Child Psychiatry Hum Dev (2015) 46:118–129
DOI 10.1007/s10578-014-0458-2
ORIGINAL ARTICLE
The Association Between Parenting Stress, Parenting Self-
Efficacy, and the Clinical Significance of Child ADHD Symptom
Change Following Behavior Therapy
Corey L. Heath • David F. Curtis • Weihua Fan •
Robert McPherson
Published online: 26 March 2014
Ó Springer Science+Business Media New York 2014
Abstract We examined parenting stress (PST) and self-
efficacy (PSE) following participation in behavioral parent
training (BPT) with regard to child treatment response.
Forty-three families of children diagnosed with ADHD
participated in a modified BPT program. Change in PST
and PSE was evaluated using a single group, within-sub-
jects design. Parenting outcomes based on child treatment
response were evaluated based upon (1) magnitude and (2)
clinical significance of change in child symptom impair-
ment. Parents reported significant improvements in stress
and self-efficacy. Parents of children who demonstrated
clinically significant reduction in ADHD symptoms
reported lower stress and higher self-efficacy than those of
children with continued impairments. Magnitude of child
impairment was not associated with parent outcomes.
Clinical implications for these results include extending
treatment duration to provide more time for symptom
amelioration and parent-focused objectives to improve
coping and stress management.
Keywords Behavioral parent training (BPT)
Family
skills training
Parent outcomes
Parenting stress

