftenbeccimeoverly directiveand negativein their parentingstyle.

Frequentdisplaysof noncompliance
with parentalor otheradultdirectivesplace

significantdemandsupon the parent. Parentsof childrenwith ADHD are often

addressing
variousschool,peer,and siblingdifficultiesinvolving the childrenwith

ADHD (Anastopoulos& Farley,2003;Barkley, 1990). Parentscontinueto be involved

in the child's life throughadolescence

(Barkleyet al., 1991). A directrelationshiphas

beenfound betweenthe severityof child misbehaviorand the parents'emotional

response(Befera& Barkley, 1985). Barkley(2000)states,

In areaswhereany reasonable
and competentparentwishesto be involvedin

child rearing,parentsof a child with ADHD mustbecomeinvolved-doubly

involved. They must seekout schools,teachers,

professionals,
and other

communityresources.They will find themselveshavingto supervise,monitor,

teach,organize,plan, structure,reward,punish,guide,buffer, protect,and nurture

their child far more than is demandedof a typical parent. They alsowill haveto

meetmore often with otheradultsinvolvedin the child'sdaily life-schoolstaff,

pediatricians,
and mentalhealthprofessionals.Then thereis all the intervention

with the neighbors,Scoutleaders,coaches,and othersin the community

necessitated
by the greaterbehaviorproblemsthe child is likely to havewhen

dealingwith theseoutsiders.To makemattersmore difficult, the increasedneed

of a child with ADHD for parentalguidance,protection,advocacy,love, and

5+
 nurturancecan be hiddenbehinda fagadeof excessive,demanding,and at times

obnoxiousbehavior. (p. 5)

Breenand Barkley (1988)reporta more stressfulparent-childrelationshipin the

ADHD population.Significantcoerciveparent-childinteractionsare reportedto exist rn

the ADHD population(Buhrmester,Camparo,Christensen,

& Gonzalez,1992). Strained

parent-childrelationsmay explainthe increasedincidenceof frequentcoerciveparent-

child interactionsthat is reportedto exist.

Kottmanand Robert(1995)reportthat teachersand schoolcounselorsfrequently

find parentsof childrenwith ADHD as resistant,angry,and uncooperative.Mothersof

childrenwith ADHD reportfeelingmore depressed,

restricted,frustrated,and less

competent(Beck,Young, & Tanowski,1990). Negativeaffectivequalitiescontributeto

the stressin their familiesand in their parentingrole (Mash & Johnston,1983a).

Comparedto parentsof non-ADHD children,parentsoften hold themselvespersonally

responsiblefor their children'snoncompliantbehaviors(Sobol,Ashbourne,Earn,&

Cunningham,1989). Distressedmothersof childrenwith ADHD havealtered

perceptionsof and lower tolerancefor their children'smisconduct(Barkley, 1990). The

resultis that the parentresortsto a punishment-based

parentingstyle insteadof utilizing a

reinforcement-based
parentingstyle. Somespeculatethat repeatedfailure to achieve

compliancefrom a child eventuallyleadsto the child withdrawingfrom the parentin an

(Barkley& Cunningham,7979).
attemptto avoid furtherpunitiveexperiences

Birth ordermay be a relevantfactorfor consideration.Youngerchildrenwith

ADHD are more stressfulto parentsthan olderchildren(Mash & Johnston,1983a).

Higher levelsof parentingstressarecommonamongparentsof first-bornchildrenwith

35
ADHD (Mash & Johnston,1990). Family sizeis found to correlatesignificantlywith

higherlevelsof parentingstress(Mash& Johnston,1983c).

Goldsteinand Goldstein(1992)speculatesomeparentsassumemost of their

child'sproblemsresultfrom deliberatenoncompliance
ratherthan incompetence.Parents

misinterprettheir child'smisbehavioras intentionaland respondnegativelyto the child.

A persistentnegativeresponsefrom the parentinducesa stressfulparentexperience.

Someproposethat if the negativebehaviorsare seenas part of the disorder,and therefore

not controllable,parentswill becomelessupset(Dix & Grusec,1985).

A child'shealthstatusmay inducestressin the parentingrole. SinceADHD is

consideredto meetcriteriafor what definesa valid medicalor mentaldisease(cf.,

Wakefield,1992,1999),this constructmay be generalized

to childrenwith ADHD and

their parents. Parentaldepressionand other psychopathologyoccursmore often in

parentswith a child with ADHD thannormalcontrols(Cunninghamet al., 1988;Laheyet

al., 1988),which may contributeto parentingstress. Negativelife eventsmay alsoplay

a role in parentingstress(Campbellet al., 1986).

Cunninghamand Barkley (1919)reportparentsof childrenwith ADHD often

becomeoverly directiveand negativein their parentingstyle. Parentsreport

considerable
stressin their parentingrole when their child displaysoppositionalor

defiantbehaviors(Anastopoulos
et al., 1992). Marital discordand depressionmay also

be reportedby theseparents(Laheyet al., 1988). Behavioralparenttrainingprograms

addressparentingstressdifficultiesoften seenin the ADHD population(Laveeet al.,

1996).

Familv Dynamics.
 Childrendemonstrating
disruptivebehaviorsmay experiencemore family

adversities.Familiesof ADHD childrenoftenexhibit maternalstressand depression,

paternalalcoholabuse,and inappropriate
parentaldiscipline(Fischer,1990;Mash &

Johnston,1990). Hyperactive,inattentive,impulsive,and aggressive

behaviorsarelabel

as beingdisruptive(Sheltonet al., 2000). Thesebehaviorsare often seenin the ADHD

population.Parentswith poor behaviormanagement

skills experiencemore parental

their children'sdisruptivebehaviors(Heller,Baker,Henker,&
stresswhen addressing

Hinshaw,1996;Stormont-Spurgin,
& ZentalT,
1995).

Lambertand Hartsough(1984)note significantfamilial characteristics

are seenin

the ADHD population.The characteristics

includea parentalhistoryof hyperactivityand

infanttemperament,
a parentalfocuson the child'sacademicachievement,
and strained

parent-childinteractionsand discipline.A higherfrequencyof divorceand separationis

alsoevidentcomparedto controls(Brown & Pacini, 1989). Parentalseparationand

singleparentingwere found to be associated

with childhoodaggression(McGee,

Williams. & Silva. 1984). However.no clearevidenceis associated

betweenbroken

homesand a child being diagnosedwith ADHD (Werry,Reeves,& Elkind, 1987).

Althoughnumeroussourcesfor parentingstressexist,researchers
assertthat the child's

ADHD-relatedproblemsand otherclinically relevantcharacteristics

arethe primary

sourcesof parentalstressin parentsof childrenwith ADHD (Barkley,1990;Fischer,

1990;Mash & Johnston,1990).

Mash and Johnston( 1990)and Pistermanet al (1992)reporta changein parenting

stylemay enhanceparentalself-esteem.Comparedto controls,mothersreportafter

completinga parenttrainingprogramthat they experiencereductionsin stress,increases

11
JI
 and observedimprovementsin the overallseverityof their child'sADHD
in self-esteem,

et al., 1993). This effectresultsfrom an improvedparent-child

symptoms(Anastopoulos

accountfor a
relationship.Parentand child relationalcharacteristics
interpersonal

portionof the overallvariancein parentingstress.However,child behavioral

areespeciallypowerfulpredictorsfor the
and maternalpsychopathology
disturbances

enduranceof stresswithin the family (Anastopoulos

et al.,1992).

Marital Discord

The overt presenceand negativeimpact of parentalstressreflectsthe level of

maritalfunctioningin the home. Comparedto controls,a relativelyhigherincidenceof

maritaldiscordis found within the ADHD population(Befera& Barkley, 1985;Barkley,

et al., 1988).
Fischer,Edelbrock,& Smallish,1990;Cunningham

Harvey (2000) hypothesizesthat ADHD children are lessforgiving of parental

Childrenwith ADHD dependon externalfeedbackfrom the parentsfor

inconsistencies.

and learninginhibitionskills. Childrenwith ADHD presenttheir parents

self-regulation

with more frequentand more difficult problems(e.g.,Johnston,1996). Increasedstress

upon the maritalor partnerrelationshipis evidentwhen child behavioralproblemsare

presentedon a high frequencybasis. The enduringstressupon the marital relationship

negativelyaffectsthe child (Harvey,2000). Reciprocityis maintainedin a family with

ongoingmaritaldiscord, Reciprocityis a significantfactorwhen a memberin the family

haspoor self-regulationor disinhibition.

beliefs
Harvey (2000)finds supportfor similaritieswithin couples'child-rearing

and disciplinepracticespositivelyaffectthe child with ADHD. Dissimilarparenting

placechildrenwith ADHD at greaterrisk for developinga additional

approaches

38
behavioralor emotionalproblems.Parentingdissimilaritycontributesto relatedfindings

that parentsof ADHD childrenaremore likely to divorcethanparentsof non-ADHD

children(Barkley,Fischer,Edelbrock,& Smallish,l99l). Thesefindingsarenot

supportedin studieson parentingsimilaritiesandparentingalliancefor parentswith 2-

year-olds(Belsky,Crnic, & Gable,1995). However,an experienceof lack of support

from one spousenegativelyaffectsthe unsupported

parent'ssenseof self-esteem

(Harvey,2000). Consequently,
parentswith childrendiagnosedwith ADHD are at

increasedrisk of experiencingdepression,
anxiety,and maritaldiscord(Cunninghamet

a l . , 1 9 8 8 ;L a h e ye t a l . , 1 9 8 8 ) .

Barkley ( 1990)identifiesparenttrainingas one of the recommended

treatments

for childrendiagnosedwith ADHD. Parenttrainingon behavioraland sociallearning

principlespositivelyaffectsthe.maritaldiscordseenin the ADHD population(Laveeet

al., 1996). Parenttrainingreinforcescooperativeparentingstyles.

Parental M aladjustments

Forehandand McMahon ( 1981) reportparentsof defiantchildrenarenotably

moredepressed
thanparentsof a child without behavioraldisturbances.Parentsof

hyperactivechildrenwith severebehavioraldisturbances
tend to exhibit antisocial

personalitydisorderand substance
abuse(Biederman,Munir, & Knee, 1987;Laheyet al.,

1988;Reeves,Werry,Elkind,&Zametkin,1987;Stewart,DeBlois,& Cummings,1980;

Werry et al., 1987). Parentalpsychopathology

is associated
with an increasedrisk for

antisocialoutcomesin hyperactivechildren(Weiss& Hechtman,1986).

Smith and Barrett(2000)reportthe existenceof maternaldepressionin mothers

of childrendiagnosedwith ADHD, Significantmaternaldistressis generallyassociated

externalizingbehaviorproblemsin children(Breen& Barkley, 1988). Mothersof

and self-efficacy(Mash &

childrenwith ADHD experiencelower self-satisfaction

in parentsof
abuseareoverrepresented
Johnston,1983). Depressionand substance

ADHD children(Biederman,Faraone,Keenan,& Tsuang,1991). This impliesthe

significancefor concurrenttreatmentsfor the problemsthat interferewith effective

parenting(Evans,Vallano,& Pelham,1994). Behavioralparenttrainingprograms

empowerthe parentsto constructivelyaddressthe child's externalizingbehaviors

(Barkley,1997c).

Identiflting ADHD in Children

Assessment.

Barkley (1988)reportsthe reliabilityand validity of child behaviorratingscales

are potentially threatenedby their construction,use, and interpretation.Direct

observationof targetbehaviorswithin eithera naturalor a controlledsettingcontributes

may
to the validity of the ratingscalefindings. Ratingscalesand directobservations

yield inconsistentand uniquediagnosticdata(Mash& Terdal, 1981). Inherentconstruct

validity challengesexist within behaviorratingscales.Theselimitationsaremost notable

pertainingto inattention,hyperactivity,and impulsivity. Absoluteagreement

in subscales

for ADHD
is not expectedwhen assessing
betweentwo or more forms of assessment

ratingscalesdo producevaluabledatausefulfor diagnostic

(Barkley,1988). Regardless,

(Mash &
screeningand continueto be uspdto identify childhoodpsychopathology

tools for ADHD arethe

Terdal,1981; McMahon, 1984). Recognizedassessment

ConnersParentRatingScaleand the ConnersTeacherRatingScale.

40
 The originalversionof the ConnersParentRatingScale(Conners,1970)consists

of 93 items. The revisedversionof the ConnersParentRatingScaleis reducedto 48

items(Goyette,Conners,& Ulrich, 1978). A brief lO-iteminstrumentthat screensfor

(Conners,
core symptomsof hyperactivityis the AbbreviatedSymptomQuestionnaire

1985). Variousforms of the AbbreviatedSymptomQuestionnaire

exist as well

(Ullmann,Sleator,& Sprague,1985).

The primary functionof the originalConnersTeacherRatingScale(Conners,

1969)is to identify hyperactivechildren. The instrumentis alsoutilizedto assessthe

effectsof stimulanttherapies(Conners,1913). This 39-itemscreeningtool is the most

(Barkley,1988). A revisedversionof
utilizedratingscalein childhoodpsychopathology

the ConnersTeacherRatingScale(Goyetteet al., 1978)is alsoavailable.Goyetteet al

notesthe ConnersAbbreviatedSymptomQuestionnaire
is recommended
by Keith

Connersto screenfor changesin hyperactivityand conductproblemsafterthe initiation

of stimulanttherapy.

Loney and Milich (1981)reportthe Iowa ConnersTeacherRating Scaleis alsoan

instrumentthat measuresfor hyperactivityand conductproblems.This instrumentis

sensitiveenoughto differentiatebetweenaggressive
and hyperactivebehavioral

(Barkley,1988). The limitationof the ConnersRatingScaleseriesis that

presentations

due to practiceeffectsthe instrumentshouldbe administeredat leasttwice beforebeing

usedto assessinterventioneffects(Barkley,1988).

Achenbachand Edelbrock(1983)developedthe 138-itemChild Behavior

Checklist(CBCL) to assessfor behavioralproblemsand socialcompetence.The CBCL

is the most well-developed,

empiricallyderivedbehaviorratingtool availableto assess

41
socialcompetenceand behavioralproblemsin children(Barkley,1988). The CBCL

effectivelymeasureschangesin childrenfollowing a parenttrainingprogram(Webster-

Stratton,1984). The CBCL is alsoavailablewith a TeacherReportForm (CBCL-TRF).

The significantdifferencein the teacherreportform is that the 20 itemsof social

competencein the CBCL arereplacedwith measuresof adaptivefunctioningin the

schoolsetting(Barkley,1988).

The EybergChild BehaviorInventory(ECBI; Eyberg,1980)is a brief 36-item

instrumentthat demonstratessensitivityto treatmenteffectsfrom parenttraining (Eyberg

& Robinson,1982:-
Eyberg& Ross,1978;Packard,Robinson,& Grove, 1983;Webster-

Stratton,1984). The ECBI is significantlycomparableto directobservations

of

noncompliance,
parent-childinteractions,
and the child'slevel of activity and

(Robinson& Eyberg,1981;Webster-Stratton
temperament & Eyberg, 1982). The scale

is appropriatefor children2-12 yearsand takesapproximatelyl0 minutesfor a parentto

complete.

Diagnosis.

Fabianoand Pelham(2002) note a limitation of the DSM-IV-TR (APA, 2000).

They reportthe list of diagnosticsymptomsis what typically generates

variousscreening

tools for ADHD. They asserttypicalADHD screeningtools do not identify the degreeto

which the symptomaticbehaviorsresultin problemsof daily life functioningor the

impactof this dysfunction.Impairmentin daily life functioningis the primary reason

familiesof a child with ADHD seekservices(Angold,Costello,Farmer,Burns,&

Erkanli, 1999). Someargueand state,"[A]n assessment

with an emphasison diagnosis,

without any evaluationof a child'simpairedfunctioning,is missingthe very reasonmost

42
familiesareseekingservices"(Fabiano& Pelham,2002,p. 151). A comprehensive,

of presentingproblemareasis necessary
systematicassessment to operationalize
the

areasof dysfunctioninto targetbehaviors(Mash & Terdal, 1997). The diagnosisof

ADHD is complicatedand often subjectivein nature(Purdie,Hattie,& Carroll, 2002).

At the presentthereis no singleacceptable

measureto diagnosisADHD.
'l'reatment
oJADHD

August,Realmuto,MacDonald,Nugent,and Crosby(1996)reportADHD is a

commonlydiagnoseddisorderin childrenwith clinical evidenceof inattention,

hyperactivity,and impulsivity. ADHD oftenpresentssecondaryproblemssuchas non-

compliance,socialdifficulties,andeducationalproblems(Barkley, 1996). Stimulant

therapyis shownto be effectivewith the core symptomsof ADHD. However,stimulant

psychosocialproblems(DuPaul,&
therapiesdo not reducethe disorder'sassociated

Barkley, 1990). Concurrentpsychologicalinterventions,

suchas parenttraining,are

to addresssecondaryconcerns(Anastopoulos
recommended et al., 1991). The treatment

of ADHD is consideredto be curative.

Newby (1996) reportsthe effectivetreatmentfor ADHD involves the successful

managementof symptomsratherthan an attemptto cure symptomsof inattention,

hyperactivity,and impulsivity. Behaviormanagement

involvesa broadarrayof methods.

Structuringthe physicalenvironment,deliveringeffectivecommands,and utilizing

consistentand immediatebehavioralconsequences
are importantbehavioralmanagement

methods.Childrenwith ADHD demonstrate

a difficulty in constructivelygeneralizing

what is learnedinto othersettings.An argumentis madefor the implementationof

behavioralprinciplesto be conductedwherethe behavioralproblemsreside. Therefore,it

^a
+J
 to deliverbehavioralinterventionsat the point of performance(Barkley,
is necessary

1991a).

Chroniset al (2001)reportthe treatmentfor ADHD shouldaddressfunctional

impairmentin severalimportantdomains(e.g.,socialrelationships),
ratherthan

the child
enoughto encompass
diagnosticsymptoms.Treatmentmust be comprehensive

(Chroniset a1.,2001).Individualsin the

andimportantfiguresin the child'senvironment

child's life reinforcethe newlv learnedbehaviorover time.

Pelhamet al (1998)and Swanson,McBurnett,Christian,and Wigal (1995)report

stimulanttherapy,behaviormodification(e.9.,parenttraining,schoolintervention),and

the combinationof medicationand behaviormodificationare shownto be effective

treatmentsfor ADHD. The treatmentfor ADHD is not consideredto be curative in

nature. The benefitsachievedfrom a combinedapproachare a temporaryreductionof

symptomsrelatingto behavioraland otherpsychosocial (Anastopoulos&

disturbances

Farley,2003). Somereport that a combinedmedicationand behavioraltherapeutic

approachis more effectivethaneithermedicationor behaviormodificationalonein

bringingchildrenwith ADHD into a normalrangeof functioning(Pelham&

Waschbusch,1999). A normalrangeof functioningis consideredto be within 1 standard

deviationof the mean(Pelham& Murphy, 1986). Researchdemonstrates

that when a

treatmentmodality is removedADHD symptomsoften return to pretreatmentbaseline

levels (Anastopoulos& Farley, 2003; MTA CooperativeGroup, 2004a).

Anastopoulosand Farley(2003)assertthat the prognosisof a child with ADHD

dependsupon the sustaineddurationand intenselevel of treatmentdeliveredover time.

are deemedineffective
Behavioraltreatmentsthat are fadedbeforeend-pointassessments
(Klein & Abikoff ,1997 MTA CooperativeGroup, 1999). Therefore,pharmaceutical

interventionsand behavioraltreatmentsmust be deliveredin an intenseand sustained

mannerto effectivelymodify behavior(Pelhamet al., 2000). The multimodaltreatment

approachis a therapeuticapproachwith potentialsynergisticeffects(Kendell,Panichelli-

a deficit of information
Mindel and Gerow, 1995). Childrenwith ADHD demonstrate

processingand a delayin rule governedbehaviorswhen relatingto peopleand tasks

(Barkley, 1997a). Thus this deficit effectsnormal everydayfunctioning.

Abikoff ( 1991)reportsoffice-basedtherapiesinvolving cognitiveinterventions

arenot effective. Treatmentmust be flexible and implementeddirectly in the settings

wherethe children are most impaired. The efficacy for providing treatmentat the point

of performanceis alsoendorsed(Barkley,1997a).A significantelementrelatingto

childrendiagnosedwith ADHD is the childrenunderstandand haveknowledgeof the

expectationsfor appropriatebehaviors. However, the children fail to apply what they

know in the appropriatesituatioh(Pelham& Bender, 1982).

Fabianoand Pelham(2002) report an effectivetreatmentfor ADHD must be

in orderto improvesocialfunctioning.The psychosocialimpairment

comprehensive

with ADHD is severeandpervasive.The psychosocialimpairmentsresultin

associated

difficultiesacrossmultiple socialdomains,suchas in the home,in school,and in public.

Purdie,Hattie,and Carroll (2002)reporton a meta-analysis

of 74 studies

examiningbehavioral,cognitive,and socialfunctioningof childrenwith ADHD. The

largeroveralleffect sizessupportmedicalinterventionsover educational,psychosocial,

or parenttraininginterventions.However,thereis little supportfor a generalization

of

45
treatmenteffects in improving educationalperformancefrom medicationtherapyalone

(Purdieet al., 2002).

Fabiano,Pelham,Gnagy,Coles,andWheeler-Cox(2000)reporton a meta-

analysisof 70 studiesincludingthe studiesinvolvingbetween-group,

within-subject,and

single-subject
designson the treatmentof ADHD. Fabianoand colleaguesconcludethat

behaviormodification.medication.and combinedtreatmentsall resultin moderateto

substantialeffect sizesdependingon the studydesignand the measureemployed. Most

researchon ADHD is conductedfrom a medical frame of reference(Purdieet al., 2002).

A medical framework focuseson the effectsof pharmacologicaltreatmentson behaviors.

Purdieand colleaguesarguedesignissuesmust be consideredwhen reviewingmeta-

analyticstudiesof ADHD-focusedinterventions.Most researchoutcomeson the

treatmentof ADHD tend to be basedon a small samplesize (Purdieet al., 2002).

