A Randomized Controlled Trial of a Parent Training and Emotion Socialization Program for Families of Hyperactive Preschool-Aged Children

Behavior Therapy 44 (2013) 302 – 316

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A Randomized Controlled Trial of a Parent Training and Emotion Socialization Program for Families of Hyperactive Preschool-Aged Children Sharonne D. Herbert Elizabeth A. Harvey Jasmin L. Roberts Kayla Wichowski Claudia I. Lugo-Candelas University of Massachusetts Amherst

The present study evaluated the effectiveness of a parent training and emotion socialization program designed specifically for hyperactive preschoolers. Participants were 31 preschool-aged children whose parents were randomly assigned to a parent training (PT) or waitlist (WL) control group. PT parents took part in a 14-week parenting program that involved teaching parenting strategies for managing hyperactive and disruptive behavior as well as emotion socialization strategies for improving children's emotion regulation. Compared to WL mothers, PT mothers reported significantly less child inattention, hyperactivity, oppositional defiance, and emotional lability; were observed using significantly more positive and less negative parenting; and reported significantly less maternal verbosity and unsupportive emotion socialization practices. Results provide some support for the effectiveness of this parenting program for reducing attention-deficit hyperactivity disorder (ADHD) symptoms and associated problems in preschool-aged children.

Keywords: parent training; ADHD; emotion socialization; preschoolaged children

ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD) is characterized by developmentally deviant levels Address correspondence to Elizabeth Harvey, Ph.D., Department of Psychology, Tobin Hall, 135 Hicks Way, University of Massachusetts, Amherst, MA 01003; e-mail: [email protected]. 0005-7894/44/302–316/$1.00/0 © 2012 Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd. All rights reserved.

of inattention and/or hyperactivity/impulsivity that interfere with functioning at home, in the classroom, and with peers (American Psychiatric Association [APA], 2000). Children with ADHD are at increased risk for a host of difficulties (Barkley, 2006), and it is estimated that half develop comorbid oppositionaldefiant disorder (ODD; Waschbusch, 2002). Although ADHD is typically not diagnosed until elementary school age, there is growing evidence that symptoms often emerge during the preschool years (Applegate et al., 1997). In fact, the American Academy of Pediatrics (AAP) has recently extended the age range covered by its guidelines for diagnosing and treating ADHD down to age 4 (AAP, 2011). With this growing recognition that ADHD often emerges during the preschool years has come a striking increase in the use of stimulant medications in preschool-aged children (Zito et al., 2000), which has motivated researchers to examine the efficacy of psychopharmacological interventions for preschoolers (e.g., the Preschoolers with AttentionDeficit/Hyperactivity Disorder Treatment Study [PATS]; Kollins et al., 2006). Although the PATS (Greenhill et al., 2006) and other studies (e.g., Short, Manos, Findling, & Schubel, 2004) found some evidence that stimulant medication is efficacious in this age group, effects varied by outcome measure, with changes observed on some measures of ADHD symptoms (Greenhill et al., 2006), but not on others (Abikoff et al., 2007). In addition, effect sizes appear to be lower for preschool-aged children (PATS were .35 for parents and .43 for teachers) than for

parent training for hyperactive preschoolers school-aged children (Multimodal Treatment Study of Children with ADHD [MTA] were .52 for parents and .75 for teachers; Greenhill et al., 2006). Moreover, psychopharmacological treatment in preschool-aged children has been associated with declines in growth rates (Swanson et al., 2006), moderate to severe adverse events (e.g., emotional outbursts, difficulty falling asleep, repetitive behavior/ thoughts, decreased appetite) in almost one-third of preschoolers (Wigal et al., 2006), and much higher rates of children discontinuing medication (11% in PATS) compared to school-aged children (less than 1% in the MTA study; Wigal et al.). These results, coupled with the fact that little is known about the long-term effects of psychopharmacological agents on brain development in young children, signal the need for further study, as well as exploration of alternatives to drug therapy. Although psychopharmacological interventions for preschoolers have received increased attention, the AAP recommends that behavioral treatments such as parent training should be the first line of treatment (AAP, 2011). Parent training, a short-term intervention that teaches appropriate responses to poor conduct, has long been shown to be an effective treatment for preschool-aged children with conduct and oppositional problems (e.g., Cunningham, Bremner, & Boyle, 1995; Reid, Webster-Stratton, & Baydar, 2004; Schuhmann, Foote, Eyberg, Boggs, & Algina, 1998), and a few studies (e.g., Drugli & Larsson, 2006) have found that parent training can reduce symptoms of ADHD among children with conduct problems. A smaller body of research has evaluated the effectiveness of parent training for preschool-aged children with significant ADHD symptoms. Six of these studies (Huang, Chao, Tu, & Yang, 2003; Kern et al., 2007; Matos, Bauermeister, & Bernal, 2009; Sonuga-Barke, Daley, Thompson, Laver-Bradbury, & Weeks, 2001; Strayhorn & Weidman, 1989; WebsterStratton, Reid, & Beauchaine, 2011) found significant reductions in ADHD symptoms immediately following parent training, and the four studies (Bor, Sanders, & Markie-Dadds, 2002; Pisterman et al., 1989; Pisterman et al., 1992; Strayhorn & Weidman, 1991) that conducted follow-up assessments discovered that improvement in children's behavior could be observed as much as 1-year posttreatment. Moreover, a number of these studies have found improvement in symptoms associated with ODD (e.g., Bor et al., 2002; Huang et al., 2003; Pisterman et al., 1989; Pisterman et al., 1992), which are often comorbid with ADHD symptoms even in the preschool years (Harvey, Friedman-Weieneth, Goldstein, & Sherman, 2007). These studies suggest that parent training may be a promising treatment for