Parenting self-efficacy
C. L. Heath
W. Fan
R. McPherson
Department of Educational Psychology, University of Houston,
Houston, TX, USA
C. L. Heath (&)
D. F. Curtis
Department of Pediatrics, Psychology Section, Baylor College of
Medicine and Texas Children’s Hospital, 6701 Fannin Street,
CCC 1630.31, Houston, TX 77030-2399, USA
e-mail: clheath@texaschildrens.org
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Introduction
Attention-Deficit/Hyperactivity is often considered in
terms of implications for child behavior. While childhood
impairments of hyperactivity, impulsivity, and inattention
often contribute to difficulties in a child’s social and aca-
demic functioning [1, 2], behavioral difficulties may also
present challenges for others within the family system.
Children with ADHD have been found to exhibit a pattern
of behavior including greater noncompliance, increased
demands on parents’ time, and decreased adaptability to
change, which has been found to be stressful for their
parents, and which is associated with more negative par-
enting practices [3–5]. Parents may be faced with more
challenging caregiving demands as they try to effectively
manage their child’s difficult behaviors, which may present
implications for parents’ satisfaction and well-being related
to their caregiving role [6]. While behavioral parent
training (BPT) has demonstrated strong outcomes for
improving ADHD-related child behaviors [7], less is
known about parent outcomes that result from their par-
ticipation in their child’s intervention. Thus, further con-
sideration of parents’ outcomes following BPT may
provide meaningful implications for clinical practice with
these families. Given parents’ primary role in implement-
ing strategies to promote behavior change in their children,
knowledge of the relationships between child and parent
response to behavioral intervention may help to inform
intervention.
The primary goals for BPT are (1) to educate parents
about the nature and function of disruptive child behaviors,
(2) to improve parent effectiveness for preventing, man-
aging and correcting problem behaviors, (3) to improve
child behavioral compliance, and (4) increase family har-
mony and wellbeing [8, 9]. Clinical techniques employed
Child Psychiatry Hum Dev (2015) 46:118–129
within BPT typically consist of contingency management
strategies that improve parents’ use of reinforcement,
punishment, and problem-solving strategies to manage
child behaviors [9–11].
While BPT focuses on improving child behavior, par-
ents are considered the ‘agents of change’ and are tasked
with implementing strategies to facilitate child behavior
change. Thus, parents are the direct focus of BPT inter-
vention techniques and child behavior changes are thereby
mediated by parents’ implementation of contingency
management strategies. Consequently, BPT may be carried
out either exclusively with parents or within a family ses-
sion with child participation often relegated to facilitating
parents’ rehearsal of new strategies [12, 13]. Studies of
BPT have consistently demonstrated positive and clinically
meaningful child behavioral changes, with treatment effect
sizes reported as medium to large [7, 11, 14]. Specifically,
BPT has been associated with significant amelioration of
children’s inattentive, hyperactive/impulsive, and disrup-
tive behaviors [11, 12, 15].
Parenting of Children Diagnosed with ADHD
Children with ADHD exhibit a pattern of hyperactivity,
inattention, and impulsivity that often presents challenges
to their parents, who must assume a more active role in
managing child behavior given these deficits in self-regu-
lation. Parenting experiences may differ significantly for
parents who have a child with ADHD compared to those of
children without ADHD. Research has indicated various
links between child behavior problems and parenting
practices. Parenting practices characterized by warmth,
responsiveness, and positive regard have been associated
with more favorable outcomes for children with ADHD,
including less severe ADHD symptoms as well as greater
social acceptance and social skills [16, 17]. However,
families of children with ADHD have been found to exhibit
less warmth and engagement when engaged in problem
solving and greater use of an authoritarian parenting style
[4, 18, 19]. Further, difficulties coping with children’s
disruptive behaviors have also been linked to parent chal-
lenges with treatment implementation and adherence when
participating in child-focused interventions [20]. Stress and
perceived self-efficacy related to one’s role as a parent are
two dimensions of caregiver well-being that have been
negatively associated with having a child with ADHD [18,
21, 22]. Additionally, low parenting self-efficacy has been
linked to less favorable child outcomes for families par-
ticipating in intervention for ADHD [23]. Thus, consider-
ation of parent coping and confidence in managing child
behaviors is important not only with regard to parent well-
being, but also as it relates to parents’ ability to participate
successfully in an intervention for their child.
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Parents of children with ADHD report higher levels of
parenting stress, or distress associated with the parenting
role, than parents of children without this disorder [18, 19,
21, 24]. Parenting stress has been linked to higher levels of
child behavior problems [25]. Symptoms of inattention
have also been positively associated with parental distress
above and beyond associated disruptive behaviors [21].
Deficits in child self-regulation, including emotional
lability, difficulties with executive functioning, and
aggressive behavior, have also been found to mediate the
relationship between child hyperactive behaviors and par-
ent distress [26]. Therefore, the relationship between child
behavior problems and parenting stress is believed to be
bidirectional [27].
Parenting self-efficacy depicts parents’ beliefs about
their confidence and competence in carrying out parenting
tasks. Parents of children with ADHD report significantly
lower parenting self-efficacy than do parents of children
who do not have ADHD [22]. Of note, parents with higher
parenting self-efficacy have been shown to use more
effective parenting practices compared to those with lower
parenting self-efficacy [28]. Further, parents who endorse
higher self-efficacy have been shown to report more posi-
tive beliefs about behavioral interventions, and thus dem-
onstrate more favorable treatment outcomes [29]. Thus,
parents who report high self-efficacy may have stronger
skills or greater confidence for providing the structure and
support needed for children exhibiting ADHD symptoms.
It is therefore important to consider the relationship
between parent and child outcomes as they relate to child-
focused treatment for ADHD. Parenting stress and self-
efficacy may be particularly salient among families of
children with ADHD, as they may be associated with
parents’ ability to manage difficult child behaviors and
achieve optimum benefits from behavioral intervention
[30].
There are many studies that evaluate the efficacy of BPT
for improving child behavioral outcomes, yet relatively
fewer studies have examined the relationship between child
and parent outcomes. Though less studied, understanding
parent experiences in BPT is compelling to determine
whether treatment results are exclusive to the identified
child or if they also extend benefit to caregivers who par-
ticipate in the intervention. Studies have demonstrated
positive changes in parenting stress and self-esteem for
caregivers participating in BPT [31–34]. For instance,
participation in the Triple-P Enhanced program has evi-
denced increased parenting self-efficacy following treat-
ment as well as use of more adaptive parenting practices;
however, this program includes a module specifically
promoting personal coping strategies for parents [35].
Gerdes et al. [33] recently examined changes in parental
functioning following participation in BPT and found that
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parent participation was associated with both statistically
significant and clinically meaningful improvements in
parenting behavior. Further, mothers reported significant
improvements in their own parenting stress, though statis-
tically significant improvements were not reported for
parenting efficacy. These findings indicate beneficial
changes in parent functioning through participating in
child-focused treatment. However, the study did not
examine the relationship between child outcomes and
parenting outcomes. The current study seeks to build on the
work of Gerdes et al. [33] through an examination of the
relationships between child and parent outcomes following
BPT.
As parents are the agents of change in BPT interven-
tions, it is worthwhile to examine factors that may influ-
ence their ability to carry out this intervention to promote
positive behavior changes for their children. To this end,
the current study examines parents’ outcomes of stress
(PST) and self-efficacy (PSE) following their participation
in a manualized BPT intervention for their child’s ADHD.
We hypothesized that parents would report improvements
in these domains of functioning following completion of
BPT, defined as decreased parenting stress and increased
parenting self-efficacy. A unique contribution of this study
was the examination of the associations between child
treatment response and parenting outcomes to determine
whether child outcomes were differentially associated with
parent outcomes. Child treatment responses were evaluated
in two ways. The first considered the magnitude, or degree
of symptom change in response to treatment. We hypoth-
esized that parents whose children displayed a greater
magnitude of ADHD symptom reduction would report
greater parenting self-efficacy. We predicted that these
parents would also report less parenting stress compared to
parents of children displaying a smaller magnitude of
symptom change. Secondly, child treatment responses were
evaluated based on the quality or clinical significance of
child treatment responses. Clinical significance was deter-
mined by cutoff scores on standardized symptom rating
scales. We hypothesized that parents of children whose
ADHD symptoms were reduced to the ‘‘normal range’’
(defined as ‘‘within normal limits’’ on norm-based rating
scales) would report greater parenting self-efficacy and less
parenting stress than parents of children with persistent
impairment.
Methods
Participants
This study took place within an outpatient psychology
service in a pediatric hospital setting and was granted IRB
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Child Psychiatry Hum Dev (2015) 46:118–129
approval from the affiliated educational institutions. Par-
ticipants consisted of 43 primary caregivers of children
ages 7–12 years who were diagnosed with ADHD-Com-
bined Type. Forty-seven families were originally con-
sented; however, 4 families dropped out during their
treatment, reflecting a 9 % attrition rate. All participating
families were initially referred to the Disruptive Behavior
Disorders Treatment Program for ADHD intervention.
Diagnostic procedures were conducted by a licensed child
psychologist, and determinations of ADHD-C were estab-
lished by clinical consensus derived from data collected
through clinical interviews, detailed reviews of develop-
mental and medical histories, and parent and teacher rat-
ings on broad and narrow-band behavioral rating scales,
including the Behavior Assessment System for Children—
Second Edition (BASC-2) and the Disruptive Behavior
Rating Scale [36, 37]. Study participation was not adver-
tised to the public and was only offered to those who were
referred for behavioral treatment for ADHD within the
outpatient hospital clinic setting. Therefore, participants in
this investigation reflect a true clinical sample. Female
caregivers were selected for the primary analyses for two
reasons. First, they were the majority of participants and
they participated more regularly in BPT sessions than male
caregivers. The research literature also indicates that
mothers are most often the primary participants in BPT and
that they typically spend more time than fathers in direct
caregiving roles [38].
Eligibility criteria included evidence of impaired atten-
tion and hyperactivity/impulsivity as indicated by T-scores
of 65 or greater on the BASC-2 [36]. Children with co-
morbid symptoms were included as long as these concerns
were less severe than their ADHD symptoms, as indicated
by comparably lower ratings on the BASC-2. Caregivers
were required to have legal guardianship of the child and
have no current involvement in legal, custody, or child
protective services at the time of their enrollment. Families
of children receiving pharmacological intervention were
also included since ADHD-related impairment served as
the primary eligibility criterion, and thus eligible children
continued to demonstrate significant impairment even with
medication use. A large majority of participants (95 %)
were parents; thus, future references will be simplified,
collectively referring to participants as ‘‘parents’’.
Exclusion criteria were also established for this study.
Families were excluded if the child presented another
behavioral health diagnosis that required intervention pri-
ority, such as an anxiety disorder, mood disorder, or trauma
related condition. Children were also excluded if present-
ing with diminished cognitive abilities including borderline
intelligence, intellectual disability, or receptive language
disorders. Finally, those in need of immediate family or
individual stabilization were excluded, including those
Child Psychiatry Hum Dev (2015) 46:118–129 121

Table 1 Caregiver descriptives (N = 43) Table 2 Child descriptives (N = 43)