Fabianoand Pelham(200D announcebehavioralmodificationis deemedto be

necessary
in the treatmentof ADHD by variousprofessionalassociations.Fabianoand

Pelhamreport behavioraltherapyis supportedin the treatmentof ADHD by the

AmericanAcademyof Child and AdolescentPsychiatry(1991),the AmericanMedical

Association(Goldman,Genel,Bezman,& Slanetz,1998),the AmericanPsychological

Association(Pelhamet al., 1998),the U.S. Departmentof Education(2000),the

AmericanAcademyof Pediatrics(2001),and the NationalInstitutesof HealthConsensus

ConferenceStatement( 1998).

Fabianoand Pelham(2002) and the MTA CooperativeGroup (2004a)stressthe

importancethat treatmentsfor ADHD must be comprehensiveand sustainedin order to

remaineffective. Most behaviorparenttrainingprogramsfocuson the management

of

46
noncompliance
and poor rule-governed
behavior.This focusis consistentwith the high

prevalenceof concurrentopposition-defiant
disorderand conductdisorderseenin the

ADHD population(Newby, 1996).SomeassertADHD is not a disorderthat is

effectivelytreatedwith a singulartreatmentapproach(Anastopoulos& Farley,2003).

BehavioralThernpy.

Prins (1994)reportschildrenwith ADHD requiremore prompts,cuesand

reinforcements
than normalchildren. Childrenwith ADHD benefitmost from a

structuredenvironment,which shouldbe maintainedindefinitely. Targetbehavior

problemsareeffectivelyaddressed
with operantconditioningbehavioralintervention

(van der Krol et al., 1998).

strategies

Fabianoand Pelham(2002) report behavioralinterventionsare effective for

reducingbehavioralproblemsand functionalimpairmentsin childrenwith ADHD.

Behavioralinterventionshavebeenutilizedto treatADHD-relatedsymptomsin children

for more than 25 years(e.g.,O'Leary,Pelham,Rosenbaum,

& Price, 1916),and other

(O'Leary& Becker, 196l). As per meta-analyticreports,

behavioraldisturbances

behavioralinterventionsarealsoeffectivein a classroomsetting(DuPaul& Eckert,1997;

Jadadet al.. 1999).

Unlike medicationtherapies,behavioralinterventiontechniquesdo not pose

undesirablesideeffects. However,if medicationsareconcurrentlyusedbehavioral

treatmentsallow for a potentialreductionin medicationdosagesnecessaryto reach

normalization(Froelich,Doepfner,& Lehmkuhl,2002; MTA CooperativeGroup,

2004a). A dosagereductiondecreases
the side effect potentials,such as a growth delay

or growth bluntingin children(MTA CooperativeGroup,2004b). Additionally,

A'7
behavioralinterventionscan be appliedto childrennot respondingto stimulanttherapies

( P e l h a m1, 9 9 1 ) .

The symptomsof ADHD areconsideredchronic. Behavioralinterventionsmay

produceeffectiveoutcomes.Behavioralinterventionsmust remainintenseand sustained

within the child'senvironmentfor benefitsto be maintained(Frazier& Merrell, 1997). It

is arguedthat thereis a lack of evidenceendorsinglong-termeffectsand generalizability

of treatmenteffectsfrom behavioraltherapyin ADHD populations(Pelham,1991;van

der Vlugt, Pijnenburg,Wels, & Koning, 1995). Interestingly,behavioraland medication

therapiesdemonstrateonly short-termeffectiveness.Exceptionsmay be reported

of thesetherapies.However,the withdrawalof
regardingthe short-termeffectiveness

eithertherapytendsto yield a returnto baselinemeasures(MTA CooperativeGroup,

2004b).

Pelhamet al (1998)reportreviewingthe entirebehavioraltreatmentliterature

availableon treatmentof ADHD at the time of publication.They concludethat parent

proceduresareempiricallyvalid
trainingand classroomcontingencymanagement

treatmentprotocols.Additionalsupportfor behavioralparenttrainingis availablefor

children(Brestan& Eyberg,1998),many of whom are also

conduct-disordered

diagnosedADHD (Barkley,2000).

Danforth' s BMFC P rocedure.

Patterson(1982) reportsan effectiveuse of punishmentproceduresreduce

procedureis consideredto be a
externalizingbehaviors.The time out from reinforcement

punishmentprocedure(Masters,Burish, Hollon, & Rimm, 1987). The time out from

strategies.When
reinfbrcementprocedureis oftenutilizedin behavioralmanagement
usedby parentsor teachersas intended,the time out from reinforcementtechniquecan be

a constructivebehavioralmanagement
tool.

Danforth(1998)designedthe BehaviorManagementFlow Chart (BMFC) to

addressnoncompliancein school-aged
children. Danforthoutlineshow to formally

utilize the time out from reinforcement

procedure.The protocolis basedon the

hypothesized behaviorpresentin childrenwith ADHD (Barkley,

deficitsin rule-governed

1994). Danforth assertsthe potentialnegativeside effectsfrom medicationsand that

2O7oto 3OVoof childrenwith ADHD do not havea positiveresponseto stimulanttherapy

(DuPaul& Barkley, 1990)demonstrates

the needfor improvedparenttrainingprograms.

The BMFC utilizesa forwardchainingbehavioralapproach(Martin & Pear,1996). The

forwardchainingapproachis taughtto the parentsto managechild noncompliant

behaviors.

Danforth ( 1999)reportson the utilization of the BMFC procedurewith a mother

and her monozygotictwin ADHD/ODD boys. Prior to his study,no direct observation

outcomedatadocumentingparqnttrainingfor familieswith twin ADHD/ODD boys

existed. Concordanceratesfor monozygoticADHD twins are reportedto approximateat

807o(Hechtman,1994). Childrenwith ADHD respondto behaviormanagement

proceduresin distinctways (Pelham& Hinshaw,1992). The typical BMFC program

involves8 weekly sessionsafterbaselineandup to 3 telephoneinterviewsper week with

the motherto addressspecificbehavioralproblems.The BMFC is completedwith a 6-

monthfollow up session(Danforth,1999).

Daley,Thompson,Laver-Bradbury,andWeeks(2001)reporton a
Sonuga-Barke,

structuredparenttrainingprogram(viz., Danforth,1998)deliveredby mentalhealth

49
cliniciansduring individualparenttrainingsessions.Sonuga-Barke
and colleaguesassert

that the BMFC interventioncan serveas an effectiveprocedurefor treating3 yearold

as a stand-alone
childrendiagnosedwith ADHD. The BMFC is not conceptualized

parenttrainingprogram. Its intendeddesignis to assistparentswith ongoingbehavioral

with child with disruptivebehavioralproblems.The BMFC procedureis

management

consideredonly as a componentof a largertreatmentinterventionprogramto treat

childrenwith ADHD (Danforth,2001).

Cogni rive-Behavi oraI Therapy.

Froelich et al (2002) reportson the efficacy and generalizationeffectsof

cognitive-behavioral
interventionsfor childrenwith ADHD. Froelichand colleagues

interventionsfor ADHD is enhancedwhen

assertthe efficacyof cognitive-behavioral

self-instructional
skills,self-assessment,
and self-monitoringare combined. Combining

treatmentandbehavioralparenttrainingis consideredlogical (Horn,

cognitive-behavioral

Ialongo,Greenberg,Packer,& Smith-Winberry,1990). Their assertionis in contrastto

perspective(e.g.,Abikoff,
otherreportson treatingADHD from a cognitive-behavioral

r99l).

van der Krol et al (1998)arguethat addressing

the identifiedtreatmentgoalsfrom

perspective,
a cognitive-behavioral suchas a cognitivemodelingtechnique,assiststhe

child with ADHD in overcomingspecifictaskand interpersonal

problems. However,

embeddingcognitive-behavioralstrategiesin a multimodal treatmentprotocol doesnot

resultin significantbehavioralimprovement(van der Krol et al., 1998).

necessarily

Mathesand Bender(1991)reportself-monitoringis effectivewhen usedwith

pharmaceutical attendingand on-taskbehaviorswith 3

interventionsto,increase
elementaryschool-aged
boys. The potentiallimitationof the self-monitoring,or other

cognitive-behavioral
techniques,
is its short-termeffectiveness.It is arguedthat in the

ADHD population,a generallypredictablereturnto baselineis expectedwhen treatment

is discontinued(RussellA. Barkley,personalcommunication,March 19, 2003). An

interestingaspectof this studyis that the positivetreatmenteffectsare identifiedto occur

at the point of performance.

Barkley (1998)reportsADHD reflectsa neurologically-based

deficit in

behavioralinhibition. The main premiseof understanding

the disorderis that children

with ADHD do not possessthe cognitivecapacityto think throughthe consequences

of

their actions(Barkley,1998). Increasingthe children'sawareness

on the connection

is not justified due to the assumed

betweenthe behaviorsand the pendingconsequences

neurologicalunderstandings
relatingto ADHD (Anastopoulos& Farley,2OO3).

Additionally,cognitive-behavioral
treatmentdoesnot provideclinically important

changesin the behaviorand academicperformancein children with ADHD (Pelhamet

a l . ,1 9 9 8 ) .

Amy (1998)reportsteachingparentsto encouragechildrenwith ADHD to pay

attentionto their own behavior,to plan ahead,and to reapthe benefitsfrom prosocial

interactionsis effective. Amy's studyincludedparentsof 37 childrenwhoseagesrange

from 5 to 11years.Parentsreceived6 cognitive-based

trainingsessions.The 3 skills

taughtare identifyinga child'sproblembehaviors,punishingchildrenimmediatelyafter

an undesirablebehavior,and havingthe child recallwhat he or shedid wrong. Social

activitiesareusedas rewardsfor goodbehavior. Also, at the beginningof the parent

trainingprogram,eachchild stoppedtakingtheir prescribedmedication,Ritalin.

5l
Therapistshelpedthe childrenwith ADHD think aboutthe situationsthat triggerproblem

behavior,discussedalternativeways to act,and instructedthem in socialskills. The

children'sresponses
includean initial extinctionbursttype response.By the third week

the childrendisplayedbehavioralimprovement.Parentself-reportsat one-yearfollow up

revealthe children'simprovedbehavior,obedience,and attentionhad not faded.

However,the parentsreportaggressive
behavioris evidentat times. None of the children

rn the studyresumedstimulantmedicationtherapy(Amy, 1998). The rigor of this study

is not notedin this publishedar(icle.

The cognitive-behavioral
approachto treatingchildrenwith ADHD is challenged

by Barkley's(1997b)theoryof ADHD relatingto the cognitiveimpairmentin the 4

executivefunctions. Barkley assertsthat ADHD is a developmental

delay disorderof

inhibition. Therefore,he assertsADHD is not treatablefrom a cognitive-behavioral

perspective.Alternatively,othersmaintainthat by creatinga well structuredenvironment

the potentialfor increasedstimulusself-control(van der

the child with ADHD enhances

Krol et al., 1998). Arguably,meta-analyticreviewsreportpositiveoutcomeswith

cognitiveinterventionsfor impulsivity(e.g.,Baer & Nietzel, 1991). However,the studies

typically areconductedwithin a controlledsettingratherthan a clinical setting. Notably,

efficacyof cognitivetreatmentsis stronglydemonstrated

in othernon-ADHD childhood

disorders(Durlak,Fuhrman,& Lampman,1991;Kendall& Gosch,1994;Lochman,

1992).

Medication Theranv.
'(19g2)and

Abikoff unOff"in Barkley Q99a)reportmedicationsare an effective

shortterm treatmentfor the core ADHD symptoms. Medication therapyeffectively, but

'\)
temporarily,returnsthe childrento a normalizedlevel of functioning. Further,stimulant

therapy(e.g.,methylphenidate)
producesa clinically significanteffect in TOVoof the

cases(Gunning,1996).

van der Krol et al (1998)reportsclinicians,teachers,and physiciansneedto find

an effectivecombinationof the varioustreatmentinterventions(e.g.,medications,

behavioraltherapy,and variouscognitive-behavioral
interventions)in orderto effectively

meetthe individualizedneedsof eachchild. Somearguebehavioralinterventionsshould

be attemptedalone and beforethe introductionof medications(Gunning, 1996).

However,it is arguedthat the commencement

of a treatmentplan for ADHD without

medicationtherapyis consideredinadequate
(Barkley,personalcommunication,March

19,2004).

Pelham,Schnedler,Bologna,and Contreras(1980)reportthe combined

administrationof medicationsand behaviortherapyis more effectivethan either

treatmentmodalityalone. This approachis endorsedto obtainenduringeffectivesfrom

short-terminterventions(Satterfield,Satterfield& Shell, 1981). When a child is a

positiveresponderto medication,parentsand teachersare inclinedto rely on medication

as the soleform of treatment(Gunning,1994;Pelham& Gnagy, 1999). Medication

therapywithout behavioralstrategies
and skills is not likely to improvethe child'slong-

term prognosis(Pelham& Gnagy,1999).

It is generallyagreedonly threetreatmentapproaches
havebeenvalidatedas

effective short-termtreatmentsfor ADHD. The effective short-termtreatmentsfor

ADHD includebehaviormodification,stimulantmedicationtherapies,and the

combinationof these(Richterset al., 1995). Medicationsarefar more employed,areless

53
expensive,and havemore shortrtermempiricalsupportthanpsychosocialtreatments

(Pelhamet al., 1998). However,20Voto 30% show an adverseresponseor no responseat

all to medicationtherapy(Pelham& Hinshaw,1992,Swansonet al., 1995;Wells, 1987).

Argumentsare maderelatingto positivemedicationresponders

that the majority

doesimprovebut their behaviorsarenot normalized.Positivemedicationresponders

often remain 1 standarddeviationabovethe norm (Pelham& Murphy, 1986). Others

reportmedicationeffectswithin a normalizedrangeof functioning(Abikoff & Klein,

1992). Significantlong-termimprovementsfrom medicationtherapyonly arenot evident

(DuPaul& Barkley, 1990).

If medicationaloneis deemedthe necessarvand sufficient treatmentfor ADHD.

therewould be little needfor consideringothertreatments.Medicationis lessexpensive

thanpsychosocialapproaches
(Pelhamet al., 1998). However,datedstudiesthat have

followedchildrentreatedwith psychostimulant
medicationfor periodsup to 5 yearshave

failed to provideany evidenceof improvementsin the long-termprognosisfor a child

with ADHD (Charles& Schain,1981;Satterfield,

Hoppe,& Schnell,1982;Weiss&

Hechtman,1993). Currentpharmaceutical
researchmay challengetheseresearchers'

claims.

Perring(1991)reportsomeprofessionals
and parentspossessethicalobjectionsto

the useof medicationto modify children'sbehavioraland intellectualfunctioning. When

parentsare not pleasedwith a medicationregimen,they voice their dissatisfaction

on a

rangeof issues.Their argumentsagainstmedicationtherapyoften includea subjective

discomfortwith their child beingplacedon a psychostimulant

medication,unacceptable

medicationsideeffects,and a lack of a desiredtreatmentresponse.Someresearchers

announcethereis little evidencefor long-termbeneficialeffectsof medicationon either

behavioror psychologicalfunctioning(Weiss& Hetchman,1993). Othersreporton the

potentialfor long-termundesirablephysicalside-effects
from stimulanttherapy(MTA

CooperativeGroup, 2004b).

Swanson(1993)endorsesthe short-termeffectsof stimulanttherapy. However,

stimulanttherapyis announcedas the treatmentof choicefor ADHD for the long-term

of ADHD symptoms(Klein & Abikoff, 1997). For thosechildrenwho do

management

responseto medicationstimulanttherapy,many fail to fall within the normalizedrangeof

functioning(Wells et al., 2000). Positiveeffectswith stimulanttherapiesarereported,

but medicationalonedoesnot produceconsistentimprovementsin academic

performance
or in peerrelations(Pelham& Hinshaw,7992;Swansonet al., 1995).

Debatecontinueson stimulanttherapy'seffect upon the long-term courseof the disorder

(MTA CooperativeGroup,2004b;Weiss& Hetchman,1993).

School -B ased I nterventions.

Barkley (2000) reportsmany children are referredfor an ADHD assessment

prior

to enteringthe formal educationsettingin first grade. In schoolsettings,80Voof children

diagnosedwith ADHD tendto havea comorbiddiagnosisof a behavioralor learning

disorder(Reid,Maag,Vasa,& Wright, 1994). Thus,public schoolsmust to provide

thesechildrenwith specialservices.Generaleducationteachersare expectedto provide

educationalmodifications,as requiredby Section504 of the RehabilitationAct of 1973

(Reid& Katsiyannis,
1995;Reidet al,1994).

Mathesand Bender(1991)reportmany schoolsare strivingtowardsserving

childrenwith ADHD within the mainstreamclassrooms.School-based

programs

55
typically focuson peerrelations,classroomconduct,and schoolachievement(Arnold et

a1.,1991;Bierman,
Miller, & Stabb,1987;Pfiffner& Barkley,1988).Short-termresults

of school-based
interventionsareoptimistic, However,evaluationsof the long term

effectsof theseprogramsarequite limited (Cole,Underwood,& Lochman,l99l; Offord

& Bennett,1994). Researchhasalsoshownthat a few consultationvisits deliveredat

schoolare ineffective(Fuchs& Fuchs,1989). Thus,an intensiveclinical formularymust

be createdand implementedin the classroomto effectively treat ADHD within the

schools.A potentialchallengerestsin the readinessand willingnessfor the school

districtsand its teachersto incorporatea comprehensive

protocolfor the mainstream

classroomnecessary
to meetthe individualneedsof eachADHD student.

SociulSkills.

Sheridan,Dee,Morgan,McCormack,andWalker (1996)offer a manualized

socialskills programfor childrendisplayingexternalizingbehaviordisorders.Some

studiessuggestthat childrenwith ADHD aremore likely to be rejectedby peersthan

childrenwith otherdisruptivebehaviors(Carlson,Lahey,Frame,Walker, & Hynd, 1987;

Popeet al., 1989). Internalizingsymptomscontributeto poor self-imageand poor self-

esteem. Sheridanand colleaguesarguethat in order for externalizingbehaviorsto

improve,suchas thoseseenin the ADHD population,treatmentmust first addressissues

pertainingto internalizingbehaviors.Oncetheseissuesare addressed,

achievingchange

in externalizingbehaviorsis a more realisticgoal. Afterwards,the child can more easily

generalizethe learnedskills due to their improvedself-concept(Sheridanet al., 1996).

DuPauland Eckert(1994)reportsocialskills developmentprogramsdo not reveal

compellingevidencewithin the ADHD population.Specifically,they arguethat the

56
socialskills learnedin treatmentdo not generalizeto home,classroom,or playground

settings.Severalauthorscontenda multimodalinterventionstrategythat includessocial

skills trainingis necessary

for childrenwith ADHD to obtainsuccessfuloutcomes(e.g.,

Cantwell,1996;Cousins& Weiss, 1993). Findingsfrom a studyconductedin a large

universitysettingrevealsociallyrejectedchildrenmay benefitsubstantiallyfrom social

skills trainingwhen their parentsaretrainedto facilitatetransferof treatmenteffects

(Frankel,Myatt, Cantwell,& Feinberg,1997). Parentstrainedin deliveringpositive

reinforcementfor desirablesocialbehaviorsmay createtreatment generuhzation

effects.

Neurotherapy.

Nelson(2003)reportson a literaturereviewof l0 researchreportsincludingboth

analogand clinical trails of treatingADHD with neurotherapy.One studyusedbehavior

therapytreatmentas a control in comparingneurotherapy

to psychostimulants
(Rossiter

& La Vaque, 1995). Two of the studiesutilizeda wait-listcontrolgroup (Linden,Habib,

& Radojevic,1996;Patrick,1996). Five studiesevaluatedneurotherapyfrom a pretest-

posttestdesignand two useda "learner"to "nonlearner"comparisonformat. Sevenof

thesel0 studiesshowedpositiveresultsin favor of neurotherapy

in the treatmentof

ADHD. The outcomesof the remainingthreewere uncleardue to a lack of proper

analysis(Nelson.ZOOtll.
statistical

Accordingto the recognizedcriteriato determinetreatmentefficacy (Chambless

and Hollon, 1998),neurotherapy

is an efficacioustreatmentto reduceADHD-related

symptoms(Nelson,2003). Further,it is determinedthat if one of the studies(e.g.,

Rossiter& La Vaque, 1995)had utilizeda differentcontroland the outcomeremained

the same,the evaluationof neurotherapy

in the treatmentof ADHD would havebeen

57
efficaciousand specific(Nelson,2003). Specifically,the neurotherapist
trains downthe

of individual'swith ADHD
excessivelyhigh thetato betabrainwaveratioscharacteristic

(Thompson& Thompson,2003). The high thetato betabrainwaveratio is a biological

markerfor ADHD (Maloneet al., 1994). This biologicalmarkeris addressed

by

neurotherapy.Although limited researchexiststhat provideconvincingevidenceof its

in treatingADHD, the availableresearchoutcomesarepromising.

effectiveness

Nontraditionaltreatmentsfor ADHD are numerous. Nontraditionaltreatmentsfor

ADHD include,but arenot limited to, dietarymodifications,exercise,laseracupuncture,

meditation,antifungaltreatment,relaxationtraining,perceptualstimulation,and

neurotherapy.However,convincingevidencefor the effectiveness

of thesetreatmentsis

(Arnold,1999;Pelhamet al., 1998).

nonexistent

Summationof Single TreatmentModalities

Whalenand Henker(1991)highlightindividualdifferenceswith children's

responseto eithermedicationor psychosocial

treatment.The infrastructureof the current

mental healthsystemsupportsoffice-basedinterventionsratherthan treatmentwithin the

children'snaturalsetting(Pelhamet al., 1998). However,thereexistsno empirical

evidencefor the effectivenessof office-basedtherapiesfor the ADHD population

(Pelhamet al., 1998). Deliveringtherapeuticinterventionsat the point of performanceis

endorsed(Barkley,1997a).