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preschool ADHD and point to the need for more research to develop and evaluate effective parent training programs designed for this population. Parent training programs that have been used with hyperactive preschoolers share many curricular and format features, with most programs emphasizing the increase of positive parent-child interactions, the reinforcement of positive behavior, differential attention (praising positive behaviors and ignoring negative behaviors), as well as use of effective commands, tangible rewards, and appropriate consequences (e.g., Bor et al., 2002; Huang et al., 2003; Kern et al., 2007; Pisterman et al., 1992; Strayhorn & Weidman, 1989). These strategies may be helpful in managing ADHD symptoms as well as commonly co-occurring symptoms of ODD. However, although these components have been shown to be crucial to the success of many parenting programs, parent training may be improved by teaching parents emotional socialization strategies to help children develop better emotion regulation. Parents’ emotion socialization practices play a key role in children's development of emotional competence (i.e., emotional knowledge/understanding, emotion regulation, expression of emotion). Three categories of parental emotion socialization behaviors are thought to guide the regulation of emotions, the acquisition of regulation strategies, and the understanding of emotions and regulation: (a) parental expressivity of emotion, (b) parental discussion of emotion, and (c) parental reaction to children's emotion (Eisenberg, Cumberland, & Spinrad, 1998). By contributing to children's understanding of which experiences and expressions of emotion are appropriate, parental emotional expressivity is thought to affect children's evaluation of their own emotional experience and expression (Dunsmore & Halberstadt, 1997). Parents’ discussion of emotion is also thought to contribute to emotion regulation by sharpening children's awareness of emotional states (Melzi & Fernández, 2004). Finally, parents’ reactions to children's emotions can either assist children in maintaining proper levels of arousal or contribute to children's emotional overarousal. In particular, parents’ nonsupportive reactions to children's negative emotions are linked to negative social and emotional outcomes for children, and parental reactions that are supportive are related to better child outcomes (e.g., McElwain, Halberstadt, & Volling, 2007). Explicitly teaching parents these emotion socialization practices may be important in helping hyperactive preschool children develop better emotion regulation. Emotion regulation consists of monitoring, evaluating, and modifying one's emotional reactions (Cole, Martin, & Dennis, 2004) and is essential for positive social behavior (Domitrovich, Cortes, &

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Greenberg, 2007). Developing emotion regulation skills is an important task during the preschool years (Denham & Burton, 2003), and may be particularly challenging for children experiencing symptoms of ADHD, because executive dysfunction may interfere with regulating not just behavior, but affect as well (Barkley, 1997). Indeed, children with ADHD have been reported to experience more emotion dysregulation compared to children who do not have ADHD (Anastopoulos et al., 2011). In addition, children with ADHD who have comorbid symptoms of ODD may experience further disruption in emotion regulation, because a number of the core symptoms of ODD (e.g., temper tantrums, easily annoyed, angry/resentful; APA, 2000) directly involve emotion dysregulation. Research linking externalizing symptoms with emotion dysregulation (Cole, Zahn-Waxler, Fox, Usher, & Welsh, 1996; Rydell, Thorell, & Bohlin, 2007) provides support for this possibility. Explicitly training parents in emotion socialization may therefore play a key role in helping hyperactive children develop better emotion regulation. Intervention programs designed to improve children's emotional regulation have generally trained teachers or staff to teach children how to recognize, label, and express emotions (e.g., Denham & Burton, 1996; Domitrovich et al., 2007; Izard et al., 2008). However, parents may have more opportunity than teachers to help children learn about emotions as they are experiencing them. Although a number of parenting programs seek to foster positive parentchild interactions (e.g., Sharry, Guerin, Griffin, & Drumm, 2005), most do not explicitly address teaching emotion socialization skills. The newest version (revised 2008) of the Incredible Years parent training program has incorporated teaching parents emotion coaching and emotion regulation strategies and, when combined with child training, has been shown to improve functioning in preschool children with ADHD (Webster-Stratton et al., 2011). Only one set of studies has directly evaluated the effectiveness of an intervention specifically designed to improve parents’ emotion socialization skills (Havighurst, Wilson, Harley, & Prior, 2009; Havighurst, Wilson, Harley, Prior, & Kehoe, 2010). This program was evaluated on a community sample and resulted in improved emotion socialization practices in parents immediately following the intervention (Havighurst et al., 2009), as well as increases in children's awareness of emotion and emotion regulation at a 6-month follow-up (Havighurst et al., 2010). More research is needed to develop and evaluate parent emotion socialization programs for clinical populations. In particular, teaching emotion socialization skills, in conjunction with behavior management strategies, to parents of children with

ADHD symptoms may be a promising approach for these children who are at risk for difficulties with emotion regulation (Anastopoulos et al., 2011).

the present study ADHD symptoms can emerge during the preschool years and although there is some evidence for the efficacy of pharmacological treatments (Greenhill et al., 2006), more research is needed to develop empirically supported treatments for preschoolers who show early symptoms of ADHD. The present study evaluated the effectiveness of a new parent training and emotion socialization program for parents of hyperactive preschoolers using a randomized controlled trial. The Parenting Your Hyperactive Preschooler program (Harvey, Herbert, & Stowe, 2010) actively teaches parents emotion socialization skills in addition to providing education about ADHD, fostering the development of appropriate expectations among parents regarding hyperactive behavior, and tailoring parenting techniques to the unique needs of hyperactive preschoolers. This program was designed not only to help parents manage hyperactivity, but to reduce and/or prevent co-occurring symptoms of ODD and emotion dysregulation. The primary goal of this study was to test the hypotheses that based on mothers’ report (a) children whose parents took part in parent training (PT) would show fewer symptoms of ADHD, ODD, and emotion dysregulation compared to children on a waitlist (WL), and (b) PT mothers would use better discipline and emotion socialization practices compared to WL mothers. A secondary goal was to explore whether father-report and observational data (available on a smaller subset of these children) would corroborate findings based on mother-report.