Caregiver characteristics n % Child characteristics n %

Caregiver role Child gender

Biological parent 35 81.39 Male 34 79.07
Adoptive parent 6 13.95 Female 9 20.93
Custodial grandparent 1 2.32 Child age
Not reported 1 2.32 7 years 17 39.53
Marital status 8 years 14 32.55
Married 36 83.72 9 years 9 20.93
Divorced/separated 2 4.65 10 years 2 4.65
Never married 4 9.30 12 years 1 2.32
Other 1 2.32 Current medications
Caregiver ethnicity None 11 25.58
Asian 2 4.65 Stimulant 20 46.51
Black/African American 7 16.28 Atypical ADHD medications 4 9.30
Caucasian 19 44.18 Stimulant ? other medications 5 11.63
Latino/hispanic 10 23.25 Other 3 6.97
Biracial 5 11.63 Current educational placement
Caregiver age Regular education 34 79.07
25–35 16 37.21 Mainstream classroom with resource support 8 18.60
36–45 21 48.83 Mostly separate special education classes 1 2.32
46–55 4 9.30 IEP/504 accommodations
Not reported 2 4.65 Yes 12 27.91
Highest education completed No 27 62.79
High school diploma or less 9 20.93 Not reported 4 9.30
Specialized trade/technical degree 8 18.60 Retention
Undergraduate degree 16 37.21 History of grade retention 2 4.65
Advanced degree 10 23.25 Never retained 41 95.34
Annual household income Type of previous mental health treatment
Less than $40 K 6 13.95 Psychotherapy 4 9.29
$41 K–$80 K 9 20.92 Diagnostic evaluation 4 9.30
Over $80 K 24 55.81 Psychiatric medication 5 11.63
Not reported 4 9.30 Other 2 4.65
Caregiver mental health history Multiple services received 6 13.95
Current or past mental health diagnosis 10 23.25 No services 21 48.84
No mental health diagnosis 31 72.09 Not reported 1 2.32
Not reported 2 4.65
Number of children in family
1 child 10 23.25 The majority of parents were between 36 and 45 years old
2 children 23 53.49 (49 %). Most self-identified as non-white (57 %) distrib-
3 children 8 18.60 uted across 4 racial categories, but the most prominent
Not reported 2 4.65 single group of parents was white (43 %). Families pre-
dominantly included multiple children, with 74 % report-
with a high level of risk to harm themselves or others as ing at least 2 or more children living within the home.
assessed by reported history of self-harm or violent Parents were also diverse with regard to educational
behavior, current suicidal or homicidal ideation, current or attainment with 21 % receiving a high school diploma or
recent substance abuse, or evidence of extreme ratings on less, 19 % receiving specialized trade-related training, and
the Aggression subscale of the BASC-2. 60 % completing college or an advanced degree. Parents
Participants represented a relatively diverse background also reported generally high annual incomes with 56 %
with regard to age, ethnicity, and family size. There was a earning over $80,000 per year. Thus this clinical sample was
broad range in caregiver ages, ranging from 26 to over 65. diverse, but represented a relatively high socioeconomic