Treatmentslackingin convincingefficacyfor ADHD includetraditionalone-to-

one therapy,socialskills trainingemployedalone,play therapy,dietarymodifications,

meditation,antifungaltreatment,relaxationtraining,
exercise,laseracupuncture,

cognitivetherapy,perceptualstimulation,and neurotherapy.The only effectiveshort-

58
term treatmentsfor ADHD arebehavioralmodification(Pelhamet al., 1998)and

stimulantmedication(Spenceret al., 1996;Swansonet al., 1995). Somesuggestthat

medicationplus otherinterventionsofferslittle benefitover medicationsalone(Klein &

Abikoff, 1991). However,individualdifferencescannotbe ignoredand the multimodal

for somechildren(Jacob& Pelham,1999;Pelhamet al.,

treatmentapproachis necessary

1993). When usedin combination,behavioralmodificationand stimulanttherapy

typicallyproducegreatereffectsthaneitherimplementedalone(Pelham& Murphy,

1986;Pelham& Waschbusch,1999). A comprehensive

treatmentapproachis necessary

to addressthe complexityand chronicityof the ADHD disorder(Chroniset al., 2001).

However, an elaborateorganizationalsystemof servicesneededto deliver a thorough

treatmentparadigmtendsnot to be availableoutsideof a universitysetting.

MTA CooperativeGroup

More than a decadeago,DuPauland Stoner(199$ announcethat the medicaland

psychologicaldisciplinesrecognizethe management
of ADHD symptomsrequiresa

multifacetedand long-term treatmentapproach.They also note any single treatment

modalityis insufficient.The MultimodalTreatmentStudyof Childrenwith ADHD is the

largestand most well-controlledstudyexploringthis assertionin child mentalhealthto

date(MTA CooperativeGroup,.1999).

The MTA CooperativeGroup is a National Institute of Mental Health (NIMH)

investigativeeffort is designedto correctfor possiblepreviousresearchlimitations. The

six sitesselectedat variousuniversity-based

hospitalsacrossthe United States

implementeda multimodal concept. The researchproject includesthe medication

management-only,
the intensivebehavioraltreatment,the combinedmedication-

59
behavioraltreatment,and the communitycaretreatmentgroups. The behavioral

interventionsconsistedof parent-training,
child-focusedinterventions,and school-based

trainingsand interventions.Th6 medicationmanagement-only

interventionconsistedof a

hydrochloride(Ritalin)followedby monthly visits for

titrationof methylphenidate

medicationpositiveresponders.A pill placebowas not utilizeddue to two identified

factors. First,the purposeof the studywas not to determinethe effectiveness

of Ritalin.

Second,the researchers'
held concernsof probablesignificantattritionratesin a placebo

groupduring the 14-monthmultimodalclinical trial (Jensen,2001). Attrition rates

preventthe researchersfrom generalizingthe efficacy findings from short-termto long-

term results.Argumentsfor the scientificobligationto includea placebo-controlled

groupin the MTA study(Breggin,2001),and a defenseof the MTA studyprinciple

investigators'decisionto excludea placebocontrol(Jensen,2001),arefound in the

literature.

The MTA CooperativeGroup studyincludes579 childrendiagnosedwith

ADHD-Combinedtype, agesI .0 to 9.9 years. Participantswere randomlyassignedin a

14-monthclinical trial in the treatmentof ADHD. The MTA studvresearches

3 main

areasof interest.First,the MTA study'snotedintentionsareto examinethe eventual

long-termeffectsand comparisonsof medicationand behavioraltreatments.Second,the

possiblebenefitsof combiningmedicationandbehavioraltherapiesare explored. Third,

the effectiveness
of a systematicdeliveryof servicesversusa routinedeliveryof

community care is examined(MTA CooperativeGroup, 1999).

The MTA CooperativeGroup (1999)reportsat the end-pointof the l4-month

randomizedmultimodalclinical trial, notablereductionsin ADHD symptomsin all4

60
groupsare found. Significantdifferencesarefound in between-group
comparisons.

Combinedtreatmentsand medicationmanagement-only
interventionsprovidedbetter

overalloutcomesthan behavioralinterventions.
or communitycare. A reported

confoundingvariableis that many subjectsin the communitycaregroup alsoreceived

medicationtherapy(MTA CooperativeGroup, 1999,2004b).

MTA CooperativeGroup (1999)initially reportsmedicationpositiveresponders

maintainedeffectiveness.Basedon the degreeof therapeuticimpact after2 months,the

positiveeffectsof intensebehavioralinterventionssubsidedand the deliveryof

behavioralinterventionswas stopped,This inconsistentdeliveryof behavioral

interventionsover the l4-month studyis a significantlimitationof the MTA study's

findings(Swansonet al., 2001).'It is arguedthat the MTA studyresultsprovideno

justificationfor consideringa psychosocial

or a medication-psychosocial
intervention

paradigmas a first-linetreatmentfor ADHD (Klein, 2001). Alternativeinterpretations

of the initial MTA studydataprovideno observableadvantage

of medicationover

psychosocial (Breggin,2001).
interventions

Swansonet al (2001)reportson a secondaryanalysisof the initial MTA

CooperativeGroup data. They report the datafrom the combinedtreatmentapproach

yieldsa l2Vaimprovementover medicationalone(68Vovs. 56Vo,respectively).Further,

the initial MTA reportfinds non-significant

effectsfrom the intensivepsychosocial

interventionsover the nonspecifictreatmentdeliveredin the communitycarecomparison

group. Somenote non-significantfindingsmay be due to local effectsof the treatment

sites,demographicelements,or otheruncontrolledfactors,and not from unfavorable

effectsof the manualizedpsychosocial

interventions(Swansonet al., 2001).

61
 Pelhamand Gnagy(1999)reporton the methodologyof the MTA Cooperative

Group study. They arguepsychosocial

treatmentswerewithdrawnrelativelyearly in the

study,yet the medicationtherapycontinuedthroughoutthe 14-monthevaluationperiod.

Sincemedicationcontinuedthroughoutthe study.maintenance
of psychosocialtreatment

effectswithout medicationin the combinedtherapiesgroupcould not be evaluated

(Pelham& Gnagy, 1999).

MTA CooperativeGroup (2004a)reportson a24-month follow-up of the NIMH

study (MTA CooperativeGroup, 1999). Five hundredforty of the original 579 children

in the MTA study participatedat the 24-monthfollow-up point. The patternof

superiorityfor medicationmanagement
over eitherthe combinedtreatmentsor the

behaviortherapy-onlypersisted.However,the effectsizeon ADHD and ODD measures

droppedalmostin half from the l4-month endpointto the evaluation10 monthslater.

Most subjectsin the combinedand medicationmanagement

groups(85Vo-86Vo)

continuedto receivesomeform of medication. Fewer behaviortherapyand community

caregroupparticipants(44Vo-69Vo,
respectively)receivedmedicationduring the 10

monthsfollowing the originalstudy'send point (MTA CooperativeGroup,2004a). The

dosagelevelsof the medicationmanagement

groupat24 monthsrevealeda significantly

higherdosagethan thosereceivingcombinedmedication-behavioral
interventions(MTA

CooperativeGroup, 2004a). The MTA study only utilized methylphenidatein the groups

receivingof medication.At the 24-monthfollow-up,the medicationonly and combined

medication-behavioral
therapygroup participantswere being treatedwith

(73.4Vo),dextroamphetamine
methylphenidate (10.4Vo),
permoline(I.4Vo),imipramine

62
(lVo),bupropion(O.3Vo),
andhalperidol(0.3Vo),
and 3.17odiscontinued
the useof

medications(MTA CooperativeGroup, 2004a).

The MTA CooperativeGroup (2004a)reportsslightly betterparentalsatisfaction

self-reportsin the behavioraltherapygroup over the medicationmanagementgroup at the

14-monthend point. Seventyfour percentof the parentsfrom the behavioralgroupwere

suggested
to incorporatea medicationinto their children'sbehavioralintervention

regimenat the l4-month end point. However,56Voof the behavioralgroup remained

unmedicated,at 24-months.Deteriorationof the therapeuticbenefits at the 24-month

periodis not notablyreportedby the parentsof the behavioralinterventiongroup.

Desiredeffectiveness
from behavioralinterventionsafterendingthe deliveryof

interventionsinfersits potentialfor long-termbenefits(MTA

behaviorally-oriented

CooperativeGroup. 2004a)

Lastly, the MTA CooperativeGroup (2004a)reportsthe original MTA study

statisticalanalysesareevaluatedat the .05 level of significance.However,the 24-month

follow-up datais comparedat a.0l level of significance.Cautionis stressedrelatingto

the conclusionthat the marginalsignificanceof the differentialtreatmenteffectsof

negativeor ineffectivedisciplinemay actuallybe a Type II error (MTA Cooperative

Group,2004a). The significantfinding of the MTA study's24-monthfollow-up is that a

significantportion of the medicationgroup and the combinedmedication-behavioral

therapygrouplost someof its initial benefitseenat the l4-month end point (MTA

CooperativeGroup, 2004a).

Fabianoand Pelham(2002\ stressthe treatmentfor ADHD must be sustained.

(Abikoff, 1997;
Behavioralinterventionsterminatedbeforethe end point assessment
MTA CooperativeGroup, 1999)is lesseffectivethan when it is implemented

continuously (Chroniset al.,2001). If behavioral

until theend point assessment

interventionsareterminated,clinicianscan expecta degreeof clinical deterioration

towardsbaselinelevels. Therefore,a systematicprogramfor maintenance

and relapse

preventionis encouraged
(Fabiano& Pelham,2OO2).The relevancefor treatment

continuitynecessary
to createtreatmentefficacyis recognizedby behaviorallyoriented

clinicians(Chroniset al., 2001). A more detaileddiscussionon the effectsof partial

reinforcementand spontaneous
recoveryis availablefor review (e.g.,Masterset al.,

19 8 7 ) .

Parent Training

Anastopouloset al (1993)suggestthat behavioralparenttrainingdoesnot reduce

the core symptomsof ADHD. Behavioralparenttrainingprovidesthe parentswith a

methodto constructivelymanagethe child'sundesirablebehaviorsat home and in public.

The goal of the variousparenttrainingprogramsis to promotemore positive,compliant,

and prosocialbehaviors.Simultaneously,
parenttrainingprogramsfocuson decreasing

negative,defiant,and disruptivebehaviors.Typically,this is achievedby trainingparents

in more positive,consistent,and predictablebehaviormanagement

skills (Barkley,1987,

1991c;Forehand& McMahon, 1981;Patterson,

Dishion,& Reid, 1992;Webster-Stratton

& Spitzer,1996).

Barkley (1998)and Cantwell( 1996)reportthat parenttrainingis a widely used

and acceptedinterventionapproachto addressthe needsof childrenwith ADHD. Many

parenttrainingprotocolsplacean emphasison consequence

basedinterventions,suchas

rewardsand punishments(Habboushe
et al., 2001). Otherparenttrainingprogramsfocus
on aspectsof sociallearningand operantconditioning(Barkley,1997c).Parentself-

efficacyand parent-childrelationshiparekeystonesto the approachof parenttraining

(Barkley,Karlsson,& Pollard,1985).

Newby ( 1996)lists the primary goalsof parenttrainingprogramsfor children

with ADHD. Among the most importantcoreprinciplestaughtis the deliveryof

immediate,specific,and consistentconsequences
in responseto the children'snegative

and positivebehaviors.The minimal componentsin a behaviorparenttrainingprogram

arethe building of the parents'factualknowledgeaboutADHD, the building of the

parent-childrapport,and enhancingthe parents'attendingskills (Newby, 1996). Newby

alsonotesthat the deliveryof commands,the developmentof informal social

reinforcement,
the teachingof formal behaviormodificationsystem,the constructive

utilization of time out from reinforcementprocpdures,the managementof behaviorin

public places,and the handlingof futurebehavioralproblemsarenecessary

elementsof a

constructiveparenttrainingprogram(Newby, 1996). Thesenotedcomponentsare

represented
in somemanualizedparenttrainingprograms(e.g.,Barkley,7997c).

Parenttrainingprogramsarebeneficialto the child diagnosedwith ADHD and to

othersin the child's socialenvironment.The primary objectiveof behavioralparent

trainingis to facilitateparentalcontrolover child behaviorproblemsin the homeand in

public. Parentscreatean environmentwhereconsistentopportunitiesto experience

successand lessfrustrationarerealizedwhile functioningin the parentrole. The results

includeimprovementsin the parent-childrelationship,in the parents'psychological

adjustment,and in the child'sself-concept (Anastopoulos& Farley,

and self-esteem

2003).
 Rationalefor Parent Training.

Anastopoulosand Farley(2003)endorsethe useof parenttraining. They report

parenttrainingis one of the most commonlyemployedinterventionsfor ADHD. They

alsoreportADHD is presentin 5-'7Vo

of the generalchild population.ADHD is one of

the most frequentlycited reasonsfor referralto mentalhealthprofessionals,

pediatricians,

and schoolpersonnel(Barkley,1998). A child with ADHD facesthe risk for a multitude

of psychosocialdifficultiesacrosshis or her lifespan(Anastopoulos& Shelton,2001).

Parenttrainingdirectlyor indirectlyaddresses
currentand anticipatedpsychosocial

difficulties.

Greenhillet al (1999)report l0-20Voof thosewho takethe medicationsdo not

showclinically significantimprovementsin the primaryADHD symptoms.Even when

positiveresultsarerealizedfrom pharmaceutical
interventions,
somechildrenexperience

sideeffectsthat are sufficientin severityor frequencyto discontinuestimulanttherapies.

Additionally,someparentsmakea consciousdecisionnot to utilize medicationas a

meansof treatingchildren'sADHD symptoms(Anastopoulos

& Farley,2OO3).

Anastopoulosand Farley (2003) report that parenttraining is effective for

childrenwho are taking stimulanttherapies.Externalizingbehaviorsoften seenwith

ADHD in childrenincludeoppositionaland defiantbehaviors,aggression,

and conduct

problems.Parenttrainingteachesthe parentsbehaviorally-oriented
methodsto address

theseexternalizingbehavioralproblems. Where medicationregimensare not entirely

effectivefor thesebehavioraldisturbances,
parenttrainingprogramsare deemedwell

justified and effective(Forehand& McMahon, 1981; Patterson

, 1982). Several

(e.g.,Barkley,1981;ForehandandMcMahon,1981;Patterson,1982)
researchers provide

66
early frameworksfor contemporarybehavioralparenttraining programs. Percentages
of

improved compliancegreaterthan 60Vosuggestthat a normalizing effect is evidentfrom

parenttrainingprograms(Forehand,1911).

Forehandand McMahon ( 1981) workedwith mother-childdyadsin a clinic.

Repeateddemonstrations
and ggidedpracticein behaviormanagement
methods,often

wereprovidedto thesemothers.A 6 to 8 sessiontutorialformat

usingtwo co-therapists,

with one family at a time providedrole modelingbehavioraltechniquesand assigning

actionbasedhomework. This format is derivedfrom applicationsof an additionalearlier

parenttraining program (Patterson,1982). Theseconceptsare still utilized today. The

resultsfrom thesepioneeringstudiesprovide the basic therapeuticdesignand rationale

for currentbehavioralparenttrainingprograms.

SupportFor Parent Training.

Pistermanet al (1992) report conductingparenttraining in a group format is

effectivefor preschoolers
in improvingtheir complianceand on-taskbehaviors.They do

not reporteffectiveness of attention.Additionally,they reportthat parental

on measures

skills and overallstyleof interactionarepositivelyaffected.

compliance-management

Studiesthat includeschoolagedchildrenwith ADHD find that parenttrainingprograms

skills (Anastopoulos,
improvechild complianceandparentalbehavioralmanagement

DuPaul,& Barkley, 1991;Pistermanet al., 1989a).Parentmediatedbehavioral

interventionsare found to be effectivein improving compliancein ADHD preschoolers.

to othernon-targetbehaviorsis not evident(Pistermanet al.,

However, generalization

1989b).During a child's preschoolyears,behavioralproblemspeak and parentalstress

and parentallow self-esteemare acute(Pistermanet al., 1992). This lendsjustification to

67
the utilizationof a behavioralparenttrainingprogramwhile the child is still in the

preschoolyears.

Noncompliancetendsto reflectnegativeparent-childinteractions.Persistent

noncomplianceand defiancemaintainsfamily tensionoften seenwithin the ADHD

population.Noncomplianceis an appropriatetargetbehaviorin parenttrainingprograms

(Barkley,1987).

Anastopoulos& Farley (2003) presentan argumentrelating to functional

impairmentand parentalsatisfaction.They note medicationtherapyis equal to or better

thana psychosocial-parent
trainingprogramaloneor in combinationwith medications

are basedon the corepsychiatricsymptoms.However,when

when measurements

is evaluatedon the changesin the level of functionalimpairmentand

effectiveness

parentalsatisfaction,
the combinationof behaviortherapyand a medicationregimen

producestherapeuticbenetltsbeyondmedicationalone. Their assertions

challengethe

reportsfrom the MTA CooperativeGroup study. However,children diagnosedwith

ADHD and an anxietydisorderexperiencegreaterbenefitsfrom a medication-

trainingmultimodaltreatmentparadigm(Anastopoulos& Farley,
psychosocial-parent

2003). In additionto reducingovertchild behavioralproblems,evidencesuggeststhat

parenttrainingproduces,"anticipatedchangesin the child'semotionalfunctioning"

(Anastopoulos
& Farley,2003,p. 201). Behavioralparenttrainingis an essential

componentin the treatmentof ADHD. Alternatively,typical parenttraining programs

areineffective(Barkley,1998).

and Fletcher(1992)hypothesizethat
Barkley,Guevremont,Anastopoulos,

improvedcopingskills and perceptionsof self-efficacymay help parentsfeel betterabout

themselvesand their children. Parentsof ADHD children report they are more confident

of their own child-rearingabilities,and more conscientious

and objectivein handling

their childrenaftercompletinga behaviorparenttrainingprogram(van der Krol et al.,

1998). van der Krol and colleaguesalsoreporta generalreductionin family disruptions.

After parentscompletea behavioralparenttraining program,an impressionof improved

child behavioris created.which may or may not be accurate(Barkleyet al., lgg2).

Brestanand Eyberg( 1998)reportthat parenttrainingis recognizedas one of the

most effective approachesto preventingand reducingexternalizedproblem behaviorsin

children. Childrenwho exhibit high levelsof externalizingbehaviorsalsotend to show

high levelsof internalizingbehaviors(Achenbach,1991). Parenttrainingused

concurrentlywith a socialskills programmay be broadand flexible enoughto help

familiescopewith aggressiveand noncompliance

behaviors.Parentswho participatedin

a parenttrainingprogramwhile,theirbehaviorallydisorderedchildrenalsoparticipatedin

a social skills treatmentprogramreport continuedstressreductionat a I yearfollow-up

(Kadzin,Siegel,& Bass,1992). Long-termeffectsfrom combiningsocialskills training

with parenttrainingare yet to be determined.

Anastopouloset al (1993)reporton 36 mothersof childrendiagnosedwith

ADHD who completeda behavioralparenttrainingprogram(viz., Barkley, 1987). The

mothersin the studyreporta reductionin their subjectivestress,an enhancedself-esteem,

and a reductionin severityof their children'sADHD symptoms.An assumptionof the

findingsis that changesin parentingstyleprovidethe childrenopportunitiesfor acquiring

greaterself-controlover their own behavior.Comparedto a wait-listcontrol,parentsin

the parenttraininggroupreportsignificantpsychosocialfunctionalimprovementat
sessionnine. For thosenot reportingimprovement,it is arguedthat the parenttraining

interventionsinhibiteda potentialexacerbation
of ADHD-relatedsymptomsseenin the

childrenat the time of referral. Given the understanding

that ADHD is a chronicdisease

(Barkley,1990),treatmentimprovementsof ADHD symptomsarenot likely to

permanentlydisappear.However, ADHD symptomsare likely to be more effectively

managed.Data collectedat a 2,monthfollow-up endorsethe maintenance

of treatment

gains(Anastopoulos
et al., 1993).

Smith and Barrett(2000)utilizedBarkley's(1987)manualizedparenttraining

programwith 3 girls diagnosedwith ADHD. Their studyexaminesthe effectiveness

of

parenttrainingto reducesecondaryconcernsof ADHD. Parentself-reportsrevealan

improvementon issuesof noncompliance

andemotionalfunctioning(Smith & Barrett,

2000).

Parenttrainingprogramsareoften,but not necessarily,

conductedin a group

parenttraining format. A typical group consistsof parentsfrom five to eight different

families(Barkley, 1981,l99lc). Recently,suggestions

aremadethat two additional

sessionsshouldbe added(RussellBarkley,personalcommunication,March 19,2004).

Futureversionsof the 10-session

format(e.g.,Barkley, 1997c)shouldincludea session

on medicationscurrentlyavailablein the treatmentof ADHD, and a sessioncommittedto

the discussionof the point of performanceconcept.

Smith and Barrett(2002)notestimulantmedicationsareusedto managethe core

symptomsof ADHD. They argueparenttrainingis designedto addresssocial,academic,

and behavioralproblems. Parenttrainingis reportedto be effectivein improving

children'srateof compliance(Cousins& Weiss, I 993; Pistermanet al, 1992;Pollardet

al., 1983;Smith& Barrett,2000),
socialskills(Sheridan
et al., 1996),and self-esteem

(Barkleyet al., 1992;Cousins& Weiss,1993;Horn et al., 1990).Therefore,parent

trainingis recommended
to addressthe functionaldifficultiesassociated
with ADHD

(Pelham,Wheeler,& Chronis,1998). Trainingeitherparentsor childrenproduces

positiveeffects,but providingtrainingto both parentsandchildrenproducesthe most

significantimprovementat l-year posttreatment(Webster-Stratton& Hammond, 1997;

Webster-Stratton,
Kolpacoff,& Hollingsworth,1988;Webster-Stratton,
Hollingsworth,

& Kolpacoff, 1989). The utilizationof a parenttrainingprogramas part of the

multimodal"realworld" approachto treatingADHD is endorsed,especiallywith the

ADHD-combinedtype clinical presentations

(Edwards,2002). Smith andBarrett

findingssuggestan improvementin more overtbehaviors,but not in reducingcovert

behaviors.Additionally,parenttrainingis not effectivein reducingoff-taskbehaviors

(Smith & Barrett, 2002). Their findings may imply that parenttraining alone is an

ineffectivetreatmentinterventionto addressthp inattentioncore symptomof ADHD.