Method participants Participants were 31 preschool-aged children (23 boys, 8 girls) with developmentally deviant levels of hyperactivity/impulsivity. The sample included 26 European-American (non-Hispanic), 2 AfricanAmerican, 1 Latino, and 2 multiethnic preschoolaged children who were 34 to 76 months old (M = 54.92 months, SD = 10.79). All 31 children had mothers participate and 18 children had fathers participate at either pretest or posttest assessments. Seven mothers were single and the combined median family income was $84,000. Inclusion criteria were (a) Behavior Assessment System for Children 2– Parent Report Scale (BASC 2-PRS; Reynolds & Kamphaus, 2004) hyperactivity scores of 65 or higher, or (b) at least six hyperactive/impulsive symptoms based on the Diagnostic Interview Schedule of Children, Fourth Edition (DISC-IV; Shaffer,

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Enrollment Assessed for eligibility (n = 52)

Excluded (n = 21)

♦ Not meeting inclusion criteria (n = 9) ♦ Declined to participate (n = 12) Completed pretest (n = 31) ♦ 17a mothers & 11 fathers later assigned toi ntervention

♦ 14 mothers & 6 fathers later assigned to waitlist Randomized (n = 31)

Allocated to intervention (n = 17) ♦ Received intervention (n = 17)

Allocation

Allocated to waitlist (n = 14)

Follow-Up Lost to follow-up (n = 0) Discontinued intervention after 1 session (n = 2) ♦ No longer interested (n = 2) Completed posttest ♦ 17 mothersb & 10 fathers

Lost to follow-up (n = 1) ♦ Could not be reached (n = 1) Completed posttest ♦ 13b mothers & 3 fathers

Analysis Analyzed Questionnaire data (n = 17) ♦ 17 mothers & 12 fathers (intent-to-treat analyses; missing data at pretest or posttest carried forward/backward) Audiotaped data (n = 11 mothers PT)

Analyzed Questionnaire data (n = 14) ♦ 14 mothers (intent-to-treat analyses; missing data at posttest carried forward from pretest) ♦ Waitlist fathers not included in analyses Audiotaped data (n = 10 mothers)

a

One mother was missing some data at pretest

b

11 mothers in the intervention group and 10 mothers in the waitlist group completed audiotaped assessments at posttest

FIGURE 1

Flow Chart Showing Participant Recruitment and Allocation to Intervention.

Fisher, Lucas, Dulcan, & Schwab-Stone, 2000). Children who showed evidence of mental retardation, autism, Asperger's syndrome, or cerebral palsy were excluded. There were 3 PT children and 1 WL child on medication for ADHD at pretest. One child in the PT group discontinued medication and another child in the PT group began to take medication during the parenting program. Figure 1 presents a flowchart of participant screening and enrollment. Based on a power analysis, this study sought to enroll between 28 and 42 families in order

to detect large effect sizes (between .8 and 1.0) with a power of .80.

intervention The Parenting Your Hyperactive Preschooler program has two components delivered over 14 sessions. The first 8 sessions focus on traditional parenting strategies that have been shown to be effective in managing child behavior and tailoring these strategies for use with hyperactive preschoolers. Session 1 educates parents about hyperactivity in preschoolers

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and provides techniques for channeling hyperactive behavior. Sessions 2 through 4 focus on reinforcing children's appropriate behaviors through the use of praise, attention, and tangible rewards. Sessions 5 through 7 address setting limits through the use of effective commands, consequences, and time-out. Session 8 focuses on teaching children problemsolving and negotiating skills. The last 6 sessions focus on emotion socialization strategies designed to improve children's emotion regulation. Session 9 provides families with psychoeducation about emotion regulation. Session 10 teaches parents to help children identify and label emotions. Sessions 11 and 12 focus on handling negative emotion, session 13 teaches approaches for helping children experience positive emotion, and session 14 helps parents model emotion regulation and expression. The program is designed to be conducted in a group setting, which allows parents to receive support from other parents. Parents engage in role-playing to practice new techniques and are assigned homework designed to help them enhance the learning process by using these techniques in real-life situations. Each session lasted approximately 1½ hours.

procedure Participants were recruited from September 2009 to March 2011 through newspaper press releases and distributing flyers to medical offices, schools, and community centers throughout western Massachusetts. Potential participants were mailed a research screening consent form, which they returned by mail. Parents were contacted by telephone to complete the ADHD section of the NIMH DISC-IV. Parents were also administered questions from the hyperactivity subscale of the BASC-2-PRS, and were screened for exclusion criteria. Eligible families then completed questionnaires during a group pretest session. Prior to this pretest session, parents were mailed a research consent form; demographic, psychosocial history, and BASC-2 questionnaires; and audiotape equipment to record 1 hour of parent-child interaction. After the pretest session, children were randomly assigned to one of two groups (PT and WL). Each child was matched with another child based on gender and hyperactivity severity. The second author used an online random number generator to assign one member of the pair to the PT group. If there were an odd number of children, a trio was formed, and 2 of the 3 children were randomly assigned to the PT group. Seventeen children were assigned to the PT group and 14 children were assigned to the WL. Parents completed all pretest measures again at posttest sessions, which were conducted 1 week after the 14 th session. Families assigned to the WL completed posttest measures either

in their homes or at the clinic. Parents were free to seek additional treatment at any point, but were asked to inform research staff if there were any changes in their treatment during the course of the study. One family in the treatment group and no families in the control group sought additional treatment. Parent training sessions were held at a university-based community mental health clinic. Five groups were co-led by staff clinicians, six of whom were clinical psychology doctoral students, one of whom was a school psychologist, and one of whom was a licensed psychologist and lead author of the curriculum. Between three and six families participated in each group and were not charged for the program. Supervised activities were available on site for children during the group sessions for a small fee. Written informed consent was obtained from all parents who participated. The study was conducted in compliance with the authors’ Institutional Review Board.

treatment integrity The second author, a licensed psychologist, held weekly meetings with clinicians to review each session. She watched videotapes of each session to verify adherence to the protocol. Leaders used a detailed curriculum guide, so it was rare that group leaders did not cover the important points of the intervention. In the few instances in which the material was not covered, the second author noted it in supervision and the group leaders discussed the material at the beginning of the next session. measures Screening Measures The BASC 2-PRS assesses a broad range of psychopathology in children ages 2 through 21. The hyperactivity subscale was used for screening, and has demonstrated good reliability (α = .87) for preschool children (Reynolds & Kamphaus, 2004). The DISC-IV (Shaffer et al., 2000) is designed for children age 6 and up, but the ADHD section has been successfully adapted for use with younger children and demonstrated good reliability with a preschool sample (inattention α = .83 and hyperactivity α = .76; Harvey, Youngwirth, Thakar, & Errazuriz, 2009). Behavior Rating Scales The BASC 2-PRS and Disruptive Behavior Rating Scale (DBRS; Barkley & Murphy, 1998) measured parents’ reports of their children's behavior. The externalizing and internalizing composites of the BASC 2-PRS were used for this study, and have demonstrated good reliability for preschoolers (α = .91 and α = .89, respectively) and 6-year-old children (α = .95 and α = .92, respectively; Reynolds & Kamphaus, 2004).