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status. Finally, nearly one quarter of parents endorsed
having their own formally diagnosed mental health con-
cerns. Detailed information regarding participant charac-
teristics is provided in Tables 1 and 2.
Measures
Background Information Questionnaire
This demographic form is a one-page questionnaire
(developed specifically for use within the Family STARS
program) completed by parents to provide information
about their child’s family context. Information was also
gathered related to the child’s school experiences and
treatment history such as medication use, prior participa-
tion in psychotherapy, etc.
Parenting Stress Index-Short Form
The Parenting Stress Index-Short Form (PSI-SF) [38] was
used to assess parents’ level of stress associated with caring
for their child, including items to assess lack of social
support, depression, and feelings of incompetence in the
parenting role. The scale includes 36 items and requires
5–10 min to complete. The PSI-SF is comprised of three
subscales: Parenting Distress, Difficult Child, and Parent–
Child Dysfunctional Interaction. A Defensive Responding
scale is also included, which measures the extent to which
a parent may be underreporting or denying problems [39].
There is also a Total Stress score, which provides a global
marker of parent coping. For the purpose of this study,
parents’ full scale Total Stress score was used in analyses.
The items in the PSI-SF are 5-point Likert-type rating
scales, where high scores represent high levels of parenting
stress. Scores between 15 and 85 are considered to be
within the ‘‘normal’’ range for stress. Scores of between 85
and 89 represent a high level of stress and scores greater
than or equal to 90 indicate clinically significant or severe
parenting stress [39]. Internal consistencies for the PSI-SF
have been reported as follows: Parent Distress (a = .87),
Parent–Child Dysfunctional Interaction (a = .80), Difficult
Child (a = .85), and Total Stress (a = .91) [39]. The PSI-
SF Total Stress index has been found to have test–retest
reliability of r = .84 [39]. Items on the PSI-SF were
derived using factor analysis of the long form of the Par-
enting Stress Index. Overall the PSI-SF displays adequate
concurrent validity with the long-form Parenting Stress
Index (r = .95) [39].
Self-Efficacy for Parenting Tasks Index
The Self-Efficacy for Parenting Tasks Index (SEPTI) [40]
was used to measure parents’ self-efficacy beliefs with
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Child Psychiatry Hum Dev (2015) 46:118–129
regard to parenting tasks across the domains of nurturance,
health, discipline, achievement, and recreation. The SEPTI
consists of 36 items and requires 5–10 min to complete.
This measure requires parents to rate their perceived
competence on a 6-point Likert-type rating scale. Scores on
this scale may range from 36 to 216, with higher scores
representing higher parenting self-efficacy. Cronbach’s
alpha levels for the domains have been reported as follows:
Recreation (a = .82), Achievement (a = .74), Discipline
(a = .86) Nurturance (a = .77), and Health (a = .73) [40].
Cronbach’s alpha for the full scale, which was used in this
study, has been reported as a = .91 [40]. Though there
have been few studies evaluating the validity of this scale,
it has displayed moderate concurrent validity with the
Parenting Sense of Competence Scale [41].
Behavior Assessment System for Children: Second Edition
The BASC-2, [36] was used to evaluate child behavioral
symptoms. The BASC-2 is intended to assess severity of
child behavior across a number of domains in relation to
same age peers. The Parent Report Scale was used as a
measure of child symptom severity in this study. While
there is evidence to suggest that parent and teacher ratings
may differ, ratings collected from these informants in the
current sample did not differ significantly [42–44]. The
Attention Problems and Hyperactivity scales were used in
the primary analyses, as these domains represent core
symptoms of ADHD. The Attention Problems scale of the
BASC-2 measures the degree to which parents believe the
child pays attention, listens to directions, and displays on-
task behavior. The Hyperactivity scale assesses a parent’s
perception of the child’s activity level and ability to self-
regulate and control impulses. BASC-2 ratings of Attention
Problems and Hyperactive/Impulsive symptoms were
averaged to create a composite ADHD symptom index for
measuring both baseline and post-treatment symptom
severity within a single variable. Internal consistencies for
the PRS range from .80 to .95 [36]. Cronbach’s alpha
coefficients for the two subscales utilized in this study have
been reported as high for Attention Problems (a = .89) and
high for Hyperactivity (a = .86). Test–retest reliability for
the PRS ranges from .65 to .92. Subscales on the BASC-2
PRS have been found to correlate highly with the original
BASC (r = .76–.96) [36].
Procedures
After receiving a comprehensive diagnostic evaluation by a
licensed psychologist, families participated in a pre-treat-
ment consultation prior to their participation in this study.
Pre-treatment consultation served to identify specific
treatment needs, to discuss best practices for the child’s
Child Psychiatry Hum Dev (2015) 46:118–129
presenting problems, and to inform families about the study
and alternative treatments available. Once consented,
families were enrolled to participate in the Family Skills
Training for ADHD-Related Symptoms (Family STARS)
Intervention. Family STARS provided a manualized
behavior therapy program that combined BPT with a sep-
arate child-focused self-regulation training component. The
course of the Family STARS intervention consisted of 10,
1-h appointments with concurrent child and parent sessions
during the first 45-min. The final 10–15 min of each ses-
sion was dedicated to whole family discussion, behavioral
rehearsal of session strategies, and planning of weekly
home therapy assignments.
Parent sessions employed BPT procedures specific to
improving ADHD-related behavior management skills.
Parent sessions focused on two main content areas:
increasing awareness and knowledge of interference from
ADHD and developing effective behavioral skills for
managing child ADHD-related problems. While this study
aimed to evaluate parenting stress, there were no specific
parent training topics that focused on stress management
and the intervention was not designed to treat parenting
stress. Session objectives emphasized parenting skills for
promoting desirable behavior through use of behavioral
routines, positive and negative reinforcement, and punish-
ment strategies. Numerous skills were covered in parent
sessions, including the use of differential attention, effec-
tive commands, behavioral goal setting, and use of effec-
tive routines and logical consequences. Methods for
correcting problem behaviors were later introduced; how-
ever, a continued emphasis was maintained for promoting
success and child mastery of desirable behaviors. The
parent session curriculum utilized materials adapted from
well-established BPT programs to focus more specifically
upon ADHD-related behavioral needs [45–49].
Child session objectives emphasized the introduction
and frequent rehearsal of commonly used/needed self-
regulation skills and were structured to complement the
content presented in parent sessions each week. Child
sessions followed a highly structured format in which a
specific target behavior was reviewed and rehearsed
throughout the session, with feedback and reinforcement
provided by the clinician for child performance. Further,
sessions included presentation of a specific behavioral
strategy each week reflecting content presented within
parent sessions, such as coping with stressors/consequences
or implementation of a token economy/daily report card.
Therapy services were provided by clinicians in the
clinic with training backgrounds ranging from advanced
graduate students and pre-doctoral interns to postdoctoral
and clinical faculty. All clinicians received individualized
training regarding the treatment protocol and were required
to demonstrate clinical competency by successfully
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completing a standardized ‘‘check out’’ on session activi-
ties prior to delivery of treatment services. Live supervision
and treatment fidelity checks were conducted by the prin-
cipal investigator and members of the research team.
Analysis
This study employed a single group, within-subjects A-B
design to evaluate changes in parents’ reported levels of
parenting stress and self-efficacy from baseline to post-
treatment. A one-way repeated measures Multivariate
Analysis of Variance (MANOVA) was utilized to evaluate
changes in PST and PSE from baseline to post-treatment.
The two dependent variables in this analysis were PST and
PSE, and the independent variable ‘‘time’’ was designated
by two endpoints: pre-treatment and post-treatment.
A second examination was conducted to determine if
changes in parenting outcomes were related to children’s
treatment response. This analysis used post hoc t-test
comparisons of parenting stress and parenting self-efficacy
based on child treatment response. Independent-samples
t-tests were conducted to determine whether parents of
children whose ADHD symptoms greatly improved
(Higher Treatment Responders) differed from parents of
children with less ADHD symptom improvement (Lower
Treatment Responders). Child treatment response was
categorized in two different ways, (1) based upon the
magnitude of change, and (2) based upon the clinical sig-
nificance of symptom change. In order to determine the
magnitude of child symptom change, parents’ BASC-2
ratings of Attention Problems and Hyperactive/Impulsive
symptoms were averaged to create a composite ADHD
symptom index for measuring both baseline and post-
treatment symptom severity within a single variable. A
difference score was then calculated to determine the
degree of change in ADHD symptoms from baseline to
post-treatment, with higher difference scores representing
greater improvement in child symptoms. Magnitude of
change was dichotomized into categories for higher treat-
ment responders (change in ADHD symptoms C1SD) and
lower treatment responders (change in ADHD symptoms
\1SD) based on the t distribution.
Parenting outcome as related to child treatment response
was also categorized by the clinical significance of
behavior change. BASC-2 rating scale cutoffs were used to
determine the clinical significance of post-treatment child
symptoms (i.e., clinically significant—T-score C70, at
risk—T-score 60–69, and within normal limits—T-score
\60). Independent-samples t-tests were conducted to
determine whether parents of children whose ADHD
symptoms returned to the developmentally typical range
(BASC-2 T-score \60) [36] differed from parents of
children whose symptoms remained above this range
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124 Child Psychiatry Hum Dev (2015) 46:118–129

following completion of the BPT intervention (BASC-2
T-score C60). Outcomes for parents of children whose
symptoms returned to the normal range were compared to
outcomes for parents whose children’s symptoms contin-
ued to be in the ‘‘At Risk’’ or ‘‘Clinically Significant’’
range.
Results
Descriptive statistics for each of the measures included in
these analyses are presented in Table 3. No between-group
differences were observed in parents’ pre-treatment ratings
of stress (PST) or self-efficacy (PSE) based on post-treat-
ment child outcome. The first analysis examined change in
parent stress and self-efficacy over time using a MANOVA
(PST 9 PSE 9 TIME). A significant interaction was
observed between these two variables over time, F (2,
41) = 15.89, p \ .001; Wilks’ k = .56, partial g2 = .44.
Main effects evidenced statistically significant changes
from baseline to post-treatment for both PST,
F(1) = 12.74, p \ .001, and PSE, F(1) = 28.65, p \ .001.
Parents reported a significant decrease in stress related to
treatment participation as well as a significant increase in
self-efficacy in conjunction with BPT (see Table 3). Effect
sizes observed were consistent with a moderate treatment
response for PST and a large treatment response for PSE.
These results supported our first hypothesis, confirming
significant improvements for parents associated with par-
ticipation in their children’s treatment.
With regard to the second hypothesis, parents of chil-
dren who exhibited greater magnitude of change were
expected to demonstrate greater improvements in PST and
PSE at post-treatment. Modest correlations were observed
between change in PSE and PST (r = - .34), and between
PST and change in child ADHD symptoms (r = - .37),
while a weak correlation was observed between change in
PSE and change in child symptom severity (r = .13). No
significant differences were detected based on the magni-
tude of change in child ADHD symptoms in parenting
stress (see Table 4). Thus, the degree of change in child
ADHD symptoms did not influence parents’ post-treatment
ratings of stress and self-efficacy. These results indicated
that there were no significant differences between ‘‘higher
treatment responders’’ and ‘‘lower treatment responders’’ in
terms of parents’ stress and self-efficacy. Despite differ-
ences in the magnitude of child symptom changes, PST and
PSE improved for both groups of parents.