DuPaul,Barkley,and Connor(1998)acknowledgethat parenttrainingaloneis

not effectivein reducingthe core symptomsassociated

with ADHD. However,due to its

effectiveresponseto contingentbehavioralmanagement parenttrainingis

techniques,

seenas the most recognizable

non-medication
treatmentoptionto addressthe more overt

behaviorproblems.When usedin combinationwith medications,parenttrainingis

helpful in reducingADHD symptoms(Klein & Abikoff, 1997;MTA CooperativeGroup,

1e99).

Generalizingtreatmentgainsacrosssocialsettingsis a challengein the ADHD

population.Parenttrainingimprovesbehaviorsin childrenwith ADHD in their home

11
(Dubey,O'Leary,& Kaufman,1983;Forehand,Rogers,McMahon,Wells, & Griest,

1981; Gittelman-Kleinet al., 1980;Horn, Ialongo,Popovich,& Peradotto,1987;

McGoey,Eckert,& DuPaul,2Q02;Peed,Roberts,& Forehand,1997;Pelhamet al.,

; o l l a r de t a l . , 1 9 8 3 ) .
; i s t e r m aent a l . , 1 9 8 9 P
1988P

of benefitsfrom behavioralparenttrainingprograms
A convincinggeneralization

to settingsoutsideof the home is not reported. generalizationeffectsare

,Inconsistent
reportedto the children'sschoolsetting(Forehand,Breiner,McMahon, & Davies,1981;

McMahon & Davies,1980). Cautionis offeredrelativeto positivetreatmenteffectswith

preschoolers,where rapid maturationcan mask treatmenteffectsin the youngerchildren

(Pistermanet al., 1989b). Without early interventionsat homeand in the school,many

behavioralsymptomscontinueto appearand often escalateoncethe demandsof

elementaryschoolareplacedon the child (Campbell,1990;Olsen&Ho2a,1993). An

increasein child compliance,the useof appropriateparentalcommands,the knowledge

of appropriateparentingtechnigueswith positive parentalstatementsmay generalize

from the home settingto otherenvironmentsover a long periodof time (McGoeyet al.,

2002). Using the literatureon older children with ADHD to infer efficacy of

interventionswith preschoolchildrenwith ADHD fails to addressvariousdevelopmental

andenvironmentalissues(McGoey& DuPaul,2000).

A follow-up sessionwith parentsafter the completionof the parenttraining

programis encouraged or ongoingdifficulties.

to addressany unanticipated

at the follow-up session.Finally, a

difficultiesare alsoaddressed
Generalization-related

parenttraining program in the treatmentparadigmfor ADHD children may yield the

72
 to acquirethe desiredtreatment
effectof reduceddosagesof medicationsnecessary

effects(Froelichet al., 2002).

Ar gumentsAgainst Parent Training.

Newby et al (1991)reportthat little efficacyexistswith parenttrainingprograms.

ln the past,a limited numberof empincalstudieson parenttrainingwith ADHD

populationsexist (Anastopoulos
et al., 1993;Erhardt,& Baker, 1990;Pistermanet al.,

et al.. 1989a;Pbllardetal., 1983).Currently,cautiousoptimismis

1992:Pisterman

on the efficacyof parenttrainingprogramsfor childrendiagnosedwith ADHD

suggested

(Anastopoulos
& Farley,2003).

Barkley (1997a) stressesthat therapeuticinterventionsmust be deliveredto

children with ADHD at the point of performancein order to be effective. Othersreport

that parenttrainingsessionsheld in the homearemotivating,but that much more

informationneedsto be given to the parentsthantime allows (van der Krol et al., 1998).

in the homeand schoolyield behavioralimprovements.

Operantprinciplesadministered

of theseimprovementsto othersituationsis poor and that

However,generalizatton

acquiredimprovementsare shortlived (Prins,1994). When the behavioralinterventions

are suspended,problematicbehaviorstend to return to baselinemeasures(Sheltonet al.,

2000;Smith & Barrett,2000). Sheltonandcolleagueshighlightthe short-term

of behaviorparenttrainingprograms.
effectiveness

Cunningham(1997)reportsparentalmotivationor readinessto changemay be

low in communitysamples.Complianceby parentsin both attendingthe training

can be problematic
strategies
meetingsand following throughon the recommended

(Cunningham,Brenner,& Boyle, 1995;Kazdin, 1987;Offord & Bennet",1994). Parent

-a
t3
reportedimprovementsassociatedwith parenttraining programsrevealthat

improvementsseenby week 5 often declineafterweek 9 (Smith & Barrett,2000).

DuPaulandBarkley (1990)notepsychostimulants
arethe most powerful short-

term treatmentfor ADHD. However, othersreport that parenttraining doesnot improve

children'sADHD externalizingbehaviorswhen stimulantmedicationsareconcurrently

present(Horn et al., 1991;Ialongoet al., 1993).

Sheltonet al (2000) report soberingfindings of an intensive,full-day, multi-

methodclassroominterventionat a 2 yearfollow up. Their studyspansan entireschool

yearfor kindergartenchildrendisplayingdisruptivebehaviors.They reportthat no

positiveeffectsareobservedfollowing a parenttrainingprogram. However,many

parentsof the high risk childrendid not attend,or sporadicallyattended,the offered

parenttrainingsessions.The researchers
alsonotethat raterbias may be evidenton the

reportsof the children'sbehaviorsobservedin the classroom.The children'steacher

conductedthe pretestand posttestmeasures.Thesesameteachersalso implementedthe

interventionsthroughoutthe kindergartenschoolyear(Sheltonet al., 2000). Using the

child's teacherto implementthe protocolandconductpretestand posttestbasedon

observationmeasuresmay have affectedthe posttestfindings. Someresearchersreport

clinical gains from parenttraining with the ADHD populationdo not generalizeto the

to improveoverallsocialfunctioning(Purdieet al., 2002).

degreenecessary

Weinberg(1999)reportsthat parentsof 25 childrendiagnosedwith ADHD

participatedin a 6-weekparenttrainingprogram. Sociallearningtheory,communication

skills,consequences,
time-out,discipline,and tokeneconomyarepresented.Reports

show an increaseparentalknowledgeand understanding

aboutADHD and behavioral

74
management parentalstress.However,no improvementsin the
skills and a decrease

children'sbehaviorsarereportedat the completionof the program. Parentself-reportsof

only mild stressreductionis reportedfollowing their participationin a parenttraining

programspecific to ADHD population(Weinberg, 1999).

Weinberg(1999)reportsthat parenttrainingprovidesan educationaldynamicto

parentsof childrendiagnosedwith ADHD. Weinbergalsonotesgeneralizalion

of

positive treatmenteffectsis not determined.However, maternalADHD symptomsare

reportedto be a possiblesignificantfactorwhen parent-training

programsdo not yield

desirableresults(Sonuga-Barke,
Daley,& Thompson,2002).

Abikoff and Gittlman( 1984)assertthat behavioraltreatmentsdo not typically

normalizeADHD symptomsin children. Functionallevels of children diagnosedADHD

tendto be 1 standarddeviationabovenormativemeansat post-treatment

(e.g.,Pelhamet

al., 1988). The benefitsof behavioralinterventionsaretypically limited to periodswhen

the programis beingimplemented.When treatmentis withdrawnmany childrenoften

lose the gains madeduring treatment. Few studiesshow maintenanceof treatmentgains

beyonda few monthsafterthe terminationof therapy(Ialongoet al., 1993). Failureof

behavioralmanagementprogramsare often due to unwillingnessor inability of parentsor

teachersto implementthe behavioralprogramsas directed,with noncomplianceand

dropoutfrom trainingbeingcommon(Fuchs& Fuchs,1989;Prinz & Miller, 1994;Witt,

1986). Otherunfortunateelementsseenin parenttrainingstudiesincludehigherdrop out

ratesfrom lesseducatedparents(Pistermanet al., 1992),and from lower SES groups

(Firestone& Witt, 1982).

l5
 The efficacyof behaviortherapyis dependenton 3 primary factors. Thesefactors

includethe motivationandcapabilitiesof the significantadultsin the child'slife, the

and the skills of the groupleader. If key adultsare

situationalbarriersto implementation,

unwilling or unableto implementthe behavioralinterventions,

and if the obstaclesor

objectionsto the interventionsarenot overcome,thenbehaviortherapywill not be

effectivein real-worldsettings.Despitethe empiricalevidencefor its efficacyin

treatmentchildrenwith ADHD, thesefactorsare significant(Pelhamet al., 1998).

Further,it is arguedthat inconsistencies

in parenttrainingliteraturemay exist as a result

or designissues(Dubey,O'Leary,& Kaufman,1983;Whalen & Henker,

of measurement

1991).

Closing to the Review of Literature

Chroniset al (2001)announces
that oncean initial diagnosisof ADHD is made,

monitoringdiagnosticsymptomsservelittle usefulpurpose.An treatmentfocuson

functionalimpairmentis endorsed.Chronisand colleaguesdraw attentionto the

differencesbetweenthe treatmentgoalsof behaviorallyorientedclinicians(Mash &

Terdal, lgg|)versus the goalsfrom a psychiatricapproachin the evaluationof treatment

of ADHD (e.9.,MTA CooperativeGroup, 1999).

effectiveness

Greeneand Ablon (2001) arguethe findings from the MTA CooperativeGroup

study produceslittle new informationto createan effective individualizedtreatmentplan

for the ADHD population.Further,improvingsocialfunctioningwas not a primary focus

of the MTA CooperativeGroup study(Greene& Ablon, 2001). A temporaryreduction

of ADHD symptomsis not a good predictorof long-term outcomesfor the children

diagnosedwith ADHD. When controlledfor the severityof ADHD symptoms.conduct

76
problems,depression,
and aggression,
children'slevel of socialfunctioningis a

significantpredictorof long-termoutcomesin the ADHD population(Greene,

Biederman,Faraone,Sienna,& Garcia-Jetton,
l99l; Greeneet al., 1999),

The issueof efficacyversuseffectiveness

(Hoagwoodet al., 1995;Weisz et al.,

1995)relatingto the exportabilityof the empiricalfindingsconductedin university-based

hospitalsand clinics remainsunderstudied.Complianceby parentsin both attendingthe

trainingmeetingsand following throughon the recommended

strategiescan be

problematic(Cunninghamet a1.,,1995;Kazdin; 1987;offord & Bennet,1994). Parenral

motivationor readinessto changealsomay be low in familiesof childrenwith ADHD

(Cunningham,1997).Manualizedprogramspresenta structuredformat,but the clinician

addsa dynamic that makesthe programeffective for the group participants(Kendall,

Chu, Gifford, Hayes,& Nauta,1998). Additionalresearchon the exportabilityof

behavioraltreatmentand their effectiveness

in real world settingsneedsto be conducted

(Pelhamet al.. 1998).

t7
 CHAPTER THREE

A Brief Reviewof the Study

The study's primary focus is the efficacy of a manualizedparenttraining program

for the treatmentof ADHD in a communitysetting.The exportabilityof an empirically-

basedbehavioralparenttrainingprogramto an uncontrolledsettingwould identify a valid

treatmentoptionto parentswith childrendiagnosedwith ADHD. The identificationof an

exportableinterventionin the treatmentof ADHD is valuablefor parentsand children

who do not havereliableaccess,to

a major university'sbehavioralclinic.

In this study,the secondeditionof Barkley's(1997c)Defiant Children:A

Clinician'sManualfor Assessment
and Parent Training is systematically
replicatedin

two uncontrolled,non-universitybasedclinical settings.The first settingis the principle

investigator'sprivatepracticegrouproom. The secondsettingis a developmentaland

behavioralpediatricgrouppractice,which is locatedin an adjacentcounty. The principle

investigatorconductsall 10 groupsessionsin both settingswith parentswhosechildren

arediagnosedwith ADHD. The investigatedareasin this studyareparentalstress,

relationshipsatisfaction,parentaldepression,and the behavioraldisturbancesof the

childrendiagnosedwith ADHD. The studycollectsand analyzesthe databasedon a

pretest-posttest
researchdesign.

ResearchQuestions

l. Do parentsor caregiversof childrendiagnosedwith ADHD reporta

statisticallysignificantreductionof parentalstressas measuredby pretest-posttest

on the ParentingStressIndex (Abidin, 1995)aftercompletingRussell

responses

78
Barkley'sDefiant Child (1991c)manualizedparenttrainingprogramin a privatepractice

or pediatricoffice setting?

2. Do parentsor caregiversof childrendiagnosedwith ADHD reporta

statisticallysignificantreductionof maritalor partnerrelationshipdistressas measured

by pretest-posttest
responses (Snyder,
on the Marital SatisfactionInventory-Revised

1991)aftercompletingRussellBarkley'sDefiantChild (1997c)manualizedparent

trainingprogramin a privatepracticeor pediatricoffice setting?

3. Do mothersor femalecaregiversof childrendiagnosedwith ADHD reporta

as measuredby pretest-posttest
statisticallysignificantreductiohof depressive'mood

on the Beck DepressionInventory(Beck,Steer,& Brown, 1996)after

responses

completingRussellBarkley'sDefiantChild (1991c)manualizedparenttrainingprogram

in a privatepracticeor pediatricoffice setting?

4. Do fathersor male caregiversof children diagnosedwith ADHD report a

mood as measuredby pretest-posttest

statisticallysignificantreductionof depressive

on the Beck DepressionInventory(Beck,Steer,& Brown, 1997)after

responses

completingRussellBarkley'sDefiantChild (1991c)manualizedparenttrainingprogram

in a privatepracticeor pediatricoffice setting?

5. Do parentsor caregiversof childrendiagnosedwith ADHD reporta

behaviorsin their childrenas measured

statisticallysignificantreductionof undesirable

by pretest-posttest on the EybergChild BehaviorInventory(Eyberg& Pincus,

responses

1999)aftercompletingRussellBarkley'sDefiantChild (1991c)manualizedparent

trainingprogramin a privatepracticeor pediatricoffice setting?

Participants

l9
 The participantsof the studyarethe parentsof children ages2to 12 years. The

participants'childrenarediagnosedwith ADHD. The child's diagnosisof ADHD is

madeby a licensedfamily physician,pediatrician,psychiatrist,or nursepractitioner.The

diagnosticmethodologyutilizedby theselicensedphysiciansor nursepractitionersto

makethe ADHD diagnosisis not known. Referralsare solicitedfrom medicaldoctorsor

nursepractitionersin RowanCounty,CabarrusCounty,and the nearbysurrounding

countiesof northeastern
Charlotte,North Carolina.

The exclusioncriteriaincludeparentsof childrendiagnosedwith ADHD with

known comorbiddiagnosesof a major neurololical,medical,or psychiatriccondition

that preventsthe child from benefitingfrom a behavioralintervention,substantiated

reportsof abusein the home,suicidalor homicidalideation,and moderateto profound

mentalretardation.Thesenotedexclusionarycriteriareflectsimilar exclusioncriteria

seenin previousstudies(e.g.,MTA CooperativeGroup, 1999). The exclusionarycriteria

areinitially screenedby the licensedphysicianor nursepractitioner.A generalsecond

screeningis conductedby the principleinvestigatorby a review of the demographicdata

and a brief discussionwith the referredparent. The principleinvestigatordiscusses

any

referralsthat possiblymeetexciusioncriteriawith the referringphysicianor nurse

practitioner.The decisionto denyor acceptthe referralinto the studyis jointly made.

The final decisionto includeor excludethe referralinto the studvis madebv the

principleinvestigator.

Exclusioncriteriaarenot basedon the age,race,gender,or socioeconomicstatus

of the parentsor their children. The demographics

of the parentsarecollectedand

presentedfor discussionin the final draft of the dissertation.The parentsare informed

 via brochure(seeAppendixA),,flyer (seeAppendixB), or in personthat the lg-week

parenttrainingprogramis free and no insuranceclaimswill be filed.

The principleinvestigatorof this studymakestwo requestsof the participants.

First,participantsarerequestedto completethe pretestand posttestinstruments.

Second,

the participantsare askedto attendall 10 groupsessions.It is not known if theserequesrs

wereoutlinedto participantsin similar studies.Singleparentparticipantsare first

inquiredif thereis a significantotherpersonin their life who is involvedin the parenting

role in raisingtheir child. If their responseis yes,they areinstructedto makeresponses

on the pretestand posttestinstrumentsin relationto the significantother. If the

single
parentparticipantreportsno otherpersonin their life or their child's life fulfillins
the
parentingrole, the participantdoesnot to respondrelationshipbaseditems.

In the eventthat a participantdoesnot attenda session,the principleinvestigator

providesthe participantwith all handoutsdistributedfrom the classthat he

or shemissed.

The principleinvestigatorstronglyencourages
the participantschedulea one hour sessron
at his privatepracticeoffice to reviewthe missedsession'scontentand homework.

However,it is not mandatedthat the participantscheduleor keepthis makeup

session
appointment.

The parents'participationin the studyis entirelyvoluntary. Voluntary

participationstatusis madeknown to all participantsbeforetheir commencement

of the
program. Additionally,the participantsare informedthat havethe option
to quit the
programwithout consequence
at any time duringthe l0-sessionprogram. A stipendfor

the parents'participationin the studyis not offered.

Instrumentation

81
Parental Stress

The third editionof the ParentingStresiIndex (PSI) (Abidin, 1995)assesses

parentself-reportsof stress.The PSI is a 12O-itemassessment

tool. The PSI questions

areansweredon 4-pointLikert scales,5-pointLikert scales,and Yes-Nodichotomous

responsechoices.The PSI is comprisedof a Child Domain,a ParentDomain,a Total

Stressscoreand a Life Stressscore. The Child Domain is subscaledinto

distractibility/hyperactivity,
adaptability,reinforcesparent,demandingness,
mood,and

adaptabilitycategories.The ParentDomain subscales

arecompetence,
isolation,

attachment,
health,role restriction,depression,
and spouse.The Total Stressscoreis

usedto quickly assessfor stressfulparent-childsystemsand to identify parentswho areat

risk for developingdysfunctionalparentingbehaviors.A Life Stressscoreprovidesa

view of the level of stressoutsidethe directparent-childrelationship(Adamakos,Ryan,

& Ullman, 1986;Dubow, 1988). The Life Stressscorereflectsthe intensityof stressthat

the parentis experiencing.

Abidin (1995)reportsthe reliabilitycoefficientsfor the 2 primary domainsand

the Total Stressscorearegreaterthanor equalto .90,therebypostinga stronginternal

consistency.The test-retest
reliabilitycoefficientsare .55 for the Child Domain, .70 for

the ParentDomain,and .65 for the Total Stressscoreat a 1-yearinterval(Abidin, 1995).

The instrument'sdiscriminatevalidity is demonstrated

with hyperactivechildren(Beck,

Young, & Tarnowski,1990),and depressed

mothersof childrenwith conductdisorder

(Webster-Stratton,
1988). The concurrentvalidity is evidentfor the PSI on the Child

Domain and the ParentDomain measuringhyperactivity,stress,and self-esteem

of

parentswith hyperactive
children(Mash& Johnston,1983a,1983b,1983c).The

82
utilizationof the PSI is endorsedin the evaluationof parentsof defiantchildren(Barkley,

1997c).Five selectsampleitemsfrom the PSI,(Abidin,1995)and the letterof

permissionfrom the publisherto reprinttheseitemsareofferedfor review (seeAppendix

c).
Marital or RelationshipDiscord

The revisededitionof the Marital SatisfactionInventory(MSI-R) (Snyder,1997)

measures
the natureand extentof relationshipdistressin couples.The MSI-R is a 150-

item instrumentthat utilizesa True-Falsedichotomousresponseformat. This instrument

assesses
the homeenvironmentof familieswith childrenor adolescents
with emotionalor

behavioraldisturbances.The MSI-R alsoassesses

the relationship'sassetsand liabilities

in coupleswheremaritaldiscordis not the primarycomplaint(Snyder,1991).

The MSI-R is comprisedof I I domainscalesand2 reliability scales.Domain

scalesincludethe Global Distressscale,the AffectiveCommunicationscale,the

Problem-SolvingCommunicationscale,the Aggressionscale,the Time Togetherscale,

the Disagreement
About Financesscale,the SexualDissatisfaction
scale,the Role

Orientationscale,the Family History of Distressscale,the Dissatisfaction

With Children

scale,and the Conflict Over Child Rearingscale.The 2 reliabilityscalesare the

Inconsistency
scaleand the Coriventionalizatioh
scale.The MSI-R is endorsedas a

strongrelationshipsatisfactionsurveyrelatingto its empiricaldevelopment(Dixon,

1985),its psychometricproperties(Fowers,1990),and its ability to measurea broad

spectrumof relationshipsatisfactionissues(Burnett,1987;Waring, 1985).

Snyder(1991)reportsa high correlationof a .94 to .98 rangefrom the original

Marital SatisfactionInventoryto the revisededitionof the Marital SatisfactionInventorv.

83
Discriminantvalidity is demonstrated
in the MSI-R with parentsof emotionallyor

behaviorallydisturbedchildrenor adolescents
(Westerman& Schonoholtz,1993).In

comparisonto the Marital AdjustmentTest (Locke-Wallace,1959)and the Dyadic

AdjustmentScale(Spanier,1916),the MSI-R correlateshighly on the Global Distress

scale. Syndernotesthat the MSI-R domainscalesof communicationdifficulties,global

distress,and conflict over child rearingscalescorrelatestronglywith the Minnesota

MultiphasicPersonalityInventory(MMPI) (Hathaway& McKinley,1967) on the

Psychopathic
Deviancescale. Also, the MSI-R correlateswell with the MMPI

Depressionscale,and a Paranoia-Schizophrenia-Hypomania
triad (Snyder,1997).

SnyderreportstheseMMPI profile configurationsareconsistentwith poor impulse

control,hypersensitivity
to perceivedcriticism,and a historyof impairedinterpersonal

relationships.ThesenotedMMPI profilespredispose
the personfor impaired

relationshipfunctioning(Snyder,1gg7).The MSI-R measures

of parentalconcernsabout

childrenand conflict over child rearingcorrelatesstronglywith the PersonalityInventory

for Children(Wirt, Lachar,Klinedinst,& Seat,1984),which reflectsinternalizingand

externalizingdisordersin childrenor adolescents

(Snyder,Klein, Gdowski,Faulstich,&

LaCombe,1988). Five selectsampleitemsfrom the MSI-R (Snyder,1997)and the letter

of permissionfrom the publisherto reprint theSeitems are availablefor review (see

AppendixD).