parent training for hyperactive preschoolers The DBRS is a 26-item rating form that assesses inattention, hyperactivity-impulsivity, and oppositional defiant behavior based on DSM-IV criteria. Parents rated their children's behavior using a 4-point Likert scale. The DBRS has demonstrated generally good validity for 3-year-old children and good reliability for the hyperactive/impulsive subscale (mothers’ α = .83, fathers’ α = .80), inattention subscale (mothers’ α = .87, fathers’ α = .86), and the ODD subscale (mothers’ α = .86, fathers’ α = .87; Friedman-Weieneth, Doctoroff, Harvey, & Goldstein, 2009). Emotion Regulation The Emotion Regulation Checklist (ERC; Shields & Cicchetti, 1997) is a 24-item measure completed by parents and consists of items describing processes central to emotionality and regulation. Parents rated how characteristic each item was of the child from 1 (rarely/never) to 4 (almost always). The composite ERC score has demonstrated good convergent validity and the lability/negativity and emotion regulation subscales have demonstrated good reliability (α = .96 and α = .83, respectively; Shields & Cicchetti) and were used in this study. The lability/ Negativity subscale included items reflecting mood lability, lack of flexibility, and dysregulated negative affect (e.g., “Has wild mood swings,” “Gets over it quickly when he/she is upset or unhappy” [reversed], “Responds angrily when an adult sets limits”). The emotion regulation subscale included items describing empathy, emotional self-awareness, and responding positively to others (e.g., “Shares in feelings of others,” “Is able to say when he/she is feeling sad, angry or mad, fearful or afraid,” “Responds positively when adults approach him/her in a friendly or neutral way,” “When another child acts aggressively toward child, he/she reacts appropriately [e.g., expresses anger, fear, frustration, or distress but does not return aggression]”). Self-Report of Parenting The Parenting Scale (Arnold, O'Leary, Wolff, & Acker, 1993) is a 30-item self-report scale, which yields scores for laxness, overreactivity, and verbosity. Ratings were made using a 7-point Likert scale. Scores were averaged across items that loaded on each factor according to the Arnold et al. (1993) factor structure, where high scores indicate dysfunctional parenting. The Parenting Scale has demonstrated adequate internal consistency (α = .83 for laxness, .82 for overreactivity, and .63 for verbosity), good test-retest reliability (.83 for laxness, .82 for overreactivity, and .79 for verbosity), and has been found to correlate with observations of parenting and child behavior (Arnold et al.).

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Parental Emotion Socialization The Coping With Children's Negative Emotion Scale (CCNES; Fabes, Eisenberg, & Bernzweig, 1990) is a self-report scale assessing parental coping in response to children's negative emotion. For each item, the CCNES provides a hypothetical scenario in which the respondent's child feels upset. The parent is asked to rate the likelihood of responding to the scenario in six possible ways (e.g., get upset with him/her for being so careless and then crying about it) on a 7-point Likert scale ranging from 1 (very unlikely) to 7 (very likely). This scale yields the following subscales: distress reactions, punitive reactions, expressive encouragement, emotion-focused reactions, problem-focused reactions, and minimization reactions, with a mean Cronbach's alpha for subscales of the CCNES of .77 (ranging from .69 to .85; Fabes, Poulin, Eisenberg, & Madden-Derdich, 2002). These subscales were collapsed into two scores: Supportive Emotion Socialization was computed by averaging the expressive encouragement, emotion-focused reactions, and problem-focused reactions subscales. Unsupportive Emotion Socialization was computed by averaging the distress reactions, punitive reactions, and minimizing reactions subscales. Audiotaped Assessment of Parent-Child Interaction Parents were asked to use a microcassette player to record 1 hour per parent of a naturalistic interaction with their children. Parents were asked to record during times that tended to be challenging in order to assess parents’ strategies when faced with difficult child behavior. Home audiotaped observations were chosen instead of laboratory observations because we were especially interested in expression of affect, and it was thought that parents and children would feel more comfortable expressing affect in home audiotaped observations than in laboratory observations. Unfortunately, few fathers completed audiotape recordings, so only mothers’ audiotaped data were analyzed in this study. Graduate and undergraduate research assistants were trained to code the audiotapes and two raters overlapped for all participants in the study. Coders were not informed of each family's group assignment or the pretest/ posttest status of the tapes. Intraclass correlations (ICCs) were calculated to determine reliability for each code. A global coding system was developed for this study and was designed to capture positive parenting, discipline, and emotion socialization practices that have been associated with positive child outcomes (e.g., Fabes et al., 2002; Hagen, Ogden, & Bjørnebekk, 2011; Kendziora & O'Leary, 1993), and that were targeted by this parenting program.

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Codes included child misbehavior, emotion talk, negative affect, positive parenting, effective use of commands, and use of consequences. Parents’ responses to negative affect are thought to be a critical component of emotion socialization (Fabes et al., 2002) and were coded as follows. If a child experienced negative affect during the 5-minute interval, coders were asked to rate parents’ reactions to the negative affect using the following codes, which were largely based on CCNES dimensions: parental distress, punitive reaction, expressive encouragement, emotion-focused reaction, problemfocused reaction, minimizing/discouraging expression of emotion, and positive thinking. Global ratings were made every 5 minutes and ranged from 1 to 7 on frequency and intensity (or quality) for each code, except emotion talk and positive thinking, which were only rated on frequency. Several codes were omitted from further analysis as a result of very low incidence, including child emotion talk, parent emotion talk, parent punitive reactions, parent expressive encouragement, parent consequences, parent emotion-focused reactions, parent minimizing/discouraging, and parent positive thinking. In addition, parent problem-focused reactions quality (ICC = -.15) was omitted due to inadequate interrater reliability. Thus, the following codes were used: child misbehavior frequency (ICC = .80) and intensity (ICC = .84); child negative affect frequency (ICC = .94) and intensity (ICC = .84); positive parenting frequency (ICC = .73) and intensity (ICC = .60); parent commands frequency (ICC = .77) and quality (ICC = .59); parent negative affect frequency (ICC = .73) and intensity (ICC = .71); parent distress reactions frequency (ICC = .69) and intensity (ICC = .58); and parent problemfocused reactions frequency (ICC = .68). In sum, all codes that were retained had ICCs greater than or equal to .60, with the exception of parent commands quality and parent distress reactions intensity. These two codes may have been lower due to the more subjective nature of the codes, and were kept because they were only slightly below .60 and were clinically important. However, caution should be taken in interpreting results based on these codes. When relevant, frequency ratings were multiplied by intensity ratings to create a measure that reflected the frequency of each dimension weighted by the intensity with which the behavior occurred.