Table 3 Descriptive statistics for outcome variables at pre-treatment and post-treatment

Pre-treatment (T1) Post-treatment (T2)
Variable M SD Range M SD Range d

PSTa 97.97 15.18 72–136 88.88 18.51 38–121 .54

PSEb 160.60 14.34 131–205 172.81 17.66 132–204 .76
Child hyperactivity symptomsc 77.56 8.61 64–101 66.21 11.96 43–92 1.09
c
Child attention symptoms 70.47 5.57 55–82 65.02 7.84 46–82 .80
a
Measured using the Parenting Stress Index—Short Form [39]
b
Measured using the Self-efficacy for Parenting Tasks Index [40]
c
Measured using the Behavior Assessment System for Children—Second Edition, Parent Rating Scale [36]

Table 4 Parenting outcomes by child treatment response

T2 Variable \1SD of change C1SD t d Within Continued t d
M (SD) M (SD) normal limits impairment
M (SD) M (SD)

PST 93.35 (18.28) 82.06 (17.17) 2.03 .64 74.31 (15.23) 95.49 (16.40) -3.95 *1.34
PSE 169.0 (19.04) 178.53 (13.94) 1.56 .57 184.77 (13.58) 167.42 (17.18) 3.23 *1.12
The length of time between T1 and T2 was represented by 10 weeks of participation in BPT
Magnitude of child symptom change—Standard deviation based on t distribution. \1SD of change (n = 26), C1SD (n = 17)
Clinical Significance of child symptom change: within normal limits = T \ 60 (n = 13); Continued Impairment = T C 60 (n = 30); AR = at
risk, T = 60–69 (n = 17); CS = clinically significant, T C 70 (n = 13)
Asterisk denotes significance at p \ .001 level