PctrentalDepression

The secondeditionof the Beck DepressionInventory(BDI-II) (Beck,Steer,&

Brown, 1996)is a 21-iteminstrumentthat measures

the severityof depressionin

individualsolderthan l3 years. The higherthe obtainedscoreis, the greaterthe severity

of depression.Beck and his colleaguesreportthat the BDI-II is createdto correlateto the

corresponding in theDSM-ly (APA, 1994).

diagnosticcriteriafor depression

Beck, Steer,and Garbin(1988)identifythe first editionof the BDI as an effective

quick assessment
of parentaldepression.The coefficientalphaof internalconsistencyon

the BDI-II is .92 with the outpatientpopulationand .93 with the collegestudent

population(Beck et al., 1996). Strongconstructvalidity is announcedwith the BDI-II

(Beck et al., 1996). Beck and his colleaguesreportpatientswith mood disorderstendto

scorehigheron the BDI-II thanpatientswith anxiety,adjustment,or otherdisorders.

Two selectsampleitemsfrom the BDI-II (Beck et al., 1996)and the letterof permission

from the publisherto reprint theseitems are availablefor review (seeAppendix E).

Child B ehavioral D isturbance

The revisededitionof the EybergChild BehaviorInventory(ECBI) (Eyberg&

Pincus,1999)is a 36-iteminstrument.Eachitem is answeredon a 7-point Likert scale

formatand an associated
Yes-Noresponse.The ECBI assesses
a broadscopeof

disruptivebehaviors.The ECBI is applicablefor childrenages2 to 16 years.

Eybergand Pincus(1999)reportthe internalconsistencycoefficientfor the ECBI

as .98 on both the Intensityscaleandthe Problemscale.The test-retest

reliability

correlationsof the ECBI IntensityandProblemsscalesare .86 and .88 respectivelyat the

3-weekinterval(Robinson,Eyberg,& Ross,1980),and .80 and .85 at the 12-week

interval(Funderburk,Eyberg,& Behar,1989). The ECBI correlatessignificantlywith

the total scoreof the Child BehaviorChecklist(Achenbach& Edelbrock,1983)with 4 to

16 yearolds (Boggs,Eyberg,& Reynolds,1990). Additionally,the ECBI Intensityand

Problemscalescorescorrelatesignificantlywith the ParentingStressIndex (Abidin,

85
1995)on both the Child Domain and the ParentDomain scores(Eyberg,Boggs,&

Rodriguez,1992). Discriminantvalidity on the ECBI is demonstrated

acrossvarious

diagnosticcategories(Ross,Blanc,McNeil, Eyberg,& Hembree-Kigin,1998). The

ECBI demonstrates
sensitivityto treatmenteffectsfrom parenttrainingusing behavioral

(Eyberg& Robinson,1982;Eyberg& Ross,1978;Packardet al., 1983;

interventions

Webster-Stratton,
1984). The ECBI is endorsedas a usefulinstrumentto evaluatethe

effectsof a behavioralparenttrainingprogram(Barkley,1988). Threeselectsample

itemsfrom the ECBI (Eyberg& Pincus,1999)and the letterof permissionfrom the

publisherto reprinttheseitemsareavailablefor review (seeAppendixF).

Assumptions

The exportabilityof Barkley's(1997c)manualizedparenttrainingprogramwhen

appliedto the ADHD populationin the privatepracticeor developmental-behavioral

pediatricoffice settingis the focus of interest. The four instrumentsnoted aboveare

utilized to assessand report on the effectivenessof the program. A purposiveselectionof

the notedassessment
instrumentsis madefor datacollectionand analvsis.

The selectionof the assessment

instrumentsis basedon the instrument'seaseof

administrationand scoring. The amountof time needed,the easeof completionby the

parents,and the ability to analyzethe instruments'responses

in a pretest-posttest
format

arerelevantfactorsconsideredin the instrumentselectionprocess.Additionally,

instrumentselectionis consideredfor the possiblefuturereplicationof this study.

The estimatedtime requiredto completeall 4 instrumentsis approximately1

hour. This time estimationto completethe pretestdatadoesnot includethe reportingof

demographicinformation(seeAppendixG) and the readingand signingof the informed

consentto participatein researchforms (seeAppendixH). Participantsare alsoaskedto

readand sign the authorizationof consentto releaseinformationform for communication

with their children'steacherand pediatrician(seeAppendixI). Thesedataareto be

collectedbeforethe participants'commencement
of StepOne of the program. The

approvedand signedArgosy UniversityHumanSubjectsReview Committeeand Internal

ReviewBoard forms areavailablefor review (seeAppendixJ).

The manualizedprogramunderstudy(Barkley,7997c)is deliveredin a stepwise,

weekly fashion. The parenttraining programis effective when deliveredduring an

individualtherapysession(Barkley,1997c).However,the programis to be deliveredin

a group format during this study. The Home Situation Questionnaire,the School

SituationsQuestionnaire,the plrent and teacherforms of the Disruptive Behavior

Disorders Scale(Barkley, 1997c),are administeredat the pretestand posttestportionsof

the study. Thesequestionnaires

serveonly as feedbackfor the participants.These

instrumentsareneithercollectednor analyzedin the final dataanalvsis.

Procedures

The secondeditionof Barkley's(1997c)Defiant Children:A Clinician'sManual

for Assessment
and Parent Trainingprogramis to be systematically
replicatedin this

study. The programconsistsof a l0-stepformatthat is conductedin 9 consecutive

weeks. A 1-monthfollow up sessioncompletosthe program. Prior to commencingstep

one,the principleinvestigatorassuresthat the participantscompleteall pretest

instruments,demographicforms and informed consentforms for their participationin the

study. Participantsprovidethe signedconsentfor the principleinvestigatorto

communicatewith their child's physicianandteacherduring the program. The principle

81
investigator'scommunicationwith the child's pediatricianand teacheris on an as needed

basisonly. Each sessionis 9O-minutes

long andcommenceswith an invitationfor

participantcommentand discussion.Eachof the program's10 stepsis briefly

summarized.A discussionof the previousweek'shomeworkassignmenttakesplace

duringeachsession.A more thoroughreview of eachstepis availablefrom the

manualizedparenttrainingprogramunderstudy(viz., Barkley, 1997c).

StepOne: Why Children Misbehave

Step one hastwo primary objectives. The participantsinformed of the causeand

maintenance
factorsof defiantbehaviors.A discussionis facilitatedrelatineto the

reciprocalintrafamilialand interpersonal
interactionsthat contributeto childhood

misbehavior(Barkley, 1997c).A secondgoal of the session,althoughnot notedin the

manual,is to commenceconstructivegroupformulationand cohesionof the participants.

The clinicianreinforcesthat the programis designedto train participantsin behavioral

and sociallearningprinciplesand is not a processorientedgroup. However,participant

interactionoutsideof the grouptrainingsettingis supported.A portionof the first

sessionis attributedto discussingvariousbehavioralprinciplesand intervention

constructs.A diagramof oppositionaldefiantinteractionsis photocopiedfrom the

manual(Barkley, 1997c). The oppositionaldefiant interventionsdiagram is presentedto

and discussedwith the particip4nts.

The homeworkassignment
for stepone is the completionof the Family Problems

Inventory,which is distributedby the clinician to eachparticipant. The Family Problems

Inventoryis utilizedonly as a participantfeedbacktool and is not collectedfor analysis.

The secondassignmentis for the participantsto childprooftheir home(Barkley, l99lc).

Step Two: Pay Attention

The goal of steptwo is to educatethe participantson how their style of parent-

child interactioncan effecttheir children'smotivationfor positivebehavior. The

cliniciantrainsthe participantsin attendingbehaviorstowardsthe children'spositive

behaviors.Simultaneously,
participantsdo not attendto negativeor undesirable

behaviors.In session,the participantspracticethe attendingbehaviorsto be usedonce

returninghome. The objectiveis to createa more positiveparent-childinteraction

pattern.The clinicianreviewsthis week'shomeworkaftercommunicatingthe rationale

for developingattendingbehaviors.

The cliniciandistributesthe handoutassociated

with steptwo: PayingAttentionto

Your Child's Good Play Behavior. The homework assignmentfor steptwo is to begin

15-20minutesof specialtime practiceperiodsbetweenthe children and the parentson a

daily basisand to recordthis experience(Barkley,1997c).

StepThree:Increasing Complianceand IndependentPlay

The primary objectivefor stepthreeis for the participantsto generalizethe effects

from the previouslylearnedattendingskills into settingsoutsideof specialtime. The

cliniciantrainsthe participantsto effectivelyutilize attendingskills to increaseimmediate

child compliancewith parentor caregivercommands.The clinicianteachesthe

participantshow to give effectivecommandsand how to constructivelycorrectthe child

when the child disruptstheir activities.The participantsareto plan for brief training

periodsof attendingto their child's compliancein varioussettingsat homeon a daily

basis.

89
 with step
The cliniciandistributesand thoroughlyreviewsthe handoutsassociated

three:PaltingAttention to Your Child's Compliance,Giving EffectiveCommands,and

Attendingto IndependentPlay. The clinician modelsthe presentedbehavioralmethods

and instructsthe participantsto increasethe monitoringof their children'sbehaviors.

Additionally, the participantsare informed to continuethe specialtime periodswith the

child (Barkley, 1997c).

StepFour: WhenPraise Is Not Enough: Poker Chips and Points

The primary objectiveof stepfour is to establisha formal positivereinforcement

systemin the homethat makesprivilegescontingentupon child compliance.Participants

are to createa developmentallyappropriatetoken economyin the home for their children.

The participantsareurgedto generouslyand consistentlyreinforcethe child with tokens

for observedpositivebehaviors,and
compliancewith parentaldemands.However,the

participantsarecautionednot to arbitrarydispensetokensor privilegesto their children.

The clinician distributesand reviewsthe handoutassociatedwith step folur'.Home

Poker Chip/PointSystem.The clinicianfacilitatesa discussionwith the participants

regardingthe tokeneconomysystem.The homeworkassignmentis to continuewith the

to designand implementa tokeneconomyin the

methodstaughtin the previoussessions,

home,and to bring a list of their child's privilegesand targetbehaviorsto the next

session(Barkley,1997c).

StepFive: Time Out! and Othet Disciplinary Methods

There are 2 objectivesin stepfive. First, the participantslearn the difference

betweenand the effectiveuse of the cost responseand the time out from reinforcement

behavioralprocedures.Second,the participantsaretrainedin how to implementthe cost

90
responseand time out from reinforcement
proceduresinto their hometoken

reinforcementsystem.The clinicianpreparesthe participantsfor the importanceof the

sessionregardingits degreeof difficulty and its dependence

on consistency.The

clinicianthoroughlydiscusses
commonerrorsmadeby parentsor caregiversin the

utilizationof the cost responseand time out from reinforcementtechniquesthat may have

yieldedunsuccessful
outcomesin the past. The cliniciandistributesthe handout

associatedwith step five: Time Out! and Other Disciplinary Methods.

The clinicianthoroughlyreviewsand modelsall stepsof the procedure.

Additionally,the clinicianinstructsthe participantsto utilize the time out procedurefor

only one or two noncompliantbehaviorsduringthis week. A thoroughreview of the

constructiveuseof the time out from reinforcement

procedureis necessary.The

participantscontinueto utilize the previouslytaughtmethodsduring this week (Barkley,

1997c).

Step Six: ExtendingTime Out to Other Misbehavior

The primary goal of stepsix is for the clinicianto assistthe participantsin

resolvingany problemsencountered
when usingthe time out procedureduring the past

week. A discussionis conductedon the applicationof the time out from reinforcement

procedurefor one or two additionalnoncompliantbehaviorsobservedin the home.

Sincethereare no handoutsassociated
with stepsix, the cliniciandistributes

variousresourcematerialsrelevantto parentsor caregiverswith children diagnosedwith

ADHD. For example,the cliniciandistributescontactinformationof the local CHADD

office and applicablewebsitesthat providesadditionalADHD relatedresources(e.g.,

www.the-adci-clinic.com).
Also, the clinicianprovidesthe locationand telephone

9l
numberof the local parentsupportgroupfor parentswith a child diagnosedwith ADHD.

The homeworkfor this week includesthe continuedutilizationand recordinsof the time

out method(Barkley,1991c).

StepSeven:Anticipating Problems:Managing Children in Public Places

The primary goal for step sevenis to train participantshow to apply the

previouslytaughtchild behaviormanagement
methodsin a public setting. The clinician

teachesthe participantsa four-stepthink aloud-thinkaheadprocedurefor anticipating

and reducingchild misbehaviorin public. The clinicianreinforcesthe value of

anticipatingproblembehavioras the key to successin managinga child'smisbehaviorin

public. The cliniciandistributesand discusses

the relevantdetailspertainingto the

handoutassociatedwith stepseven:Anticipating Problems-ManagingChildren in Public

Places.

The homeworkfor this stepinvolvesthe participantsmakingtwo bogusshopping

trips to storesfor practiceand to recordany information relevantto their experienceon

thesetrips. Also, the participantsareto contacttheir child'steacherto receivefeedback

regardingtheir child'sin classroomand out of classroombehaviors.The participants

continueto use the previouslytaughtmethods(Barkley, 1991c).

StepEight: Improving SchoolBehaviorfrom Home: The Daily SchoolBehavior Report

Card.

The clinicianreviewsthe natureof any,problemtheir childrenare displaying

when at school. Also, the clinicianteachesthe participantshow to implementa daily

schoolbehaviorreportcard for their children.

92
 The cliniciandistributesand reviewsthe handoutassociated
with stepeight:

Usinga Daily SchoolBehaviorReportCard. A discussionis facilitatedon incorporating

the program'sdaily reportcardwith the daily parent-teacher

communicationjournal

currentlyutilized in the public and most privateschoolsin the geographicregion. The

homeworkassignmentis the implementationor incorporationof the program'sdaily

schoolbehaviorreportcard. The participantscontinueto usethe previouslytaught

methods(Barkley, 1997c).

StepNine: Handling Future BehaviorProblems

The goal for stepnine is to encouragethe participantsto think aboutthe possible

futurechild behaviorproblemsand how they could utilize the previouslytaughtmethods

to addresstheseproblems. If no othertypesof treatmentareto be utilizedwith the child

or participantafterthe I -monthfollow up session,the clinicianpreparesthe participant

for the discontinuanceof therapy. The proceddresfor stepnine include the review of the

program's homework assignmentsand to review the think aloud-thinkahead methodfor

misbehavior.The cliniciandistributesand thoroughlyreviewsthe handoutassociated

with step nine'.Managing Future BehaviorProblems. The clinician challengesthe

participantswith hypotheticalbehaviorproblemsand discusses

how they may

autonomouslyhandlethe behavioralproblem(Barkley,1997c).

Thereis no homeworkassignment
for stepnine. For the purposeof this study,the

participantscompletethe posttestinstrumentsduringor at the end of this session.

Step Ten: BoosterSessionand Follow-Up Meetings

Stepten is a generaloverviewand closureof the program. An opendiscussionis

held relatingto the participants'implementation

of all previouslytaughtprocedures.The

93
clinicianprovidesdirectionand supportfor makingany necessary
correctionsto the

hometoken system.A brief discussionis held relatingto the continuanceor

discontinuance
of the hometokensystemin the future. The clinicianreviewsthe useof

the daily schoolbehaviorreportcard and discusses

the appropriateness
for its future

discontinuance.Additionally,the cliniciandiscusses
any otherneedsof the participants

or the children,suchas a referralfor psychopharmaceutical

assessment
or treatment.The

natureand degreeof the children'sdisruptivebehaviorsat post-treatment

are discussedat

the participants'discretion.The clinicianoffersthe participantsany resourceinformation

as neededor requested(Barkley,1997c).

DataProcessing
and Analysis

The demographicdatacollectedat pretestaresummarizedand discussedto yield

a descriptionof the subjectsparticipatingin this study. The parentself-reportdata are

collectedat the pretestand the posttestsegmentsof the study. The pretestand posttest

dataarecalculatedfor statisticalanalysis.The frequencydatacollectedfrom the ECBI

are considerednon-parametric.A Chi Squareanalysisis usedfor this frequencydata.

The PSI, the BDI-II, and the ECBI instrumentsutilize a Likert scaleformat. Likert scale

dataareconsideredand analyzedas intervaldata(Ravid,2000). The dichotomous

portionof the PSI and dichotomousformatof the MSI-R yield continuousdata. Thus,

theseare analyzedfrom a parametricdataperspective.The dependent-/test is usedfor

the analysisof all parametricraw data. The degreeof freedomfor a dependent-r

analysis

is n- 1. The participantself-repqrtsare hand-scoredwith the scoringtemplatesprovided

by the instrument'spublisher.The pretest-posttest

dataareprocessedand analyzedwith

the SPSS@
GraduatePack 10.0for Windows@computerstatisticalsoftwareprogram.
 CHAPTER FOUR

Restatementof the Purpose

The purposeof the studyis to identifythe efficacyof RussellBarkley's

manualizedparenttrainingprogramwith the ADHD populationin a communitysetting.

The studyexploresthe program'sability to contributeto a reductionin parentalstress,in

maritalor relationshipdiscord,hnd in depression

as reportedby the parentsor caregivers

of a child diagnosedwith ADHD. Additionally,the studyexaminesparentor caregiver

self-reportsregardingthe behaviorsof their childrendiagnosedwith ADHD.

Specifically,do the parentsor caregiversreportimprovementin their children's

behaviorsafterthey completethe programunderstudy(viz., Barkley,1997c).

In this chapter,the demographicprofile of the participantsand the representarive

childrendiagnosedwith ADHD is presented.The statisticalanalysisand outcomesof

the instrumentsutilized to addresseachresearchquestionare offered for review. Tables

arepresentedto supplementthe reportedfindings. An alphalevel of 0.05 is usedfor all

statisticalanalyses.All statisticalanalyseswereevaluatedin a directionalmanner.

Participants

Sixty four parentsor caregiverswere referredto the study by a licensedfamily

physician,pediatrician,or nursepractitioner.Forty individualscompletedthe pretest

instruments.A total of 31 participantscompletedthe lO-session

program,includingthe

pretestand posttestinstrumentsusedfor analysis.The sampleincludes22 femalesand 9

maleswhoseagesrangefrom2J to 63 years. The meanageis 40.36 years. The

participants'relationto the representative

childrendiagnosedwith ADHD includesl8

mothers,7 fathers,I step-father,3 grandmothers,I grandfather,and I long-term

95
girlfriendof a father. Two of the participantsaresingle,l8 are married,and 11 are

and one Asian-NativeAmericancomprisethe

divorcedor separated.Thirty Caucasians

participantsin the samplepopulation. The educationalbackgroundof the participants

rangedfrom high schoolgraduateor equivalentto the doctoraldegree.Seven

participantsreporttheir level of educationas high schooldiplomaor equivalent,l0 as

somecollegeor vocationaltraining,3 as a2-year degree,T as a4-yeardegree,1 as a

degree,and 3 as a doctoral-leveldegree.
masters-level

Twenty four participantsmaintainedpart-timeor full-time employmentand 7

was 8O.3Vo
wereunemployedwhile in the study. The rateof attendance at the scheduled

program. The femaleparticipantsattended80.5Voand the male participants

1O-session

attended68Voof the sessions.Threeof the participantsarediagnosedwith ADHD, 9 are

being treatedfor a psychiatricdisorder,and 9 are being treatedfor a chronic medical

condition.

The study'sparticipants'fulfillthe parentingrole for a total of 26 children

diagnosedwith ADHD, including21 boys and 5 girls. The children'sagesrangefrom 3

to 12 years. The participantsindicatetheir children'sADHD diagnosisas 4 with ADHD-

PredominantlyInattentiveType,9 as ADHD-PredominantlyHyperactive/Impulsive

Type, and 8 as ADHD-CombinedType. Zero childrenwere identifiedas being

diagnosedADHD-NoI OtherwiseSpecified.Nine reportsof the childrenindicatethe

inclusionof a comorbidpsychiatricdisorder.Eighteenreportsof the childrenindicatean

absenceof a comorbidpsychiatricdiagnosis.

reportingof theirchild's
couplesshowedinconsistent
The participating

psychiatricand medicalstatus.Two of the four participatingcouplesprovided

96
inconsistentreportsof their child's ADHD type specifierdiagnosis.Thirteenparticipant

reportsindicatedthat the parentor caregiveris not awareof the ADHD type specifieron

their children. Four participantsreportnot beingawarewhetheror not a comorbid

diagnosisis madeon their children.

The participantsreportedthat 29 of the children are and 2 are not taking

medicationsfor ADHD. Thereare 15 participantreportsthat the medicationsare

achievinga desiredresult. Ten participantsreport they are not pleasedwith the resultsof

medicationtherapy. Two of the parentcouplereportsshow inconsistentperceptionsof

medicationtherapyeffectiveness
with their children. Four participantsdid not comment

on their perceptionof medicationtherapyeffectiveness

with their children. Table I

showsthe agerangesof the participantsand of their representative

children.

91
Table 1. ParticipantReportof Age Ranges

Participants Vo

AgeRanges

20-30 + 12.9

3r-40 l5 48.3

4l-50 8 25.8

51-60 a
J 9.6

>60 I 3.2

Total 31 t00.2

MeanAge 40.36years

Children
Representative n Vo

Age Ranges

2-4 I 2.9

5-8 2l 61.8

9-12 l2 35.3

Total 34 100.0

Mean Age 7.88years

98
 StatisticalOutcomeof ResearchQuestions

Parental Stress

The first researchquestionaskswhetheror not parentsor caregiversof children

diagnosedwith ADHD will reporta statisticallysignificantdecreasein their experience

ofparentalstress.Thesedataareobtainedby pretestand posttestresponses

on the

ParentingStressIndex (PSI) (Abidin, 1995)and the completionof RussellBarkley's

DefiantChild (1991c)manualiz,ed
parenttrainingprogram. The 1O-session
programwas

conductedin a counselingprivatepracticeor pediatricoffice setting. The null hypothesis

statesthat thereis no statisticallysignificantdecrease

betweenthe pretestand posttest

responses
on the PSI.