attendance Mothers who were assigned to the PT group attended a median of 11 group sessions (M = 9.53, SD = 4.09), and fathers attended a median of 7 group sessions (M = 6.47, SD = 5.50). When parents missed a session, a group leader spent 20 to 30 minutes

either by phone or before or after the next session reviewing the material that the parent missed.

data analysis To assess for the effectiveness of the intervention, analysis of covariance (ANCOVA) was used to compare PT and WL groups on each posttest measure using the respective pretest score as a covariate. ANCOVA accounts for pretest individual variability on measures of child and parent functioning and has been shown to produce unbiased results and possess greater power than conducting ANOVA on change scores (i.e., testing Treatment × Time interactions; Van Breukelen, 2006). For analyses of audiotaped parenting, posttest observed child misbehavior and negative affect were also added as covariates in order to control for differences in child behavior during the taped interaction. Child behavior varied across tapes and given previous experimental research documenting that child behavior affects parenting behavior (e.g., Brunk & Henggeler, 1984), it was important to take into account individual differences in how difficult the child was during the interaction. Because there were not enough fathers to conduct betweengroup comparisons (only 3 WL fathers completed posttest data), paired samples t-tests were used to compare PT fathers’ pretest scores to their posttest scores. One-tailed tests were used for a priori predictions. Effect sizes were calculated using Cohen's d (using posttest marginal means for ANCOVA analyses). Two children substantially changed their treatment between pretest and posttest (i.e., one child in the PT group began medication during treatment and another child in the PT group stopped taking medication). In tables of results, footnotes indicate the few changes in significance after excluding these two children from analyses.

Results missing data Using an intent-to-treat approach, pretest data were carried forward for missing posttest data, and posttest data were carried backward for missing pretest data. All 17 PT mothers completed posttest measures. One WL mother could not be reached to complete posttest data. One mother who participated in the PT group completed posttest but was missing some pretest measures. Eleven PT mothers and 10 WL mothers had complete audiotape data at posttest (missing data was due to a combination of parents forgetting to complete the recording and technical failure of tapes). One PT mother completed posttest but not pretest taping. Twelve PT fathers completed pretest or posttest measures. Two fathers completed pretest but not posttest, and one father completed posttest but not pretest.

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parent training for hyperactive preschoolers Table 1

Means and Standard Deviations of Pretest and Posttest Mother-Report in Parent Training (PT) and Waitlist (WL) Groups Variable

Child behavior DBRS inattention DBRS hyperactivity-impulsivity DBRS ODD BASC 2-PRS externalizing BASC 2-PRS internalizing ERC lability/negativity ERC emotion regulation Mothers’ parenting Overreactivity Laxness Verbosity CCNES supportive CCNES unsupportive

Pretest

Posttest

Pretest vs. Posttest

PT M (SD) n = 17

WL M (SD) n = 14

t

PT M (SD) n = 17

WL M (SD) n = 14

t

PT t

WL t

1.74 (0.57) 1.91 (0.56) 1.46 (0.54) 71.24 (11.65) 58.12 (13.58) 2.50 (0.30) 3.19 (0.41)

1.69 2.10 1.36 71.14 57.21 2.46 3.31

(0.61) (0.56) (0.80) (13.32) (11.54) (0.46) (0.39)

0.21 0.93 0.43 0.02 0.20 0.30 0.82

1.12 1.51 1.01 62.94 55.06 2.22 3.18

(0.59) (0.65) (0.67) (9.06) (10.52) (0.33) (0.40)

1.60 2.10 1.26 69.36 57.21 2.40 3.15

(0.56) (0.59) (0.84) (17.11) (13.80) (0.59) (0.50)

2.29⁎ 2.60⁎⁎ 0.93 1.27 0.49 0.98 0.16

5.09⁎⁎⁎ 2.77⁎⁎ 3.00⁎⁎ 3.23⁎⁎ 1.28 3.60⁎⁎ 0.08

0.86 0.02 0.98 1.20 0.39 0.73 1.72 †

3.24 (0.57) 3.02 (0.93) 3.89 (0.75) 5.65 (0.76) 2.27 (0.48)

3.04 2.90 4.04 5.75 2.38

(0.91) (0.68) (0.60) (0.65) (0.47)

0.75 0.40 0.62 0.38 0.65

2.93 2.58 3.22 5.65 2.15

(0.54) (0.80) (0.85) (0.89) (0.56)

2.95 2.62 3.94 5.72 2.61

(1.11) (0.73) (1.14) (0.81) (0.69)

0.08 0.17 2.00⁎ 0.23 2.08⁎

2.31⁎ 4.07⁎⁎⁎ 3.53⁎⁎ 0.06 1.32

0.53 1.88⁎ 0.43 0.37 2.59⁎

Note. DBRS = Disruptive Behavior Rating Scale; BASC 2-PRS = Behavior Assessment System for Children, Second Edition-Parent Rating Scale; ERC = Emotion Regulation Checklist; CCNES = Coping with Children's Negative Emotion Scale. † p b .10, * p b .05, ** p b .01.

effectiveness of randomization Children in the PT and WL groups did not differ significantly on gender (13 boys and 4 girls in the PT group and 10 boys and 4 girls in the WL group), χ 2 (1) = 0.04, p = .84, or age, t(29) = 0.54, p = .59 (PT M = 53.96 months, SD = 12.20; WL M = 56.08 months, SD = 9.10). T-tests for independent means were conducted comparing the PT and WL groups on all maternal pretest measures, and no significant differences were found, suggesting that random assignment was successful (see Tables 1 and 2).

descriptive statistics Means and standard deviations for pretest and posttest outcome variables for all mothers are presented in Tables 1 and 2. PT mothers reported significant decreases from pretest to posttest on the DBRS inattention, hyperactivity, and ODD subscales; ERC Child lability/negativity; BASC externalizing subscale; and maternal overreactivity, laxness, and verbosity; and were observed to decrease their command frequency and have children who decreased in their expression of negative affect.