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Child Psychiatry Hum Dev (2015) 46:118–129
Analysis of the third hypothesis was conducted to
determine if the quality or clinical significance of change
predicted improved PST and PSE for parents of children
whose ADHD symptoms evidenced changes to within the
range of normal functioning. ‘‘Within Normal Limits’’
change was defined as post-treatment child ADHD symp-
tom severity that was within the normal/non-ADHD
symptom range (BASC-2 T-score \ 60) [36]. ‘‘Continued
Impairment’’ change was defined by continued ADHD
symptoms showing any level of impairment (BASC-2
T-score C 60). Statistically significant differences in PST
were noted between these two groups at post-treatment.
Parents of children whose ADHD symptoms improved to
within the normal range reported significantly less stress
following BPT compared to those of children with con-
tinued impairment (see Table 4). Significant differences in
post-treatment PSE were also noted. Parents of children
whose symptom changes at post-treatment were within the
normal range also reported significantly higher PSE than
those of children with continued impairment (see Table 4).
Discussion
This study examined parenting outcomes associated with
parents’ participation in behavior therapy for their chil-
dren’s ADHD. In response to the first research question,
parents indeed reported improvements in their own func-
tioning following BPT, as defined both by decreased par-
enting stress and increased parenting self-efficacy. We also
presented research questions that inquired about two types
of Higher Treatment Responses for children and how these
ADHD symptom improvements were associated with par-
enting outcomes. These results suggest that even when a
large degree of child ADHD symptom change resulted
from BPT, the magnitude of change did not influence the
outcome ratings of PST and PSE. Conversely, the clinical
significance of child ADHD symptom change was associ-
ated with significantly improved PST and PSE.
Regarding the first hypothesis, improvements observed
in parenting stress and parenting self-efficacy after BPT
proved to be significant and represented a moderate effect
size. This suggests that parents’ ability to cope with their
child’s ADHD as well as their confidence to carry out their
everyday demands as parents significantly improved. These
findings were consistent with those from previous research
that demonstrated improved parent functioning following
participation in BPT [33, 35].
In this study, parents reported both a statistically sig-
nificant and clinically significant increase in overall PSE
from baseline to post-treatment. Regardless of how chil-
dren responded to therapy, parents experienced benefits
related to their own self-efficacy for carrying out parenting
125
tasks. Since self-efficacy is also associated with task ini-
tiation and persistence, these findings suggest that parents
who participate in BPT may become more motivated and
more likely to persist when faced with difficult parenting
tasks. Parents also reported a statistically significant and
clinically significant decrease in overall PST from baseline
to post-treatment. Consequently, parents appeared to cope
better with their child’s ADHD-related behavior problems
by participating in BPT, regardless of child treatment
outcomes. This is particularly worthy of note since the
treatment under evaluation did not include parent stress
management techniques as intervention targets. Though
parents evidenced greater improvements regarding their
ratings of self-efficacy compared to parenting stress, this
difference is likely due to the inherent primary goal of
treatment being to improve parents’ confidence and com-
petence to carry out behavior management strategies.
Whereas, the latent intent for improving parent coping or
parent stress management was not operationalized into any
specific therapy procedures. While the direction of this
relationship is clear (i.e. ADHD symptom reduction is
associated with decreasing parenting stress), causation
cannot be determined by these data. The removal of a
stressor (child disruptive behaviors) may be responsible for
improved parenting stress. Conversely, improvements in
parent coping may also lead to greater consistency of
effective parenting and thereby promote greater ameliora-
tion of children’s ADHD-related impairments.
The second part of this study examined two different
types of ‘‘Higher Treatment Response’’ for children and
parent outcomes associated with each. The first way HTR
was defined was based upon the magnitude of child ADHD
symptom change (C1SD change in symptom severity)
based on the t distribution. Hypothesis 2 predicted that
improvements in parenting stress and parenting self-effi-
cacy would be positively associated with improvements in
child ADHD symptoms that were C1 standard deviation of
change compared to baseline functioning. ‘‘Higher Treat-
ment Response’’ was also defined by the clinical signifi-
cance of child ADHD symptom change (change in BASC-
2 ratings below clinically significant cut-offs: T-scores
\60). Accordingly, hypothesis 3 predicted that significant
parenting outcomes would be positively associated with
child ADHD symptom improvements that fell below norm-
based rating scale cut-offs representing clinically signifi-
cant impairment.
Results indicated no significant differences in parenting
outcomes associated with a large magnitude of child
symptom change (hypothesis 2). Thus, at post-treatment,
parents of children who demonstrated greater magnitude of
improvements did no better with regard to their parenting
stress or self-efficacy than parents of children who expe-
rienced less reduction in ADHD symptoms. An example of
123
126
this would be the instance of a child responding to treat-
ment with a two standard deviation change in symptoms
(e.g., Time 1 ADHD Composite T-score = 90, Time 2
ADHD Composite T-score = 70). While this change rep-
resents a 2SD change and a very large main effect for the
treatment, the child’s symptoms remained within a clini-
cally significant level of impairment (i.e. [1SD than non-
ADHD norm group). In instances such as this, the magni-
tude of change may have been deemed less pertinent to
parenting outcomes than the continued impairment or
clinical significance of child symptom change. As a result,
parents of children who demonstrated large reductions in
ADHD symptoms felt equally efficacious and stressed as
parents whose children did not respond with as much
symptom change. However, these results should be inter-
preted in the context of the small sample size, which may
have ultimately not allowed sufficient power to detect
group differences based on magnitude of change.
On the contrary, the clinical significance of child
ADHD symptom change did result in meaningful out-
come differences for parents. Parents of children whose
symptoms abated to a level of severity deemed ‘‘Within
Normal Limits’’ reported significantly less stress and
greater parenting self-efficacy. Compared to the previous
example of [2SD change, this means that even a very
small change (e.g. 0.25SD) can result in significant par-
enting outcomes as long as this change represents sub-
clinical impairment (symptoms falling below clinical cut-
offs on norm-based rating scales). In essence, these par-
ents experienced treatment outcomes for their children
where the severity of their ADHD symptoms was no
different than those of their non-ADHD peers. These
clinically significant child improvements may have
therefore promoted less stressful contexts for parenting
experiences that were more consistent with those of par-
ents of children without ADHD. Likewise, parenting self-
efficacy also increased as parents learned more effective
ways to manage their children’s difficult behaviors. Par-
ents of children who demonstrated more favorable out-
comes were more likely to experience more positive
parent outcomes, and thus may have been better able to
continue implementing specific behavioral strategies to
support their children’s functioning. The current analyses
do not permit conclusions about the causal influence upon
the relationship between child and parent treatment
response. Parenting stress may decrease as parents learn
new behavior management skills, which may further
result in more effective implementation of strategies to
better reduce child symptoms. Reduction of child symp-
toms may also prompt parents’ improvements by allevi-
ating significant parenting challenges. Additional study is
needed to better understand causal elements of these
relationships.
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Child Psychiatry Hum Dev (2015) 46:118–129
Limitations and Future Directions
There are three main limitations in need of mention for this
study. The first of these is the quasi-experimental, single-
group design. Since this study was not a controlled trial, it
is not possible to prove that changes in parent functioning
observed at post-treatment were exclusively the result of
treatment effects. For instance, it is possible that other
confounding factors such as time or repeated exposure to