A paired-sampledependent-rtest was conductedon the participants'pretestand

posttestresponses.The resultsproducedstatisticallysignificantimprovementsin the

overallChild Domain,t = 3.451,/crit( 05.zt\= 7.703.Statistically

significantdifferences

arealsofound within the Child Domain scaleincludingthe Distractibility/Hyperacrivity

subscale, 2ay= '1.701;the Adaptabilitysubscale,t = 3.409,/crit(.05.

t = 2.920,/crit(.05, 2e)=

1.699;the Demandingness
subscale, = 1.697;theMood subscale,
t= 1.996,/crit(.05.g0) /=

= 1.697;andthe Acceptabilitysubscale,
2.581,/crit(.0-5,r0; t=2.430, /crit(.05,
zy= 1.699.No

significantdifferencewas found on the Child Domain ReinforcesParentsubscale,t =

| .169,lcnt tol= 1.697.

(.05,

The resultswithin the ParentDomainrevealone subscalewith significant

findings. The Spousesubscaleresultwas significant(r = 1.862,/crit(.05,

zs)=1.699).The

resultsin the ParentDomain scale,and the Competence,

Isolation,Attachment,Health,

Role Restriction,and Depressiohsubscales

were not statisticallysignificant.

99
Table2. ParentinsStress

Pretest-Posttest

Domains n DifferenceMean SD /-score

Child Domain 28 10.1786 15.6064 3.451-

DistractibilitylHyperactivity 29 2.5862 4.1698 2.920-

Adaptability 30 2.9667 4.7669 3.409.

ReinforcesParent 3l 0.8065 3.8420 1.169

Demandingness JI t.45t6 4.0484 1.996'

Mood 31 1.2903 2.7832 2.581-

Acceptability 30 1.5000 3.3810 2.430'

ParentDomain 29 2.8621 13.3623 1.153

Competence 29 0.4483 3.4495 0.700

Isolation 31 - 1.0968 2.2855 -2.612

Attachment 3l 0.6774 3.8244 0 .986

Health a1
JI -.02258 2.8132 -0.447

Role Restriction 30 0.2000 4.2296 0.259

Depression 31 0.9677 3.5822 L504

Spouse 30 1.3000 3.8251 1.862.

Total Stress 2l 12.3704 22.9818 2.791

Life Stress 31 1.0000 9.6575 0 .577

Note. * - indicatesstatisticallysignificantdifferenceat p<.05,one-tailed.

100
 the resultsarethe ParentDomainscale,t = 1.753,/.,i1(.0s,28)
Specifically, = 1.701; the

Competencesubscale,t = O.JOO, zs;= 1.701;the Isolationsubscale,t = -2.672,tcrit

/crir(.05,

( 0s.30)-- 1.697;the Attachmentsubscale,r = 0.986,/crit(.05,

:o;= I .697; the Healthsubscale,

t = -0.44J,/crit(.05,
ro;= 1.697;theRole Restriction t = 0.259,/crir
subscale, zr= 1.699',
(.05,

and the Depressionsubscale,t = 7.504,/crit(.05,

ju = | .69'7.

The resultsof the Total Stressscalewas statisticallysignificant,t = 2.79J, /crit(.05,

2 6 l =1 . 7 0 6 .H o w e v e r , t h e r e s u l t s o n L i f e S t r e s s s c a l e w a s n o t s i g n i f i c d r r t , t = 0 . 5 7 7 , t " r i 1

= 7.697. Table2 reflectsthe statisticalfindingsfrom the sample'spretest-posttest

(.0.5,30)

self-reportson the PSI.

Marital or RelationshipDiscord

The secondresearchquestionaskswhetheror not parentsor caregiversof

childrendiagnosedwith ADHD will reporta statisticallysignificantreductionon marital

or relationshipdiscord. The datawas obtainedby pretestand posttestresponses

on the

revisededitionof the Marital SatisfactionInventory(MSI-R) (Snyder,1991)and the

completionof RussellBarkley'sDefiantChild,(1997c)manualizedparenttraining

program. The 10-session

programwas conductedin a counselingprivatepracticeor

pediatricoffice setting. The null hypothesisstatesthat thereis no statisticallysignificant

betweenthe pretestandposttestresponses
decrease on the MSI-R.

A paired-sampledependent-/test was conductedon the participants'pretestand

posttestresponses.The analysisrevealedan absencea statisticalsignificanceon all

domains.The outcomeis a failureto rejectthe null hypothesis.Table 3 reflectsthe

statisticalfindings from the sample'spretest-posttest

self-reportson the MSI-R.

101
Table 3. Marital or RelationshipDiscord

Pretest-Posttest

Domains n Difference Mean ^SD /-score

Inconsistency 28 0.3929 2.4089 0 .863

Conventionalization 28 -0.3511 1.8097 -t.044

Global Distress 28 -0.5714 4.5577 -0.663

Affective Communication 28 - 0.1071 3.6244 -0.156

ProblemSolvingCommunicatidn 28 -0.8929 4.2369 -1.115

Aggression 28 0.3214 r.8867 0.902

Time Together 28 -0.5000 2.0994 -1.260

Disagreement
About Finances 28 0.1786 2.O317 0.464

SexualDissatisfaction 28 -0.57
t4 3.4365 - 0 .880

Role Orientation 28 -0.4643 2.0213 -1.212

Family History of Distress 28 -0.2500 1.8782 -0.104

Dissatisfaction
With Children 25 0.1200 2.0273 0.296

Conflict Over Child Rearing 25 -8.0002 1.2220 -0.327

Note. * - indicatesa statisticallysignificantdecrease

at p<,05,one-tailed.

Parental Depression

The third and fourth researchquestionsask whetheror not parentsor caregivers

of childrendiagnosedwith ADHD will reporta statisticallysignificantreductionin their

depressive
experiences.Thesedataareobtainedby pretestand posttestresponses
on the

secondeditionof the Beck DepressionInventory(BDI-ID (Beck,Steer,& Brown, 1996)

102
and the completionof RussellBarkley'sDefiantChild (1991c)manualized
parent

trainingprogram. The 10-session

programwas conductedin a counselingprivate

practiceor pediatricoffice setting.The null hypotheses

statethat thereis no statistically

significantdecrease
betweenthe pretestand posttestresponses
on the BDI-II.

A paired-sample
dependent-/
testwas conductedon the participants'pretestand

posttestresponses.The analysisrevealsan absencea statisticalsignificancefor eitherthe

male or female participants. The outcomeis a failure to reject the null hypotheses.Table

4 reflectsthe statisticalfindings.fromthe sample'spretest-posttest

self-reportson the

BDI-II.

Table4. Parentor CaregiverDepression

Pretest-Posttest

Gender n DifferenceMean SD r-score

Total 3l -0.4516 6.3500 -0.396

Male Participants 9 1.0000 2.4495 1.225

FemaleParticipants 72 - 1.0455 1.3516 -0.661

Note. * - indicatesa statisticallysignificantdecreaseat p<.05,one-tailed.

Undesirable Child B ehaviors

The fifth researchquestionaskswhetheror not parentsor caregiversof children

diagnosedwith ADHD will reporta statisticallysignificantreductionin their children's

undesirablebehaviors.Thesedataareobtainedby pretestand posttestresponses

on the

EybergChild BehaviorInventory(ECBD @yberg& Pincus,1999)and the completionof

103
RussellBarkley's DefiantChili Q997c)manualized
parenttrainingprogram. The 10-

sessionprogramwas conductedin a counselingprivatepracticeor pediatricoffice

setting.The null hypothesisstatesthereis no statisticallysignificantdecreasebetween

the pretestand posttestresponses

on the ECBI.

A paired-sample testwas conductedon the pretestand posttest

dependent-/

responses
on the ECBI Intensityscale. Data analysisyield a statisticallysignificant

result,t = 4.463,/crit(.05,
2q = 1.697.

A Chi Square2 x 2 analysiswas conductedfor the ECBI Problem scale. The data

analysisyield no statisticallysignificantchangeon the pretest-posttest

responses.Table

5 reflectsthe statisticalfinding from the sample'spretest-posttest

self-reportson the

ECBI.

Table5. UndesirableChild Behavior

Pretest-Posttest

Scale n DifferenceMean SD r-score

Intensity 30 ,19.1333 23.4840 4.463.

Scale dft
Problem 1065 1 0.871

Note. * - indicatesa statisticallysignificantdecrease

at p<.05,one-tailed.

104
 Summary

Thirty one parentsor caregiversof childrendiagnosedwith ADHD completedthe

pretest-posttest
self-reportinstrumentsand the l0-sessionmanualizedparenttraining

program(viz., Barkley,1997c).The demographicprofile of the participantsis diversein

their relationshipto the child, maritalstatus,employmentstatus,and educational

background.Fifty eight percentof the participantsweremarried,but only 4 couples

attendedthe program.

The majority of the representativechildren (92.3Vo)are reportedto have taken

ADHD-relatedmedicationsduringthis study. However,someinconsistency

betweenthe

participatingcouplesexistsin termsof perceivedmedicationeffectiveness.The parents

or caregiversreport not being awareof the ADHD type specifierfor l3 of the children

diagnosedwith ADHD. Further,two of the four participatingcoupleswere inconsistent

in the knowledgeof their child's ADHD diagnosticspecifiertype. The participants

indicate9 of the representative

childrenare identifiedas havinga comorbidpsychiatric

diagnosis.Participantsreportthat 18 of the representative

childrendo not havea

concurrentdiagnosable
psychiatricdisorder.Althoughnot specificallyreflectedin the

demographicdata,3 of the representative

childrenwerediagnosedwith insulin dependent

diabetesmellitus(IDDM). Thesechildren'smedicalstatusrequiredcreative

restructuringof the programrelatingto restrictingfood while a child is in time out.

Amendmentto the programfor thesechildrenis discussedin the following chapter.

The pretest-posttest
responsesfrom the 31 participantsproducedvaried statistical

findingsthat warrantdiscussionand interpretation.A relativelylow numberof

participantresponses
are availablefor dataanalysisand interpretation.Chapter5 of this

105
dissertationprovidesthis discussionof the findings. Recentresearchrelatingto the

treatmentof ADHD and the direction for possiblefuture researchis also offered for

discussion.

106
 CHAPTER FIVE

Summary

Identifyinga valid exportabletreatmentto addressany psychologicaldisorderis a

challenge.The etiologyof ADHD is basedin geneticand biologicalmarkers. The

symptomsof the disorderareexpressed

behaviorally,which impactthe child acrossmost

socialsettings.ADHD is associated
with numerouspsychosocialinsultsupon the

diagnosedchild and othersin proximity to the child. ADHD may not be met with

empathyor sympathyby the generalpublic. This public opinionmay not be basedon

fact. Social comparisonoften occurswhen the aberrantbehaviorscannotbe ignoredin

public or in the school. This possiblesocialstigmabeginsin childhoodand may continue

throughoutadulthood.Even if the parentis not diagnosedwith ADHD, the medicaland

socialeffectsof the child's disorderencroachupon the adult'sability to confidentlyand

competentlyfunctionin the parentingrole.

The NationalInstituteof Mental Healthrecognizesthe challengesfacedby

individualsdiagnosedwith ADHD and,as a result,facilitateda six-sitemultimodalstudy

interventions(MTA CooperativeGroup, 1999). An expanded

of evidenced-based

versionof the first editionof Barkley's(1987)Defiant Childrenparenttrainingprogram

was part of this multimodalstudy.

Exportability studiesof manualizedbehavioralparenttraining programswith the

ADHD populationwere not located.This relativelack of exportabilityresearchimposes

limits on the utility of the programin a communitysetting. Additionally,the absenceof

exportabilitystudieson behavioralparenttrainingprogramsprohibitsthe identificationof

any programinadequacies.The majority of the vastresearchrelatingto the treatmentof

107'
ADHD endorsesthe effectiveness
of oharmaceutical
and behavioralinterventions.

Studiestendto be conductedin'a controlled,universitysetting.

The purposeof this studyis to examinethe exportabilityof Barkley's (1997c)

DefiantChildrenmanualizedparenttrainingprogramwhen appliedto the ADHD

population.Persistentbehavioraldisturbances
resultin a significantnegativeeffectupon

the parentand the child. This resultmay be maintainedby a parent'svaliantbut

ineffectiveattemptto fulfill the parentingrole. A child's behavioralresponseto

ineffectiveparentingmay generalizeto othersettings.The identificationof an effective

behavioralparenttrainingprotocolfor usein the communityis paramountto the child

with ADHD as well as forothers*ittin the child'slife.

diagnosed

A systematicreplicationof Barkley's(1997c)Defiant Childrenmanualizedparent

trainingprogramcontributesto the pool of clinical knowledgein the treatmentof ADHD.

This studywas conductedoutsideof a universityenvironment.The resultsprovide

insightinto the exportabilityof the manualizedprogram. A pretest-posttest

designwas

used. Each participantprovided voluntary self-reporton four instrumentsfor data

analysis.Someparticipantsindicatedon the ParticipantDemographicForm that a

follow-up letter summarizingthe findings to be mailed to them at the completion of the

dissertation(seeAppendixK).

Participants

Sixty-fourindividualswere originallyreferredand acceptedinto the study. Forty

of thoseparticipantscompletedthe pretestinstruments.Both pretestand posttest

instrumentsnecessary
for the study'sstatisticalanalysiswere completedby 31

participants.The parentor caregiverparticipantsfunctionin the parentingrole for 34

108,
 boys and 5 girls. The agesof the
childrendiagnosedwith ADHD, representingZg

childrenrange
participantsrangefrom2J to 63 years. The agesof the representative

from 2 to 12 years. A notablefactoris that l3 of the parentor caregiverparticipantswere

not awareof their child's ADHD diagnosticspecifier.Due to the relativelysmall number

design,inferencesand generalizations
of adultparticipantscompletingthe pretest-posttest

of the study'soptimisticfindingsare limited.

Conclusions

PorentctlStress

The ParentingStressIndex (PSI)(Abidin, 1995)examinesthe effectof the

behavioralparenttraining prognam(Barkley, 1991c)on parentalstress. Resultsreveal

statisticallysignificantimprovementsin the PSI Child Domain scaleand on five of the 6

Child Domain subscales.Resultsof the PSI ParentDomain scaleand four of the 7

show nonsignificantimprovements.However,the Spousesubscaledid show a

subscales

statisticallysignificantimprovement.The improvementon the PSI Total Stressscalewas

significant.The improvementfound on the PSI Life Stressscalewas not significant.

subscalefindings,a collective
may be basedon independent
Althoughinterpretations

of the PSI scalesand subscales

interpretation (Abidin, 1995). However,
is encouraged

the incongruentsignificancebefweenthe Child and the ParentDomain scoresmake

challenging.Additionally,otherpolarizedfindingson the EybergChild

interpretation

BehaviorInventoryIntensityand Problemscalesreflectthat parentingproblemspersistat

posttest(Eyberg& Pincus,1999).

resultsacrossthe PSI subscales.A

findingsrevealinconsistent
Presented

statisticallysignificantlevel of improvementwas found on the Child Domain andthe

109
Total Stressscales.Theseimprovementsindicatean overallreductionin stresswithin the

parent-childrelationship.Additionally,the potentialfor the developmentof a

dysfunctionalparentingstyle is reduced.A nonsignificantimprovementon the Parent

Domainreflectsthat dimensionsrelatingto parentfunctioningwerepositively

influenced,but the participantscontinueto experiencea senseof inadequacyand being

overwhelmedin the parentingrole. A nonsignificantimprovementon the Life Stress

scaleindicatesthat factorsoutsideof the parent-childsystemcontinueto negatively

influencetheir relationship.

Findingsshoweda mixed effectupon the parentor caregiverfollowing the

completionof the program. Behavioralparent.training

is reportedto reduceparental

stress(Anastopoulos
et al.,1993;Pistermanet al., 7992;vander Krol et al., 1998). The

mixed findingsmadea comparisonwith otherresearchfindingsrelatingto parentalstress

difficult.

Mctrital or RelationshipDiscord

The revisededitionof the Martial SatisfactionInventory(MSI-R) (Snyder,l99l)

evaluatesparticipantreportsrelatingto maritalor relationshipdiscord. Resultsreveala

nonsignificantimprovementin the consistencyof the participantself-reportson the MSI-

R Inconsistency
scale. A nonsignificantimprovementwas also seenon the MSI-R

scale.Resultsfrom thesetwo validity scalesreflecta potential

Conventionalization

of perceptualdistortionswithin the parentor caregiverrelationships.

decrease

Statisticallysignificantimprovementswerenot found on any of the MSI-R profile

scales.Nonsignificantimprovementsin the relationshipwere found on eight of the 11

profile scales. Findingsreflecta generalincreasein relationshipsatisfaction,

in shared

ll0
interests,in a mutualexpressionof affectionandunderstanding,
and in the sexual

relationsof the participants.Improvementswere alsofound in the willingnessto

mutuallysolveproblemsin the relationshipand in addressing

financialconcerns.A

decrease
was evidentrelatingto negativeinfluencesfrom unresolvedchildhood

experiences
and conflict over child rearingstrategies
upon the relationship.

Conversely,pretest-posttest
analysisshoweda nonsignificantdeteriorationin

participantrelationshipson the Aggression,the Role Orientation,and the Dissatisfaction

With Childrenscales.Thesefindingsshowedthat the participantscontinueto experience

a degreeof physicalor emotionaldiscordwithin their relationships.Findingsalso

reflectedthat adult relationshiprolesbecamelessegalitarianand that they continuedto

experienceconcernsrelatingto their parent-childrelationships.

A concurrentcomparisonis madebetweenthe optimisticfindingson the noted

eightprofile scalesandthe two validity scalesof the MSI-R and the significantfindings

on the PSI Spousesubscale.This comparisonlendssupportto the contentionthat

participationin a behavioralparenttrainingprogramhasa positiveeffecton the parenting

relationship(Anastopoulos
et al.,1993;Lavee,Sharlin,&Kat2,1996). Although the

findingswere not statisticallysignificant,a degreeof changewithin the family systemis

determinablefrom the participantresponses.However, findings do not afford a concise

response
to the research
questionas stated.

Parental Depression

The secondeditionof the Beck DepressionInventory(BDI-ID (Beck,Steer,&

Brown, 1996)evaluatesthe depressive

experienceof the male and the female

participants.Findingsfrom the 9 maleparticipantsreveala nonsignificantdeterioration

111
of their depressiveexperience.The 22 femaleparticipantsreporta nonsignificant

improvementfrom their depressiveexperience.Further,assumptionsof thesefindings

arelimited due to the small numberof responses

for analysis.Findingsfrom this study

cannotsignificantlysupportothers'assertions
that parenttrainingreducesmaternal

depressionin motherswhosechildrendisplayexternalizingdisorders(Barkley, 199'7c;

Forehand& McMahon, 1981). However,a comparisonof the BDI-II with the PSI

Depressionsubscaleresultsdisplaya trendtowardsa decrease

in the participants'

depressive
experiences
following participationin a behavioralparenttrainingprogram.

Undesirable Child B ehavior s

The EybergChild BehavioralInventory(ECBI) (Eyberg& Pincus,1999)

evaluateschangein the represefltativechildren's behaviorsby participantself reports.

The effectof the children'snegativebehaviorfollowing parenttrainingis dependent

upon the participants'implementationof the presentedbehavioralstrategies.Research

indicatesthat behavioralparenttrainingcontributesto a reductionof negativebehaviors

displayedby childrendiagnosedwith ADHD (Anastopoulos

& Farley,2003;Klein &

Abikoff, 1997;Pistermanet al., 1989a;Smith & Barrett,2000). Findingsindirectly

supporttheseresearchers'
assertions.

Reportson the ECBI Intensityscalereveala statisticallysignificantimprovement

in the severityof the children'sexternalizingbehaviors.However,a nonsignificant

reductionis found in the numberof behavioralproblemareas.This incongruenceacross

scalesreflectsthe existenceof ongoingparentingproblems(Eyberg& Pincus,1999).

Inconsistentor inaccurateimplementationof the presentedbehavioralparentingstrategies

may explainthis disparity.The rateof attendance

in this stepwiseprogramwas 80.3%.

112
Further,most participantswho misseda trainingsessiondid not schedulea make-up

sessionwith this principleinvestigator.Thus,someparticipantsreceivedthe training

information only from the handouts.Theseparticipantsmay or may not have reador

implementedthe behavioralstrategies
presentedin the handouts.Participantskills

acquisitionand programcompliancearefactorsto considerwhen examiningthe findings.

Additionally,an operationaldefinitionof negativebehaviorsmay yield a more

accurateinterpretationof the findings. The ECBI measuresnegativechild behaviorsby

the numberof problemareasand the intensitywithin that problemarea. In orderto

comparefindings, future researchmust identify whetherthe reportedreductionof

behaviorproblemswas in termsof the numberof or the intensityof the problem

behaviors.

GeneralDiscussionof the Program and Findings

Parentcommentsendorsean improvementof the parent-childrelationship

following Step 2 of the program. Participantverbal reportsnote that spendingspecial

time with their child was their most subjectivelyrewardingexperienceduring the

program. Initially, participantsdisplaynotableapprehension

aboutattemptingthe

presented
techniquesbeyondStep3. Commentsvolunteeredlater in the programreflect

a fearthat the implementationof a point systeminvolving expectedchild behaviorsor the

enforcementof consequences
for child misbehaviors
might resultin the returnof

noncompliance
and otherunacceptable
behaviors.

Threerepresentative
childrenwerediagnosedwith insulin dependentdiabetes

mellitus. As a result,Steps5 and 6 were amendedto addressrecommendation

to not

retaina meal for the child if the child earnsa time out from reinforcementintervention

ll3
during meal times (Barkley,1997c).Agreementsweremadebetweenthe principle

investigatorand the parentswith the childrendiagnosedwith insulin dependentdiabetes

mellitus. Theseparentswereto only providethe food materialsfor a meal following

completionof the time out. The child was expbctedto createhis or her own meal with

the providedfood materials.The lack of convenience,

of a preparedmeal waiting in the

refrigeratorfor the child aftermeetingthe expectations

for time out discontinuance,
was

highlightedas the aversion.Theseparentsverbalizedthe effectiveness

of the program's

amendment.A motherof a boy with insulindependentdiabetesmellitusstatedrelating

to the programamendment,"We told him what we'd do. He tried us once. This worked

fine."