Table 2

Means and Standard Deviations of Mothers' Pretest and Posttest Audiotape Observations in Parent Training (PT) and Waitlist (WL) Groups Variable

Pretest PT M (SD) n = 11

Posttest WL M (SD) n = 10

t

PT M (SD) n = 11

Pretest vs. Posttest WL M (SD) n = 10

t

Child misbehavior 2.94 (1.72) 2.57 (1.28) 0.55 2.36 (1.03) 1.84 (0.67) -1.34 Child negative affect 5.77 (4.35) 3.41 (2.84) 1.46 3.51 (2.04) 2.76 (2.10) 0.84 Mothers’ positive parenting 13.17 (6.97) 11.00 (3.73) 0.88 11.83 (4.39) 9.72 (3.73) 1.18 Mothers’ commands frequency 2.33 (0.59) 2.31 (0.66) 0.08 1.98 (0.33) 2.24 (0.58) 1.27 Mothers’ commands quality 2.99 (0.71) 3.28 (0.69) 0.94 3.19 (0.90) 3.18 (0.45) 0.02 Mothers’ negative affect 2.90 (1.72) 3.02 (1.35) 0.18 2.19 (0.76) 2.50 (1.28) 0.70 Mothers’ distress reactions 2.02 (0.94) 2.61 (1.15) 1.28 2.31 (1.02) 2.00 (1.61) 0.61 Mothers’ problem focused reactions frequency 1.50 (0.34) 1.55 (0.58) 0.24 1.45 (0.39) 1.41 (0.27) 0.25 †

p b .10, * p b .05.

†

PT t

WL t

1.14 2.16* 0.71 2.16⁎

1.73 1.42 0.66 0.33 0.32 1.17 1.05 0.85

0.85 1.71 0.81 0.40

†

† †

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WL mothers’ reported significant decreases in maternal laxness and significant increases in unsupportive emotion socialization practices.

parent training effects on maternal report of mother and child behavior ANCOVAs were conducted to compare PT and WL groups on mothers’ posttest rating scales, with each respective pretest score entered as a covariate (see Table 3). Children in the PT group were rated significantly lower on posttest DBRS inattention, DBRS hyperactivity/impulsivity, DBRS ODD, BASC externalizing, and ERC lability/negativity compared to children in the WL group. These differences represented medium- to large-sized effects. There were no significant differences on mothers’ posttest BASC internalizing behavior or the ERC emotion regulation scale. Mothers who participated in the PT group reported being less verbose compared to the mothers in the WL group (Table 3), and this effect was medium-sized. Although mothers in the PT group reported significant decreases in overreactivity and laxness from pretest to posttest (Table 1), they did not differ significantly from the WL group at posttest on either variable. Mothers in the PT group reported using unsupportive emotion socialization practices significantly less often than mothers in the WL group, and this effect was medium-sized. However, no differences were observed in supportive emotion socialization practices.

Because children varied in age, we explored whether treatment effects varied as a function of age by entering child age as a between-subjects factors (older children = 57 months or older, n = 16; younger children = less than 57 months, n = 15). There was a Treatment × Child Age interaction for supportive emotion socialization practices, F(1, 26) = 5.71, p = .02. There was a significant effect of treatment on supportive emotion socialization for younger children, F(1, 12) = 3.66, p = .04, (PT group marginal mean = 5.96, WL marginal mean = 5.61), but not older children, F(1, 13) = 1.99, p = .18.

exploratory analyses Observed Mother and Child Behavior Results of ANCOVAs for observational ratings are presented in Table 4. Ratings of audiotaped observations did not reveal significant differences between groups in children's misbehavior or negative affect. Mothers who participated in the PT group were rated as engaging in more positive parenting and expressing less negative affect, controlling for observed child behavior, compared to mothers in the WL group. These differences represented large-sized effects. No other audiotape measures were significantly different between groups. When child age was entered as a factor, there was a significant Treatment × Child Age interaction for parent negative affect, F(1, 14) = 7.20, p = .02. There was a significant effect of treatment on parent negative affect for mothers of older children, F(1, 7) = 23.70, p = .002, (PT marginal mean = 1.98,

Table 3

ANCOVA: Comparison of Parent Training (PT) and Waitlist (WL) Mother-Reports Variable

Child behavior DBRS inattention DBRS hyperactivity-impulsivity DBRS ODD BASC 2-PRS externalizing behavior BASC 2-PRS internalizing behavior ERC lability/negativity ERC emotion regulation Mothers’ parenting Overreactivity Laxness Verbosity CCNES supportive CCNES unsupportive

PT Marginal Mean (SE) n = 17

WL Marginal Mean (SE) n = 14

F(1, 28)

p

Cohen's d

1.11 1.58 0.97 62.91 54.79 2.21 3.22

(0.11) (0.12) (0.13) (2.37) (2.18) (0.08) (0.08)

1.61 (0.12) 2.02 (0.13) 1.30 (0.14) 69.40 (2.54) 57.54 (2.41) 2.42 (0.09) 3.10 (0.09)

10.40 6.57 3.05 3.58 0.71 3.36 0.91

.002⁎⁎ .008⁎⁎ .046⁎ .035⁎ .203 .039⁎ .170

0.87 0.71 0.44 0.48 0.23 0.45 0.27

2.85 2.54 3.28 5.75 2.21

(0.14) (0.11) (0.20) (0.10) (0.12)

3.04 (0.16) 2.67 (0.13) 3.87 (0.22) 5.72 (0.10) 2.56 (0.10)

0.85 0.64 3.82 0.04 6.69

.183 .215 a .030⁎ .420 .007⁎⁎

0.22 0.17 0.60 0.04 0.56

Note. DBRS = Disruptive Behavior Rating Scale; BASC 2-PRS = Behavior Assessment System for Children, Second Edition-Parent Rating Scale; ERC = Emotion Regulation Checklist; CCNES = Coping with Children's Negative Emotion Scale. a Effect approaches significance after omitting children who made substantial changes to their treatment, F(1, 26) = 2.59, p = .06. † p b .10, * p b .05, ** p b .01.