the parenting measures may have contributed to these
parenting outcomes. However, changes observed in par-
enting stress and self-efficacy were not limited to a few
individual participants; rather, improvements in parent
functioning were observed to represent a group effect with
moderately high levels of change. It would be beneficial for
future studies using randomized trials to compare these
differences in BPT outcomes for parents to those observed
for a control group. This would allow greater generaliz-
ability of these conclusions related to the extent to which
parents’ outcomes may be directly attributable to their
participation in BPT for their children’s ADHD.
Second, parent ratings of child behavior were utilized in
this study as a measure of child symptom improvement.
Parent ratings of child behavioral symptoms may have
somehow been biased by their personal experiences of
parenting self-efficacy and parenting stress. While no
multicollinearity was noted among these measures at
baseline, it could not be determined if parents’ active
participation in their children’s therapy colored their view
of their children’s symptoms at outcome. The decision to
use parent data was based on multiple considerations. BPT
objectives focus primarily upon improving child manage-
ment in the home setting, with relatively less emphasis
placed on indirect intervention in the school setting. Fur-
ther, parent ratings of child ADHD symptoms were con-
sistent with the teacher data that were also collected for this
sample [44]. Future research may be strengthened by
inclusion of use of multiple informants as well as obser-
vational data on child outcomes.
Another possible limitation was a potential selection
bias. Participants were seeking behavioral intervention for
ADHD at a large outpatient hospital setting with many
significant barriers to access (e.g. treatment waitlists,
referral requirements, traffic, parking costs, etc.). The
process of seeking services in this setting was complex,
time-intensive, and may not necessarily reflect the typical,
community-based experience for families seeking care for
a child with a simple presentation of ADHD. Therefore,
this sample may represent children who were previously
minimal treatment responders and/or parents with greater
socioeconomic resources. Specifically, the sample may
consist of caregivers who have persisted in seeking treat-
ment because they are experiencing a high degree of
Child Psychiatry Hum Dev (2015) 46:118–129
distress. Additionally, other characteristics of the partici-
pants may have influenced the outcomes of the analyses.
The majority of the sample identified themselves as high
socioeconomic status regarding both income and educa-
tion, and children were relatively young. Thus, parent
experience and ability to implement the skills presented in
BPT may have differed based on these demographic fac-
tors. Finally, it is important to note that all caregivers in
this study were female, and thus results reported here may
not reflect the experience of fathers. Future research
examining fathers’ experience will be important in gaining
a more complete picture of families’ experiences when
participating in BPT.
Summary
Parents in this study reported significant improvements in
parenting stress and self-efficacy over the course of par-
ticipation in a BPT intervention. While magnitude of
change in child symptoms was not associated with differ-
ential parenting outcomes, the clinical significance of
improvement in child ADHD impairment was associated
with differences for parenting stress and self-efficacy. The
results of this study offer several important implications for
the practice of psychology, particularly related to deter-
mining appropriate markers for treatment termination,
developing parent-focused treatment objectives to improve
overall family functioning when indicated, and identifying
strategies to promote the sustainability of treatment effects.
The findings of this study suggest that the clinical signifi-
cance of ADHD symptom reduction is most relevant to
improvements in parenting stress and self-efficacy. While a
high degree of change in child impairment (e.g. C1SD)
may serve as a good marker for child therapy progress, it
may not ultimately influence key parenting outcomes if it
does not indicate amelioration of impairment. This is
important because continued parenting stress and low self-
efficacy may subsequently affect parents’ implementation
of behavioral strategies as well as the consistency and
sustainability of their use of these methods after finishing
treatment. These findings support the need to prioritize
‘‘quality over quantity’’ when evaluating the significance of
child symptom impairment. While parents’ outcomes
should certainly not be the sole determinant of a family’s
progress and readiness for termination, we believe that
parents’ stress and self-efficacy may be one aspect to
consider given the potential for stress and self-efficacy to
influence parents’ ability to maintain fidelity of imple-
mentation after treatment ends.
Despite the fact that the large majority of families in this
study achieved significant child symptom reduction, most
parents still reported some continued (though lesser)
127
degree of child symptom impairment at post-treatment. For
these families, parents failed to show significant personal
benefits with regard to their parenting self-efficacy or their
parenting stress. Consequently, treatment modules are
needed that can extend the duration of time-limited pro-
tocols to address cases where significant child impairment
remains. This may simply require extending the duration of
treatment to promote improved intervention adherence and
fidelity. Regularly assessing the parents’ perceptions of
child symptom severity and parenting stress and parenting
self-efficacy may also be used to guide decisions around
termination readiness. Persisting distress or low parenting
self-efficacy may then shift the focus of treatment to
include new objectives targeting parents’ individual well-
being and ability to carry out the strategies learned during
BPT.
Possible parent-focused intervention targets may include
identification of stressors, implementation of individual
and couple coping strategies, and presentation of self-
monitoring tasks for managing reactions to daily stressors.
Further, intervention targets may also focus on the devel-
opment of clearer parenting roles and expectations as a
couple, improving the parental alliance, strengthening
communication between parents, and learning strategies for
healthy conflict resolution [35, 50]. Inclusion of these
modules when indicated may augment the improvements in
parenting stress over the course of BPT. This focus would
allow BPT objectives to extend beyond their direct focus
on child behaviors to help parents improve their own
functioning, which may then lead to more favorable
improvements in child impairments.
It is imperative for BPT to ultimately improve parenting
outcomes in order to promote more effective and sustain-
able child treatment outcomes. The chronic nature of
ADHD has been well established [11, 51], which may add
pressure to a course of brief intervention to promote more
long-lasting effects for this clinical population. For this
reason, ongoing assessment of parenting stress and par-
enting self-efficacy may help clinicians better understand
not only families’ termination readiness, but also serve to
guide continuity of care recommendations and possible
step-down procedures for ending behavior therapy. Spe-
cifically, reevaluation of child ADHD symptoms as well as
parenting stress and self-efficacy upon completion of a
time-limited BPT protocol may help inform other treatment
considerations such as medication trials and behavioral
consultation booster sessions.
Overall, the results of this study suggest that parents’
well-being significantly improves when they participate in
a modified BPT program to address their children’s
ADHD. When considering treatment outcomes for children
with ADHD, it is therefore compelling for clinicians to also
evaluate parents’ response to intervention in order to
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improve their satisfaction with care and their sustained
ability to carry forth the strategies learned throughout the
course of behavior therapy. These findings highlight the
importance of actively engaging parents in their child’s
treatment, most notably illustrating that parents also benefit
from the intervention process. Further, parents participat-
ing in time-limited BPT may benefit from flexibility related
to duration of treatment, and clinicians may consider
structuring additional assessment endpoints to evaluate
needs for continuation of BPT for families until optimal
child outcomes are achieved.
References
1. Shanahan MA, Pennington BF, Yerys BE, Scott A, Boada R,
Willicutt EG et al (2006) Processing speed deficits in attention-
deficit/hyperactivity disorder and reading disability. J Abnorm
Child Psychol 34:584–601
2. Stormont M (2001) Social outcomes of children with AD/HD:
contributing factors and implications for practice. Psychol Sch
38:521–531