Most participantsnote an eventualdegreeof enthusiasmby the children's

teachersin utilizing the Daily SchoolBehaviorReportCard. The anticipatedand initial

resistancefrom the local teachersstemmedfrom two aspects.First, during the study,the

teacherswere askedto provideparentswith daily feedbackregardingtheir child's

behaviorat school,insteadof the areaschools'alreadypresentweekly feedbackformat.

Second,the primary methodof behavioralmanagement

in the local areapreschoolsand

elementaryschoolsis cost-response,
a punishment-based
procedure.Parentsreportedan

unwillingnessof threeteachersto participateregardingthe Daily SchoolBehaviorReport

Card identifiedin Step8. Thesethreeteachers,were

employedat local privateschools.

Interestingly,one of theselocal privateschoolsrecentlyrequestedthat the principle

investigatortrain its teachersbasedon the behavioralstrategies

presentedin the

manualizedprogramunderstudy. This requestby that privateschoolaffordsoptimism

for future ADHD studentsin that school.

114
 Most participantsverbalizedthat they gainedvaluableknowledgeand skill to

assisttheir child towardsan optimallevel of functioning. At Step 10,two femaleparents

report their jubilation relatingto being able to eat an entire meal at a restaurantas a

iamily.

Approvalof the DefiantChildrenprogram(Barkley,1997c)was not universally

by all participants.One grandmotherparticipantvoicedthat,while she

expressed

recognizesRussellBarkley as a key figure relatingto the treatmentof ADHD, shewill

resumeher previousbehavioralmethodswith her male grandchild.Unfortunately,her

Shedescribedthe manualized
parentingapproachis predominantlypunishment-based.

programas,"nice." However,this grandmotherfrequentlyvoicedher blatant

with the directionsgiven for most stepsof the program. Additionally,a

noncompliance

not availablefor the scheduledStep 10 groupsession

secondgrandmotherparticipant'was

due to an impulsive4-dayleave. Shedid not inform any family memberof her plansfor

a departure,but eventuallycontacteda family memberby telephonefrom Washington,

acknowledgea
DC. Shecompletedsession10 upon her return. Both grandmothers

on the demographicdocumentscollectedat pretest.

persistenthistoryof psychopathology

Participantswereoffereda free l-hour make-upsessionin this investigator's

duringthe courseof the program. This service

counselingoffice for any missedsessions

only 4 parents
was availableat their discretion.Despitethe 80.3Vorateof attendance,

took advantageof this opportunity. Each of thbse4 parentsusedthis free serviceonly

once.

show a disruptionin the

responses
The resultsof the participantpretest-posttest

that previouslymaintainedthe family's homeostasis.

dysfunctionalcopingstrategies

115
However,no researchquestioncould be unequivocallyanswered.Most reportedfindings

from the professionalliteraturewere not replicatedat a level of statisticalsignificance.

However,a generaldegreeof programeffectiveness

is evidentacrossmost measures.

Due to the relativelysmall samplesize(n - 3l), limitationsdo exist in generalizingthe

findings. Additionally,someparticipantsrefusedto provideresponses

to selectitemsor

selectinstruments.Therefore,someanalysesarebasedon a samplesizelessthan 31.

Improvementsthat were found in the pretest-posttest

analysesmay be better evaluatedby

a largersamplesizein futurestudies.

Recommendations

Future Research

Additionalor replicatedresearchon the exportabilityof the secondeditionof

RussellBarkley's (1997c)DefiantChildrenmanualizedparenttrainingprogramwith the

ADHD populationis justified. Findingssuggestthat the behavioralapproaches

implementedby the parentsproducedbenefitsfor the parentand the child. ADHD type

specifierdid not presentas an identifiablesignificantfactor. A larger study may better

evaluatethis factor.

Partic ipant Considerations.

A degreeof participantattritionwas expected.Only 48Voof the original64

referralsto the study actuallycompletedthe entireprogram. Offering a free program,

plus providingday and evening'sessions,

was dot sufficientto discourageparticipants

from leavingin the study. A monetaryincentiveor havingthe participantspay for the

programmay yield a betterrateof participantretainment.

116
 Someparticipantbehaviorscreatedchallenginggroupdynamics. A more

thoroughscreeningfor participantpsychopathology
may reduceunexpectedparentalor

caregiverbehavioralaberrations.A comprehensive
screeningof the participantsmay

alsocontributeto a smallersubiectrateof attrition.

Continuedcontactwith ihe participantsis not a plannedaspectof the study. This

researcher
had severalunplannedcontactswith someof the participantsin public. They

verbalizeda mixed responserelatingto their continuationof the learnedbehavioral

strategies.Someparticipantsreportedthat they no longer utilized the strategiestaughtto

them during the program. They reportedthat the child's undesirablebehaviorshave

resurfaced.They alsoreportedtheir decreased

interestin maintaininga behavioral

programin the home. Theseunsolicitedparentresponses

receivedafterthe completion

of the program suggestthe short-termeffectivenessof the behavioralstrategies.This also

impliesa possiblereturnto a dysfunctionalhomeostasis

in their families. Short-term

effectivenessof behavioralinterventionsas a treatmentlimitation is reportedin other

research(e.g.,MTA CooperativeGroup, 1999). However, other parentsreportedthat the

positiveeffectswere sustained.A 6-monthor a 1-yearfollow-up as part of the planned

study may contributeto a betterunderstandingof the actualenduranceand long-term

effectsof a behavioralparenttraining programin the community.

Trainingelementaryschoolteachersin classicalconditioning,operant

conditioning,and sociallearning-based
behavioralprinciplesmay improvefuture

findings. Also, a proactivestancemay be possiblewith teachertrainingsin behavioral

strategies.Significantbehavioralproblemsmay diminishor neverdevelopat schoolwith

teachersthoroughlytrainedin behaviorprinciples.Supportfor teachertrainingsmay be

117
found throughadaptations
of a manualizedbehavioraltrainingprogramfor a mainstream

classroomsetting.

Findingsproducednonsignificantimprovementsacrossseveralmeasures.A

largersamplesizewould increasethe statisticalpowerof the study(Shavelson,1988).

The increasedpower of a futurestudymay yield statisticallysignificantresultsand afford

a greaterdegreeof confidencein generalizingthe findings.

I nstrument Considerat ions.

Somechallengeswerefound relatingto the instrumentsusedin the study. For

example,a notabledisplay of resistancefrom the participantswas evident when they

were askedto respondto the MSI-R (Snyder,l99l). Twenty-fiveof the 3l participants

completedthe MSI-R. Two additionalparticipantscompletedthe MSI-R, but refusedto

answerthe itemsrelatingto partnerrelationswhile functioningin the parentingrole.

Only four couples(l2To'of all participahts)participatedtogetherin the study.

Eighteen(58Vo)of the participantsweremarried. However,many of the marriedcouples

havebeenin more thanone marriage.Eleven(35Vo)of the participantswere divorcedor

separated.The history of adult interpersonaldifficulties with theseparticipantsmay

generalizeto the parent-childrelationship.Poor adult interpersonal

skills may negatively

effecttheirchildren'semotionsand behaviors.In futureresearch,using an instrument

that measuresthe effect of adult interpersonalbehaviorsupon the child may yield

valuableinformationto this familial dvnamic.

For this study,the participantswerepromptedto respondto the MSI-R instrument

basedon a significantotherwho is involvedin the parentingof the child diagnosedwith

ADHD. The significantotherwas not necessarilya spouse.Regardless,

some

118
participantsrefusedto offer responses
on the MSI-R. Othermaritalor relationship

instrumentsmay betterassessthe relationalcharacteristics

of the adultsfunctioningin the

parentingrole of a child diagnosedwith ADHD.

Threeof the four selectedinstrumentshavescalesand subscales.Multiple scales

presenteda potentialchallengein evaluatingthe null hypotheses.

and subscales

Extrapolationsof the datawere necessary.Interpretation

of the dataacrossthe scalesand

subscalesopensthe resultsto debate. Each researchquestionrelied on the overall

findingsof a specificinstrument.Futureresearchquestionsand hypotheses

may needto

be more specificand identifiableto instrumentsubscales

as opposedto generalized

constructssuchas thoseproposedhere.

Other Future ResearchConsiderations.

FutureresearchshouldexamineBarkley's(1991c)behavioralparenttraining

programduring the summer. Parentstend to stop ADHD-related medicationtherapy

duringtheir child's summerbreakfrom school. Conductinga replicationstudyduring

the summercan isolatemedicationeffectsfrom the behavioralprogram. Additionally,

future studiescan utilize an ADHD supportgroup as a control group to elicit empirical

findings. Other studiescan examinethe effectsof a behavioralparenttrainingprogram

upon behavioralsocialskills programs(e.g.,Sheridan,1995).

Future researchon manualizedbehavioralparenttraining programsshould

includethe additionof a questionnaire

at posttest.A questionnaire
can be generated
to

addresses
issuesrelatingto medicationchangesfor the child during the courseof the

program,changesin participantrelationships, and possible

participantsatisfaction,

influencesof culturaldifferences.Also, a narrativereportfrom or an interviewwith the

lr9
participantsat posttestmay be usefulto directfuturestudies,includingpossiblerelapse

preventionstrategies.Finally, a qualitativestudymay capturethe familial and other

interpersonal
dynamicsaffectedby the parentor caregiver'sparticipationin the program.

Thesedynamicswerenot comprehensively
assessable
by the instrumentsutilized this

study.

Changesin the participants'demeanorwere witnessedas they progressed

through

the program. Seeingthe pleasurein many participants'facesas they describetheir actual

experiences
as becomingmore alignedwith what they hopedparenthoodwould be like

for them was a professionallyfulfilling experiencefor me.

RecentFindings Relevantto ADHD

Interpretations
of the findings(Connerset al., 2001) and of the study's

methodology(Breggin,2001; Klein, 2001) provokedebatewhetheror not the MTA

CooperativeGroup study will yield a collective acceptanceof the findings across

professionaldisciplines.Two recentlypublishedfindingspromptfurtherargument

relatingto the explorationof evidence-based

interventionsin the treatmentof ADHD.

El-Zein et al. (2005) report in a small study that a 3-month continueduse of

methylphenidateinduceda significantincreasein chromosomalaberrations.E|-Zein and

colleaguesnote a well represented

examinationof stimulantuse-cytogenetic
effect

studiesin animals. However,they reportan absenceof studiesexaminingstimulantuse-

cytogeneticeffects in humans. Theseresearchers

report all chromatid-typeaberrations

are clear breaksin the chromatifl. Further,thesebreaksor gapsare found that indicate

deletionswithin the chromosome.All 12 participantsdisplayedcytogeneticanomalies

after 3 months of methylphenidatetreatment(El-Zein et al., 2005).

t20
 A probabilityof mutagenicor carcinogeniceffectsin humansmay be considered

by many as unacceptable
stimulantmedicationside-effects.Althoughthis studyincludes

only 12 child subjects,futurereplicationstudieswith largersamplesizesare indicatedto

examinethe safeutility of this otherwiseacceptedand effective short-termintervention

for ADHD. Futurefindingsmay impactthe utility of the NIMH MTA Cooperative

Group findings.

Neurofeedbackis often dismissedas an investigationalor experimental

intervention. Neurofeedbackis not includedas part of the multimodal NIMH study on

ADHD (MTA CooperativeGroup, 1999). However,a replicationstudyreveals

encouragingfindingsin a studycomparingthe effectiveness

of neurofeedback
versus

stimulanttherapiesin reducingsymptomsassociated
with ADHD. The studyreportsno

significantdifferencebetweenneurofeedback
and stimulanttherapiesin reducing

ADHD-related symptoms(Rossiter& La Vaque, 2004). The findings of the El-Zein et

al. (2005)and Rossiterand La Vaque(2004)siudiesmay somedayalterthe accepted

courseof treatmentfor ADHD.

Closing

Attentionis drawnto the necessityfor ongoingresearchacrossvariousdisciplines

in the treatmenton ADHD. The methodologyand datainterpretationdebaterelatingto

the NIMH MTA CooperativeGroup study,plus the notedrecentstudieson

methylphenidate
and neurofeedback,
underscore
the needof ongoingresearchin first-line

interventionsfor ADHD, Additional researchrelevantto behavioralstrategiesis also

warranted.This study'sfindingsareoptimistic. Behavioralparenttrainingstrategies

shouldto be emphasizedas part of a useful short-termtreatmentapproachto ADHD,

121
regardless
of setting. However,replicationof this studyin additionalcommunitysettings

is neededto endorseBarkley's (1991c)DefiantChildrenmanualizedbehavioralparent

trainingprogramas a sociallyvalid treatmentfor ADHD.

122
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t64
APPENDICES

165
 AppendixA

ADHD Brochure

r66
 j't 2 lt z
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168
AppendixB

ADHD Flyer

t69
 ATTENTION PARENTS
Is your child between2 - 12 years old and is diagnosedwith
ADHD by his or her doctor?

Would you be interestedin learning a style of parenting that

may:
o Reducestressin the role of being a parent with a child
diagnosedwith ADHD
o Improve parent-child interactions
o Improve interactions with your spouseor significant
other

Would you be interestedin and willing to be a participant in a

doctoral dissertation research project for Parents with a child
diagnosedwith ADHD?

If yes,would you be willing to completethe necessaryforms

and attend 9 group sessionson a weekly basisand a final
sessionat a L-month follow-up point?

Costof the Group ProgrAMZFREE

If you answere
aYeS to all of the abovequestions,please
contactTroy L. Schiedenhelm,MA, LPC, NCC, NBCCH

639-9973
Thank you. I look forward to meetingand working with you.
Your participationin this researchprojectis entirely voluntary
and you may quit at any time, without any consequences.
adhd parentinggroup flyer.doc

ll0
 AppendixC

ParentStressIndex (PSI) ScreeningInstrument

111
Figure l. Sampleitemsfrom the ParentingStressIndex

2. Mychild is so activethat it exhaustsme. SAANSDSD

29. Being a parentis harderthan I thoughtit would be. SAANSDSD

47. My child turnedout to be more of a problemthan I had expected.SA A NS D SD

70. I feel trappedby my responsibilities

as a parent. SAANSDSD

79. I often feel guilty aboutthe way I feel towardmy child. SAANSDSD

Note: "Reproducedby specialpermissionfrom the Publisher,PsychologicalAssessment

Resources,Inc., 16204North FloridaAvenue,Lutz, Florida33549,from the Parenting
StressIndex by RichardR. Abidin, Ed.D.,Copyright1995by PAR, INC. Further
reproductionis prohibitedwithout permissionof PAR, INC."

n2
 HM
Pc!,ohobgiosl
Annsmuonl
T"3YP
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O€rnbff 19.2004

Tryy Lanco Schicdcnhchl

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Salirbury,Notth ftraliss 28l'14

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ln 1esponxr:to yCIlr rroirs r€qu65qpiruis$ott iB l*ctk g"slcil tB lcu_to instd! ry e five (5)
sarnpfuttcms ftom the Pucming $Se$sIndcx {PST)in thc Aplendix of fctn dmrmd,m $tled
fiu{rlry Par*nlr a{Attanttan frcfreff E$ryt;rffithd4,fiiwrlM Crtlir}s* rf .5}utlttadc
&,eplteattoda!"f,utsell Ea'hlry's frefia$ Chtl*n Nww/ikad Farciut Tlaffiiffig hvgrmrtn a
Cnmnuxtrp ,5?trtrrg, If rdditiuaml coSw st nedtd, tt utll bo rruruy m silttt b FAR ffir
furthcr pcmiirelon-

Thi* Agrwnl is $tbjscr tD thc folknring rustrictiffiar

(1) Tha followiag.radit lfos $dfi bc placcd af tbr bottom oflhr rrmo titlo
rn ximilsr ftant pugc rn eiry ond all mrbrinl usad:

"Ropsduced by ryacinl pemi*sion Afthe Rfiltrhet frSm.blagicrl

. Aaat.*r"tm Sms$srrr hrq l6.t0t bkdhFLdCr &rrrnlr! Lrts,
Florida 3354S,fixm tts pamting $mer fndm by Rinhrrd R-
Abi6i$, Ed.tr., Cspyrlght lP95 ry PA& le" filrtha rproductioo
--tcTorrldbitad withst$gerairs,lou",*f-p,{Rtlaa

tv'! Hms sf rtr ndsdnt sr*y be sold- grvm auray,wurcd fupqposcr

otbsr thatr rbsrs dcscribtd sborfia.

i3) Payrnsrt of a porrnlerlou &p lpiH bc uralvud-

{4) Or$ stlpy uf any of t}rs u}ef€rial reffsduccd wili bo rcn t $e

Ilrhli*s to in{tcekb thst tlm popcr crdit Ur6 hrr bocilrusod,
^!ilddd"&f6.|rna

A rlrrdltl+r uJ-irrnprrglivr, rrrnmrmr,rt xuJqtirlnr rmd urrptlnrilelgd rsra,icr,

n3
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yoorrerccfifittq{l[{$lbq\rtrorhkfiilf,. lwillrah,snsrlbt$arraneduryioyouit*1Ul'
ra*frds,

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StCN'tTljRE Of PRSFESSOXREQIIIKX$r

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r+ uscmd tnrrrgautfitr rt*db sfthnra ffi flErwmmeoded tnthc Stwr&n&p efil@ii*lllr,l
.r*f JoryeMryd*rf f**nq. xrd I xnrnnc full napcmfblllty fs tbc proprr rlrc of rll msrtolc
-'rud por this ASrrrtnie

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A nrr*ii*&n rf lturrr+wd,rrr
{ti|+Eni.irt nfirr{unr rs!{l unAsxrtjrled rff{,hq

114
 AppendixD

Marital SatisfactionInventory- Revised(MSI - R) ScreeningInstrument

175
Figure2. Sampleitemsfrom the Martial SatisfactionInventory- Revised

53. Our relationshiphasbeendisappointingin severalways. TF

113.When we disagree,my partnerhelpsus to find alternatives

acceptable

to both of us. TF

131. My partnerand I rarely argueaboutthe children. TF

140. Our childrendo not show adequaterespectfor their parents. TF

job,
148. Rearingchildrenis a nerve-wracking TF

Note: Selecteditems from the Marital SatisfactionInventory-Revised(MSI-R)copyright

@ 1991by WesternPsychologicalServices.Reprintedby Troy L. Schiedenhelm for
displaypurposesby permissionof the publisher,WesternPsychologicalServices,12031
Wilshire Boulevard,Los Angeles,California90025,USA. Not to be reprintedin whole
or in part for any additionalpurposewithout expressedwritten permissionof the
publisher.All rightsreserved.

r76
 :-!$*l0M l6:l{ll FF0FLvrrlr &iuill*llw !ltvlttl +?t{ 8tt !il} r-r6l r {gl/[F F-{|l
li/'![/{r{ !{rf{ &l:l &r.q *ft, ?lt* llgtlt$( pstw gtrc$l Sool

blnrmrbsl$, !0S*

I!o'y L|rE8cttid|nl|ettr
f:S Sau*r lf,rrkreUrrt
sr$rbd;Y. t'lc $fi*

DcrtMr, Sttit d;hefnr.

fip*h,finS e* copy:*ghud b* fidc|d fn t'rr{t drn*sttti
llrrJ( ywr naa l.5,n|! rrc tidcy,*rynrdb$
drrrtrulta e*UhAribry U:dr.rdy **M&p'u*

h tspin} &nttffilhtqr dlrs$mhsrr EE'11S,

Wilt|rn }t{i&dlDgfEr.}Se1dr*red|m,imls*
11L ilo nd-l*f a&* *r*i|,*.1 Fr5ryeadatlrnr@, nlr&d flt4s-r), rn prvldur **t *e nryilrd llrr su
;oUaflrlrg 'tqrrilr'd natisa lnih a#cr{n

lri|# it||r t || lr tt t 'rilffir lF*gltt f,fi'Is FfrfE ceftilf ,'* l' n|b|q ;{Eiitfd
rynn-l;xr1 r ll-rror-r. t4rlrcpr-fir-ftSrf fi6rrl ry-t!*F-f trr pH5'' S-tt
pr$-#d *1r. iiifi' il-rr rff r{rrf . ta ri*s ffi r- trr UrA- tc D l! ffi c h rh-
e ii-'|Jrtr w -1611ti Fdrnittral qrrrrrr{En lrrrml |rrpfferr. ll t|ttr trtx

F61rcxs41 61ithfr {u&erl*rqon a.(ktiL bprys.brud co5tfu ot;tu* dlrrddsa 3n-cqdmd^tnl

dk&tbqd.$ro mgr <661gu;itrc nnt pur buaUganf ir&ilnr' l* rnjl n ilFctdh*Smlf ds@ d 8y
otlur onrdb (.ttldtd. d.irtr,trtlc sa s'*id$f,i|$l H|&lyborn*dmd.
*r rrull rr !||tltt silddffi fur lb crytEt!! It lott
t{a qpr*1b Tnrrtr {nl*!ef le {d* lrn*wrt
"-"1s;r"':f iahrr *q "f*;*^q-plrrr!*riap-to r*irrt*&- --

*-rsr|ll@

Str}trrr

lrrst Vflrhtn*11hsgtFd r l**r-rilrjrf.r"!*||alrdr fl$It-ftfit . F q{|f{D6t . HfiFl$*|*tl$

111
 AppendixE

Beck DepressionInventory- II (BDI - II) ScreeningInstrument

178
Figure3. Sampleitemsfrom the Beck DepressionInventory- SecondEdition

5. Guilty Feelings

0 I don't feel particularlyguilty.

I I feel guilty over many thingsI havedoneor shouldhavedone.
2 I feel guilty most of the time.
3 I feel guilty all of the time.

17. Irritability

0 I am no more irritablethanusual.
1 I am more irritablethanusual.
2 I am much more irritablethanusual.
3 I am irritableall the time.