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parent training for hyperactive preschoolers Table 4

ANCOVA: Comparing Parent Training (PT) and Waitlist (WL) Mothers' Audiotape Observations Variable

PT Marginal Mean (SE) n = 11

WL Marginal Mean (SE) n = 10

F

p

Cohen's d

Child misbehavior Child negative affect Mothers’ positive parenting Mothers’ command frequency Mothers’ command quality Mothers’ negative affect Mothers’ distress reactions Mothers’ problem focused reactions frequency

2.33 (0.26) 3.08 (0.47) 12.49 (1.14) 1.95 (0.14) 3.29 (0.22) 2.05 (0.22) 2.06 (0.34) 1.42 (0.09)

1.88 (0.27) 3.24 (0.50) 9.00 (1.20) 2.28 (0.15) 3.08 (0.23) 2.66 (0.23) 2.27 (0.36) 1.44 (0.10)

1.42 0.05 3.52 2.46 0.42 3.54 0.17 0.03

.125 .412 .040* .068 † .264 .039* .349 .435

0.51 0.08 0.85 0.71 0.29 0.59 0.16 0.06

†

p b .10, * p b .05.

WL marginal mean = 3.24), but not for younger children, F(1, 4) = .03, p = .87.

did not report a significant change in supportive emotion socialization practices.

Father Report Paired samples t-tests were used to compare fathers’ reports of parenting and child behavior (Table 5). At posttest, fathers in the PT group rated their children significantly lower on the DBRS inattentive subscale and hyperactive/impulsive subscale, compared to pretest reports. The difference in DBRS hyperactivity/impulsivity represented a large-sized effect, and the differences in inattention represented a medium-sized effect. Similar to mothers, fathers reported a significant and large-sized decrease in unsupportive emotion socialization practices, but

The present study examined the effectiveness of a parent training and emotion socialization program specifically designed for hyperactive preschoolers, which included teaching emotion socialization strategies to improve children's emotion regulation as well as parenting strategies to manage hyperactive and disruptive behavior. Results of the present study generally supported the effectiveness of the program in reducing ADHD and ODD symptoms, decreasing children's emotional lability, and improving parents’ emotion socialization.

Discussion

Table 5

Paired Samples T-Test of Parent Training (PT) Father-Reports Variable

Child behavior DBRS inattention DBRS hyperactivity-impulsivity DBRS ODD BASC 2-PRS externalizing behavior a BASC 2-PRS internalizing behavior a ERC lability/negativity ERC emotion regulation Fathers’ parenting Overreactivity Laxness Verbosity CCNES supportive CCNES unsupportive

PT Pretest M (SD) n = 12

PT Posttest M (SD) n = 12

t

p

Cohen's d

1.50 (0.74) 1.81 (0.53) 1.65 (0.73) 67.99 (7.23) 52.76 (10.36) 2.30 (0.37) 3.02 (0.30)

1.26 (0.45) 1.47 (0.46) 1.28 (0.74) 61.60 (12.68) 50.60 (12.30) 2.19 (0.39) 3.14 (0.40)

1.91 3.49 1.73 1.77 0.84 0.93 1.43

.042⁎ .003⁎ .055 †b .055 † .212 .185 .091 †

0.53 1.00 0.51 0.56 0.27 0.28 0.43

1.71 0.01 0.87 0.06 2.31

.057 † .498 .202 .477 .020⁎

0.50 0.00 0.25 0.04 0.70

3.06 2.82 3.81 5.47 2.72

(0.68) (0.84) (0.51) (.62) (.55)

2.86 2.82 3.67 5.46 2.56

(0.71) (0.75) (0.54) (.64) (.63)

Note. DBRS = Disruptive Behavior Rating Scale; BASC 2-PRS = The Behavior Assessment System for Children, Second Edition-Parent Rating Scale; ERC = Emotion Regulation Checklist; CCNES = Coping with Children's Negative Emotion Scale. a n = 10. b Effect becomes significant after omitting child who made a substantial change to his treatment, t (10) = 2.45, p = .017. † p b .10, * p b .05.

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parent training effects on child outcome Mothers reported significantly fewer child inattentive and hyperactive/impulsive symptoms after parent training compared to mothers on the waitlist. Similarly, fathers rated their children as showing significantly fewer inattentive and hyperactive/ impulsive symptoms at posttest compared to pretest. The effect sizes for this study were in the medium- to large-sized range, which were similar to some previous studies of preschool aged-children (Huang et al., 2003, Sonuga-Barke et al., 2001; Strayhorn & Weidman, 1989, 1991), and larger than others (Bor et al., 2002; Kern et al., 2007). Thus, although ADHD is a neurobehavioral disorder, the present study's results suggest that symptom expression can be reduced through parent training implemented during the preschool years. The relatively few randomized controlled trials of parent training for older children with ADHD have found significant decreases in ODD-related behavior (e.g., Chacko et al., 2009), but results have been mixed with respect to decreasing ADHD symptoms (e.g., Anastopoulos, Shelton, DuPaul, & Guevremont, 1993; Hoath & Sanders, 2002). Consistent with the notion that there is greater neuroplasticity early in development (Nelson & Bloom, 1997), cross-study comparisons suggest that effects of parent training on ADHD symptoms may be stronger for younger children than for older children. However, it is not clear whether changes in ADHD symptoms reflect changes in how children's ADHD symptoms are expressed and managed in their environment or whether changes occur in brain function. Further research is needed to directly test these possibilities. Mothers’ reports also indicated significant effects of parent training on ODD symptoms. Few controlled studies of parent training for hyperactive preschoolers have directly measured ODD symptoms as outcome measures, and those that have yielded mixed findings (e.g., Bor et al., 2002; Kern et al., 2007; Matos et al., 2009). Our failure to find effects on observed misbehavior and negative affect stands in contrast to previous studies that have found such effects using observational data (e.g., Bor et al., 2002; Pisterman et al., 1992; Strayhorn & Weidman, 1989) and may be a result of instructions given to parents. Parents were instructed to record their children during times that were particularly difficult for them. Thus, even if children were engaging in less misbehavior and negative affect overall, it might be difficult to capture that difference by taping the most difficult hour of the week. Studies that found significant differences using observational data did not give these instructions and instead requested families to complete either structured tasks or interact