3. DeWolfe NA, Byrne JM, Bawden HN (2000) ADHD in preschool
children: parent-rated psychosocial correlates. Dev Med Child
Neurol 42:825–830
4. Harold GT, Leve LD, Barrett D, Elam K, Neiderhiser JM, Nat-
suaki MN et al (2013) Biological and rearing mother influences
on child ADHD symptoms: revisiting the developmental interface
between nature and nurture. J Child Psychol Psychiatry 54:
1038–1046
5. Whalen CK, Ogders CL, Reed PL, Henker B (2011) Dissecting
daily distress in mothers of children with ADHD: an electronic
diary study. J Fam Psychol 25:402–411
6. Counts CA, Nigg JT, Stawicki JA, Rappley MD, Von Eye A
(2005) Family adversity in DSM-IV ADHD combined and inat-
tentive subtypes and associated disruptive behavior problems.
J Am Acad Child Adolesc Psychiatry 44:690–698
7. Fabiano GA, Chacko A, Pelham WE, Robb J, Walker KS, Wy-
mbs F et al (2009) A comparison of behavioral parent training
programs for fathers of children with attention-deficit/hyper-
activity disorder. Behav Ther 40:190–204
8. Barkley RA (2005) Attention deficit hyperactivity disorder: a
handbook for diagnosis and treatment. Guilford, New York
9. Garland AF, Hawley KM, Brookman-Frazee L, Hurlburt MS
(2008) Identifying common elements of evidence-based psy-
chosocial treatments for children’s disruptive behavior problems.
J Am Acad Child Adolesc Psychiatry 47:505–514
10. Diamond G, Josephson A (2005) Family-based treatment
research: a 10-year update. J Am Acad Child Adolesc Psychiatry
44:872–887
11. Pelham WE, Fabiano GA (2008) Evidence-based psychosocial
treatments for attention-deficit/hyperactivity disorder. J Clin
Child Adolesc Psychol 37:184–214
12. Curtis DF (2010) ADHD symptom severity following participa-
tion in a pilot, 10-week, manualized, family-based behavioral
intervention. Child Fam Beh Ther 32:231–241
13. Webster-Stratton CH, Reid MJ, Beauchaine T (2012) Combining
parent and child training for young children with ADHD. J Clin
Child Adolesc Psychol 40:191–203
14. Fabiano GA, Pelham WE, Coles EK, Gnagy EM, Chronis AM,
O’Connor BC (2009) A meta-analysis of behavioral treatments
123
Child Psychiatry Hum Dev (2015) 46:118–129
for attention-deficit/hyperactivity disorder. Clin Psychol Rev
29:129–140
15. Bor W, Sanders MR, Markie-Dadds C (2002) The effects of the
Triple-P positive parenting program on preschool children with
co-occurring disruptive behavior and attention-deficit/hyperactive
difficulties. J Abnorm Child Psychol 30:571–587
16. Hurt EA, Hoza B, Pelham WE (2007) Parenting, family loneli-
ness, and peer functioning in boys with attention-deficit/hyper-
activity disorder. J Abnorm Child Psychol 25:413–424
17. Keown LJ (2012) Predictors of boys’ ADHD symptoms from
early to middle childhood: the role of father–child and mother–
child interactions. J Abnorm Child Psychol 40:569–581
18. Lange G, Sheerin D, Carr A, Dooley B, Barton V, Marshall D
et al (2005) Family factors associated with attention deficit
hyperactivity disorder and emotional disorders in children. J Fam
Ther 27:76–96
19. Tripp G, Schaughnecy EA, Langlands R, Mouat K (2007) Family
interactions in children with and without ADHD. J Child Fam
Stud 16:385–400
20. Kazdin A (1995) Child, parent and family dysfunction as pre-
dictors of outcome in cognitive-behavioral treatment of antisocial
children. Behav Res Ther 33:271–281
21. Podolski C, Nigg JT (2001) Parent stress and coping in relation to
child ADHD severity and associated child disruptive and
behavior problems. J Clin Child Psychol 30:503–513
22. Primack BA, Hendricks KM, Longacre MR, Adachi-Mejia AM,
Weiss JE, Titus LJ et al (2012) Parental efficacy and child
behavior in a community sample of children with and without
attention-deficit hyperactivity disorder (ADHD). Atten Defic
Hyperact Disord 4:189–197
23. Hoza B, Owens JS, Pelham WE, Swanson J, Conners CK, Hin-
shaw SP et al (2000) Effect of parent cognitions on child treat-
ment response in attention-deficit/hyperactivity disorder.
J Abnorm Child Psychol 28:569–583
24. Theule J, Wiener J, Rogers MA, Marton I (2011) Predicting
parenting stress in families of children with ADHD: parent and
contextual factors. J Child Fam Stud 20:640–647
25. Joyner KB, Silver CH, Stavinoha PL (2009) Relationship
between parenting stress and ratings of executive functioning in
children with ADHD. J Psychoed Assess 27:452–464
26. Graziano PA, McNamara JP, Geffken GR, Reid A (2011)
Severity of children’s ADHD symptoms and parenting stress: a
multiple mediation model of self-regulation. J Abnorm Child
Psychol 39:1073–1083
27. Neece CL, Green SA, Baker BL (2012) Parenting stress and child
behavior problems: a transactional relationship across time. Am J
Intellect Dev Disabil 117:48–66
28. McLaughlin DP, Harrison CA (2006) Parenting practices of
mothers of children with ADHD: the role of maternal and child
factors. Child Adolesc Ment Health 11:82–88
29. Johnston C, Mah JW, Regambal M (2010) Parenting cognitions
and treatment beliefs as predictors of experience using behavioral
parenting strategies in families of children with attention-deficit/
hyperactivity disorder. Behav Ther 41:491–504
30. Van den Hoofdakker BJ, Nauta MH, van der Veen-Mulders L,
Sytema S, Emmelkamp PM, Minderaa RB et al (2010) Behav-
ioral parent training as an adjunct to routine care in children with
attention-deficit/hyperactivity disorder: moderators of treatment
response. J Pediatr Psychol 35:317–326
31. Anastopoulos AD, Shelton TL, DuPaul GJ, Guevremont DC
(1993) Parent training for attention-deficit hyperactivity disorder:
its impact on parent functioning. J Abnorm Child Psychol 21:
581–596
32. Chacko A, Wymbs BT, Flammer-Rivera LM, Pelham WE,
Walker KS, Arnold FW et al (2008) A pilot study of the feasi-
bility and efficacy of the strategies to enhance positive parenting
Child Psychiatry Hum Dev (2015) 46:118–129
(STEPP) program for single mothers of children with ADHD.
J Atten Disord 12:270–280
33. Gerdes AC, Haack LM, Schneider BW (2012) Parental func-
tioning in families of children with ADHD: evidence for
behavioral parent training and importance of clinically mean-
ingful change. J Atten Disord 16:147–156
34. Treacy L, Tripp G, Baird A (2005) Parent stress management
training for attention-deficit/hyperactivity disorder. Behav Ther
36:223–233
35. Hoath FE, Sanders MR (2002) A feasibility study of enhanced
group Triple P-positive parenting program for parents of children
with attention-deficit/hyperactivity disorder. Behav Change 19:
191–206
36. Reynolds CR, Kamphaus RW (2004) BASC-2: behavioral
assessment for children manual, 2nd edn. AGS Publishing, Circle
Pines
37. Barkley RA, Murphy KR (2006) Attention-deficit hyperactivity
disorder: a clinical workbook, 3rd edn. Guilford Press, New York
38. Fabiano GA (2007) Father participation in behavior parent
training for ADHD: review and recommendations for increasing
inclusion and engagement. J Fam Psychol 21:683–693
39. Abidin RR (1995) Parenting Stress Index—professional manual,
3rd edn. Psychological Assessment Resources, Odessa
40. Coleman PK, Karraker KH (2000) Parenting self-efficacy among
mothers of school-aged children: conceptualization, measure-
ment, and correlates. Fam Relat 49:13–24
41. Johnston C, Mash EJ (1989) A measure of parenting satisfaction
and efficacy. J Clin Child Psychol 18:167–175
42. Biederman J, Faraone SV, Monuteaux MC, Grossbard JR (2004)
How informative are parent reports of attention-deficit/hyper-
activity disorder symptoms for assessing outcomes in clinical
129
trials of long-acting treatments? A pooled analysis of parents’ and
teachers’ reports. J Pediatr 113:1667–1671
43. Achenbach TM, McConaughy SH, Howell CT (1987) Child/
adolescent behavioral and emotional problems: implications of
cross-informant correlations for situational specificity. Psychol
Bull 101(2):213–232
44. Curtis DF, Chapman S, Dempsey J, Mire S (2013) Do ADHD-
related classroom behaviors change in response to clinic-based
behavior therapy? J Clin Psychol Med Settings 20:114–122
45. Barkley RA (2013) Defiant children: a clinician’s manual for
assessment and parent training, 3rd edn. Guilford, New York
46. Cunningham CE (2005) COPE: large-group, community-based,
family-centered parent training. In: Barkley RA (ed) Attention-
deficit hyperactivity disorder: a handbook for diagnosis and
treatment, 3rd edn. Guilford, New York, pp 480–498
47. Cunningham CE (2007) A family-centered approach to planning and
measuring the outcome of interventions for children with attention-
deficit/hyperactivity disorder. J Pediatr Psychol 32:676–694
48. McMahon RJ, Forehand RL (2005) Helping the non-compliant
child: family-based treatment for oppositional behavior, 2nd edn.
Guilford, New York
49. Sanders MR (1999) Triple P-positive parenting program: towards
an empirically validated multilevel parenting and family support
strategy for the prevention of behavior and emotional problems in
children. Clin Child Fam Psychol Rev 2:71–90
50. Gottman JM (1998) Psychology and the study of marital pro-
cesses. Ann Rev Psychol 49:169–197
51. Barbaresi WJ, Colligan RC, Weaver AL, Voigt RG, Killian JM,
Katusic SK (2013) Mortality, ADHD, and psychosocial adversity
in adults with childhood ADHD: a prospective study. J Pediatr
131:1–8
123