Note: Beck DepressionInventory- SecondEd,ition. Copyright @ 1996by Aaron T.

Beck. Reproducedwith permissionof the publisherHarcourtAssessment, Inc. All rights
reserved.

t79
tuo,brl|' l00l
vhFril ff0i) fr3f-0t{p
Trurl Edhdsnhd*
tyq{y Sgunfifte Surlcrr' xJ,fi
$$ f(plblil$n Asnr
Adbkrr''Nf llt*{
Hs: S$.Eprrrior Jf,rlatl+ry* eootld*ffidr f*g&$
Dcst&. f,qfid,l&nldm:
?an* pu Sr ptr soaupsndnansfifid Qs$tcr ** f'fiX tryrdsgfmnkdr * ryftdrros
It nrr 1d 17frEn 6t d Dryrlrrlilr tirrqpry-.lsalrd&lan @Di-IA fu or fn ycur
dscsltrl ilhnr&t *nidd *T$trlngtsmc qf Afid* Prldf lllryrrdt {tltDlrtt{dr
ChCIdlF.: A Syllsorltlof4lhicr of luuoll BrfiAfr Dd,st Qhll&rr *haur$rt Frrrrr
Ttdrl[8FYott|E b rCiuotdry l5ttieg-.
lryr tuv* !$ SJ.me lo fu wr nf ilir smmirl ftr ttr grqporcr.r rlrd *cvr ff b e;
&llo*r{Ef Tnmr lsd Mldec,&
Fllrr ull thr g*Um"trgc€SFid$sn't*w
xlmffrWuxttolr trllrctrctt *S*eo?rril"gCJteFn,
OoEl1nllhf
G ll${tty*rr,s*T, B$L
As!*!{$ocd ?ifh pcanirrion*ffu guhl{rbtrl*sus{rrt furuffidf ho. *ll rlffi
tfll*.rtd,

TbtsL iat*rl* ineurnrkiair, Ifynr md ddffftnrtr **lust plrrrr sg$t nls

tr

Stun6dyr

W
Cmtncttrprdrtix
bfdnqutn.u

c;-r - -rt.l,Lg' lf fxtl- - tfrr-,:= f=t-t ffi

---DI!-rr-EE--.-.-

180
 Append.ixF

EybergChild BehaviorInventory(ECBI) ScreeningInstrument

181
Figure4. Sampleitemsfrom the EybergChild BehaviorInventory

ll.Argueswithparentaboutrules 123456 7 YesNo

18.Hitsparents 1234567 YesNo

24. Yerballyfightswithfriendsownage | 2 3 4 5 6 7 Yes No

Note: "Reproducedby specialpermissionof the Publisher,PsychologicalAssessment

Resources,Inc., 16204North FloridaAvenue,Lutz, Florida33549,from EybergChild
BehaviorInventoryby SheilaEyberg,Ph.D.,Copyright l974by PAR, Inc. Further
reproductionis prohibitedwithout permissionof PAR, Inc.

182
 Fsyrftoloslcel
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Y:YTY
1c?tl l{, rto€Sr.iVEhir
rura ir.o{ils. TXd9
l,il nlg $dS'J*11

n'lffi
*nt Vl* SpqS: tlrqFi*dffici{,ntt
Ootsbtr 19.?004

Troy Lmce $cftiedslh*trm

5?3SouthM.einShcl
$ali*bury,Hor& Curulinn?S144

Bstr Mr. ftshicd*jplm:

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satrpleltsmtrftsdnth! eybfrg {hild Bshsvtcrrtnrmtory GffiD ln ec Appamdl*ci y.n r
dinsffition tiflcd nrrirdry Pwtrw ufJn*r#in I\ft8 JSplr:ncrftdtrOtiy14rrsf d;6trra.,{
-$r*tancl$e-*afiiwtianrf &w*a{t SwHcy'r&fdrrt CW*:en *t*ntglttsadd_pwwrf ?}afi*ry.
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FAR for furtixr pexrrimion.
-X
hi* Agrsemefitis wbjeccta the frllawing res&isisars:

{t) Thc fnllowillg ordit li$e will beplme* m rhr httml sfrtr ?srxorirlc
nr ainrilgrfrols pugcm nnymd all maml&l ueld;
,'R*Fsdusodhy spssisl
Fffinlisrim afse mlirhef, fglrchol4iost
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Rda{df,?.1549,&om thr E:t6f {Idld Balevimlnrudrry,bygft**t"
ny{* p_h.n.,Csgrright 19?*fu5,Fjr.It, I**- Itrrtu rEindrxdon ir
FnoedbiMwithordp*rrnirsim ofFAR, Irr,*

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otlnrthsn thnssdr$fflb$dsbdve.

t3) Frpnrcntof n pwris*tcn ec rlrfil ba rryrlvad-

(4) On* copyof xny of ths nrnfrrid rryadnmd wi[ be nm to the

Futili*trarb indinarethnt ths Fmptr cfdit linc hts b!€a [l6d"
*'t{A ldlr.tAa! t.tlad*

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"*n,rc*

183,
 TVfO frOplEE *frhls fumis"gis* Jtgllcsd rhstild b6 lt€SM md rmmcd m fit to indisati
tgrEd16il r*i& tlrc ebovcr,id,fiin&}, I will nfirn * futrlf ffi.nffid ooHfb pu SrrXtutu
1r(xur
recortlp"

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ExsruttveAssirtsuf
m theCbsirnrnstd CFtl

AffiFTTN AHI}AGRESS: *C(SHTH} I$DAGTffiTK

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$$fi-{TURE OF ltf(fiFESSCIR RE*UIRED:

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tr: uns sxrdintag tb* $$dlc sf &frffGtcrtr s rwrucudod lutha lhmdme'Jbr S&msftorrd
a*d Psyrllnlogttol lbl$r3ln d I slerms ftU rnrpsrulbilitr fs tbc FqSu rrl ofall uaciclx
usad p.r this Agrcoreof

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ro{rrrhrrr *rrd unprrrlll*led xrnicr

184
 AppendixG

ParticipantDemographicForm

185
Demographic Data

Name Respondent Number

Pleaseindicateyour responseby clearlyplacingan 6'X" next to the desiredresponse

choice. Somequestionsrequirea numericalresponse.Pleaseanswerthesequestionsby
placinga numberin the providedspace.

L Your child's gender: _ Male Female

2. Your child'sage: - Yearsold

3. Your relationshipto your child: _ Mother _ Step-mother

_ Father _ Step-father

4. Marital Status:

. Single(nevermarried)

. Married If married,how long: _ years

Divorced/Separated

. Same-sexPartnership

5. Your Age: _20-30 yearsold

3l-40 yearsold

_ 41-50yearsold

_ 5l-60 yearsold

_ over 61 yearsold

186
6. Ethnic/RacialAffiliation:

White (non-Hispanic) _ African-American

_ Native AmericanIndian _ Hispanic

_Asian/Asian-American _ Middle Eastern

Other

7. Placeof Residence: _ RowanCounty StanleyCounty

_ CabarrusCounty Union County

_ MecklenburgCounty _ Other _

8. Has your child beendiagnosedwith AttentionDeficit HyperactivityDisorder

(ADHD) by a licensedmedicaldoctor(e.g.,family doctor,pediatrician,
psychiatrist)?

_Yes _No

If Yes, what type?

_ PredominantlyInattentiveType

_ PredominantlyHyperactive/Impulsive
Type

_ CombinedType

Not OtherwiseSpecifiedType (NOS)

_ I'm not sure

9. Does your child takemedicationsfor ADHD? _ Yes _ No

If yes,do you observethe desiredresultsfrom the medications?

Yes

_ No (pleasedescribe)

187
10. problemsfor
Doesyour child haveany additionalpsychiatric/psychological
which he or sheis receivingtreatment?

- Yes No Not sure

I 1. Have you everbeendiagnosedwith AttentionDeficit HyperactivityDisorder

(ADHD)?

_Yes _No

If Yes, are you receivingtreatment?_ Yes _ No

If Yes, what type: _ Medications _ Psychotherapy

_ neurofeedback/EEG
biofeedback

' other (pleasespecify)

12. Is your child receivingtreatmentfor a medicalillness? _ Yes _ No

If Yes, for what?:

13. Are you receivingtreatmentfor a medicalillness? _ Yes _ No

If Yes, for what?:

14. Are you beingtreatedfor any psychological,emotional,or chemicaldependency

problems?

Yes No

If Yes,pleasespecify:

188
 AppendixH

Consentto Participatein ResearchForms

189
 Informed Consent to Participate in Research

The purposeof this researchis to determinethe effectivenessof a parentingprogram

designedto addressbehavioralproblemsin children(DefiantChildren:A Clinician's
Manual for Assessment and ParentTrainingby RussellA. Barkley (1991). Specifically,
the program'seffectiveness is beingmeasuredwith a parent,or both parents,who havea
child diagnosedwith AttentionDeficit HyperactivityDisorder(ADHD) by his or her
family physician,pediatrician,or psychiatrist.

If you participatein this research,you will be asked(a) to completea demographics

form, (b) to completeforms before startingand after completingthe program relatingto
parentingstress,maritalsatisfaction, depression,and behavioralproblemsdisplayedby
your child, plus forms relevantfor parentalfeedback,(c) read and sign consentforms for
the researcher to communicatewith the child's diagnosingphysician,and (d) readand
sign consentforms for the researcher to communicatewith your child's teacher,if
necessary during the courseof this program. Finally,beforebeginningthis research,you
will be askedto read and sign this Informed Consentto Participatein Researchform.

Your participationwill take approximately4 months. Specifically,the program is

constructedas 9 consecutiveweekly sessionswith one (1) final sessionas a 1 month
follow up. Eachsessionis approximately90 minuteslong.

Your participationin this researchis strictlyvoluntary. You may refuseto participateat

all, or choseto stopyour participationat any point in the research,without fear of penalty
or negativeconsequences of any kind.

The information/datayou provide for this researchwill be treatedconfidentially, and all

raw data will be kept in a securefile by the researcher.Your name is requestedfor
coordinationwith being assigneda Respondent Numberonly, and is usedto increasethe
accuracyof datacollectionprocedures.Resultsof the researchwill be reportedas
aggregatesummarydataonly, and no individuallyidentifiableinformationwill be
presented.

You alsohavethe right to review the resultsof the researchif you wish to do so. A copy
of the resultsmay be obtainedb'ycontactingthb researcher at the addressbelow:

Troy L. Schiedenhelm
523 SouthMain Street
Salisbury,North Carolina28144

Thereexistspotentialpersonalbenefitsfrom your participationin this study,includingan

improvedparent-childrelationship,an increasein your child's compliancewith your
requests,and an improvedexperienceof being a parentwith a child diagnosedwith
ADHD. Additionally,your participationmay contributeto an improvedunderstanding of
treatingADHD on an outpatientbasis,not affiliatedwith a university-basedhospital.

190
I, , haveread and understandthe foregoing
informationexplainingthe purposeof this researchand my rights and responsibilities
as a
subject.My signaturebelow designates my consentto participatein this research,
accordingto the termsand conditionsoutlinedabove.

Signature Date

Print Name

191
 Troy L. Schiedenhelm,MA

ProfessionalDisclosureStatement-Informed
Consentto Participatein ResearchForm

Mr. Schiedenhelmearneda MaSterof Arts degreein Clinical Psychologyin 1996from

West ChesterUniversityin West Chester,Pennsylvania.Mr. Schiedenhelm possesses
degreecandidacyin the CounselingPsychologyEd.D. doctoralprogramat Argosy
University(formerlyThe Universityof Sarasota)in Sarasota,
Florida.

Mr. Schiedenhelm holdsLicensedProfessional Counselor(LPC) credentialsin North

Carolina(NC-LPC #4028:03101/02) and in SouthCarolina(SC-LPC#2891:09/19/98-
Inactive). He alsoholds nationalboardcertificationas a NationalCertifiedCounselor
(NCC #61153:09/30/99),and as a NationalBoard CertifiedClinical Hypnotherapist
(NBCCH #2654: 06/30/00).

Mr. Schiedenhelm conductedhis Masterof Arts Clinical PsychologyInternshipat the

Universityof Pennsylvania Children'sHospitalof PhiladelphiaBio-BehavioralUnit.
The internshipinvolvedconductingresearch-based behavioralinterventionswith children
and adolescentsdemonstratingsevereor aberrantbehaviorsfrom a factor analytic
perspective.He hasmore than 5 yearsof post-Jicensure clinical experiencein the private
practice,hospital,and communitymentalhealthcenterarenas.He possesses direct
clinical experienceworking with the child, adolescent,
adult,and geriatricpopulations.
While working at PiedmontBehavioralHealthcareServicesin Salisbury,North Carolina,
he servedas an Adult Individual and Group Mental Health Therapist-Ill, which follows
his clinical experiencesas a Child & AdolescentTherapist(Family Preservation
Specialist,AdolescentDrug & Alcohol/DualDiagnosisGroup Therapist,and an Interim
Court Psychologypositionin a collaborationbetweenPiedmontBehavioralHealthcare
andRowanCountyDepartof JuvenileJustice).Mr. Schiedenhelm currentlyfocuseshis
clinical attentionon children,adolescent,
and adultpsychopathology.

Mr. Schiedenhelm receivedexperientialtrainingfor I full yearin Group

Psychodramer/Group Psychotherapyfrom Ray Naar, PhD, ABPP, AssociateProfessorat
the Universityof PittsburghSchoolof Medicine.

Mr. Schiedenhelm's preferredclinical-theoretical

perspectiveis a behavioral-humanistic
approachin the context of solution-focusedand family systemstherapies,but also utilizes
Adlerian/psychodynamic, variouscognitive/cognitive-behavioral/behavioral (classical
and/oroperantconditioning,and sociallearningapplications), clinical hypnotherapeutic,
eye movementdesensitization reprocessing (EMDR), play therapy,plus other
experiential/process-based techniquesas clinically appropriateand necessarywith client
and/orclient's legal guardianapproval.

Currently,Mr. Schiedenhelm is the principleinvestigatorin his doctoraldissertation

study:"Training Parentsof AttentionDeficit HyperactivityDisorderedChildren:A
SystematicReplicationof RussellBarley'sDefiantChildrenManualizedParentTraining
Programin a CommunitySetting."

192
Feesfor Services

All feesassociatedwith the participationof Mr. Schiedenhelm's

doctoraldissertation
researchproject are FREE-OF-CHARGE.

No feesor co-paymentswill be collected.Your insurancecompanywill not be billed for

your participationin the study.

Mr. Schiedenhelm you in any way, for your

will not be payingyou, or compensating
participationin the program.

Length of the Program

The programunderstudyconsistsof 9 consecutiveweekly groupsessions, with a final

sessionat a I -monthfollow-up point of the program. The program'sdesigninvolvesa
step-wisedevelopmentand progressionof skills to be utilizedto addressbehavioral
problemsexhibitedby your child diagnosedwith ADHD. Therefore,it is importantfor
the parentto be presentat eachgroup sessionin order to obtain the maximum benefit
from the program.

Confidentiality

Mr. Schiedenhelm takesall possiblenecessaryprecautionsto maintainstrict

confidentialityof a parent'srecordsand/orwhat is statedby the parentwhile presentat
the facility. Under certaincircumstancesor otherwiseauthorizedor permittedto be
disclosedby statute,informationmay be required"/legallymandatedto be disclosed
without the parent'sapproval.

Mr. Schiedenhelm will maintainconfidentialitywith the following exceptions:

-You give Mr. Schiedenhelm writtenpermissionto communicate
(written or verbal) with someoneelseor an agency
-Mr. Schiedenhelm determinesyou are a dangerto yourselfor others
-Mr. Schiedenhelm is orderedby the courtto discloseinformation
-Reportsof or suspectedactsof child/minor/dependentadult abuseor
elderlyabuse
-Discussionof ybur case/therapy/treatment processduring clinical
supervisionon a "as needto know" basisonly
-In the professional judgmentof Mr. Schiedenhelm it is deemednecessary
and appropriate,in accordancewith reasonableand appropriate
standards of professionalpracticeand the AmericanCounseling
Association'sCodeof Ethicsand Standardsof Practice.

193
Mr. Schiedenhelm retainsall informationprovidedby you within a locked,secure
environment.Providingyour nameon any materialsduringthe studywill be utilizedto
coordinatethe dataonly. The parent'snameis assignedto a "RespondentNumber" and
will be utilized in that manner. Any informationsubmittedto Argosy Universityor in the
dissertationwill be as aggregatedataand no nameswill be disclosed.

Confidentiality in Group Therapy Sessions

Confidentialityis stressed to all parentsof "What is saidin group,staysin group." It

cannotbe guaranteed that all parentswill adhereto this perspective.Informationwill not
be releasedby Mr. Schiedenhelm to any spouseor family member,includingminors,
unlessgivenprior writtenpermission.

Complaintsfor professionalmisconductaresubmittedto:

North CarolinaBoard for LicensedProfessional

Counselors
P . O .B o x 1 3 6 9
Garner,NC21529

ArgosyUniversity
Human SubiectsReview Committee/InstitutionReview Board
5250 nth Sireet
Sarasota,FL 34235

Methods of Contact: During and after my participationin the study, I may be contacted
in the followingway(s):

This section MUST be completed,initial all that apply:

Telephone: Home _ yes _ no, Work _ yes _ no

Other_yes _no
PlectseSpecrfy:

TelephoneNumberswhereI may be reached:

LeaveMessageon Telephone:_ yes _ no

If Yes, initial all that apply: _ home _ work _ other

Mail: - yes - no. If Yes,initial all that apply - home - work - other

Address:

t94
Do you wish to receivea mailedcopy of a summaryof the final findingsfrom the study?

Yes No

No personis permitted on thesepremisesat'any time carrying weaponsof any type

or to be under the influenceof alcoholor drugs,exceptfor the taking of prescription
medicationsas prescribedby a physician.

If a seriousemergencyexists(suicidal/homicidal thoughts,intentions,or attempts),call

911 or go directlyto the nearesthospitalemergencyroom.

By signing this form, I understand that participation in the parent training program
is entirely voluntary and that I may terminate my participation in the study at any
time, without consequencesof any type. I also understand that no guarantee is
provided in terms of my successfrom my participation in the study, and that
participation in the study may result in changesin how I perceive others or myself.
Plus I understand that aspectsmay change in my life, which I did not anticipate.

By signing this form, I agree I have reviewed and fully understand this Professional
Disclosure Statement-Informed Consent to Participate in Research Form (pp. 1-4).
Any questions I may have had in regards to this form have been answered to my
satisfaction. I voluntarily agree to participate in the dissertation research project as
outlined in this form from Troy L. Schiedenhelm,MA, LPC, NCC, NBCCH.

Participant's Signature (initials) Date

Troy L. Schiedenhelm,
MA, LPC, NCC, NBCCH Date

195
 AppendixI

Authorizationto Consentto ReleaseInformation Form

t96
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Lyerly Cona*dlng tt*rvit*6 LLC
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198
 AppendixJ

HumanSubiectReview Committee/Institutional
Review Board Forms

199
200
201
202
 AppendixK

ParticipantFollow-upLetter

203
 Troy L. Schiedenhelm,
MA, LPC, NCC, NBCCH
523 SouthMain Street
S a l i s b u r yN, C 2 8 1 4 4
(704) 639-9913 fax (704) 639-0869

Date: August4,2005

To: Participantsof the ParentTrainingProgram

RE: RequestedFollow-up Letter

First,I wish to expressmy gratitudeto you for participatingin the behavioralparent

trainingprogramstudyearlierthis year.

This letter is to give you feedbapkregardingthe findings from the study. This follow-up
outcomesummaryletteris sentto you by your request.

The title of my doctoraldissertationis, "Training Parentsof Attention Deficit

HyperactivityDisordered Children: A SystematicReplicationof RussellBarkley's
Defiant Children ManualizedParent Training Program in a CommunitySetting."

Four instrumentswere usedfor the pretest-posttest

dataanalysis.Theseinclude:
- The ParentingStressIndex (PSD(Abidin, 1995)
- The Marital SatisfactionInventory- Revised(MSI-R) (Snyder,1991)
- The Beck DepressionInventory- II (BDI-II) (Beck,Steer,& Brown, 1996)
- The EybergChild BehaviorInventory(ECBI) (Eyberg& Pincus,1999)

Demographicdatawere alsocollectedto describethe participantgroup. All namesor

personallyidentifyingfeaturesremainedconfidential.All dataanalyseswere calculated
usingthe SPSS@statisticalsoftwareprogram.
,
Statisticallysignificantimprovementswerefound on the Child Domain and the Total
Stressscalesof the PSL Non-significantimprovementswere found on the Parent
Domain and the Life Stressscalesof the PSL

No statisticallysignificantimprovementswerefound on the MSI-R. However,non-

significantimprovementswere seenon eight of the I 1 scaleswithin the MSI-R.

Non-significantimprovementsin the maleparticipantdepressive experienceswere found

on the BDI-II. Femaleparticipantreportsreveala non-significantworseningof their
depressivemood experienceat the end of the program.

The intensityor severityof child behaviorshoweda statisticallevel of improvement.

However,the numberof behaviorproblemareasdecreased only slightly on the ECBI.

204
In summary...

Regardingthe ProgramParticipants

The findingsshow that the participantsexperienceda degreeof stressreduction

after completing the program. Marital or significantother relationshipswere not
significantlyaffected,but many dynamicswithin their relationshipsdid show a degreeof
improvement.Male participantdepression did show a degreeof improvement,but the
femaleparticipants'depressive mood did not improve.

Regardingthe Behaviorsof the Participants'ChildrenDiagnosedwith ADHD

The children'sbehaviorsdid improve. The severityof the problembehaviorsdid

decreasesignificantly.The numberof problemareasdecreased slightly.

Thus,the behavioralmanagement strategies

taughtto and usedby the participants
in this studydid havea positiveeffecton behaviorproblemsseenin the participants'
childrendiagnosedwith ADHD.

If you haveany questionsor concernsregardingthis follow-up letter,pleasefeel free to

contactme at your discretion.

Again, I thank you for your participationin my doctoraldissertationstudy.

BestRegards,

Troy L. Schiedenhelm

205