in a laboratory setting (e.g., Bor et al., 2002; Pisterman et al., 1992; Strayhorn & Weidman, 1989). Thus, although the observation method used in the present study may have been effective in detecting effects of the treatment on parenting, a different observational method might be better for detecting effects on child behavior. Mothers who took part in parent training reported improvement in their children on one of two subscales of an emotion regulation checklist. Effects were not observed on a subscale that assessed mothers’ perceptions of children's emotional awareness, positive responses to others, and empathy. A number of the items on this scale are interpersonal in nature and seem to combine emotion regulation with social skills. It may be that more time was needed before effects on these more complex behaviors would be observed consistently. It is also possible that an intervention that more directly targeted social skills in addition to emotion regulation would result in significant effects on this subscale. In contrast, improvement was observed on a subscale assessing mothers’ reports of children's emotional lability/ negativity. The parenting program placed a strong emphasis on how to respond to children's negative affect (e.g., using labeling and validation), as a means of helping children cope with negation emotions, which may have reduced children's lability. Parents’ decreased use of unsupportive emotion socialization practices may have led to reductions in children's lability. It is possible that encouraging children to communicate negative emotions leads them to do so as the emotion arises, thus leading to less intense and more appropriate communication of distress. It is unknown whether effects on children's emotion lability were due to teaching parents emotion socialization skills or to training them in general parenting skills. However, taken together with work by Havighurst et al. (2010), who focused solely on emotion socialization skills, these results suggest that children's emotion competence may be improved by teaching parents emotion socialization skills. Further research is needed to replicate these findings.

parent training effects on parenting Effects of parent training were found on several observational measures of parenting and self-report of emotion socialization and verbosity but not on self-report of overreactivity and laxness. There was evidence that parent training resulted in less unsupportive emotion socialization for both mothers and fathers, and resulted in more supportive emotion socialization for mothers of younger children. These findings corroborate previous research that demonstrated improved emotion socialization practices in parents of preschoolers (Havighurst et al., 2010). In

parent training for hyperactive preschoolers addition, mothers who received parent training were rated as engaging in more positive parenting and less negative affect compared to mothers on the waitlist, controlling for child behavior, though there was some evidence that effects on parent negative affect were specific to parents of older children. Although mothers in the parent training group showed significant decreases in their self-reports of overreactivity and laxness, mothers in the waitlist group also reported significant decreases in laxness, as well as slight decreases in overreactivity. It is not clear why mothers in the waitlist group reported improved parenting. None of the waitlist families reported receiving formal assistance with parenting over the course of the program; however, because they did not receive immediate treatment, parents on the waitlist may have sought informal sources of help (e.g., selfhelp literature), which were not assessed in this study, and could have resulted in their reports of less laxness.

clinical implications This study provides some support for the effectiveness of the Parenting Your Hyperactive Preschool Program and adds to the growing body of research supporting the use of early psychosocial interventions for preschool-aged children exhibiting ADHD symptoms. This parenting program reduced parent reports of children's inattentive and hyperactive/ impulsive symptoms, with effect sizes that were comparable to some previous studies that evaluated parent training for hyperactive preschoolers (e.g., Sonuga-Barke et al., 2001) and to studies that have evaluated the efficacy of pharmaceuticals (Greenhill et al., 2006; Short et al., 2004). Results also support the notion that parent training that targets emotion socialization may be successful in reducing the frequency of parents’ use of invalidating emotion socialization practices and children's mood lability. Because unsupportive parental emotion socialization practices are thought to contribute to children's poor emotion regulation abilities (Denham et al., 2000), and limited emotion regulation capabilities have been found to mediate the relationship between ADHD and later depression (Seymour et al., 2012), it is possible that participation in programs that focus on parents’ emotion socialization practices might protect children with ADHD from developing comorbid conditions. However, further research on the long-term effects of participation in this program are needed. limitations The results of the present study should be interpreted in the context of several limitations. First, although we expect that changes that were found in emotion

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socialization were due to the emotion socialization component of the program, it is not clear which aspects of the parenting program were active ingredients in change. Second, use of an observational measure of child emotion regulation to supplement parent report may have provided a more comprehensive and sensitive measure of change in emotion regulation. Third, due to a small sample size, it may have been difficult to detect modest-sized effects. A study with more power may be needed to detect these effects. In addition, this study was unable to statistically take into account the fact that families were nested within parent training groups. Fourth, our sample was not ethnically diverse and families were largely middle- or upper-middle class; thus, it is not clear whether the results are generalizable to other ethnic or socioeconomic backgrounds. Finally, demand characteristics or expectancy effects may account for some of the observed effects in this study, both for parent-report and audiotaped measures, and may account for low rates on some of the parenting audiotaped codes.

future directions Future research is needed to determine which components of this parenting program were active ingredients in change; that is, information is needed regarding the incremental effectiveness of adding emotion socialization training to traditional parent training. Second, it will be important to investigate whether this program is effective for families who are from diverse ethnic and socioeconomic backgrounds. Third, independent researchers should evaluate this intervention to fully establish empirical support for this program. Finally, studies are needed to evaluate the long-term effectiveness of this program, to determine whether gains can be maintained over time. In sum, continued research on the effectiveness of training parents of hyperactive preschoolers in discipline, positive parenting, and emotion socialization is key in the development of early interventions for children at risk for ADHD. References Abikoff, H. G., Vitiello, B., Riddle, M. A., Cunningham, C., Greenhill, L. L., Swanson, J. M…Wigal, T. (2007). Methylphenidate effects on functional outcomes in the Preschoolers With Attention-Deficit/Hyperactivity Disorder Treatment Study (PATS). Journal of Child and Adolescent Psychopharmacology, 17, 581–592. http://dx.doi.org/ 10.1089/cap.2007.0068 American Academy of Pediatrics. (2011). AAP expands ages for diagnosis and treatment of ADHD in children [press release]. Retrieved from http://www2.aap.org/pressroom/adhd.pdf American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4 th ed., text rev.). Washington, DC: Author.

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